Crew Resource Management Review (ISBN: 978-0-12-374946-8)

[Ref Crew Resource Management (ISBN: 978-0-12-374946-8)]

PART 1 The Nature of CRM

Chapter 1 Why CRM? Empirical and Theoretical Bases of Human Factors Training

Crew Resource Management (CRM) is one of the most striking developments in aviation safety over the past 10 years or so. It also has evolved from “cockpit” to “crew”. Rightly, it has become a multidisciplinary field that draws on the methods and principles of the behavioral and social sciences, engineering, and physiology to optimize human performance and reduce human error.

CRM is “using all available resources – information, equipment, and people – to achieve safe and efficient flight operations.”
– defined by John K. Lauber (1984), a psychologist member of the NTSB.


1.2 The Single-Pilot tradition in Aviation

In the early years, pilot was working on their own, but aircraft somehow grew more complex and the limitations and fallibility of pilots more evident. Therefore, co-pilot is needed to provide support for the pilot, to reduce individual workload and decrease the probability of human error. Actually, co-pilot help in communication with an air traffic control – they are not just look out the window.

1.3 Human Error in Flight Operations

Meanwhile, referring to statistics between 1959 and 1989, we realize that flightcrew actions were casual in more than 70% of worldwide accidents involving aircraft damage.

A study shown that “pilot error” was more likely to reflect failures in team communication and coordination than deficiencies in “stick-and-rudder” proficiency.


Elwyn Edwards (1972) developed his SHEL model of human factors (HF) in system design and operations. The acronym represents :

Software – usually documents governing operations

Hardware – physical resources available

Environment – external context in which the system operates

Liveware – consisting of the human operators composing the crew


Later, Edwards (1975) defined a new concept, the trans-cockpit authority gradient (TAG). The TAG refers to the fact that:

Captains must establish an optimal working relationship with other crewmembers, with the captain’s role and authority neither over- nor underemphasized.


In short, development of successful strategies to improve crew performance requires and understanding of the determinants of group behavior and how they can be influenced.


1.4 Group processed and Performance in Aviation Environment

Foushee & Helmreich, 1988; McGrath, 1964 did some research that helping us to create “flight crew performance model”, which consists of three (3) major components of group behavior:

  1. input factors
    • include characteristics of individuals, groups, organizations (culture, crew scheduling practices), regulations, and the operational environment
    • 中文簡單黎講就係”本質”
  2. group process factors
    • include the nature and quality of interactions among group members
    • 即係大家合作的”化學作用”
  3. outcome factors
    • include primary outcomes such as safety and efficiency of operations and secondary outcomes such as member satisfaction, motivation, attitudes, and so on.
    • 即係結果

Interestingly, we should notice few facts:

  • The above three factors are interrelated and the whole model is feedback loops.
  • Input factors are certainly related to the outcome factors
  • Experience and training can create changes in crew attitudes and norms. (outcome factors)

Group process factors are the linkage between input- and outcome- factors. And the group process factors can be treated as “Integrated CRM and Technical Functions”  (“Integrated CRM and Technical Functions” = Group process factors). Breaking the subordinate categories down further, “interpersonal/cognitive functions”  can be classified into three broad clusters of observable behaviors: “team formation and management tasks”, “communications processes and decision tasks”, and “workload management and situation awareness tasks”; The “machine interface tasks” fall into two clusters, the actual control of the aircraft (aircraft control tasks) and adherence to established procedures for the conduct of flight (Procedural tasks).

Here is few important points about using “inquiry”, “advocacy”, and “assertion” in communication processes:

  • “inquiry” – request clarification when we are unclear about the current operational situation or planned actions
  • “advocacy” – express your concern strongly and to advocate an alternative action strategy
  • “assertion” – be assertive! Effective conflict resolution is focused on what is right rather than who is right.

In terms of decision tasks, crew should:

  • have the “self-critique mentality”
  • review the decisions and actions with the goal of optimizing future team activities

Move to situation awareness, workload management tasks:

Situation awareness is affected by various factors – preparation/planning/vigilance, workload distribution, and distraction avoidance.

Preparation, planning, and vigilance behaviors reflect the extent to which crews anticipate contingencies and actions that may be require. Excellent crews are always ahead of the curve!

