Monday, January 8, 2007
CRM: The Good, The Bad And The Ugly
New Research On Crew Resource Management Is Transforming Air Safety
By Dr. Simon Bennett
Crew resource management (CRM), with its emphasis on open communication and teamwork, is making a major contribution to aviation safety. Recent studies are throwing startling new light on the efficacy of CRM, and how its widespread adoption can make the skies even safer.
However, CRM is not a panacea and it must be considered in its full context. Here's a critical examination of CRM, illustrated with specific accident case studies.
In his influential 1997 book, Crew Resource Management: Awareness, Cockpit Efficiency and Safety, Brian McAllister claims: "[CRM] ... is being increasingly recognised as an essential element in maintaining high cockpit safety standards."
Shari Stamford Krause asserts: "[S]tudies have shown that most safe and accident-free flights are the direct result of CRM" (Aircraft Safety: Accident Investigations, Analyses and Applications, 1996). According to authors M. Brannick, R. Roach, and E. Salas, CRM promotes safety by emphasizing "team communication, cohesion, and coordination" (Human Performance, Vol. 6).
CRM flattens workplace hierarchies, creates multiple channels of communication and encourages the widest possible participation in situation assessment and option-generation (although the final decision is always taken by the captain). As to its provenance, CRM is the airline industry's interpretation of the Human Relations (HR) approach to worker motivation/engagement, task performance and workplace organization.
The Human Relations approach to workplace organization is the antithesis of Scientific Management (a 19th century credo formulated by American Frederick W. Taylor). Where Scientific Management looks to financial reward to motivate workers (workers are assumed to be avaricious, selfish and unsocial), HR emphasizes psychological incentives, like self-actualization (i.e., realizing human potential), corporatism and collegiality.
A workplace organized with reference to Scientific Management is regimented. Tasks are performed to rigid schema and timescales. There is a "one best way" to perform every task, however simple. Managers use job analysis and time and motion study to establish the one best way for each task.
A workplace organized with reference to the Human Relations approach is one in which innovation and self-direction are encouraged. In the HR workplace, performance is measured by output rather than input, the premise being that methods of working are best designed by those with the greatest and most current knowledge -- front-line workers.
In its 1950s study of the adverse impact of automation and task specialization on textile workers' productivity, the Tavistock Institute of Human Relations "asked the workers what they felt would be a better system of organization. The workers ... eagerly responded. They formed small, internally led workgroups, eliminated some lines of authority, moved to de-emphasize job titles, and encouraged individuals to perform more than one task .... The workers knew better than management that developing stable workgroups would lead to greater efficiency." (Excerpt taken from E. Smither's 1988 textbook, The Psychology of Work and Human Performance). The insights and actions of these Indian textile workers presaged commercial aviation's CRM initiative by well over two decades.
Despite the HR school's positive impact on worker self-esteem and productivity Scientific Management is still practiced. As Smither notes: "Modern management continues to use Taylor's ideas about the standardization of work, the study of jobs, goal setting, and the scientific selection of workers."
The aviation industry uses both HR and Scientific Management to organize production. For example, it is not uncommon for exact timings to be issued for turnaround tasks. One airline prescribes the exact start time and duration (in minutes) of every turnaround activity for both its pilots, cabin crew and (sub-contracted) Dispatchers, Ramp Team Leaders and ramp workers.
Specified pilots' activities include "Technical Log review", "Pre-Flight checks" and "Tech-log signed". Specified cabin crew activities include "All pax off"; "Security and cleaning"; "All pax on"; and "Final preparation, doors closed". Specified ramp activities include "Position team and equipment"; "FOD check"; "Chox and steps"; "Hold off-load"; and "Hold on-load".
Ramp working standards are specified in service level agreements (SLAs). Management consultants encouraged one airline (an inclusive tour operator) to issue cabin crew with Check-cards specifying the exact start times and duration of all pre-flight activities (the consultants suggested that the cards be made small enough to fit into crewmembers' airside pass holders).
