CVR & CRM
“The roots of Crew Resource Management training in the United States are usually traced back to a conference, Resource Management on the Flight Deck sponsored by the National Aeronautics and Space Administration in 1979 (Cooper, White, & Lauber, 1980). This was the outgrowth of NASA research into the causes of air transport accidents. The research presented at this meeting identified the human error aspects of the majority of air crashes as failures of interpersonal communications, decision-making, and leadership. Since that time CRM training programs have proliferated in the United States and around the world.” (International Journal of Aviation Psychology, 9(1), 19-32.)
“CRM encompasses a wide range of knowledge, skills and attitudes including communications, situational awareness, problem solving, decision making, and teamwork. It can therefore be defined as a management system that makes optimum use of all available resources -equipment, procedures and people -to promote safety and enhance the efficiency of flight operations. CRM is concerned not so much with technical knowledge and skills but rather with cognitive and interpersonal skills. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for taking decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork. In aviation, as in other walks of life, these skill areas often overlap with each other.” (Crew Resource Standing Group, Royal Aeronautical Society, October 1999)
CRM has been adopted by other industries including maritime shipping, healthcare, and firefighting. In the latest edition of the International Association of Fire Chief’s CRM Manual its importance is stated frankly: “People cause accidents and make errors. Be prepared to adopt and implement a paradigm approach to error, injury and fatality prevention. Welcome to Crew Resource Management.” In some cultures, tradition dictates deference to superiors. In others, like the US, individualism directs folks to “go it alone.” In the past both these manners may have may have mitigated the effects of error on society: One, because you are a subordinate to an instructor who is looking over your shoulder, and two, because if you fowl up, you were only responsible for yourself and only you would know about it! But in an ever more complex society, with dependence on ever more complex machines, these means may fail us.
Last July the New York Times reported on a disturbing trend—patients being overdosed in a stroke scanning procedure called a CT brain perfusion scan.
“The overdoses set off an investigation by the Food and Drug Administration into why patients tested with this complex yet lightly regulated technology were bombarded with excessive radiation. After 10 months, the agency has yet to provide a final report on what it found. But an examination by The New York Times has found that radiation overdoses were larger and more widespread than previously known, that patients have reported symptoms considerably more serious than losing their hair, and that experts say they may face long-term risks of cancer and brain damage. The review also offers insight into the way many of the overdoses occurred. While in some cases technicians did not know how to properly administer the test, interviews with hospital officials and a review of public records raise new questions about the role of manufacturers, including how well they design their software and equipment and train those who use them. The overdoses highlight how little some in the medical profession understand about the operation of these scanning devices and the nature of radiation injuries, as well as the loose requirements for reporting accidents when they are detected. For a year or more, doctors and hospitals failed to detect the overdoses even though patients continued to report distinctive patterns of hair loss that matched where they had been radiated.” (NYT, 7/31/10)
Neither tradition nor individualism will assist in such an institutional convolution. According to David Brooks, “a richer and deeper view of human nature is coming into view. It is being brought to us by researchers across an array of diverse fields: neuroscience, psychology, sociology, behavioral economics and so on. This growing, dispersed body of research reminds us of a few key insights. First, the unconscious parts of the mind are most of the mind, where many of the most impressive feats of thinking take place. Second, emotion is not opposed to reason; our emotions assign value to things and are the basis of reason. Finally, we are not individuals who form relationships. We are social animals, deeply interpenetrated with one another, who emerge out of relationships. (The New Humanism –March 7, 20011 NYTimes.com)
Perhaps we need a lesson in being human. Better understanding ourselves and our relationships could be key—especially when some of our relationships are with machines. Many universities now offer advanced degrees in Applied Experimental and Engineering Psychology— “the application of psychological principles, knowledge, and research to improve the ability of humans to operate more effectively in a technological society.” (American Psychological Association) But we have other relationships to understand in the 21stCentury.
In the corporate structure, it is easy to differ one’s autonomy. Why make a fuss, the big things are dealt with by others, and the little are easy to overlook. Why make something out of nothing, especially when the commute is long and it may be our only night to catch the basketball finals. But often it is the incipient observations that are most important. Large matters start small. Time was, in a town, interpersonal relations wouldn’t let a small matter go; now, we even have to be reminded while roaming the caverns of Walmart by the televised image of Janet Napolitano, the Director of Homeland Security, “if you see something; say something!” The deadliest accident in aviation history took place March 27, 1977 at The Los Rodeos Airport (now known as Tenerife North Airport) on the Spanish island of Tenerife, one of the Canary Islands. Two passenger Boeing 747’s collided on the runway. There were 583 fatalities. All 248 aboard KLM Flight 4805 were killed. There were also 335 fatalities and 61 survivors from Pan Am Flight 1736, which was struck along its spine by the KLM's landing gear, under-belly and four engines as the KLM raced to rise above the American airliner. Ultimately the fault lay with the KLM captain who attempted take off without receiving final clearance. The KLM’s copilot questioned the commander’s desire to proceed. He was rebuffed. Shortly afterward the commander initialed take off; but this time the co-pilot kept his place, and said nothing. Several other key factors contributed to the accident. The KLM flight was severely behind schedule. There was a heavy fog. There was heavy flight congestion on the ground. Most of the planes including the two 747s were bound for The Gran Canaria International Airport. However, a bomb threat closed the airport and traffic was rerouted to the smaller Los Rodeos. The Pan Am flight had trouble reading the taxi location signs. Also, the small airport was filled past capacity with travelers. The Tower controller was overburdened and had trouble seeing the runway in the fog. There were a number of communication misunderstandings. One error did not cause the crash, but a concatenation of failures. The problem was not only on the flight deck, nor in the Tower, but in the circumstances involving the entire airport. The interrelation of all personnel and procedures were affected, as if it were one organism. Every employee has a part to play in the overall; and therefore, every employee bears the responsibility to learn from every accident, and keep in mind the tragic flip-side to a proud profession and the sleek awesome machines that can shape the powerful forces of nature.
These are the reasons that we felt that producing CVR at York are important. As the home to the CUNY Aviation Institute, our inter-departmental collaboration on CVR is in itself a testament to the mindful teachings of CRM.