Crew Resource Management


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Crew Resource Management as a Knowledge Management Tool

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Crew Resource Management

  1. 1. Crew Resource Management as a Knowledge Management Tool in the Airline Industry Lisa West LIS 880 Fall 2012
  2. 2. What is CRM?  Crew Resource Management is the sharing of knowledge and best practices to reduce errors and incidents.  Used by high reliability organizations (HROs):  aviation, military, fire services, oil production, nuclear operations, commercial shipping, medical field  CRM has been used by commercial airlines since 1981
  3. 3. History  Initiated by NASA in 1979  NASA discovered crashes due to lack of:  Interpersonal communication  Poor decision making  Lack of leadership skills
  4. 4. Evolution of CRM  United Airlines adopts CRM in 1981.  Used Blake and Mouton’s “Managerial Grid” concept: examine one’s managerial style  Training through lecture and non-jeopardy scenarios  1986 group dynamics emphasized: team building, decision making, situation awareness, stress management, “breaking the chain of errors”
  5. 5. Evolution of CRM  1990s grows to include pilots, flight attendants, dispatch, maintenance  Currently Federal Aviation Administration (FAA) Advanced Qualification Program (AQP) requires CRM to be incorporated into all aspects of training  Error management is a key component to CRM  Required by FAA and International Civil Aviation Organization (ICAO) for airlines in 185 countries
  6. 6. CRM Components  Communication  Leadership Skills  Decision-making  Situation Awareness  Monitoring  Crosschecking  Understanding one’s limitation
  7. 7. CRM Components  Social Skills  Cooperation  Team building, team maintenance, considering and supporting others, conflict resolution  Leadership/Management Skills  Authority, standards maintenance, planning, coordination, workload management  Cognitive Skills  Situation Awareness  Awareness of systems, the environment, and time  Decision Making  Diagnosis of threat, problem resolution, risk assessment, result analysis
  8. 8. CRM Training  Initial Training      Lectures Case study review Audio/visual material Practical exercise Line Oriented Flight Training (LOFT) role-playing  Annual re-training  Line Operation Safety Audits (LOSA)
  9. 9. LOSA  Real life data collection  Flight deck crew actions  Threats and errors  Threat and error management  CRM skills evaluated and recorded  Strict “non-jeopardy” conditions  Data used for training development
  10. 10. Statistics  Poor CRM major contributor in Greek fatal aviation accidents from1983 to 2003  60% of US Navy and Marine Corps. accidents from 1991 to 2000 involved CRM failure in cockpit.  Aviation Safety Reporting System (ASRS) reports 70% of incidents involved inadequate communication of information  General aviation crashes in Australia due to loss of situational awareness, a CRM skill
  11. 11. Statistics  98% of flights face threats  Errors occur on 82% of flights  70% decrease in crashes since the inception of CRM
  12. 12. Keys to CRM success  Operational and cultural shift  An environment that facilitates communication  Not a one-time fix, but continuing component of a safety culture  Trust in organization  Self-disclosure of information
  13. 13. Keys to CRM success  LOSA observations resulting in changes to Standard Operating Procedures (SOPs)  Sharing of information  Information management  Verbal cues among stakeholders
  14. 14. CRM Learning History  United Airlines flight 232  Sioux City, Iowa crash July 19, 1989  CRM cited by Captain Haynes and National Transportation Safety Board (NTSB) as major reason 185 of 296 people on board survived.  In 34 min. prior to crash, 31 pieces of communication per minute  NTSB cockpit voice recorder transcript
  15. 15. CRM Learning History  Flight 232 taught United Airlines CRM transfer of knowledge saves lives  Was a benchmark of best practice in:         Communication Leadership skills Decision-making Teamwork Situation awareness Monitoring Cross-checking Understanding one’s limitations
  16. 16. CRM Issues  No training standards  FAA and Civil Aviation Authority (CAA) support training through assistance and recommendations  Difficult to transfer to other cultures
  17. 17. CRM as cost reduction  Cost of commercial aviation accident       $100 million Lost revenue Loss of employee productivity Disruption in routes Poor customer perception Loss of reputation
  18. 18. CRM as life saver  CRM promotes teamwork  Discovers and reduces accidents and errors  Part of organizational learning  Creates benchmarks of best practices  Shares knowledge  Behavioral changes  SAVES LIVES!
