Crew Resource Management as a Knowledge Management Tool

1. Crew Resource Management as a
Knowledge Management Tool in the
Airline Industry
Lisa West LIS 880 Fall 2012

2. 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

3. History
 Initiated by NASA in 1979
 NASA discovered crashes due to lack of:
 Interpersonal communication
 Poor decision making
 Lack of leadership skills

4. 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”

5. 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

6. CRM Components
 Communication
 Leadership Skills
 Decision-making
 Situation Awareness
 Monitoring
 Crosschecking
 Understanding one’s limitation

7. CRM Components
 Social Skills
 Cooperation
 Team 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

8. CRM Training
 Initial Training
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Lectures
Case study review
Audio/visual material
Practical exercise
Line Oriented Flight Training (LOFT) role-playing
 Annual re-training
 Line Operation Safety Audits (LOSA)

9. LOSA
 Real life data collection
 Flight deck crew actions
 Threats and errors
 Threat and error management
 CRM skills evaluated and recorded
 Strict “non-jeopardy” conditions
 Data used for training development

10. Statistics
 Poor 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

11. Statistics
 98% of flights face threats
 Errors occur on 82% of flights
 70% decrease in crashes since the inception of CRM

12. 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

13. Keys to CRM success
 LOSA observations resulting in changes to Standard
Operating Procedures (SOPs)
 Sharing of information
 Information management
 Verbal cues among stakeholders

14. CRM Learning History
 United 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

15. CRM Learning History
 Flight 232 taught United Airlines CRM transfer of knowledge
saves lives
 Was a benchmark of best practice in:
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Communication
Leadership skills
Decision-making
Teamwork
Situation awareness
Monitoring
Cross-checking
Understanding one’s limitations

16. CRM Issues
 No training standards
 FAA and Civil Aviation Authority (CAA) support training
through assistance and recommendations
 Difficult to transfer to other cultures

17. CRM as cost reduction
 Cost of commercial aviation accident
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$100 million
Lost revenue
Loss of employee productivity
Disruption in routes
Poor customer perception
Loss of reputation

18. CRM as life saver
 CRM promotes teamwork
 Discovers and reduces accidents and errors
 Part of organizational learning
 Creates benchmarks of best practices
 Shares knowledge
 Behavioral changes
 SAVES LIVES!

19. 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/>.

Anonymous. "Communication And Knowledge--Keys To CRM." Flying Safety 63.7 (2007): 26.
Academic Search Premier. Web. 07 Oct. 2012.

Beal, George M., and Joe M. Bohlen. The Diffusion Process. Rep. N.p.: Farm Foundation, 1957. Print.

Berber, Leon, Melanie Attan, and Chong Lee. "5-M Model Approach To Accident Investigation."
Aviation Knowledge (2012): n. pag. Web. 07 Oct. 2012.

Boeing. "A History of Boeing Aviation Safety Improvements." Fact Sheet-The Boeing Company.
Boeing, Dec. 2009. Web. 19 Oct. 2012.
<http://www.boeing.com/commercial/safety/fact_sheet_Boeing_Safety_History.pdf>.

Brown, John Seely., and Paul Duguid. The Social Life of Information. Boston: Harvard Business
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
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
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20. Sources

Guidelines for Line-Oriented Flight Training. Proc. of Proceedings of a NASA/Industry Workshop Held at NASA Ames
Research Center, Moffett Field, CA. NASA. Proceedings of a NASA/Industry Workshop Held at NASA Ames Research
Center. NASA. Web. 19 Oct. 2012. <http://www.crm-devel.org/resources/nasa/nasaloft/nasaloft1.htm>.
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Harvard Business Review on Knowledge Management. Boston, MA: Harvard Business School, 1998. Print.

Haynes, Al, Cpt. "Haynes Talk at Dryden." Lecture. Cpt. Haynes Presentation. NASA Ames Research Center Dryden
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<http://yarchive.net/air/airliners/dc10_sioux_city.html>.

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
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
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
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
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
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
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
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