It was suggested that start and duration times be specified for "Flight briefing" (15 minutes); "Leave crew room for a/c" (10 minutes); "Arrive a/c, CM [Cabin Manager] agrees turnround process with dispatcher" (zero minutes); 'Start equipment checks' (five minutes); 'Start dressing seat pockets' (ten minutes); and numerous other pre-flight activities. It was also suggested that task duration be varied according to aircraft type (Boeing 757 or 767) and base.
Flight and cabin crew are exposed to two quite different cultures at work. On the one hand they are told exactly what they should do, when and how they should do it and how long it should take. On the other, flight and cabin crew are encouraged to "think outside the box" should they judge it necessary on safety or security grounds (this, of course, is the philosophy behind CRM).
Optimists would argue that this admixing of cultures is unproblematic, with flight and cabin crew retaining the desire and ability to think for themselves. Pessimists would argue that prolonged exposure to drills and routines leaves flight and cabin crew unable or unwilling to think outside the box. Mixed messages may compromise CRM.
Compliance And Catastrophe
The 1998 Swissair Flight 111 disaster provides a good illustration of how the prioritization of emergency checklists (and associated coning of attention) may cause obvious solutions to be overlooked.
In the case of Flight 111, crew intuition and initiative were, for a major portion of the developing emergency, subordinated to compliance. The flight crew's implementation of an elaborate Swissair check-list procedure wasted so much time that when they finally understood what they had to do -- land or ditch immediately -- the window of opportunity had gone.
Its flight deck full of acrid smoke, the Boeing MD-11 crashed into the Atlantic five miles southwest of Peggy's Cove, Nova Scotia. There were no survivors. The accident may have contributed to the airline's eventual collapse (in the same way that Lockerbie contributed to Pan Am's demise). Canada's Transportation Safety Board (TSB) made the following comments regarding in-flight fires:
"An uncontrollable in-flight fire constitutes a serious and complicated emergency. A fire ... can propagate rapidly. Time is critical .... [The TSB recommends that] Appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously" (TSB Report Number A98H0003, 2003).
The TSB noted: "Regulations do not require that checklists for isolating smoke or odours ... be designed to be completed in a time frame that minimises the possibility of an in-flight fire being ignited or sustained ... the applicable checklist for the MD-11 could take 20 to 30 minutes to complete".
The TSB recommended: "[O]dour/smoke checklists must be designed to ensure that the appropriate troubleshooting procedures are completed quickly ... ".
A recent study of checklist procedures conducted by Cranfield University's Flight Operation Research Centre of Excellence (FORCE) revealed numerous issues:
"The study analysed the Mandatory Occurrence Reports (MOR) held by the CAA using the criteria of 'Emergency Checklists incorrectly used or omitted'. It was noted that almost 30% of reports were concerned with a lack of suitable procedure and 26% ambiguous procedures .... Problems encountered with checklists include ... Difficulty in understanding a checklist, Difficulty in following a checklist, Getting lost in a checklist, Failing to complete a step after an interruption ... ". (Excerpt taken from Jo Davies's article in Issue 65 of Focus on Commercial Aviation Safety, published by the United Kingdom Flight Safety Committee in December, 2006.)
The timeline for the Swissair 111 disaster emphasizes the problem with elaborate checklist procedures. As the TSB noted in its Final Report: "About 13 minutes after the abnormal odour was detected, the aircraft's flight data recorder began to record a rapid succession of aircraft systems-related failures. The flight crew declared an emergency and indicated a need to land immediately." It is interesting to ponder to what degree Swissair's emphasis on rigid emergency checklist procedures dulled its pilots' willingness and ability to action their CRM training.
Leaving Room For Judgement
Training regimes that prioritize the Scientific Management approach over the Human Relations approach may compromise crewmembers' ability to action their CRM training. The disabling of CRM constitutes a latent error (or "resident pathogen") in aircraft operations.
