Crew Resource Management (CRM) originated from a need to reduce pilot error and improve decision making. Four out of five aircraft crashes are caused by human error resulting from a chain of poor decisions. CRM aims to break this chain through better communication, situational awareness, and resource management among flight crews. The 1982 crash of Air Florida Flight 90 that killed 74 people demonstrated how breakdowns in CRM, including decisions made regarding de-icing and use of engine power, can lead to disaster.

1. Crew Resource Management CRM Done out of a need to avoid pilot or crew error Done to break the chain of poor decisions Aeronautical Decision Making (ADM) FAA Document ac60-22.pdf Four out of five crashes due to pilot error have a root cause that starts well before the aircraft is airborne Errors of omission, errors of commission

2. CRM Origin As Aviation Progressed, Hardware Became More Reliable Environment Became More Demanding Higher Demands Required Better Decision Making By Pilots The Human Factor Became The Weak Link

3. Air Florida Flight 90 January 13, 1982, Washington DC Boeing 737-200 crashed immediately after take-off en route to Florida Aircraft failed to develop T/O power Struck 14 th street bridge and 7 occupied vehicles on it Killed 4 people on bridge and 73 in aircraft Aircraft submerged in freezing cold Potomac river What was the chain of events that lead to the crash?

4. Air Florida Flight 90 January 13, 1982 was a bitter winter's day at Washington's National Airport with temperatures reaching only minus five degrees Celsius by the afternoon. Cloud ceilings were 400ft with visibility limited to just over half a mile in snow showers. Among the many aircraft scheduled to depart National that day was Air Florida's 737 service to Ft. Lauderdale, call sign Palm 90. Piloting that day's 2:15pm flight was Captain Larry Wheaton and First Officer Roger Pettit, both fairly young pilots enjoying their new jobs with Air Florida, a fairly new airline which expanded rapidly as the result of deregulation. ......Just before 1:40pm, the airport was closed so crews could plow National's one instrument runway, scheduled to re-open at 2:30pm. Air Florida elected to begin boarding regardless and by 2:30pm, all of the 74 passengers were on board the aircraft. Meanwhile, Wheaton had asked for Palm 90 to be de-iced in preparation for departure. The tower told the aircraft that there would be a further delay and that Palm 90 was number eleven in priority when the airport did re-open. Wheaton then instructed the de-icing to be discontinued Half an hour later, Wheaton again called for de-icing as the airport was about to re-open. By 3:10pm , de-icing was complete and ground personnel reported to Wheaton that there was only a "light dusting" or snow on the wings. Snow was still falling at National at the time. At 3:23pm , Palm 90 was cleared to push from the gate. The tug tried to push the 737, but snow that had accumulated on the ground caused it's tires to spin. Wheaton then suggested that, contrary to policy , they would use the aircraft's reverse thrust to assist in the push. http://pw2.netcom.com/~asapilot/

5. Air Florida Flight 90 The reversers were engaged for about a minute and a half, but were only successful in throwing up slush and snow. Another tug was brought in with chains and the aircraft was successfully pushed back. ......Palm 90 then taxied into position behind a New York Air DC-9 which was the last of sixteen aircraft in line for takeoff. Fifteen minutes later the New York Air aircraft was cleared for takeoff and Palm 90 was instructed to taxi into position and hold, being prepared for immediate takeoff. At 3:59pm , Palm 90 was cleared for takeoff as it was still positioning itself on the runway, visibility now down to a quarter mile. ......The departure from runway 36 requires aircraft to make a left 40 degree turn shortly after becoming airborne so as to follow the Potomac River and avoid flying over the Washington monument and the White House. The tower lost sight of Palm 90 during it's roll due to the reduced visibility, but radar showed it airborne and the tower controller instructed Palm 90 to contact the departure controller. Less than a minute after taking off, Palm 90 descended at low airspeed into the Rochambeau bridge and plowed through into the Potomac river, only it's tail not submerged. Rescue crews attempted to reach the survivors, but icy conditions prevented the passengers from being reached except by helicopter. In the end, only six people survived. http://pw2.netcom.com/~asapilot/

7. Air Florida Flight 90 ......Crews were able to recover both the FDR and CVR from the bottom of the river and both devices proved critical in solving the puzzle of Palm 90. Knowing that it had been nearly 50 minutes between the aircraft's de-icing and takeoff, investigators were curious as to what had gone on in the aircraft in that span. Their first clue came when, during the after engine start checklist, the captain replied "off" to the First Officer's call for anti-ice. Though it seems hard to believe that the captain would reply "off" to anti-ice, extensive audio enhancement has given validity to the tape. While waiting in line for takeoff, Wheaton positioned the aircraft behind the New York Air DC-9, attempting to use the aircraft's exhaust to melt the ice off Palm 90's fuselage and wings. Though Wheaton thought this a sound practice, in reality the exhaust will just melt the ice and blow it back over the wing, allowing it to re-freeze farther back in areas which the aircraft's anti-ice system can not clear. While this information gave evidence of airframe icing, further analysis showed other problems with Palm 90. Shortly before takeoff, the crew have a brief discussion concerning anomalies in the engine instrument readings. Pettit suggested that the hot (less dense) exhaust from the DC-9 ahead was causing a lower than normal reading on one of the EPR gauges. The indications seemed to return to near normal as Palm 90 got closer to takeoff. Just before takeoff, Pettit began the brief, calling out takeoff power as EPR 2.04, V1 as 138kts, Vr as 140kts, and V2 as 144kts. http://pw2.netcom.com/~asapilot/

