C R M

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C R M
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CRM

• Cockpit Resource Management
• ? Crew Resource Management
• What?
• Objective?
• Case-study (Tenerife, March 27, 1977) ? CRM

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CRM ?
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CRM ?

• The effective utilisation of all available
  resources (all crew members, aeroplane systems
  and supporting facilities) to achieve a safe and
  efficient operation.

Focus on non (fly)technical skills
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CRM Objective

• To make flying safer and more efficient by
  improving crew performance through better crew
  co-ordination and communication (CRM-course)
• Resources
• People
• Time
• Information
• Equipment

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Elements of CRM

• Communication assertiveness
• Human error
• Fatigue stress
• Situational awareness
• Personality-attitude-behaviour
• Teamwork leadership
• Decision-making
• SOPs

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CRM ? Case study

• Tenerife accident , March 27, 1977
• Which factors contributed to this accident?
• citations from air crash investigation reports
• How are these factors related to CRM Elm?
• Aim of CRM-courses

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TENERIFE ACCIDENT, March 27, 1977
Pan Am 1736
KLM 4805
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(No Transcript)
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TENERIFE ACCIDENT, March 27, 1977
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VIS 300 m
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Total crew 30 Total PAX 614 Survivors
70 (9 died later) Total cas.583
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CRM Communication

• the process of transmitting and receiving
  ideas, information, feelings and messages
• verbal (7) non verbal (55-70)
• 4 barriers to communication
• language ( foreign speech, accent, jargon,
  dialect)
• psychological (status, stress, personality,)
• physical (noise, distance, fatigue, locked door
  policy,)
• general(authority, rank, gender, perception, )

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CRM Communication

• Factors contributing to the Tenerife HAP
• However, even after the enroute clearance was
  given, the tower instructed 4805 to "standby for
  take-off" which the crew failed to hear as well
  as the clear indications that 1763 was still on
  the runway.
• In addition, Meurs did nothing to further
  enlighten van Zanten that they were not cleared
  for take-off after his initial comment. It is
  possible that Meurs was not comfortable
  challenging van Zanten due to his experience
  level.

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CRM Communication

• Factors contributing to the Tenerife HAP
• The fundamental cause of this accident was the
  fact that the KLM captain
• 1. Took off without clearance.
• 2. Did not obey the "stand by for take-off" from
  the tower.
• The fact that two transmissions took place at
  the same time. The "stand by for take-off ... I
  will call you" from the tower coincided with Pan
  Am's "we are still taxiing down the runway",
  which meant that the transmission was not
  received with all the clarity that might have
  been desired.

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CRM Communication

• KLM captain wants to depart
• KLM FO asks route clearance and T/O clearance
• Tower gives route clearance, but not T/O
  clearance
• KLM captain We go
• KLM FO reads ATC clearance again We are now at
  T/O
• Tower OK (2) STBY for T/O
• PanAm We are still taxiing down the RWY
• Tower asks PanAm to declare when they leave RWY
• KLM FE Is hij er niet af dan?
• KLM captain Jawel!

simultaneously
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CRM Human error

• Attention error
• attentional blindness (mental resources focused
  elsewhere)
• Perceptual error
• light, contrast, visual illusion, spatial
  disorientation
• Response error
• incorrect action/response

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CRM Human error

• Factors contributing to the Tenerife HAP
• Now, how is it possible that a pilot with the
  technical capacity and experience of the captain,
  whose state of mind during the stopover at
  Tenerife seemed perfectly normal and correct, was
  able, a few minutes later, to commit a basic
  error in spite of all the warnings repeatedly
  addressed to him.

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CRM Fatigue stress

• Fatigue a reduced capacity to perform mental
  and/or physical activities
• Stress a mental and physical reaction to
  pressure
• chronic
• acute

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CRM Fatigue stress

• Causes of fatigue
• lack of restful sleep
• stress
• workload
• disrupted circadian rhythms
• Identifying stress
• rapid breathing
• impatient
• sweaty hands
• negative thoughts

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CRM Fatigue stress

• Factors contributing to the Tenerife HAP
• Fatigue
• On approaching the Canaries six hours later, the
  crew were informed of the temporary closure of
  the airport and diverted to Tenerife's Los Rodeos
  airport.This was unwelcome news to the crew, who
  had already been on duty for eight hours.

