Where next for CRM?
 

Here's a question for you all. If accident rates have reached the what we might consider to be the endemic rate (and can go no lower), where does CRM need to progress to ensure that the rate does not start to rise because of 'the human factor'?

Overlooked elements of Cockpit Housekeeping
 

Question posed "... where does CRM need to progress... ?"

Not only for future pilots, but maybe more for future INVESTIGATORs, we need a safety survey of 70-years of airliner in-flight upsets, collecting the tiny components, factors, subtle lessons-learned.

The USA's NTSB has regularly pointed to the risks of Loss of Control mishaps -- but seems their own investigators are seldom familiar with earlier cases. The airlines recite lessons from NTSB & the CASTeam, but neither have proved a good source for information on the tiny contributing factors -- from which pilots might learn, and adapt. Often the new mega-airlines prove ignorant of their own historic upsets.

Previously, I collected some of these tiny factors, red flags, in Cockpit Housekeeping:
http://www.pprune.org/safety-crm-qa-...sekeeping.html

Some of the latest trends in CRM have been toward yet another re-labeling of it as TEM/R: "Threat Error Management or Recognition". This principle relies on any "threat" (as small as late for work contributing to stress all the way to uncontrollable engine fire, etc) and how this threat is recognised and therefore handled. In my opinion this principle requires EXPERIENCE and/or sound training to replace the training when it is not available (cadet style pilots operating jet transports straight from flying school).

Now, enter the realm of bean-counter where costs are cut, salaries are cut, etc, etc..... Along with this has come poor (self) discipline by way of study and standards from both pilot and airline alike. Review the statistics. Over the past 2 years judgment errors by the flight crew have soared.

CRM has become as futile a catch-phrase as "safety" has. If pilots haven't either the professionalism to appreciate it or the tools as required (training) to learn about it then we will continue down this path.

TopTup, I have been almost made a pariah for suggesting that TEM is old wine in new bottles and I am amazed at how the industry has been sold a pup with absolutely no discussion. The 2 replies to my question, so far, point to a more 'professional' approach to the job of being a pilot. In part this would be built on training but it also reflects motivation and morale. These are issues not fixed in a CRM class.

My question was more prompted by a feeling that the existing framework for CRM training is outmoded in both content and methods of delivery. Now that everyone has been exposed to the concept and that everyone has had the chance to compare the message with the operational world, I was wondering if there might be a missed trick here.

The way I see it is that CRM or NTS or TEM or whatever you wish to call it this week is just another 'tool' in our aviation 'tool box'. It is one of the many tools that we use on a regular basis whilst we go about committing aviation.

By using the tool box analagy whilst doing CRM Courses - I try to get the audience to recognise that CRM is not the "be all and end all" - it is just one of the many 'tools' that we need to make use of.

I do try to suggest as well that it is a 'tool' that we use quite a lot - albeit we don't formally recognise that we are using it if you see what I mean. I also suggest that this particular tool is likened to an adjustable spanner - it should be adjusted to fit the nut that it is being used on - so the CRM has to be similarly adjusted for the operation that it is having to work in.

As a helicopter man myself and also operting in the SP domain - I almost throw up if I am asked to watch a video of good or bad CRM in action using the good old 737 cockpit!!

But that then poses a problem in finding suitable training material from my particular industry - but that is my problem.

So what next? - keep doing it but keep it relevant, keep it simple, keep it fresh, keep it in context.

Practically - after the rather painful/dull/boring/mantra-fied initial Foundation/Core course and when doing annual refresher courses - make it 'refreshing'.:ok:

T'charged - I agree with you.

And, as tbc is saying, it is a tool to be used. So why call it TEM/R, CRM, etc, etc? Well, for one reason the psych departments need to justify a paycheck! So why not put old wine in new bottles IF it makes us look at that wine from a different perspective? Not always a bad thing.....

Yes, the courses are (from my experience) a case of "let's just get this over and done with!" How many times have we seen that "Duck" video (747 Classic Engineer refers to FO as a duck to the Capt when the FO subtly comments on the unstable approach.... "The difference between a duck and an FO? A duck can fly") Still peddling the same stuff for 18 or 20 years!

