The history of Crew Resource Management.
The content for this section is extracted from the book Crew Resource Management: From Patient Safety to High Reliability by Safer Healthcare Founder, Board Member and author, David Marshall.
The history of Crew Resource Management began upon the aviation industry's surrender to two fundamental and incontrovertible realities:
- Human beings are fallible and will inevitably make mistakes
- Human beings are individuals, with a rich diversity of personalities, cultural backgrounds, talents and skills. Whether by nature or nurture, some are better at communicating, some better at performing under stress.
In aviation and in medicine, these quintessentially human traits collide against a professional environment in which adverse events are starkly and objectively measured: people get hurt or killed. Safety improvement initiatives based on reducing human error demand a standardized, scalable, and sustainable method for preventing un-standard human factors from causing adverse events. Simply put, Crew Resource Management methods help keep the traits that make each person wonderfully unique from causing harm to others.
Mitigating human error.
"A system not designed to expect and safely absorb human error will constantly suffer from human mistakes."
- David A. Marshall
Crew Resource Management has been studied from various scholarly and scientific angles, and several training approaches have been developed. Given this variation, it is useful to consider what Crew Resource Management is and what it is not.
Crew Resource Management is...
The definition of Crew Resource Management
- a flexible, systemic method for optimizing human performance in general, and increasing safety in particular, by (1) recognizing the inherent human factors that cause errors and the reluctance to report them, (2) recognizing that in complex, high risk endeavors, teams rather than individuals are the most effective fundamental operating units and (3) cultivating and instilling customized, sustainable and team-based tools and practices that effectively use all available resources to reduce the adverse impacts of those human factors.
Crew Resource Management has been variously described and defined by academics, consultants and various organizations. For the purpose of understanding its import and application in the aviation context, it can be defined as the following:
- A method created to optimize human and crew performance by reducing the effect of human error through the use of all resources, including people, hardware (technology) and information (process) to solve problems.
- A systems approach to safety that emphasizes the inherent nature of error, promotes a non-punitive culture, and centers on clear, comprehensive standard operating procedures (SOPs).
- A comprehensive, operationally focused, and self-convincing and hands-on system of proactively applying human factors to improve crew performance.
- A system that includes the following critical elements: (1)focuses on how crew member attitudes and behaviors affect safety, (2) adopts the crew rather than the technically competent individual as the standard training unit, (3) employs active training; the participants learn by participating rather than being lectured to, (4) imparts leadership and teamwork skills, (5) promotes crew member input teams while preserving authority and chain of command and (6) gives individuals and crews the opportunity to review and analyze their own performance and make appropriate improvements.
Crew Resource Management isn't...
Given the relatively recent emergence of Crew Resource Management program in healthcare and some initial resistance to its adoption, highlighting what Crew Resource Management isn't may be as instructive as stating what is. Crew Resource Management is not:
- A quick fix to improve patient safety. An organizational mindset and cultural shift are required.
- A stand-alone system that operates in isolation from other training activities.
- A passive series of classroom lectures.
- Off-the-shelf cook-book medicine.
- A psychological or personality assessment tool.
- A way for company management to dictate and control behavior.
- A method of managing by committee or undermining the team leader's authority. In fact, authority should be enhanced through the use of Crew Resource Management. This is primarily due to the fact that (1) all team members direct information to the team leader and (2) although all team members have the chance to be heard, the final decision on any course of action still rests with the team leader.
Crew Resource Management has been proven to effectively improve cultures (primarily patient safety) in the organizations that choose to adopt it. This was the burning platform that drove the commercial aviation industry to develop and adopt this powerful system.
Tragic airline mishaps impel cultural change.
A series of aviation disasters in the 1970's triggered the innovative shift that led to Crew Resource Management. These included the 1977 Canary Islands disaster in which two Boeing 747's collided on a runway, killing 582 people. In 1972, a Lockheed L-1011 (Eastern Air Lines Flight 401) crashed in a Florida swamp, killing 99 passengers... as the crew worked to repair a burned-out light bulb. United Airlines Flight 173, making its final approach to Portland International Airport after a routine flight on December 28, 1978, ran out fuel and crashed into a residential area, killing eight passengers and two crew members, and seriously injuring 23 others.