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CRM Fatigue stress

• Factors contributing to the Tenerife HAP
• Stress
• A growing feeling of tension as the problems for
  the captain continued to accumulate. He knew
  that, on account of the strictness in the
  Netherlands regarding the application of rules on
  the limitation of duty time, if he did not take
  off within a relatively short space of time he
  might have to interrupt the flight - with the
  consequent upset for his company and
  inconvenience for the passengers. Moreover, the
  weather conditions in the airport were getting
  rapidly worse, which meant that he would either
  have to take off under his minima or else wait
  for better conditions and run the risk of
  exceeding the aforementioned duty time limit.

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CRM Situational awareness

• an accurate mental model of all the factors
  and conditions which affect an aircraft and its
  crew
• knowing what is going on around us!
• ? GROUP Situation Awareness

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CRM Situational awareness

• Loss of S.A.
• poor communications
• confusion, concern
• exceeding personal limitations
• fixation / boredom
• high workload
• unfamiliarity

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CRM Situational awareness

• internal - external factors
• internal individual
• external task environment
• direct - indirect influence to S.A.
• direct perception comprehension
• decision making actions
• Indirect procedures, rules

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CRM Situational awareness
factors influence internal external
direct perception comprehension stress workload automation system capability
indirect experience procedures doctrines rules
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CRM Situational awareness

• Factors contributing to the Tenerife HAP
• It seems clear that van Zanten was aware that
  the clearance hadn't been received when Meurs
  checked him and he replied "No, I know that. Go
  ahead and ask." It is likely that van Zanten was
  in a rush to get to Las Palmas because of the
  delay on the ground and his crew's lack of extra
  duty hours.
• A final consideration was the difficulty with
  English of the tower controller and the 4805
  crew. With the weather as bad as it was, relying
  solely on radio communications was already a
  dangerous practice, but the non-standard
  communications of both parties lead to the
  breakdown of situational awareness.

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CRM Situational awareness

• Factors contributing to the Tenerife HAP
• Although the captain had flown for many years on
  European and intercontinental routes, he had been
  an instructor for more than 10 years, which
  relatively diminished his familiarity with route
  flying. Moreover, on simulated flights, which are
  so customary in flying instruction, the training
  pilot normally assumes the role of controller -
  that is, he issues take-off clearances. In many
  cases no communications whatsoever are used in
  simulated flights, and for this reason take-off
  takes place without clearance.

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TENERIFE ACCIDENT, March 27, 1977

• Investigation RECOMMENDATIONS
• (communication related)
• Use of standard, concise and unequivocal
  aeronautical language.
• Avoidance of the word "TAKE-OFF" in the ATC
  clearance and adequate time separation between
  the ATC clearance and the TAKE-OFF clearance

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Conclusion / aim of CRM

• Aircraft crews
• highly structured, mechanised groups
• perform very well as far as tasks are predictable
  and routine
• crisis situations trained responses tend to
  break down
• Air transportation industry
• accidents attributable to human error
• 3/4 Comm

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Conclusion / aim of CRM

• CRM is not about being nice to each other, or
  taking votes in what should be done during
  emergencies.
• Make no mistake the captain is responsible,
  meaning he has to take the final decision. His
  authority is in no way eroded.
• The huge difference with the past is that the
  captain now has to make sure he has the right
  perception of what is going on and what should be
  done about it. And this is only possible if
  adequate open communication exists around him.
  Crew members also have a responsability to assume
  in the cockpit, by themselves being assertive,
  proactive and at all time constructive.

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References

• Subsecretaria de Aviation Civil
• FAA
• AirDisaster.com
• John McCreary, Michael Pollard, Kenneth Stevenson
  and, Marc B. Wilson, University of Maryland
  Eastern Shore, Princess Anne, MD
• CRM Instructor Manual, ASD (EBBE)

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Useful websites

• www.jaa.nl
• www.icao.int
• www.ntsb.gov
• www.flightsafety.org
• www.nasa.gov
• www.airdisaster.com
• www.airlinebiz.com
• www.aviation-safety.net
• www.airsafe.com
• www.planecrashinfo.com