So the problem as I see it is COMPLACENCY form both operator and pilot alike. The delivery of the CRM courses MUST be as tbc says: tailored to the needs of the operation in question. Each airline has it's own culture. While the CRM principles are the same, the method of delivery, the methods of teaching, of demonstrating must adapt to this. One former CRM instructor boasted to me once that his course is so great that he uses the same one for a course he runs for truck company delivering freight.

Personally, I have advocated for YEARS that CRM needs to be PRACTICED. We practice and train for all types of failures (engine failures, fires, hydraulic, electrical, pneumatic, depressurisation.....) and approaches, departures... but we don't practice CRM! Why not get the FO or Capt (unknown to each other) to behave a certain way: arrogant, misinformed, lazy, lethargic, dominant, submissive, and so, and so on..... See how the subject reacts then assess, debrief and LEARN from the experience. We do this with the above types of scenarios so IF we come across them in a live situation we have the TOOLS to better handle it. This must be handled by a very experienced CRM TRI/TRE. That means time in the sim and possibly on top of the usual time. That = money.

When the CRM course is not aimed correctly then the effect can all too often have the opposite affect.

So the missed trick here I see is COMPLACENCY, borne from the reasons as per my last post: just my opinion.

Tubo, it’s not necessarily the accident rate which the industry has to worry about. Modern society, urged on by sensationalist media, could focus on an increasing number of accidents (even with a constant rate), particularly the spectacular, fatal ones.
If the accident rate has reached a platform (context specific endemic rate), this doesn’t necessarily mean that has CRM effectiveness has also peaked. It may have done in some areas, but elsewhere there could be more to come, but this might imply that a high accident rate is associated with poor CRM. I have yet to see any such an association.
Thus the point is, what more can CRM achieve in preventing human contribution to accidents irrespective of the accident rate.

In ‘low safety’ organisations, CRM training must ensure that CRM training reduces (contains) the human factor.
In ‘ultra safe’ organisations, then it might be necessary to redirect CRM training in order to maintain the ‘ultra safe’ status.

Thus, both types of organisation should keep on doing what is already being done providing it targets the appropriate safety objectives. Accident reports often suggest that CRM/safety objectives are not being met.

In organisations where CRM training is ill-conceived, then refocusing it on error management and individual behaviours may improve its effectiveness, i.e. there should be less focus on ‘soft’ team skills (I assume ill-conceived CRM has inappropriate emphasis on the Human – Human aspects).
CRM training should be rebalanced to consider all aspects of the SHELL model, particularly more on the human at the centre, the cognitive aspects, vice social niceties. There should be more emphasis on ‘self’ and individual behaviour, the interaction with the environment, procedures, and equipment, as well as human limitations, i.e. put safety and CRM into context.

In better organisations, the need is to maintain the high standard. Thus CRM needs reinvigoration (as in previous posts).
Amalberti’s paper (1) suggests attention to changes which increase demanding situations (personal, technology, and commercial); increasing expertise which tends towards routine errors – learn from them, and the need for self awareness and confidence – adaptation and responsibility (professionalism).
The success of these will depend on parallel organisational aspects, such as improving the safety and learning cultures, cultural aspects of CRM.
“… is also important to recognise that these systems are nearing the end of their life, and should not be placed off-balance by requiring operations to take place within unreachable performance and safety objectives.”

Hollnagel (2) has similar views which lead to organisational ‘resilience’, but many aspects of this can be used to redirect CRM. Existing concepts of SMS, TEM, and risk management can be used to build on ‘what we do well’ – more focus on the positive aspects of behaviour.
Hollnagel’s move away from error towards ‘performance variability’ enables clearer views of the source of success as well as of failures, and the boundaries of acceptable performance without connotation of fault, blame, etc.
Perhaps the most encouraging aspect of performance variability is the cognitive – thinking aspects which require good situation awareness and appropriate choice of action (decision making); key CRM subjects in order to make any progress at all.

(1) http://www.ida.liu.se/~eriho/SSCR/im...%20_(2001).pdf

(2) http://www.eurocontrol.int/eec/galle...ngineering.pdf

alf,

'Thus the point is, what more can CRM achieve in preventing human contribution to accidents irrespective of the accident rate.'

That was the question I asked in my original post.