In each case, tragedy traced back to human error:
- Canary Islands: in his haste to take off, the captain of the Boeing 747, a highly seasoned professional, mistakenly assumed a critical pre-flight step had been performed and barreled down a foggy runway without first obtaining takeoff clearance.
- EAL 401: crashed, in essence, because someone forgot to fly the plane. The National Transportation Safety Board (NTSB), after investigating, found that the autopilot was inadvertently switched from "Altitude Hold" to "Control Wheel Steering" mode when the captain accidentally leaned against a yolk, causing the plane to enter a gradual descent. No one in the crew noticed or heard the system's altitude alert warning because the crew was distracted by the landing gear light and the flight engineer was not in his seat when the alert sounded and thus could not hear it.
- UA 173: experienced a similar landing gear light problem. The experienced captain noticed that the plane's nose gear light failed to turn green to indicate it was properly deployed. With the control tower's permission, the pilot circled the plane and ran through his checklists to troubleshoot the problem, but the nose gear light stayed red. While circling, the first officer and flight engineer told the pilot that the plane was running low on fuel. The pilot apparently ignored the warnings. Post-crash analysis revealed that the green light bulb for the nose gear had simply burned out; the landing gear had been deployed the entire time. The NTSB found that the crash was caused by the captain's failure to accept input from junior crew members and a lack of assertiveness by the flight engineer.
In all of these cases, the aircraft were mechanically sound, the pilots and their crews technically competent. The systems and procedures in place simply did not catch these fatal mistakes in time. In short, the system was flawed.
NASA took the lead to explore how to fix the system, convening a June 1979 workshop to evaluate the causes of aviation accidents. As the above episodes imply, the workshop led to an alarming discovery: human error caused most aviation accidents... in fact, 60-80% of them. This problem was compounded by failures in leadership, interpersonal communication and decision making in the cockpit.
The 1979 workshop did not operate in a vacuum. NASA had, in fact, pioneered research into human factors and performance in aviation and aerospace in the early 1970's, at its Ames Research Center in California. NASA's human factors in aviation safety program began in 1973 when a series of interviews were conducted with airline crew members. A typical comment was: "My company trains pilots well but not captains." In a noted NASA-sponsored study, H.P. Ruffel-Smith (1979) used simulators to examine crew behaviors and performance in both routine and emergency situations. Ruffel-Smith's study demonstrated that the better crew resources were utilized and the more effectively crew members communicated, the better the crew performed.
Other NASA-sponsored research projects suggested that grafting Crew Resource Management concepts onto existing training programs in flight operations (such as Line Oriented Flight Training or LOFT) would help resolve human factor-related problems. This research recognized that improved technology and operating process would represent only a partial route to better performance and safety; the full solution depended on the crew. That way, all resources would be utilized to drive improvement.
NASA-sponsored research recognized that improved technology and operating process would partly solve human factor-related problems, but that the full solution depended on the crew.
Following NASA's lead, the FAA, in the early 1980's, incorporated a Crew Resource Management platform into its regulatory program. The stated objective was to work with the aviation industry to develop a draft Notice of Proposed Rule-Making that would address crew coordination concepts and Crew Resource Management. On January 13, 1981, at another NASA/Aviation Industry Workshop, the FAA's Charles Huettner said:
"We are embarking on an adventure into the flight training techniques of the future. In recent years a growing consensus has occurred in industry and government that training should emphasize crew coordination and the management of crew resources."
- Charles Huettner, FAA
Six generations of CRM.
Since its introduction in the early 1980's, there have been six generations of Crew Resource Management. Each successive generation was enhanced to build upon the successes and lessons learned from the previous generation(s). The following are overviews of each generation.
First Generation: Cockpit Resource Management
With crew-based training validated in concept, United Airlines (UA) initiated the first formal Crew Resource Management training course in 1981. This initiative followed the alluded to rash of serious accidents, none of which were attributable to a specific problem (including a mechanical failure) that would have prevented a safe flight.