8. Air Florida Flight 90 As Palm 90 was cleared for takeoff, Pettit advanced the throttle and immediately remarked at the abnormal indications from the EPR gauges again. Pettit remarked several time that it was "real cold", indicating that the engines indicated the takeoff EPR of 2.04 quickly before the throttles were fully advanced. Specturm analysis of the engine sounds from the CVR indicated that the engines were actually running at an approximate EPR of 1.70 throughout the takeoff. In studying the engines for signs of the anomaly, investigators found that the engine de-ice system was turned off . In re-creating the conditions, investigators confirmed that ice on the compressor inlet pressure probe would cause a higher than actual thrust reading on the EPR gauges. First Officer Pettit seemed to be aware of the anomaly during takeoff, but did not appear to have any idea what was causing it. Pettit remarked several times that "that doesn't seem right", meaning that the low throttle setting was producing a high EPR reading while the aircraft was not accelerating properly. Still, 45 seconds into the takeoff roll, Palm 90 reached it's rotation speed and pitched up abruptly, causing Captain Wheaton to exclaim "Easy!" and then, as the stall warning came on, "Forward! Forward!", indicating to Pettit to lower the nose to prevent the stall. Investigators found that ice build up in the wing leading edge and slats could cause an abrupt nose up pitch on takeoff. Pettit apparently believed that the engines were producing max thrust because at no time during the 30 second flight were the throttles advanced to provide more power to prevent stall. The recording ended with the crew's final acknowledgement of the severity of their situation. "Larry-we're going down Larry!". "I know it!". http://pw2.netcom.com/~asapilot/

9. Air Florida Flight 90 CAM-1 Captain's Cockpit Area Microphone CAM-2 First Officer's Cockpit Area Microphone RDO-1 Captain's Radio TWR Washington National Tower 15:59:16 CAM-1 Given. 15:59:16 CAM-2 Bleeds? 15:59:17 CAM-1 They're off. 15:59:18 CAM-2 Strobes, external lights. 15:59:18 CAM-1 On. 15:59:19 CAM-2 Anti-skid? 15:59:19 CAM-1 On. 15:59:21 CAM-2 Transponder? 15:59:21 CAM-1 On. 15:59:24 TWR Palm 90 cleared for takeoff. 15:59:28 TWR No delay on departure if you will, traffic's two and a half out for the runway. 15:59:32 CAM-1 Okay, your throttles. 15:59:35 [SOUND OF ENGINE SPOOLUP] 15:59:49 CAM-1 Holler if you need the wipers. 15:59:51 CAM-1 It's spooled. Real cold, real cold. 15:59:58 CAM-2 God, look at that thing. That don't seem right, does it? Uh, that's not right. 16:00:09 CAM-1 Yes it is, there's eighty. 16:00:10 CAM-2 Naw , I don't think that's right. Ah, maybe it is. 16:00:21 CAM-1 Hundred and twenty. 16:00:23 CAM-2 I don't know 16:00:31 CAM-1 Vee -one. Easy, vee -two. 16:00:39 [SOUND OF STICKSHAKER STARTS AND CONTINUES UNTIL IMPACT] 16:00:41 TWR Palm 90 contact departure control. 16:00:45 CAM-1 Forward, forward, easy. We only want five hundred. 16:00:48 CAM-1 Come on forward....forward, just barely climb. 16:00:59 CAM-1 Stalling, we're falling! 16:01:00 CAM-2 Larry, we're going down, Larry.... 16:01:01 CAM-1 I know it. 16:01:01 [SOUND OF IMPACT] http://pw2.netcom.com/~asapilot/

10. Crew Resource Management Issues on Flight 90 Decision on de-icing Pressure to get mission accomplished Non SOP use of TR Using DC-9 for De-Icing Incorrect EPR reading No cross check with fuel flow OK to overboost engines for one minute Captain not heeding signals from FO

11. What is CRM? Situational Awareness Judgment Expect Unexpected Attitude (Professional) Knowledge Lack of Situational Awareness Complacency Poor Mindset Lack of Knowledge Bad Attitude Fatigue CRM is a Tool for Error & Risk Management YES NO Source: CAP CRM

12. CRM Skills Manage (use) resources Ask the right questions - Inquiry State your opinion - Advocacy Resolve differences - Conflict Resolution Make Decisions Evaluate Constructively - Critique Source: CAP CRM

13. Defining CRM Effective use of all available resources Broad resource categories People Machinery Fuel/time Information CRM is not limited to multi-pilot crews Source: CAP CRM