In short, “interpersonal/cognitive functions” is referring interpersonal relationships (leadership, followership) and task concern.

CRM is important, somehow in most of the training programs, they are talking about “new knowledge” and “change or reinforce attitudes” to achieve certain improvements in group process and have better crew performance ultimately.


Chapter 2 Teamwork and Organizational Factors

There is a newest version of CRM – threat and error management (TEM). This includes the concept that even the finest of crews can make errors, and when they occur they are able to trap and correct those errors, and should be subsequently rewarded for their actions.

At the bottom level of  threat and error management (TEM) model, together resistance and resolution (via “resist” and “resolve”) filter out errors that may inevitably occur and prevent negative consequences – “managing our past”. “Resist” refers to aviation safety systems in the cockpit while “Resolve” is what the human brings to aviation safety, such as proficiency, experience, effective monitoring and communicating, and so on.

At the top level of TEM model, “Strategy” may be thought of as “managing our future” by recognizing threats and creating error-blocking strategies in advance. If a threat goes unrecognized or an error occurs, we have to rely on resistance and resolution to mitigate negative consequences. However, it is not an effective way in generating good outcomes.

Once an individual has been successfully qualified in a crew position the emphasis should then become how well he or she can predict or prevent errors through threat analysis, detect the inevitable errors made by the crew and correct those errors before negative consequences occur.

The “true” definition of  “teamwork” or “CRM” is its focus on the proper response to threats to safety and the proper management of crew error.

–  by Frank J. Tullo

2.2 Teamwork redefined

Actually, there is another member of the team onboard a modern flight: the fitted equipment designed to reduce workload and increase safety in coordination with the flight crew. These automation is literally a silent member of the team that will dutifully do any task it has been asked to do, whether it makes sense or not.

What’s and how to perform good CRM?

  • Captain should create an atmosphere where crewmembers feel comfortable to speak up and state opinions, ask questions and challenge if necessary;
  • Crewmembers should be charged with speaking up regardless of the atmosphere created by the captain;
  • Good CRM also is about recognizing and identifying threats, preventing errors if possible, catching those that will inevitably take place and to the extent possible, through resistance and resolution, mitigating the consequences of those that have occurred

In the 21st century aviation industry, it has now come to prefer the term Pilot Monitoring (PM) rather than Pilot Not Flying (PNF) to indicate the crewmember not primarily manipulating the controls. The reason is simply: the PM is actually an active participant in crew operations and is certainly as responsible for the safe condict pf the flight as is the Pilot Flying (PF).

Here, I share the same opinion with Frank that –

There is no argument that the captain is the team leader and will make the final decision but there will be times when he or she will be, and should be, in a follower role. That being said, I can find no difference in the attributes or traits of a good leader or a good follower – they are the same!


2.3 Traits of a “good team” in cockpit

So, let’s take a look at the desired traits of a good team, no matter you’re a leader/follower.

  1. Proficiency
    • It must include the commitment to comply with Standard Operating Procedures (SOPs)
    • Important: every time a deviation from SOPs is successful, it reinforces the act of getting away with it – this can lead to the “normalization of deviation” where the crewmember doesn’t even recognize it as a deviation because it has been done so often and sometimes by so many
  2. Effective communications
    • the communications are not confined in team members, but also the interaction with others outside and the automation
    • the communications can take many forms, both verbal and non-verbal
    • Briefings are needed to exchange information as well as clarify the task responsibilities
    • Debriefings are also necessary to emphasize “what went wrong” (but not “who was wrong”), it is important for us to think how do we prevent it from happening it again
  3. Effective monitoring
    • to detect any threat or error that can lead to negative consequences
    • if a threat or error is detected, we should become assertive
  4. Modeling
    • Setting a good example may not really make influence to others, but a bad example is enough to do immeasurable damage to others – Don’t ever deviate from SOPs or try to normalize the deviation
  5. Envisioning – “stay ahead of the aircraft”
    • another similar sayings heard in aviation circles is “never take your aircraft to any place your mind hasn’t been five minutes earlier.”
    • it is referring the situation awareness (SA)
  6. Adaptable
    • always prepare the adjustment to changes
  7. Demonstrating receptiveness
    • listening to suggestions
    • adopting the suggestion when appropriate
    • always using logic and tact to influence others
    • However, the captain is the final authority and will make the final decision!
      (The cockpit is not a democracy!)


