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Guest Editorial:

CRM: FROM THE INSTRUCTOR VIEWPOINT

 By Robert Baron (robert@aviationcrm.com)

 

In my years of being a flight, ground, and simulator instructor in high performance jets, I have had the pleasure of observing a plethora of behaviors in the area of Crew Resource Management. Additionally, as a CRM facilitator, I sometimes have access to the stories and confessions that some pilots are willing to share in a casual, relaxed setting. That said, I wanted to share some observations and recommendations for any person making an attempt to enhance their CRM skills.
        A brief history of CRM might be appropriate. One of the most clear cut examples of a human factors error occurred in 1972, when Eastern Flight 401 gradually descended into the Everglades as all three crewmembers became fixated on a landing light indication and the autopilot became disengaged. Other notable human factors-related accidents included United Airlines Flight 171 simply running out of fuel over Portland, Oregon in 1978. Nobody was paying attention! In 1982, Air Florida Flight 90 was not properly de-iced and crashed shortly after takeoff from Washington, DC. Contributing to this accident was the flightcrew's disregard for standard operating procedures. In 1985, Delta Flight 191 was caught in an unreported windshear on final approach to the Dallas/Fort Worth Airport.
        Crew Resource management, formerly known as Cockpit Resource Management, has its roots at United Airlines, where in 1980, a formal training program was set up to concentrate on the human factor in aviation. Airlines were noticing that although pilots were technically competent, their people skills were deficient. In other words, the captain could fly a perfect ILS approach, but could not work in a synergistic environment to effectively accomplish tasks. This can create a potentially dangerous and antagonistic situation. CRM, amongst other things, teaches pilots how to improve communication, prioritize tasks, delegate authority, and monitor automated equipment. Prior to United's program, the mentality in the business was “the captain is God, and what he says goes.” Thankfully, we have long thrown that thinking out the door! United's program is now called C/L/R (Command/Leadership/Resource Management). Other airlines have followed suit and CRM is now required training for all Part 121 (airline) operations. For all other operations, CRM is a prudent supplement to normal training.
        When I am instructing students in the Learjet, I put a heavy emphasis on CRM and working together as a crew. Many instructors, particularly less experienced ones, simply train the maneuvers in order to pass the checkride. My approach focuses not only how to perform the maneuver to FAA Practical Test Standards, but also how to perform the maneuver as a team. Occasionally, I need to remind the students that the Learjet is certified as a two-pilot aircraft. I expect it to be flown that way!
        To illustrate this point, let's say we are going to do steep turns. If the PF (Pilot Flying) does not try to tap the help of the PNF (Pilot Not Flying), a relatively simple maneuver like steep turns can become a nightmare. A good PNF, making the right callouts, can make the PF's life a lot easier! What kind of callouts are we talking about? Altitude and airspeed deviations for one. If the maneuver is to be done at 10,000 feet and 250 knots, the PNF is in a great position to monitor and make the necessary callouts to keep the PF on track. Bank angle is also important. Bank angle for steep turns is usually 45º. The PF should make callouts when there are significant deviations here as well. The FAA Practical Test Standards book will point out exactly how much tolerance is acceptable based on the rating sought, and should be used as a guideline for standard callouts. Another nice callout is the 90º, 30º, 20º and 10º rollout headings for your starting heading (that you had previously bugged). The PF may also have the PNF make minor power changes to adjust airspeed. This is perfectly acceptable!
        The point is, even on a simple training maneuver, the use of all available resources (i.e.; PNF) can be a huge benefit. Many pilots, however, have little or no experience in CRM or cockpit management. Or, perhaps they are getting into their first two-pilot flight deck. When they come for training, to paraphrase an earlier statement, most are technically competent, but their people skills are deficient. Let's take a look at some recurring CRM behaviors I have observed and analyze their outcomes. To keep the size of this paper manageable, I will only highlight examples from three different task areas. These will include the takeoff briefing, in-flight emergencies, and a normal ILS approach to a missed approach.