Ideally, neither approach should dominate. Managers and trainers should ensure that flight and cabin crew have the confidence and skills to move seamlessly between the two methods of work as required.
Indeed, one might argue that for reasons both of economic efficiency and safety, the Human Relations approach with its emphasis on flexibility and initiative should take precedence.
Take checklists, for example. While valuable aides-memoir, checklists are not infallible (see the FORCE research, above). As this author has noted during his time on the flight deck, operational changes (like a change to the on-board management of TCAS during ground-based maneuvers) do not always find their way onto checklists.
Technical departments sometimes miss crucial updates (unsurprising, perhaps, when one considers the fast-moving character and complexity of modern commercial aviation). Consequently, pilots who simply accept everything they are told are by definition less safe than those who routinely question and evaluate.
There is much to be said for methodical skepticism. The British Transport Police have long recognized its importance, as illustrated by their investigators' ABC mantra: Accept nothing; Believe nobody; Check everything. Sound advice.
The Human Relations approach can also benefit aircraft turnarounds. As demonstrated above, airlines are in the habit of regimenting the turnaround process. They use job analysis and time and motion study to reveal the "one best way" of performing the security check, dressing seat pockets, cleaning and re-stocking toilets, etc.
However, given that each turnaround is unique (inevitably there are variations in crew composition, experience and competence, passenger profile, ramp workers' experience and competence, passengers' utilization of facilities, etc.), surely it is better to permit cabin crew to organize the turnaround themselves rather than expect them to follow a preordained order and method of work (that cannot possibly accommodate every circumstance)?
Surely, what matters most at turnaround is that outputs (like the dressing of seat pockets, re-stocking of toilets and galleys and reception of "specials") meet the required standard, both in terms of quality and timeliness. Why should it matter exactly how those outputs are produced?
Some corporations have come to realize that trusting workers to organize themselves can produce significant benefits. Productivity improves, employee turnover drops and absenteeism falls away. Employees who are able to express themselves through their work and are fully engaged in the enterprise are productive and contented employees.
In December 2006, Business Life magazine published a short article by Bill Fischer (Professor of Technology Management) and Andy Boynton (Dean of the Carroll School of Management at Boston College) about the working methods of legendary comedy writer Sid Caesar. While Caesar was very much in charge of his writing team, he encouraged everyone to contribute as much as they could:
"Neither anarchic nor democratic, the team had in Caesar a strong central leader whose decisions, once arrived at, became the rule. Yet no one felt left out of the 'governance' process. Indeed, the transparency of communication ... and the constant banter and direct conversations helped foster team success. It was also a precursor of the learning organization. The open and intimate atmosphere inspired an exchange of knowledge that, according to Carl Reiner [a writer who went on to direct/produce several successful films] 'was like a college, everybody learning from everybody else'".
Human beings are not automatons. What Frederick W.Taylor failed to understand was that most humans resent and resist being programmed. He also failed to understand that management does not have a monopoly on insight.
As Robin Theobald explains in his book, Understanding Industrial Society: "Under Taylorism a knowledgeable management plans whilst a knowledgeless workforce does .... The principle task of the Human Relations-oriented manager is to recognise the existence and significance of informal groups and to strive to harness the energy and expertise within them ... ".
Aviation is highly competitive. Airline managers are under enormous pressure to drive down costs. Some might see the wider application of Scientific Management as a means of boosting competitiveness. While this strategy might yield short-term gains, productivity, profitability -- and air safety -- may suffer in the long-term.
Dr. Simon Bennett's latest study After Hubris, Nemesis: Why Flag Carriers Fail is available at http://www.le.ac.uk/lifelonglearning/. His other books are Human Error -- By Design? (Palgrave-Macmillan, 2001) and A Sociology of Commercial Flight Crew (Ashgate, 2006).