01/02/2015
Weekly Safety Information:
After experiencing 20 deadly crashes in one year, the aviation industry set out to improve the safety rating of the troubled industry. Investigations reveal that human error more than mechanical failure attributed to the majority of the crashes. For example, on December 28, 1978, United Airlines Flight 173 was on final approach to Portland International Airport. The cockpit crew consisted of an experienced Captain, first officer, and flight engineer. The flight had been typical by all accounts, but as they prepared for their final approach the Captain noticed that the light that indicates the landing gear is locked was not on. He radioed the tower and requested additional flight time to address the situation. Despite the crew’s efforts, the light never illuminated. Throughout the troubleshooting, both the first officer and the flight engineer had informed the pilot that the plane was running low on fuel. The pilot either ignored the warning or did not comprehend the messages. The plane crashed into a wooded residential area after running out of fuel. The post crash investigation revealed that the landing gear light had burned out and the gear had been in the locked position all along. The pilot became so engrossed in the burned out light that he forgot to fly the perfectly good airplane.
To reduce the human error, the airline industry developed a program known as “Cockpit Resource Management.” CRM focuses on five factors: communication, situational awareness, decision-making, teamwork and barriers.
· Communication – Historically, the Captain had been considered the ultimate authority on the flight deck. Many ruled the cockpit with an iron fist, thus intimidating junior officers. In several crash reviews, there was evidence that junior officers tried to share important information with their Captain; but when the Captain did not respond or utilize the information, the junior officer passively let the information drop. CRM teaches people to focus on the communication model (sender-message-medium-receiver-feedback), speaking directly and respectfully and communication responsibility. As seen in the United incident, the pilot did not listen to his flight crew and the junior officers were not assertive in their communication with the Captain.
· Situational Awareness - is the concept of maintaining attentiveness to an event. From any response perspective, situational awareness is “size-up.” It is identifying the problems and developing solutions to those problems. It emphasizes the need to recognize that situations are dynamic and problems change, especially in emergency situations. In the United incident, the pilot did not recognize the problem had increased from a light not illuminated to a fuel problem. The lack of fuel caused the crash, not burned out light.
· Decision-making is based on the risk versus benefit analysis. Too little information leads to poor decisions and too much information causes information overload making it difficult to make effective decisions. CPM training concentrates on giving and receiving information so appropriate decisions can be made. It provides the work crew with a framework to process all information and formulate plans. The leader has the ultimate authority, but processes input from his/her crewmembers to arrive at a more efficient and correct decision.
· Teamwork – There is a saying, “Together Everyone Achieves More.” Individuals working together for a common goal are more successful than individuals working by themselves. In the United incident, the pilot did not work with the flight crew to resolve the problem. He could have had the first officer fly the plane while he investigated the problem light and had the first officer fly the plane while he investigated the problem light and had the flight engineer monitor the fuel. Together they could have avoided the tragic ending to the flight.
· Barriers – Barriers are any factors that inhibit communication, situational awareness, decision-making or teamwork. These barriers could be in the form of prejudice, opinions, attitudes or stress. For example, the United Captain’s failure to listen to the junior officers because he considered himself the boss and took the entire situation upon himself. We should be aware that the newest addition to any member might just have the expertise necessary when we are faced with that unusual situation.
Since the inception of CRM, the aviation industry has reduced air crashes from 20 per year to one or two a year. It has been so successful that the concept has been adopted by the military with only a name change. What started as Cockpit Resource Management is now termed Crew Resource Management. In fact, the U.S. Coast Guard reported a 74 percent reduction in its injury rate since adopting CRM.
As humans, we are all prone to make mistakes, the mistakes that can lead to serious accidents. Cockpit Resource Management is a concept that begins to address the human factor in reducing deaths and injuries. It has worked for the aviation industry and the military. There is no reason that it should not work in any arena.
Have a Safe Day,
Webb Consulting