UA developed its program with the input of experts on improving business management. Other airlines took the same management-focused approach in their early Crew Resource Management programs. Some of them, following the results of NASA's research, included full-mission LOFT training in addition to classroom work. UA made its C/L/R program available to other carriers, but they were slow to respond. However, UA continued to fine-tune its program, making it an integral part of UA's own flight officer training. Consistent with the FAA recommendations, the main tenets of the program were to institute:
- A comprehensive system for improving crew performance.
- An operational focus on safety improvement.
- A study of how team member attitudes and behaviors affect safety.
- A training method using the team, not the individual, as the training unit.
- Active training where the participants experience and participate.
In retrospect, the business management focus of these first-generation programs proved unduly narrow. Virtually all of those programs (somewhat reflexively on the heels of the NTSB's damning report on UAL 173) emphasized correcting deficiencies in individual behavior such as a lack of assertiveness by juniors and authoritarian behavior by captains. The programs featured psychological testing and explored abstract concepts such as leadership. They advocated general strategies of interpersonal behavior but did not clearly define appropriate cockpit behavior.
Overall, despite these shortcomings, the early Crew Resource Management programs were generally well received. That said, some pilots resisted, denouncing them as charm school or attempts to manipulate their personalities.
Second Generation: Crew Resource Management
During the middle and second half of the 1980's, many commercial airlines, domestic and foreign, developed and implemented their own Crew Resource Management programs. By the time NASA held its May 1986 industry workshop, a new generation of Crew Resource Management courses had emerged. These newer programs expanded the scope of the first-generation efforts, embracing more modular, real world operations.
Second-generation programs emphasized cockpit group dynamics (team dynamics) and led to a name change, from Cockpit to Crew Resource Management. The expanded training included new topics such as team building, briefing strategies, situational awareness, and stress management and featured distinct modules on decision making and breaking error chains that can cause catastrophe. These refinements were intended partly to address pilots' resistance to first-generation programs, but also to translate abstract concepts into everyday operational tools.
However, in order to teach Crew Resource Management concepts, many of the second-generation courses still relied on exercises and games (such as Lost on the Moon and Win as Much as You Can) unrelated to aviation. Therefore, although the new courses were better received by trainees than those of the first generation, the criticism persisted that the training was heavily laced with psycho-babble; for example, the notion of synergy in group dynamics was often condemned by participants as useless jargon.
Third Generation: Further Expanding the Scope
In the early 1990's, the Crew Resource Management training began to aim at increased relevance. Crew Resource Management was integrated with technical training, focusing on specific skills and behaviors that would help pilots function more effectively in actual flight deck operations. Several airlines introduced modules connecting Crew Resource Management and flight deck automation.
Significantly, third-generation Crew Resource Management programs also expanded to address:
- Issues related specifically to the aviation system in which crews function. This included the elements of organizational culture that affect safety.
- The recognition and assessment of human factor issues.
As the name change suggests, training in Crew Resource Management was extended to other groups that shared the responsibility for aviation safety, including flight attendants, dispatchers, and maintenance personnel. Many airlines, in fact, initiated joint cockpit-cabin Crew Resource Management training. A number of carriers developed Crew Resource Management training specifically for captains, related to the leadership demands that accompany command. Advanced Crew Resource Management training was given to check airmen and others responsible for training and evaluating crew members.
Third-generation Crew Resource Management programs filled the identified need to expand the emphasis on, and the definition of, the flight crew. But they may also have had an unintended consequence: diluting the original Crew Resource Management mandate to reduce human error.
Fourth Generation: Integrating Crew Resource Management and Establishing Formal Procedures
In 1990, the FAA issued an advisory circular on Crew Resource Management; comprehensive Crew Resource Management training became a not only a reality, but a regulatory requirement. The FAA also introduced another major change with its Advanced Qualification Program (AQP).
