Crew Resource Management (CRM)

What is CRM and why do it?

Crew Resource Management (CRM) is a set of principles and procedures designed to minimize human error in a team where errors could cause a crisis. In fact, some principles are especially useful when managing a crisis.

CRM originated from the study of air crashes, which found that human error was the biggest single factor causing crashes. Mistakes in communications resulted in people becoming unaware of their situation, breakdowns in teamwork, poor group decision-making, wrong decisions, and wrong series of decisions. Other signs of human errors were lack of leadership and poor management of tasks and resources.

Later, people noticed that CRM would be useful to reduce human error in other industries.

Good CRM practice has the following characteristics:

• It actively involves everyone in the team.
• It focuses on attitudes and behaviors and their effects on safety.
• Team members evaluate their own behavior and teamwork, and make decisions on ways of improving.
• Teams needs recurrent refresher courses to maintain their skills.
• CRM needs to be incorporated into all aspects of training, rather than treated as a separate skill.
• Team members should normally practice CRM in low-stress situations so that they are more likely to use it effectively in emergencies.

How to do CRM

Communication and decision-making

Team members need to communicate freely, openly, and unambiguously with each other, so they can provide necessary information at the appropriate time. For example, they might initiate a checklist or alert others to a developing problem.

Interpersonal communication is affected by various factors:

• The skills of the particular people involved, such speaking skills, listening skills, decision-making skills, conflict resolution techniques, and the use of appropriate assertiveness and advocacy.
• The context: communication barriers such as rank, age, gender, and organizational culture, including the identification of inadequate procedures.

Good decisions minimize errors, while poor decisions can increase them. Poor decision making is a leading cause of errors, and each decision affects your future options.

The aspects of making a decision are usually as written below. They need to be seen holistically, because different decisions don't always follow the same steps or use the same order:

1. Assess the problem.
2. Look at the time frame. (Do I need to make the final decision now? If I don't, what is the exact decision I need to make now?)
3. Gather the information you need to make a decision and verify it.
4. Identify possible solutions and evaluate them.
5. Consider priorities.
6. Assess the risks. (Do I have accurate information? Is it complete?)
7. Anticipate the consequences of decisions.
8. Inform others of your decision and your rationale.
9. Monitor implementation.
10. Evaluate you decisions.

Several factors promote good decision making:

• Free and open communication among team members encourages them to actively participate in making decisions.
• You'll make a better decision if you have extra time. If you are short of time (which is normal in an emergency) consider your procedures and the available information, then select the best available option.
• You'll also make a better decision if you have thought through the general issues beforehand and analyzed a number of cases.
• Cross-check any inaccurate or ambiguous information. Even so, you may still have to go with the best information you have at the time, especially if you have to make a deadline. Just check your risks.
• Evaluate the rationale for your decision, especially if you feel under pressure to perform.

Specific skills:

1. Learn specific techniques of seeking and evaluating information.
2. A team leader’s briefings should include any relevant CRM issues.
3. You'll need effective techniques of resolving disagreements among team members, such as interpreting information and proposing courses of action. They need to maintain open communication while dealing with conflict.
4. Team members should clearly state operational decisions to other team members.
5. Team members should acknowledge their understanding of decisions.
6. Establish and communicate bottom lines for safety.
7. Be aware of influence of biases and other cognitive factors on decision quality.
8. Share the "big picture" and the game plan with the whole team.
9. If you are the person in charge and a specific problem arises, delegate it to somebody to solve and leave them to it. If everybody focuses only on a specific problem you might not notice a serious problem. As person in charge, you need to keep your eyes on the whole picture, so don't let a specific problem distract you from overall responsibility.
10. Try to provide an atmosphere that invites open and free communication.
11. Give teams some models of how to make decisions as a team. Team members can then refer to the models to make good choices in situations when they have incomplete or contradictory information.
12. If you use any automated systems, verbalize and acknowledge initial entries and changed entries.

Challenge and response

The most controversial aspect of CRM that has been the "challenge and response" environment. In the past, the pilot was trained to give orders and subordinates were trained to take them without questioning. But in some cases, the subordinates had important information that would have resulted in a different order, had the pilot known, so the pilot made an error.

In good CRM practice, the subordinate respectfully and succinctly checks that the person in charge has the necessary information. In fact, some would say that they should speak up and persistently state their information until there is some clear resolution.

More conservative senior people didn't like the way that a direct order could be questioned, but this was largely a misunderstanding. The person in charge still has the right to make the decision and to give orders. The subordinate must still take the order, because he/she is often unaware of other information that the person in charge considers in the decision.