THE TAKEOFF BRIEFING

        The takeoff briefing is one of the most important briefings during the course of a flight. Yet, I have seen a multitude of problems in this area. My philosophy is “fly as you brief and brief as you fly.” This just means that you are going to do what you said you would do. As an example, I have listened to captains give a wonderful, detailed, and illustrious briefing that sounded something like this:
 

  “This will be a standard flaps 8 departure, fly runway heading to 3000 feet. I'll have you set power on my command. Call out Power Set, Airspeed Alive, 80 Knots Crosscheck, V1, Rotate, Positive Rate, Gear Up, Yaw Damper Engaged. Any malfunctions below 80 Knots we will abort the takeoff. Between 80 knots and V1, we will only abort for engine failure, engine fire, catastrophic failure, or loss of directional control. I will call the abort and have you deploy the drag chute OR arm the thrust reversers on my command. Any malfunctions after V1, we will continue the takeoff, climb to 1500 feet, and treat it as an in-flight emergency, going to the appropriate checklist once we reach a safe altitude, clear of obstacles, and stabilized. We will return to Runway 9L. Any questions?”

        Sounds good to me! But guess what? 75% of the time that wonderful briefing is thrown out the door and the abort or takeoff procedure is deficient. Many times the event terminates as running off the end of the runway, or becoming airborne and crashing after an engine failure at V1. Yes, adhering to your takeoff briefing is THAT important!
        Although this takeoff briefing is typical for the Learjet, other aircraft will be very similar. I will break down the takeoff briefing into subparts and analyze each separately:


WHAT SHOULD BE DONE (below 1500 feet)
1. FLY THE AIRPLANE
2. FLY THE AIRPLANE
3. SEE #1AND #2
4. Perform checklist MEMORY items, (if applicable).
5. Contact ATC only to let them know you have a problem and you will need to maintain “runway heading and 1500 feet”      (or a safe altitude). This should be done just to alert ATC of your problem and so they can adjust traffic accordingly. Until you figure out what is wrong, you should hold off on declaring an emergency. You need to climb to a safe altitude first, get stabilized, retract the flaps, and then analyze the situation. You may very well have a true emergency, but declaring it at 300 feet agl (above ground level) is only going to saturate the PNF with excessive radio inquiries.

WHAT SHOULD NOT BE DONE (below 1500 feet)
1. Reading checklists (other than MEMORY items, if applicable).
2. Address the problem (other than what's required to maintain aircraft control, you should not be resetting switches, pulling back throttles, pulling FIRE T-HANDLES, etc.).
3. Having long conversations with ATC.
4. Fuel jettisoning

        Actually, this list could go on and on, but I think you get the point! Just fly the airplane until you are at a safe altitude and clear of obstacles. If you have figured out that I have seen many things that should not have been done at a particular time, you are absolutely correct! I have been in many crashes (albeit virtual, thankfully) because the PF wanted to do everything right after an engine failure on takeoff; talk on the radio, pull the FIRE T-HANDLE, jettison fuel, etc. Not only is this ANTI-CRM, and not standard operating procedure, but there tends to be a reversion to single-pilot tendencies when all hell breaks loose as well!

THE IN-FLIGHT EMERGENCY

        Let's start this topic by mentioning some of the interesting things I have observed in the simulator. One of the biggest psychological lessons that I teach is what I call the “see what you want to see syndrome.” The idea of seeing what you want to see in an airplane cockpit is very real! To cite a couple of examples, let me give you two of my favorite scenarios:

SCENARIO #1 (GEAR ELECTRICAL FAILURE)

  On the takeoff roll, I give a Landing Gear Electrical Failure, so when the PF calls for “gear up,” the gear actually remains down and locked! After the PNF makes the call “positive rate,” the PF calls for “gear up,” and the PNF gladly puts the gear handle in the up position and hastily calls “gear up.” A few minutes later, the PF calls for the After Takeoff Checklist, which includes Landing Gear-UP. The PNF responds that the gear is up! What's wrong here? When the PNF is first instructed to bring the gear up, he does. And just because the gear HANDLE is in the UP position, he sees what he wants to see, even though there is a loud rumbling noise and the aircraft will not accelerate like normal, not to mention that there are THREE GREEN DOWN AND LOCKED GEAR LIGHTS ILLUMINATED IN FRONT OF HIM! I would say that approximately 80% of the pilots I train fall victim to this “trap.” And not surprisingly, I often get both the PF and PNF together on this one!

