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1. Realização
TEAM RESOURCE MANAGEMENT
Carlos Xavier
13 de julho de 2017

2. Cause of the crash investigated by
The National Transportation
Safety Board (NTSB):
The final NTSB report cited the
cause of the crash as pilot error,
specifically: "the failure of the
flight crew to monitor the flight
instruments during the final four
minutes of flight, and to detect an
unexpected descent soon enough
to prevent impact with the ground.
Preoccupation with a malfunction
of the nose landing gear position
indicating system distracted the
crew's attention from the
instruments and allowed the
descent to go unnoticed."

3. Consequence:
In response to the accident, many
airlines started Cockpit Resource
Management (CRM) training for
their pilots. The training was
designed to make problem solving
in a cockpit much more efficient,
thus causing less distraction for
the crew.

4. What is CRM?
Cockpit Resource Management
is the sharing of knowledge and
best practices to reduce errors
and accidents/incidents.

5. CRM
 Initiated by NASA in 1979;
 NASA discovered crashes due to lack of:
1. Interpersonal communication;
2. Poor decision making;
3. Lack of leadership skills.

6. CRM
 CRM has been used by commercial airlines since 1981;
 1990s grew to include pilots, flight attendants, flight dispatch,
maintenance (Crew Resource Management);
 Currently Federal Aviation Administration (FAA) Advanced
Qualification Program (AQP) requires CRM to be incorporated into all
aspects of training;
 Required by International Civil Aviation Organization (ICAO) for
airlines in 185 countries;
 Used by high reliability organizations: aviation, military, fire services,
oil production, nuclear operations, commercial shipping, medical field,
etc.

7. Team Resource Management
(trm)
 Has its origin in Cockpit Resource Management;
 It did not take long for ATM professionals to realize that ATM
and Aviation shared common concerns: poor
communication, team performance and inadequate behavior
do not only occur in aircraft, but in ATM facilities too, and in
both situations accidents/incidents can be the tragic result;
 The development of TRM in the 1990s was a first logical
step towards improving teamwork and reducing team related
errors.

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