Here's how Wikipedia explained it:

Cockpit voice recordings of various air disasters tragically reveal first officers and flight engineers attempting to bring critical information to the captain's attention in an indirect and ineffective way. By the time the captain understood what was being said, it was too late to avert the disaster. A CRM expert named Todd Bishop developed a five-step assertive statement process that encompasses inquiry and advocacy steps:

• Opening or attention getter - Address the individual. "Hey Chief," or "Captain Smith," or "Bob," or whatever name or title will get the person's attention.
• State your concern - State what you see in a direct manner while owning your emotions about it. "We're low on fuel," or "I think we might have fire extension into the roof structure."
• State the problem as you see it - "I don't think we have enough fuel to fly around this storm system," or "This building has a lightweight steel truss roof. I'm worried that it might collapse."
• State a solution - "Let's divert to another airport and refuel," or "I think we should pull some tiles and take a look with the thermal imaging camera before we commit crews inside."
• Obtain agreement (or buy-in) - "Does that sound good to you, Captain?"

These are difficult skills to master, as they require a change in interpersonal dynamics and organizational culture.

Assertiveness comes up as an important factor in the "challenge and response" environment, because staff need to communicate clearly. Passive people easily too chicken out when they should be putting a point across. It can take some effort for passive people to learn to express a message clearly, concisely and bluntly.

Assertiveness is being willing to actively state and maintain a position until shown that other options are better. It requires the initiative and the courage to act.

Some people can be too passive because they lack confidence, or fear reprisals if they speak up. Other causes are that the other person has a position of authority or much more experience.

People who are too aggressive create an unhelpful tension that can either distract attention from the message or create resistance to it. In fact, it's possible to display behavior as a continuum from passive to over-aggressive, with assertiveness in the middle:

Passive Overly courteous "Beats around the bush" Avoids conflicts "Along for the ride."

Assertive Actively involved Ready to take action Provides useful information Makes suggestions

Over-aggressive Dominates Intimidates Abusive or hostile

Adapted from Naval Aviation Schools command website (www.netc.navy.mil)

Specific skills:

1. Develop a "challenge and response" environment. Consider it routine when people question actions and consider decisions.
2. Maintain a proper balance between respecting authority and practicing assertiveness.
3. Encourage team members to state their own ideas, opinions, and recommendations. Team members can advocate a course of action that they feel is best, even though it may involve conflict with others.
4. Encourage questions and answer them openly and nondefensively.
5. Question the actions and decisions of others.
6. Be assertive without being over-aggressive.
7. Seek help from others when necessary.
8. Offer other team members help when they look like they need it.
9. Question the status and programming of automated systems to confirm situation awareness.

Team building

This topic includes interpersonal relationships and practices, group climate, and effective leadership/followership.

Recognize the symptoms and effects of stress and fatigue in yourself and in others, and their effects on performance. For example, take notice of "tunnel vision" and seek help from the team. If you see that a team member is not communicating, draw him/her back into the team. Look at these specific skills:

1. Be sensitive to other team members’ personalities and styles, and make adjustments.
2. Keep the "tone" in the workplace friendly, relaxed, and supportive. But keep it task-oriented as well.
3. Continually monitor and adjust the group climate appropriate to the situation (e.g., allow social conversation during low workload, but not high).
4. An effective leader continues to coordinate activities and stay centered on the goals of safe and efficient operations.
5. Use all available resources to get the job at hand done.
6. Be decisive when the situation requires.
7. Show that you really want to do a good job of your task.
8. You still need to follow procedures correctly.
9. Keep calm under stressful conditions.
10. Recognize signs of fatigue and stress, and take appropriate action.
11. During times of low communication, check in with other team members to see how they are doing.
12. Manage the time available for the task.
13. Automated systems can make demands on resources, so manage them carefully.

Workload management and situation awareness

These skills relate to teams anticipating contingencies and the various actions that may be required. Excellent teams are always "ahead of the curve" and generally seem relaxed. They devote appropriate attention to required tasks and respond without undue delay to new developments. (They may engage in casual social conversation during periods of low workload and not necessarily diminish their vigilance.)

Keep aware of the operational environment and keep team members very aware of the situation. Good perception depends partly on accurate communication. Maintaining situational awareness means that you can perceive it accurately, without distortion caused by presumptions, distractions, lack of attention, boredom, stress or fatigue.