2.4 Error

Although we may have all traits of a “good team”, errors are an inevitable part of flying. In fact, we will never be able to eliminate all errors. What’s more is that we are living in a blame society – when a negative event occurs, people always hunt for the individual villain immediately.

Rightly, the performance of a team should not be based on error-free operation but instead the emphasis should be on threat recognition, detecting errors and managing, to the extent possible, the consequences of errors.

When crewmembers detect and resolve an error quickly, for all practical purposes, the error did not occur.

More is known about a crew that makes an error and manages it than is known about the crew that doesn’t make the error.


Chapter 3 Crews as Groups: Their Formation and their Leadership

3.2 Crews, Groups, Teams

Groups fly crew-served airplanes, for a number of reasons. “As a direct result of the limitations and imperfections of individual humans, multi-piloted aircraft cockpits were designed to ensure needed redundancy” (Foushee, 1984).

“You have to remember, there’s no ‘I’ in team” – by Al McGuire.

A team can overcome individual inadequacies, deficiencies and errors. In general, group’s performances will exceed the performance of any individual in any group. Please help youself to remember: A crew is actually a group!

Notes: What’s a “team”? Ref 8.7.1 below~

3.2.2 – 3.2.6 Roles, Norms, Status and Authority

A role is a set of expected behaviors associated with a particular position (not person) in a group or a team.

Airline crews have clearly defined roles for the most part. To the extent roles are clear and independent, the group will tend to function well. However, there can be role problems which will cause stress for the individuals involved and typically decreased performance from the group.

It is not unusual when the individual is getting contradictory messages or expectations about his or her behavior, he or she is experiencing role conflict. An example is : “I want you to do a high-quality, detailed job and I need it in a minute”. In other case, people may experience role ambiguity if the role is either lacking or not clearly communicated.

Norms are infrequently written down or openly discussed, they often have a powerful, and consistent, influence on group member’s behavior – by Hackman, 1976

Norms are the informal rules and they not written down, but most of us are rather good at reading the social cues that inform us of those existing norms. However, having to say that, norms are not official rules and please accept it carefully – don’t normalize the deviation!

Status is the relative ranking of individuals within a group setting, and status usually comes with the position; Authority is the right to use power and influence – the legitimate power given by the organization.

Here, I would like to emphasize that we should be charged with speaking up and challenge “authority” if necessary. In an investigation conducted by Harper et al. (1971) at a major air carrier, captains feigned incapacitation at a predetermined point during final approach in simulator trials characterized by poor weather and visibility. In that study, approximately 25% of these simulated flights “hit the ground” because, “for some reason”, the first officers did not take control even when they knew the plane was well below glide slope.

Now, let’s take a look in the features of a captain in highly effective teams (HI-E captains):

  • HI-E captains ALWAYS use “we” to talk about the total flight crew
  • Establishing effective leader/team authority relationship by 3 ways:
    1. Establish competence
      • always contained elements of technical language specific to the vocation of flying
    2. Disavow perfection
      • balanced the leader/crew relationship by having the crewmembers take responsibility for the work of the group as well
      • also make a statement suggesting they don’t know something about a particular issue even though the information is often quite readily available
      • “I just want you guys to understand that we assign the seats in this plane based on seniority, not on the basis of competence. So anything you can see or do what will help out, I’d sure appreciate hearing about it.”
    3. Engage the crew
      • do not present a “canned briefing”
      • do the briefing with humor but it is not humor to isolate (canned jokes)
      • allow and encourage conversation by the other crewmembers, particularly if it is related to the task
      • ALWAYS ask if there are any questions
      • even solicit comments about any behaviors on other crews or with the other captains that might be troublesome

Surprisingly, “safety” is not mentioned much at all by the HI-E captains, how come?

This could be explained by using “path/goal theory” as described by House and Mitchell (1974).

In fact, when a captain spends time discussing obvious tasks, the crew begins to develop a very different picture of how life will be with him or her as their leader.

Crewmembers are highly qualified in the task requirements of a role that is designed to enable the group to work. It would be extremely redundant for the leader to further discuss “safety” with them.