Much of the discussion so far has been around delivery. So do we need to raise the standards of facilitators? Or do we need better models of course development to get at 'CRM as practiced'?

A question with a question:

A 2010 BMW is safer than, say a 1980's Skoda. Your company has the money for the BMW but this will affect profits / shares / bonuses, etc, etc. The Skoda will meet the minimum criteria of transporting you from A to B. So, which one will 99.9% of "managers" purchase?

Same with CRM (or any other) facilitators. You want well put together, researched and type-specific CRM training? This costs money....Or you can get Senior Capt Smith to be promoted to "CRM Instructor" and get him to press play on the pre-packaged CRM DVD.

It's not the facilitators and it's not as if the knowledge is not available. It's about whether operators wish to pay for the expertise and training.

You get a professional instructor (in any field) with a good product based on relevant, current and knowledgable facts to deliver the training in an effective manner and then employ correct follow-up training and the results will show. Again, who's going to pay for it?

I agree. At the Flight International Crew Management Conference 3 years ago I asked a room full of Trg Mgrs and Post Holders, first, hands up who thought CRM training was a waste of time (75%) and, second, who had a budget for the development of CRM recurrent (0%). So, I suggested that if you pay nothing you get nothing in return.

I was asked to pitch for the CRM training for a UK operator. I knew it was a paper exercise so I didn't put much effort into the exercise. Sure enough, we were more expensive than doing it in house. When I asked the basis of their costing I was told they looked at the per diems and hotel bills they paid their instructors and compared it with my estimate. What they didn't do is actually cost their instructor time and the cost of employing a pilot to fly the aircraft while another pilot delivered CRM.

As long as airlines do not actually have a cost model of training, you will always get make and mend solutions.

But budgets is just one aspect. My point about facilitator competence is still valid. There are lots of facilitators out there who only know the 'show a video and discuss' approach to training.

Not sure what you mean by this reference to CAA Flight Ops Inspectors. Is it negative or postive in its meaning? Expand?

WAP

Turbo, re #7, #8 – subtleties and semantics – never a good mix.
I suggested that with apparently differing accident rates amongst world regions, a universal accident rate (platform) may not have been reached. Thus, irrespective of the rate … … etc, which is not quite as you asked.
However, we agree on the objective of the question.

Delivery? Yes, this is a problem, but not necessarily facilitation. Often the objectives of the training or the choice of subject matter is incorrect.
In addition this might be due to aspects of regulation, but not necessarily the inspectors – you can’t inspect quality into a process.

Better models – ooh … your love of the TEM (model) could be severely tested ;).
As in #7, we should look seriously at Hollnagel’s work. See Thinking about the performance of complex human

Also, see 'changing perspectives' – slide 24 http://www.vtt.fi/liitetiedostot/muu...7Hollnagel.pdf

alf, not sure I followed all of that but my reference to 'model' was in the context of course development. Most CRMI courses say little or nothing about developing courses, If CRMIs cannot develop a course then the objectives and content will be inadequate.

And I'd suggest that you can 'inspect' quality into the process if your Inspectors know what they are doing and can leave personal agenda behind.

I'll pass on TEM

Clearly there are folk here who know a bit about the topic.

So, a challenge if I may?

Can any of you demonstrate, with statistics, that CRM training has affected the accident rate, please?

CRM and accident rates
 

NASA, I think, published some data a fey years back suggesting a link between safety and CRM.

There have been some papers on the evaluation of CRM training but these tend to deal with lower levels of evaluation, such as delegate satisfaction (was it useful, was it interesting).

This question comes up periodically and I suppose the only answer is that most people feel that things are better now we have identified the social aspect of aviation as being as important as the technical process of controlling aircraft than they were before ... but it's a feeling.

I decline the challenge as I doubt that there can be any meaningful conclusion. During the era of CRM, both the concept and training has evolved to meet changing needs in industry.
Similarly the nature of accidents has changed, less single failures and more an amalgamation of factors, of which the human is a contributor.

Statistics, like models, are more often generated to suit a purpose. Accident rates are a convenient link with the public and the perception of safety, but may not contribute very much to finding safety solutions.

