Crew Resource Management as a
Knowledge Management Tool in the
Lisa West LIS 880 Fall 2012
What is CRM?
Crew Resource Management is the sharing of
knowledge and best practices to reduce errors and
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
Initiated by NASA in 1979
NASA discovered crashes due to lack of:
Poor decision making
Lack of leadership skills
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”
Evolution of CRM
1990s grows to include pilots, flight attendants,
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
Team building, team maintenance, considering and supporting
others, conflict resolution
Authority, standards maintenance, planning, coordination,
Awareness of systems, the environment, and time
Diagnosis of threat, problem resolution, risk assessment, result
Case study review
Line Oriented Flight Training (LOFT) role-playing
Line Operation Safety Audits (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
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
General aviation crashes in Australia due to loss of
situational awareness, a CRM skill
98% of flights face threats
Errors occur on 82% of flights
70% decrease in crashes since the inception of CRM
Keys to CRM success
Operational and cultural shift
An environment that facilitates communication
Not a one-time fix, but continuing component of a
Trust in organization
Self-disclosure of information
Keys to CRM success
LOSA observations resulting in changes to Standard
Operating Procedures (SOPs)
Sharing of information
Verbal cues among stakeholders
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
NTSB cockpit voice recorder transcript
CRM Learning History
Flight 232 taught United Airlines CRM transfer of knowledge
Was a benchmark of best practice in:
Understanding one’s limitations
No training standards
FAA and Civil Aviation Authority (CAA) support training
through assistance and recommendations
Difficult to transfer to other cultures
CRM as cost reduction
Cost of commercial aviation accident
Loss of employee productivity
Disruption in routes
Poor customer perception
Loss of reputation
CRM as life saver
CRM promotes teamwork
Discovers and reduces accidents and errors
Part of organizational learning
Creates benchmarks of best practices
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