Chapter 4 Communication and Crew Resource Management

4.4 Functions of Communication

Communication is a tool for achieving CRM objectives:

  1. Conveys information
  2. Establishes interpersonal/team relationships
  3. Establishes predictable behavior and expectations
    (SOPs and best practices)
  4. Maintains attention to task and situational awareness
  5. Is a management tool


Chapter 5 Flight Crew Decision-Making

Maintaining safe flight operations depends on assuring effective crew decision-making, especially under threatening conditions (Helmreich et al., 2001).

The decision-maker’s knowledge, often acquired through many years of training and experience, plays a key role in the decision process. Knowledge is the basis for recognizing situations that require decisions to be made, assessing the type and the degree of threat present, determining what information is relevant to the decision, and deciding on an appropriate course of action.

5.1.3 Aviation Decision Process Model

The aviation decision-making model, which described in Orasanu (1933), involves two major components: situation assessment (SA) and choosing a course of action (CoA).

Situation assessment (SA) involves three elements:

    1. defining (ident) the problem
    2. assessing the level of risk associated with the problem – risk assessment
    3. determining the amount of time available for solving it
      (Unfortunately, external time pressures may add on crews and action may be taken without thorough understanding of the problem)

Risk assessment includes two components:

  1. the likelihood of a threat
  2. the severity of its potential consequences


Choosing a course of action (CoA)

After the problem is defined and the conditions are assessed, a course of action is chosen.  And there are three common types of situation:

  1. Single rule-based choice – prescribed in SOPs or Manuals
  2. Multiple rule-based choice
  3. No option is readily available – Procedural management/ Creative problem-solving


5.1.4 Situational Constraints and Affordances (直觀功能、預設用途) in Choosing a Course of Action

Actually, when ill-defined problems happen, as no option is readily available, the decision-making process will become more difficult. Two strategies may be used to cope with this type of situation:

  1. Procedural management
    • in some situations, certain cues are ominous – signal potentially dangerous conditions, but leave the crew without a clear idea of the underlying problem
    • we should continuous the SA steps and somehow make a recognition-primed decision
  2. Creative problem-solving
    • in some cases, neither aircraft designers nor operations personnel imagined such a situation would arise, so no procedures were designed to cope with them
    • we may need to use “causal reasoning”, which is reasoning backward from effects to cause, as well as hypothesis generation and testing

However, we should understand a key concept: No single decision method will work for all types of situations!

Next, we need to learn the concept of “decision error” and put it into considered. People tend to have hindsight bias – we tend to define errors by the consequences. Unfortunately, we did not know if those prior decisions are errors. How can decision processes go wrong?

Recall above content: aviation decision-making model includes various steps –

  1. Ident the problem
  2. risk assessment (likelihood of a threat, and severity of consequences) under time pressure
  3. choosing a course of action

What if any step in decision-making model goes wrong, the outcome may be bad because of decision error!

Therefore, in general, there are three common types of decision error:

  1. develop an incorrect interpretation of the situation
    (lead to an inappropriate decision)
  2. perform inappropriate risk assessment
    (lead to an inappropriate decision)
  3. choose an inappropriate course of action


5.3 Behaviors that characterize effective crew decision-making

5.3.1 Taskwork skills

Situation Awareness, again!

  • good preparation/planning
  • be vigilance – monitoring progress of the flight according to the operative plan
  • be adaptive – building contingency plans to cope with uncertain situations
  • workload distribution – reassigning tasks to manage workload and revising task priorities
  • be reflective – check the assumptions and take corrective actions

5.3.2 Teamwork skills

Junior crewmembers are more likely to be effective in trapping errors made by the captain by using communication strategies: clearly describing the nature of the problem, offering a suggestion for solving it while leaving the decision up to the captain – by Fischer et al., 2000

  • crew climate – encourage openness and participation
  • error trapping – be able to disrupt the error chain by calling out the error and correcting it
  • threat defining – proactively identify threats before they become errors
  • compensatory strategies – monitor each other and back up each other



Chapter 6 CRM (Non-Technical) Skills – Applications for and Beyond the Flight Deck

6.1 Pilots’ Non-Technical Skills (NTS)

The term non-technical skills (NTS) is used to describe what they sometimes refer to as “soft” skills.