Consider practices that result in higher levels of situation awareness such as

• Preparation, planning and vigilance. Consider improving the ways you prepare in advance for required activities, anticipate contingencies, monitor and accomplish tasks, ask for new information, and respond to new information.
• Avoiding distractions and distributing workload. Make sure nonessential factors don't distract team members from critical tasks in particular and required procedures in general.
• Task allocation. Be careful how you allocate tasks to team members so you avoid overloading them, and prioritize tasks during times of high workload.

These specific skills relate to time and workload management. They reflect how well the crew manages to prioritize tasks, share the workload, and avoid being distracted from essential activities.

1. Planning
1. Include all appropriate team members in planning and then make sure that they are all aware of plans and of any changes in plans.
2. Keep ahead of the curve in preparing for planned situations or contingencies. Then when in a critical situation you will be able to maintain situation awareness and follow procedures.
3. Automated systems can be quite distracting. If you use them, anticipate how they could be distracting and prevent it. You may even have to reduce or disengage automated features as appropriate.
2. In a crisis:
1. Demonstrate and express situation awareness, for example by informing other team members what is happening.
2. Actively monitor any incoming information (e.g. communications, instrument readings) and inform other team members of anything relevant.
3. Speak up when you recognize work overloads in yourself or in others.
4. Avoid "tunnel vision" caused by stress (e.g., stating or asking for the "big picture").
5. Keep aware of factors such as stress that can make you less vigilant, and watch for team members who aren't doing their job as well as they should.
6. Distribute tasks in ways that maximize efficiency.
7. Communicate workload distribution clearly and get team members to acknowledge it.
8. Communicate task priorities clearly.
9. Don't let non-operational factors (such as social interaction) interfere with duties.
10. Prioritize non-essential tasks so you have enough resources for essential tasks.

Individual factors and stress

Many team members are unfamiliar with the negative effects of stress and fatigue on their cognitive functions and team performance, especially in potential emergencies.

You might also want to learn more about:

• the effects of personal and interpersonal problems
• the increased importance of effective interpersonal communications under stressful conditions
• how to cope with things that make you stressed
• The effects of personality and motivation characteristics
• self-assessment of personal style, and
• cognitive factors that influence perception and decision-making.

Error management

We can't completely eliminate errors, so we need to learn ways of managing them. There are different models of error management, but I suggest the following questions as my model:

• When and how do you detect errors if not at the time they occur?
• How do you detect errors at the time they occur?
• How do you minimize their effects?
• How do you recover from them?
• How do you analyze them so you can prevent them in the future?

Culture issues

While individuals and even teams may perform well under many conditions, they are subject to the influence of at least four cultures:

• the professional cultures of the individuals themselves,
• the cultures of their teams and local branch of the organization,
• the cultures of their whole organizations, and
• national cultures surrounding the individuals and their organizations.

Your CRM training needs to recognize and address these cultures to ensure they don't negatively affect team performance.

Staying flexible

You may need to be very flexible if new information becomes available and you have to change your course of action.

1. Anticipate problems.
2. Recognize any change and acknowledge it
3. See what kind of response is appropriate. You may be able to follow a standard procedure, or you follow an Habitual Response.
4. Offer alternative solutions
5. Help other people if they need it.
6. Ask for help if you need it yourself.
7. Interact constructively with others

Debriefing

One of the best techniques for training and reinforcing effective practices is to carefully debrief and analyze and critique what people did. They can be either real critical incidents or simulations, and times of either low or high workload.

It's essential that each team member can recognize good and bad communications, and effective and ineffective team behavior.

If you are the debriefing facilitator, lead the team through a self-critique of their own behavior and of their performance. At the end of the session, participants need to take away a strong sense of training accomplishment and learning.

It can be even more effective if you use video recordings of incidents during debriefing sessions. Select segments for discussion that show specific behaviors. (Erase recordings of simulations and classroom activities afterwards for privacy reasons.) Video recordings are especially compelling because they capture strengths and weaknesses and display them vividly to participants, who get to see themselves from a third-person perspective.

Specific hints:

1. Actively state the debriefing and critique agenda and ask the team for topics that they'd like to cover. You can include both CRM topics and any technical task-specific topics.
2. Set time limits and keep to them.
3. Ask the team for their appraisal of the job overall.
4. Discuss both positive and negative points of team performance.
5. Highlight the processes that were followed, coordination concepts and specific behaviors.
6. Make sure that all team members participate in the discussion, and draw out quiet or hostile team members.
7. State your own perceptions, but guard against making the team defensive. Keep your comments as objective as possible and focus on performance.
8. Make it a positive learning experience.
9. Give feedback that is specific, objective, usable, and constructive.
10. Don't preach.
11. Don't omit items worthy of team discussion.
12. Be patient.
13. Help team members to accept critique objectively and nondefensively.
14. Be constructive in probing into key areas where improvement is needed.
15. Ask the team for specific feedback on your performance.
16. At the conclusion of the session, give a clear summary of the key learning points for all participants, including the discussion leader.