  19. 19. Sources  Aircraft Accident Report-United Airlines Flight 232, McDonnell Douglas DC-10-10, Sioux Gateway Airport, Sioux City, Iowa, July 19, 1989. Rep. no. NTSB/AAR90/06. Washington, DC: NTSB, 1990. Christopher Elroy. Web. 19 Oct. 2012. <>.  Anonymous. "Communication And Knowledge--Keys To CRM." Flying Safety 63.7 (2007): 26. Academic Search Premier. Web. 07 Oct. 2012.  Beal, George M., and Joe M. Bohlen. The Diffusion Process. Rep. N.p.: Farm Foundation, 1957. Print.  Berber, Leon, Melanie Attan, and Chong Lee. "5-M Model Approach To Accident Investigation." Aviation Knowledge (2012): n. pag. Web. 07 Oct. 2012.  Boeing. "A History of Boeing Aviation Safety Improvements." Fact Sheet-The Boeing Company. Boeing, Dec. 2009. Web. 19 Oct. 2012. <>.  Brown, John Seely., and Paul Duguid. The Social Life of Information. Boston: Harvard Business School, 2000. Print.  Brown, Norman M., and Charles R. Moren. "Background Emotional Dynamics of Crew Resource Management: Shame Emotions and Coping Responses." THE INTERNATIONAL JOURNAL OF AVIATION PSYCHOLOGY 13.3 (2003): 269-86. Academic Search Premier. Web. 07 Oct. 2012.  Darby, Rick. "Indispensible CRM." Flight Safety Foundation, Sept. 2006. Web. 08 Oct. 2012. <>.  Duke, Tom, Cpt. "Training Aviation Safety Professionals." Air Line Pilot (2003): 34. ALPA. Air Line Pilot's Association, Jan. 2003. Web. 07 Oct. 2012. <>.
  20. 20. Sources  Guidelines for Line-Oriented Flight Training. Proc. of Proceedings of a NASA/Industry Workshop Held at NASA Ames Research Center, Moffett Field, CA. NASA. Proceedings of a NASA/Industry Workshop Held at NASA Ames Research Center. NASA. Web. 19 Oct. 2012. <>.  Harvard Business Review on Knowledge Management. Boston, MA: Harvard Business School, 1998. Print.  Haynes, Al, Cpt. "Haynes Talk at Dryden." Lecture. Cpt. Haynes Presentation. NASA Ames Research Center Dryden Flight Research Facility, Edwards, CA. University of Texas Homepage. University of Texas, 18 June 1993. Web. <>.  Helmreich, R. L., J. R. Klinect, and J. A. Wilhelm. "Models of Threat, Error, and CRM in Flight Operations." Proceedings of the Tenth International Symposium on Aviation Psychology. Proceedings of the Tenth International Symposium on Aviation Psychology, The Ohio State University, Columbus, OH. 1999. 677-82. Academic Search Premier. Web. 08 Sept. 2012.  Helmreich, Robert L., Ashleigh C. Merritt, and John A. Wilhelm. "The Evolution of Crew Resource Management Training in Commercial Aviation." The International Journal of Aviation Psychology 9.1 (1999): 19-32. University of Texas Homepage. University of Texas. Web. 19 Oct. 2012. <>.  Keonig, Michael E. D. "What Is KM? Knowledge Management Explained." KMWorld Magazine. Information Today, Inc., 04 May 2012. Web. 19 Oct. 2012. <>.  Lenne, Michael G., Karen Ashby, and Michael Fitzharris. "Analysis of General Aviation Crashes in Australia Using the Human Factors Analysis and Classification System." THE INTERNATIONAL JOURNAL OF AVIATION PSYCHOLOGY 18.4 (2008): 340-52. National Interagency Fire Center (NIFC). National Interagency Fire Center (NIFC). Web. 07 Oct. 2012. <>.  "Making Air Travel Safer Through Crew Resource Management (CRM)." American Psychological Association (2004): n. pag. Making Air Travel Safer Through Crew Resource Management (CRM). American Psychological Association, 06 Feb. 2004. Web. 19 Oct. 2012. <>.
  21. 21. Sources  Mckinney, E. H. "How Swift Starting Action Teams Get off the Ground: What United Flight 232 and Airline Flight Crews Can Tell Us About Team Communication." Management Communication Quarterly 19.2 (2005): 198-237. Carnegie Mellon. Web. 19 Oct. 2012.  Meintel, Julie, TSgt. "Crew Resource Management." The Journal of Air Mobility Command (2004): n. pag. Academic Search Premier. Web. 07 Oct. 2012.  Merritt, Ashleigh, Ph.D., and James Klinect, Ph.D. Defensive Flying for Pilots: An Introduction to Threat and Error Management. The University of Texas Human Factors Research Project. Flight Safety Foundation, 12 Dec. 2006. Web. 08 Oct. 2012. <>.  Nelson, Craig. "Using Crew Resource Management to Reduce Accidents." Fire Engineering., 01 Mar. 2012. Web. 07 Oct. 2012. <>.  O'Connor, Paul, Hans-Jurgen Hormann, Rhona Flin, Mike Lodge, and Klaus-Martin Goeters. "Developing a Method for Evaluating Crew Resource Management Skills: A European Perspective." THE INTERNATIONAL JOURNAL OF AVIATION PSYCHOLOGY 12.3 (2002): 263-85. Academic Search Premier. Web. 07 Oct. 2012.  O'Connor, Paul, Justin Campbell, Jennifer Newon, John Melton, Eduardo Salas, and Katherine Wilson. "Crew Resource Management Training Effectiveness: A Meta-Analysis and Some Critical Needs." International Journal of Aviation Psychology 18.4 (2008): 353-68. Academic Search Premier. Web. 07 Oct. 2012.  Salas, Eduardo, C. Shawn Burke, Clint A. Bowers, and Katherine A. Wilson. "Team Training in the Skies: Does Crew Resource Management (CRM) Training Work?" Human Factors: The Journal of the Human Factors and Ergonomics Society 43.4 (2001): 641-74. Todd Hubbard Courses. Oklahoma State University. Web. 22 Oct. 2012. <>.  Salas, Eduardo, Katherine A. Wilson, C. Shawn Burke, and Dennis C. Wightman. "Does Crew Resource Management Training Work? An Update, an Extension, and Some Critical Needs." Human Factors 48.2 (2006): 392-412. Academic Search Premier. Web. 07 Oct. 2012.  Weick, Karl E., and Kathleen M. Sutcliffe. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco: John Wiley & Sons, 2007. Print.