6.6 Systems Analysts: Non-Technical Skills (NTS) for Critical Incident Management (CIM)

Even in global commercial organizations, they develop their prototype CIM. Below table shows four main categories of skills with definition.

Categories Example ELEMENT and definition
Situation awareness Gathering information
Decision-making Considering options –
generating alternative possibilities or courses of action.
Communication and teamwork Establish a shared understanding –
create the “big picture”
Leadership Coping with pressure –
retaining a calm demeanor when under pressure and demonstrating to the team that the situation is under control;Adopting a suitably forceful manner, and don’t undermining the role of other team members

When workers are attentive, make sound decisions, share information and cooperate with fellow workers, then errors and accidents are less likely to occur – Reason, 2008

Here, we should notice that NTS is not only useful for CIM, but also needed for the routine aspects of safety-critical jobs.


PART 2 CRM Training Applications

Chapter 8 Line Oriented Flight Training (LOFT). The Intersection of Technical and Human Factor Crew Resource Management (CRM) Team Skills

8.3 Definition and Description of LOFT and LOS  – What’s LOFT, LOS?

LOFT – Line Oriented Flight Training, refers to the use of a training simulator and a highly structured script or scenario to simulate the total line operational environment for the purposes of training flight crews.

Such LOFT training can include initial training, e.g. route or airport qualification training. The appropriate term should appear as a prefix with LOFT, e.g. “Recurrent LOFT,” to reflect the specific application.

LOS – Line Operational Simulation, is synonymous with the term “full-mission simulation” but LOS avoids the other misleading and irrelevant connotations of “mission”. LOFT, then, is the use of LOS for training purposes.

Any other use of LOS should be expressly stated. For example, LOS can be used to aid in the development and evaluation of operating procedures and new equipment, proficiency checking, pilot selection for new-hire programs, or cockpit human factors research.

8.6 The change of LOFT to LOS and LOE

LOE – Line Operational Evaluations = check ride

LOE, i.e check ride, is used as a way to evaluate the crew’s CRM and specific technical skills. Rightly, it is part of the qualification and continuing qualification curricula.


8.7.1. What’s a “team”?

Now let’s move back to a very basic question – what’s a “team”?

Five (5) characteristics of a “team”:

  1. at least two individuals (人數)
  2. team members are assigned specific roles, tasks to achieve a common goal or outcome (各施其職, 達成目的)
  3. teams make decisions (共同做決策)
  4. need specialized knowledge and skills (有共同技能)
  5. embody the coordination – team members help each other and adjust to one another (互補不足, 齊上齊落)
    (Team ≠ Group)


PART 3 CRM perspective

Chapter 15 Integrating CRM into an Airline’s culture: The Air Canada process

“4 Ps” Weiner stipulates

  1. Philosophy
    • the company’s philosophy is largely influenced by the individual philosophies of top decision-makers
  2. Policy
    • broad specifications of the manner expected in operations
  3. Procedures
  4. Practices
    • the activities actually conducted


Air Canada’s seminal process over 4 stages:

  1. Awareness
  2. Practice and feedback
  3. Reinforcement
  4. Integration

CRM is not a recent phenomenon. Rightly, the concept is the product over the past three decades, with different stages, via continuous refinement and standardization.

15.11 CRM Skills

Below are essential skills covered in the Air Canada program (Dowd & Shrindruck 1999):

  1. Leadership
  2. Preparation and planning
  3. Briefings
  4. Monitor and feedback
  5. Situational awareness
  6. Communication
  7. Decision-making
  8. Workload management
  9. Crew performance


15.10 The Error Management System

The “Swiss Cheese” Error Management System is a tool to help visualize how crewmembers can manage threats and errors. (Air Canada FCTM, 2008, p.27) The model of Air Canada actually is similar to the one suggested by James Reason. The model based on the premise that accidents occur as a result of concurrent failure. There are “holes” within different layers represent the system deficiencies and errors caused by human limitations, or intentional non-compliance with standard operating procedures. Having to say that, there is a redundancy when dealing with threats and errors. If an error penetrates one slice, it can be blocked or arrested by another. The probability of an error causing an incident or accident increases as the various layers are penetrated.




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