How to establish CRM training

Effective CRM begins in initial training; it is strengthened by recurrent practice and feedback; and it is sustained by continuing reinforcement that is part of the corporate culture and embedded in every stage of training.

Good training tends to use a range of learning activities:

1. Debrief and analyze critical incidents, including near misses.
2. People should assess their own skills and those of team members.
3. Use activities to solve problems in groups.
4. Use role plays to get practice in developing strategies.
5. Give psych. tests for attitude temperament and/or personality and tell participants how they went. They will be better able to assess their own strengths and weaknesses.

Component 1: Before you start

You'll need to design your training to suit the kind of organization and its particular needs, so you should assess it. What do people already know about CRM? Do you need to survey people, analyze incident reports, or look at current procedures?

Get a commitment from all managers, starting with senior managers. It's basically good change management. Staff will accept a CRM program much more readily if they see that managers are supportive. The program might also need management support in other ways too, such as scheduled time for training, resources, and opportunity for CRM input when procedures are reviewed.

Manager support is especially necessary because supervisor can find CRM threatening. People in leadership sometimes feel threatened when subordinates question an order to check information (see below).

CRM should become an inseparable part of the organization’s safety culture. In particular, all levels of management need to support a culture that promotes appropriate questioning. Training and procedures should clearly encourage appropriate questioning and get the message through that there will be no negative repercussions for staff who appropriately question a decision of a superior.

Component 2: Initial Awareness

Effective CRM training includes initial awareness. This is typically a series of classroom presentations that focus on communications and decision-making, interpersonal relations, team coordination, leadership, and adherence to standard operating procedures, among others. This develops and defines CRM concepts, and relates them to operational safety. It also gives staff a common conceptual framework and a common vocabulary for identifying team coordination problems.

Initial awareness training often comprises a combination of training methods, such as lectures, audiovisual presentations, discussion groups, role-playing exercises, computer-based instruction, and videotaped examples of good and poor team behavior. It normally requires a curriculum that addresses CRM skills, defines CRM concepts involved, and relate directly to operational issues that staff encounter.

Many organizations have found it useful to survey staff. Surveys have helped to identify embedded attitudes regarding team coordination and management, to identify operational problems, and to prioritize training issues. In turn, that understanding often has a favorable effect on individual attitudes regarding human factor issues. The training also frequently suggests more effective communication practices.

However, classroom instruction alone does not make fundamental long-term changes in staff attitudes. Awareness training is simply a necessary first step towards effective performance training.

Component 3: Recurrent practice and feedback

Good CRM training always includes continual reinforcement, including recurrent practice and feedback. The reason is that introductory awareness doesn't make long-term behavioral changes. So include CRM as a regular part of your organization’s recurrent training.

It should contain classroom or briefing room refresher training to review and amplify CRM components, followed by practice and feedback exercises, improving skills and receiving feedback on their effectiveness. Feedback is most when it comes from self-critique and from peers, together with guidance from a facilitator with special training in assessment and debriefing techniques.

References

This version was based on "Crew Resource Management Training" Advisory circular no. 120-51E, dated 1/22/04 U.S Department of transportation, Federal Aviation Administration.

Some materials were adapted from the Naval Aviation Schools Command website e.g. https://www.netc.navy.mil/nascweb/crm/standmat/seven_skills/AS.htm

"http://en.wikipedia.org/wiki/Crew_Resource_Management" as last modified on 14 Dec. 2008.

 

Other sources

Many aviation safety websites contain valuable materials that can be helpful in developing CRM training. Websites commonly link to other websites containing related material. Aviation-related websites maintained by U.S. Government agencies include the following:

1. National Aeronautics and Space Administration (NASA), http://www.nasa.gov.
2. National Transportation Safety Board (NTSB), http://www.ntsb.gov.
3. Federal Aviation Administration (FAA), http://www.faa.gov.

See also "The Evolution of Crew Resource Management Training in Commercial Aviation" Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm http://www.fylrr.com/archives.php?doc=Pub235.pdf

Crew Resource Management (CRM) Training: Guidance For Flight Crew, CRM Instructors (CRMIS) and CRM Instructor-Examiners (CRMIES) This textbook was published by the Safety Regulation Group of the Civil Aviation Authority in the UK and is available at www.caa.co.uk. It is very good for summarizing CRM and adapting it to non-aircrew applications.