AQP allowed carriers to develop customized Crew Resource Management training for their own organizations. In exchange for this greater flexibility, carriers would be required to:
- Provide both Crew Resource Management and LOFT for all flight crews.
- Integrate Crew Resource Management concepts into technical training.
- Create detailed analyses of training requirements for each aircraft.
- Develop programs for addressing human factors in each aspect of training.
Most major U.S. airlines and several regional carriers chose AQP. A consensus found that the AQP approach improved flight crew training and qualifying.
To assimilate Crew Resource Management into actual operations, airlines began to formalize Crew Resource Management concepts by adding specifically prescribed behaviors to their checklists. This was done to ensure that decisions and actions would be informed by bottom line considerations and that the basics of Crew Resource Management would be observed, particularly in non-standard situations.
By making Crew Resource Management an integral part of all flight training, the fourth generation of Crew Resource Management made progress in solving the persistent problems with human error. But even more progress was needed.
Fifth Generation: Error Management
The fifth generation of Crew Resource Management aimed at resolving reported deficiencies in the previous iterations. For example, previous training regimens had prescribed specific behaviors but did not explain the reasons for doing so.
Dr. Robert Helmreich (a preeminent Crew Resource Management pioneer) and his colleagues set out to fix the education shortfall by defining a single, universal rationale that could be supported by pilots worldwide. They circled back to the basics: returning to the original concept of Crew Resource Management as a way to avoid error, we concluded that the overarching justification for Crew Resource Management should be error management... effective error management is the hallmark of effective crew performance and the well-managed errors are indicators of effective performance.
The Helmreich team advocated sharply defined justification accompanied by proactive organizational support. The fifth generation of Crew Resource Management would:
- Introduce and emphasize the concept of error management: managing and living with human error.
- Flow from the recognition that human error is ubiquitous, inevitable and a valuable source of information.
Therefore, Crew Resource Management would concentrate on error countermeasures that would apply to each situation:
- Avoiding error altogether. (For example, advance briefing on landing approach procedures and potential pitfalls, combined with intra-crew communication and verification.)
- Identifying and trapping incipient errors before they are committed. (For example: cross-checking navigation information before executing on it.)
- Mitigating the consequences of errors that do occur. (For example, remembering to fly the plane after a warning alarm sounds.)
Fifth-generation Crew Resource Management would include formal instruction about the limitations of human performance, including the nature of cognitive errors and slips and the performance-degrading effects of stressors such as fatigue, work overload, and emergencies.
Fifth-generation Crew Resource Management posited that in order for the error management approach to achieve full traction, organizations should (1) affirmatively concede that errors will inevitably occur and (2) adopt a non-punitive approach to all errors (except for willful violations of rules or procedures).
As suggested above, fifth-generation Crew Resource Management also stressed data gathering and reporting. Doing so would advance deeper understanding, but also help gauge program success. The FAA took the cue and, in 1997, enacted Aviation Safety Action Programs (ASAP), intended to encourage aviation organizations to take proactive safety measures and freely report incidents. American Airlines (AA) was an early adopter, working in cooperation with both the FAA and the pilots' union. Through AA's confidential, non-punitive reporting program, pilots reported safety concerns and errors. The AA program was a resounding success: during its first two-years, nearly six thousand reports were received. The data generated by its ASAP helped AA refine and improve its Crew Resource Management training program.
Although each ASAP requires delicate negotiation among the carrier, the FAA, and the pilots' union (which seeks to protect the confidentiality and non-punitive nature of incident reports), ASAP continues today to be a vital element of airline safety.
Sixth Generation: Threat Management
Crew Resource Management has evolved to a sixth generation, which builds on the fifth generation's error management theme. The sixth generation recognizes that the fifth generation's focus on pilot error (the sharp end) was appropriate; it further addresses the reality that flight crews must not only cope with human error inside the cockpit but also with threats to safety arising from the work environment as a whole.
Thus, in the sixth generation, the Crew Resource Management lens has been widened from error management to threat management. These days, traditional Crew Resource Management skills and methods are applied not only to eliminate, trap, or mitigate errors, but to identify systemic threats to safety.
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