14. Situation Awareness Knowledge of all pertinent aspects of your surroundings as it applies to the safe accomplishment of a task. Elements of Situational Awareness Weather, Aircraft Condition and Capabilities Mission Goals or Objectives Airspace, Terrain, Traffic Crew Tasking Perception Versus Reality View of Situation Incoming information Expectations & Biases Incoming Information versus Expectations Factors That Reduce Situational Awareness Insufficient Communication Fatigue / Stress Task Overload Task Underload Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions Levels of SA Level 1: The ability to Perceive and recall from memory Level 2: The ability to comprehend The ability to project future outcomes

15. Workload Affects SA Humans are essentially single channel information processors Searchlight metaphor focus of attention Resource metaphor divisibility of attention supply and demand of attentional resources single resource theory vs. multiple resource theory

16. Attentional Resources

17. SART (10D)

18. Mental Workload Measurement Criteria for a good workload metric Sensitive Selective Method should not consider extraneous load Interference free Reliable Acceptable

19. Mental Workload Measurement Workload Metric Categories Primary task measures Secondary task measures Physiological measures Subjective Measures

20. Mental Workload Measurement Primary task measures Measure performance with which a task can be performed W/INDEX program Problem As long as resources are available two tasks may yield the same performance but be different in their workload Task specific

21. Mental Workload Measurement Subjective Measures Modified Cooper Harper Scale Subjective Workload Assessment Technique (SWAT) NASA-TLX (Task Load Index)

22. Original Cooper Harper Scale on Aircraft Controllability

23. NASA Task Loading Index Technique Multi-dimensional subjective rating procedure provides overall workload score based on the sum of the weighted values of six sub-scales: Demands imposed by task Mental demand Physical demands Temporal demands Subject-Task Interaction Own performance Effort Frustration. Subscale ranges from 0 to 100, scored in steps of 5 points Marking a line Workload of a particular task is expressed by the weighting applied to each subscale Pair-wise comparisons of the six subscales The weights can range from 0 (all other subscales are more important) to 5 (no other subscale is more important).

24. TLX In-Flight Debrief Card

25. TLX can be used to project workload based on task analysis Normal use of TLX is on operational system or prototype Rater must be familiar with task Rater must have very detailed knowledge of scale Requires a lot of training and calibration time Advantages easy to use more sensitive than many other subjective methods such as SWAT and Cooper-Harper use of six subscales is important to reduce inter rater variability Disadvantages Time intensive Disruptive NASA Task Loading Index Technique

26. Evaluating Risk in the Flight Environment The Plane- Type, Equipment, Etc. The Pilot- FAA I’M SAFE Model Illness, Medication, Stress, Alcohol, Fatigue, Experience The Environment- IFR,VFR, Mountains, The Situation- Day, Night, AC Maint, Etc.. Source: CAP CRM

27. High Risk Situations Taking Off with Known Problem Midair Collision- High Density Area Inadequate Terrain Separation- CFIT Unstabilized Approach Deviation From SOP Weather COMPLACENCY Source: CAP CRM

28. Communication Factors Bias / Prejudice Relationship Choice of words Perceptions Preoccupation Intimidation Body Language Habits Motivation Attitude Education Background Assumptions Fear Mind Sets Ego Voice Tone Inflection Clarity Source: CAP CRM

29. Communication Modes of communication Verbal (7%) Non-Verbal (38%) Symbolic (55%) Communication Process (Four elements) Sender Message Receiver Feedback Source: CAP CRM

30. How to Communicate Questions to Consider “ What do they know that I need to know?” “ What do I know that they need to know?” “ What do none of us know that we need to know?” State Position Suggest Solution Be Persistent Timely Listen Carefully Keep an Open Mind Use a Predetermined “Key Phrase” To Express Non-Confrontational Discomfort With Any Situation Source: CAP CRM

31. Pilot Personalities The MACHO Pilot The Impulsive Pilot The Invulnerable Pilot The “Antiauthority” Pilot The Resigned Pilot Source: CAP CRM

32. Attitude Vs Antidote Source: CAP CRM

33. Behavioral Styles Aggressive High task oriented & low relationship oriented First consideration to the task or goal Relationship Oriented First consideration to the feeling of others Caring or nurturing style of behavior Combinations Low relationship & low task oriented traits Considered to be loners or autonomous in behavior Source: CAP CRM

34. In the Cockpit As a crew member, you have the right to assure that your life will not be compromised by any action/inaction, miscommunication, or misunderstanding. Assertive behavior in the cockpit does not challenge authority; it clarifies position, understanding or intent, and as a result enhances the safe operation of the flight. Source: CAP CRM

35. Human Problem Solving Humans Solve Problems Three Different Ways Skills-based actions accomplished will little effort dependant on mastery of basic skills Rules-based actions well prescribed procedures crew reaction to an emergency situation Knowledge-based actions ambiguous situation no clearly proscribed procedures offers a variety of options Source: CAP CRM

36. Decision Making Begins with Good Situational Awareness Evaluate Situation What needs to be corrected? What resources do you have? How can the resources be best used? Consider consequences of possible actions Make decision, inform all involved Evaluate decision, repeat as needed You make the wrong decision once, you make the right decision forever Source: CAP CRM

37. Operational Pitfalls to Sound Decision Making