Crew Resource Management
Crew Resource Management
Source: MAS-CRM-2008
This article has been illustrated using images (slides) from a presentation titled Cabin Crew Human Factors Training in Malaysia Airlines delivered by Aziz Al Rahim Hussin of Malaysia Airlines at a seminar in Bangkok on 22 April 2008. MAS-CRM-2008
This provides a context for content about Crew Resource Management training by Malaysia Airlines and the training, knowledge and skills of the Crew of flight MH370.
Images included here are not in the same order as the original presentation.
A short timeline for the development of a concept now known as Crew Resource Management follows:-
- 27 March 1977
- Two Boeing 747 aircraft collided on the runway on the island of Tenerife. 583 people were killed.[1]
- 28 December 1978
- A United Airlines McDonnell Douglas DC-8 on Flight 173[2] had trouble with landing gear but ran out of fuel while troubleshooting that issue. The aircraft crashed and ten of the 189 people on-board died.
- 1979
- An aviation psychologist Alan Diehl[3], working as an NTSB investigator, recognised pilot errors involved in the Flight 173 incident were similar to those involved in the Tenerife disaster.
- The National Aeronautics and Space Administration (NASA) sponsored a workshop Resource Management on the Flightdeck[4] following NASA research into the causes of [recent] air transport accidents. The issues were obvious: how to improve communications between members of the flight crew; how to improve the decision-making processes; and how to change perceptions of leadership from hierarchical and autocratic to more inclusive and involvement as a highly functioning team. The term Cockpit Resource Management (CRM) became the descriptor for training in these areas. Many of the airline companies represented at this workshop committed to developing CRM training programs. United Airlines was one of the early supporters of the program.
- 19 July 1989
- A McDonnell Douglas DC-10 on United Airlines Flight 232[5] was crippled when a tail-mounted engine fan disintegrated and penetrated the horizontal stabilizer and severed hydraulic lines, resulting in a highly abnormal situation - virtually total loss of control - which could have been catastrophic. However, the high degree of communications, teamwork and cooperation enabled the crew to bring the aircraft down at Sioux City, Iowa where emergency crews were ready. There were 296 passengers and crew on-board and 184 survived.
- The NTSB, in their accident report on UAL 232, stated that the flight crew interactions were “indicative of the value of cockpit resource management training".
CRM has evolved:-[4]
- The programs developed after the 1979 NASA workshop, like the United Airlines CRM training implemented in 1981 is the First Generation.
- NASA held a second workshop in 1986. The term Cockpit was replaced by Crew.
Second Generation Crew Resource Management is more team-orientated. - In the Third Generation CRM, training included flight attendants, dispatchers, and maintenance personnel.
- Fourth Generation CRM training seems to be a bit abstract. The FAA introduced an Advanced Qualification Program as a means for "custom tailoring" CRM to the specific needs of each airline and stressed the use of Line Oriented Evaluations (LOEs).[6]
- The Fifth Generation of CRM focussed on error management; the prevention of an error occurrence; trap and control any error that does occur, and mitigate consequences of errors that do occur. Many of the earlier concepts of CRM may have been absorbed into general flight training.
- The Sixth Generation introduced Threat and Error Management.
Malaysia Airlines adopted the concepts of CRM in 1992 and implemented Initial Training courses in CRM. By 1999 Malaysia Airlines also required staff to undergo refresher training, now recurring annually.
The adjacent image for Threat and error Management uses a Swiss Cheese[7] model to illustrate that a failure to identify and control a threat or error at each opportunity (each system or procedure; each human factor or role; etc) facilitates an undesired State. If a hole in each cheese lines up, the system can fail.
However, as shown in the diagram, only some of the 'holes' directly involve people.
Some of the defences against hazards are the responses to warning systems, compliance with standard operating procedures (SOPs), effectiveness of training, and the quality of the team.
Instead of a linear or stacked defence as portrayed by the Swiss Cheese model, humans interact with these other systems.
This is easily represented by the SHELL model developed by Elwyn Edwards and refined by Frank Hawkins.[8]
SHELL is an Acronym using the words Software, Hardware, Environment, and Liveware, but it's significance is the interaction between each.
The SHELL diagram below omits the possible interactions.

This slide shows what each letter represents.

The SHELL model involves Interactions. The descriptions below were influenced by an article Human Factors in Flying: Simplified with the SHELL Model published on the NaviMinds Website[8]
- Liveware to Liveware (L to L)
- Liveware (humans) at the centre of the diagram interact with other humans, eg. First Officer to Captain L to L; Flight Attendant to passenger L to L.
- Liveware to Software (L to S)
- Liveware (humans) at the centre of the diagram interact with the SOPs and guidelines that define the rules for the system. As these become computer-based rather than paper-based, humans (Liveware) are increasingly interacting with dialogs, messages and warnings on computer screens which are provided by Software.
- Liveware interactions with Hardware (L to H)
- Hardware is tangible. The physical knobs and switches of the past may be replaced by touch-screens but other tangible hardware includes controls, surfaces, displays.
- Liveware interaction with Environment (L to E)
- The physical environment within an aircraft is normally controlled within acceptable noise, temperature, humidity and pressure levels. But the Environment also includes the social or team environment and culture. External Environment factors include the weather, the airport facility and, more broadly, the Environment of the aviation industry within which aircraft operate.
Initial training is mandatory for all Cabin Crew. The one-day course covers topics including Culture, Teamwork and Communications.
At the date of this Presentation (2008) Malaysia Airlines employed 166 crew from seven nations - Japan, India, China, Korea, South Africa and Indonesia - and 4005 from Malaysia. The CRM program was developed for a multi-cultural working environment. Passengers, of course, would also be of diverse nationality and culture.
