crew resource management
DESCRIPTION
Crew Resource Management as a Knowledge Management ToolTRANSCRIPT
Crew Resource Management as a Knowledge Management Tool in the Airline Industry
Lisa West LIS 880 Fall 2012
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
HistoryInitiated by NASA in 1979
NASA discovered crashes due to lack of: Interpersonal communicationPoor decision makingLack 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, 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
CRM ComponentsCommunication
Leadership Skills
Decision-making
Situation Awareness
Monitoring
Crosschecking
Understanding one’s limitation
CRM Components Social Skills
CooperationTeam 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
CRM TrainingInitial Training
LecturesCase study reviewAudio/visual materialPractical exerciseLine Oriented Flight Training (LOFT) role-playing
Annual re-training
Line Operation Safety Audits (LOSA)
LOSAReal life data collection
Flight deck crew actionsThreats and errorsThreat and error management
CRM skills evaluated and recorded
Strict “non-jeopardy” conditions
Data used for training development
StatisticsPoor 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
Statistics
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 safety culture
Trust in organization
Self-disclosure of information
Keys to CRM success
LOSA observations resulting in changes to Standard Operating Procedures (SOPs)
Sharing of information
Information management
Verbal cues among stakeholders
CRM Learning HistoryUnited 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
CRM Learning HistoryFlight 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
CRM Issues
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$100 million Lost revenueLoss of employee productivityDisruption in routesPoor customer perceptionLoss of reputation
CRM as life saverCRM promotes teamwork
Discovers and reduces accidents and errors
Part of organizational learning
Creates benchmarks of best practices
Shares knowledge
Behavioral changes
SAVES LIVES!
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. Airdisaster.com. Christopher Elroy. Web. 19 Oct. 2012. <http://www.airdisaster.com/us/>.
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