Most texts accept that human behaviour is a frequent contribution in accidents, but not as the cause of accidents.
Accidents are rare events, thus they provide few opportunities to study human activity. And if used, the data is assembled retrospectively with hindsight, thus arguably of little value – it’s difficult to question a crew’s unannounced reasoning in fatal accidents.

An alternative is to look at behaviour in normal operations. When and why does less-than-optimum performance occur, how is this performance detected / correct. This is not the same as LOSA, where ‘error’ appears to be a prime objective, and the observer does not interview the actor, thus again the reasoning – different view points, are not established.

Using the work referenced above, particularly the concept of performance variability, it might be possible to identify changes in individual behaviour within an organisation which correlates with safety. This would require a positive view of safety looking at how the human creates safety (not less errors).

Thus the model which Turbo seeks could ditch the concept of error; CRM training would continue to direct behaviours (as it does now), but also seek to control both the variability in behaviour and the boundary of unacceptable behaviour, i.e. the person is more self adapting (flexible) and self limiting depending on the situation.

The key CRM subjects would not change, but the organisation’s view of CRM (purpose) would have to be to be reversed. CRM training would still be directed at behaviour, it would seek to bound behaviour, where the boundaries are flexible, and operations within them should be safe. Thus, the prime needs are for situation awareness and choice of action – knowing / setting the boundary of safety.

Safety statisticians might then choose to look at how close operators are to the boundary, and detect any erosion in safety margin, as opposed to counting and categorising accidents.

1. CAA Paper 2002/05: Methods used to Evaluate the Effectiveness of Flightcrew CRM Training in the UK Aviation Industry | Publications | CAA

2. %!PS-Adobe-3.0

3. http://www.aavpa.org/seminars/ess200...&%20Mourey.pdf

4. CRM - A Cost or a Benefit? …Turbo?

CRM and accidents
 

Of course, the 'cause' of an accident is the final impact with the hard object. The actions of the crew contribute to the extent that they increase the probability of the outcome.

Nancy Leveson at MIT offers a very useful comment when she says that accidents are a failure of control and what we need to look at are control mechanisms rather than errors.

If you look at any adverse event there is usually a trigger; some event that sets the ball rolling. It might be a component failure or a departure from expected procedures. It might be a change in environmental conditions.

The trigger is not always identified or recognised by the crew nor is it always fully understood in terms of it implications.

Next we sometimes find aggravators. These can be additional failures or they may be actions by individuals that make the situation worse.

Then we see moderators. These are actions that attempt to keep things safe.

Accidents occur when 'moderators' are overwhelmed.

What we are interested in is how triggers and aggravators degrade control and the effectiveness of moderators in regaining or sustaining control.

Alas, in 'safety', we have a habit of categorizing outcomes. I-LOC is the latest now that we have become bored with CFIT. But here is a question, how can CFIT be 'controlled' if the aircraft hits the ground in the middle of nowhere? It should be SFIT - stabilised flight into terrain - as opposed to I-LOC which is UFIT - unstabilised flight into terrain. OK, so I am teasing the taxonomists. Both represent a loss of control.

So, back to my original question about where next for CRM. Might I suggest that the list of topics contained in EU-OPS is irrelevant. It might have been useful guidance when we were all starting out but no longer. Instead, operators need to derive improvement targets from their SMS.

Second, modes of training delivery need rethinking.

Third, the skills of most facilitator need strengthening.

Finally, training development needs to be recognised as more important than delivery.

You want to lower accident rates?...hire more qualified pilots....put your money into training and experience, not a new fangled way of trying to get a 1500 hr pilot and a 200 hr pilot talking to each other...

Johns,

I agree fundamentally with you comment about training. I don't agree that CRM is a 'new-fangled' anything. It's a recognition that competent performance requires both the skills of manipulation and configuration plus the skills of trajectory management. CRM is part of the latter but requires the former.

Turbo - I honestly have no idea what you just said....CRM was developed out of the need to get the 'God like' Capt to listen to the scared marsh mellow on probation First officer who saw they were going to crash.

If that type of relationship didn't exist in the cockpit these days, due to the way the Chief Pilots hire.....you would simply have two guys up there with ten thousand hours each, basically being ahead of each other...personally, I think an airline can afford a couple of experienced pilots up front, considering you have 200 paying passengers in the back....