Training in Problem Solving and Decision Making (PDSM) promotes an awareness of different methods and strategies for clarifying problems and processes involved in decisions. To be effective, PSDM training has to be contextualised for the team environment, respect team structures and authority whilst encouraging open and meaningful communication. Standard Operating Procedures (SOPs) may include appropriate procedures for many potential problems. The decision to do so can involve team management.
The inclusion of Financial Defense is interesting. An Internet search for this term in the context of CRM produces limited results, including this presentation. Recognising that financial stress could affect staff work performance, perhaps critical for aircraft safety, the company clearly wanted to create awareness and provide staff with skills to mitigate the risk of financial stress. The ICAO Annex 13 Team investigating MH370 delved into the financial state of each crew member, looking at bank account balances, loans, debts and irregularities. There were no issues.
As shown above, Crew Resource Management has evolved and will likely continue to do so. Therefore, 'refresher' training is necessary simply to keep 'up-to-date'.
To remain current the training program itself would have to be updated.
This slide notes the inclusion of Threat and Error Management (TEM).
Although re-training initially took place annually, it seems that the recurrence was increased to two years, as approved by the Department of Civil Aviation (Malaysia).
IOSA is an acronym for IATA Operational Safety Audit. IOSA is an industry standard for airline operational safety auditing.[9]
Malaysia Airlines is a member of the International Air Transport Association (IATA). A condition of membership is that the airline maintain an IATA Operational Safety Audit (IOSA) registration.
Full Training is a three-day training program.
Using the wider meaning of the work 'crew', as distinct from the original 'cockpit', the training program includes participation by Flight Crew, Cabin Crew, Dispatchers and operations staff.
Even broader, is an appreciation that human factors affecting flight safety can involve many areas of operations, including:-
- Airport operations
- Engineering and Maintenance personnel
- Security staff
- Inflight Services and Catering - although cabin crew provide the actual inflight service, each aircraft is provisioned pre-flight.
- Cargo handlers - awareness of dangerous goods, correct loading procedures, security - each role is important.
Note: Following the loss of MH370, the Royal Malaysia Police interviewed all Operations staff who may have been involved with that flight.
Operationalize: to put into operation, action, or use; implement.[10]
Training improves knowledge, but Practice improves skills.
By developing scenarios and challenging training-session participants to respond using the principles of their Crew Resource Management training develops the skills that may be required in a real situation.
On 26 February 2014, just prior to flight MH370, Malaysia Airlines conducted an Emergency Response Exercise at their training facility in Kelana Jaya. The scenario involved an in-flight incident over the Malacca Strait. Scenario participants included representatives of various departments within Malaysia Airlines - engineering, communications, customer services and others.
Training scenarios could include a bomb threat, on-board fire, evacuation drills, and other situations developed from actual or known incidents and accidents.
Content for Malaysia Airlines CRM training material has been informed by two ICAO documents:-
- Human Factors Digest No 15 - Human Factors In Cabin Safety
- Human Factors Training Manual (Doc 9683). An expensive document, first published in 1998.
In addition, and to keep the training relevant and interesting, MAS referred to recent known cabin crew events or errors, passenger events, and other (top 10) events recorded in Malaysia Airlines own reporting system known as CHIRP; plus current worldwide safety issues, including lessons learnt from internal or external safety investigations.
The Annex 13 Team investigating MH370 noted that "The The Confidential Human Factors Incident Report (CHIRP), being a highly confidential report, had become the most appropriate tool for identifying potential human factor issues, especially on the behavioural patterns of flight and cabin crew." Only six reports were added to CHIRP in 2013 and none (prior to March 8) in 2014.[11]
What makes our CRM uniwque is that we include Lessons Learnt from our own and others incident/accident.
Notes and References
- ↑ Source: Tenerife airport disaster, Wikipedia
- ↑ Source: United Airlines Flight 173, Wikipedia
- ↑ Alan Diehl writing about CRM, in the aftermath of the MH17 disaster: "One such training program was first utilized by U.S. airlines and called Crew Resource Management. CRM was launched by an NTSB recommendation that I wrote after the tragic 1978 crash of a United Airlines DC8 in Portland, Oregon. By the mid-1980s, CRM was required by all major airlines in this country and it quickly spread around the globe. This training teaches pilots and others how to access risks, avoid the loss of situational awareness, improve interpersonal communication and coordination, and thereby results in enhanced collective judgment and teamwork." Malaysia Airlines tragedy proves we need international investigative body PBS News, 18 July 2014
- ↑ 4.0 4.1 Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm. Department of Psychology, Aerospace Crew Research Project, The University of Texas at Austin The Evolution of Crew Resource Management Training in Commercial Aviation
Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32.
- ↑ Source: United Airlines Flight 232, Wikipedia
- ↑ Source: Crew Resource Management
Development of CRM is described in detail in this article on the code7700 website https://code7700.com/crm.htm. - ↑ Swiss Cheese model of accident causation proposed by James Reason.
Source: James Reason HF Model, Skybrary - ↑ 8.0 8.1 Source: Human Factors in Flying: Simplified with the SHELL Model NaviMinds website https://naviminds.com/shell-model-aviation/
In a conclusion, the author states: "The SHELL model helps optimise the relationship between people and their activities within the aviation system. Investigators can use this model to collect data about human performance and component mismatches during aviation incident/accident analysis." - ↑ Source: About IOSA
- ↑ Source: Dictionary.com https://www.dictionary.com/browse/operationalize
- ↑ Source: Safety Investigation Report MH370/01/2018 1.17, Pages 211-212 including Table 1.17B - List of CHIRPs 2013 & 2014