SCENARIO #2 (NOT CHECKING CIRCUIT BREAKERS/GAUGES)

  This is another one of my favorites in the “see what you want to see” department! During the approach checklist, we are supposed to check circuit breakers on both the pilot and co-pilot side panels. What gets me here is that most pilots say “breakers in on my side” and DON'T EVEN LOOK AT THE PANEL! Or, they simply run their hands over a couple of rows and say they are all in! Why? Because they are assuming all the breakers are in because they have never had one popped out. Guess what the instructor does when he sees this behavior? You got it. One of those breakers that they “missed” is now popped and guess what that breaker protects? It might just be the landing gear, but it definitely won't be the COFFEE MACHINE!
  The same holds true for pressure gauges. When you check the air, oxygen, and hydraulic pressure gauges, make sure you're really seeing what they read, rather than what you expect them to read. 

        Although these things may seem minor at first, they can easily become factors in the “error chain” later. My advice is to always scan your panels. Every few minutes, take a good look at what's going on. Are the pressures good? Are there any popped circuit breakers? Are there any annunciator lights illuminated? Let's face it, most of the time there is not much to do during the enroute-phase. Take a look around once in a while…you may be preventing some surprises during a critical phase of the flight!
        Let's start the actual topic of in-flight emergencies with a real case study that I observed a few years back:

 DC POWER FAILURE/SITUATIONAL AWARENESS

   I had two fully qualified Learjet pilots in the simulator for recurrent training. During the training period, I gave them a dual GEN (generator) failure. This situation is considered an EMERGENCY because the only source of DC power is from the ship's batteries (which will supply backup power for only 30 minutes in this case). Because the batteries should keep everything energized after a dual generator failure, it is not the kind of emergency that is “in your face.” Rather, we need to pick up on visual clues. One visual clue will be the DC voltmeter indicating battery voltage. But a much bigger clue would be the two bright amber GEN lights illuminated on the annunciator panel! Coupled with the fact that the simulator is set up for night visuals, those amber lights are really an attention getter! Well, guess what? Neither pilot even realized that they had a dual generator failure for 15 minutes! Now you can understand the importance of scanning your cockpit once in a while. The inattention by these pilots eventually caused the ship's batteries to become depleted and they had to fly the aircraft only by reference to the little emergency “peanut gyro” with no navigation capabilities, and in IMC (Instrument Meteorological Conditions). That was not fun!

IN FLIGHT EMERGENCIES
CHECKLISTS
CRM

        This is an integrated topic since any abnormal/emergency scenario can yield the same disastrous results. When dealing with an in-flight emergency, the number 1 priority is….FLY THE AIRPLANE! This is a two-pilot crew, and nowhere else is CRM more important than during high-workload and/or emergency situations. Why does the captain (typically the PF) during an emergency, resort to being a single pilot? Maybe because he feels that the co-pilot (PNF) can't handle the situation. Maybe because if he does everything himself it “will be done right,” or perhaps he just has not had any real CRM training and this is his mindset. To make things even worse, I have seen captains completely disregard a checklist and just start troubleshooting problems from “experience.” Remember, in order to legally fly the airplane, both pilots must have a certain amount of systems and emergency procedures training within the preceding 12 months. Therefore, both pilots should be qualified to solve just about any problem that arises (in rare cases, you may be test pilots. Just ask Capt. Al Haynes from United Airlines!)
        So then, what is impressive CRM in this situation? In a nutshell, one pilot needs to be flying the airplane, while the other pilot performs the checklist procedures and talks on the radio. Tasks can be delegated, but generally this is the format. Believe me, each pilot will have their work cut out for them! Use of challenge and response checklist procedures is recommended. Also, make sure if you are using multiple checklists, and you have items that still need to be accomplished, use a sticky to remind yourself to come back to that checklist. At certain times, there may be three or four checklists being run concurrently.

THE NORMAL ILS APPROACH TO A MISSED APPROACH

        The final area I wanted to cover deals with a “normal” ILS approach to a missed approach. In this case “normal” means we have two operating engines, versus a single- engine approach. This scenario can also apply to a single-engine approach. The following case illustrates an ongoing problem:

THE PERFECT APPROACH---A DISASTROUS ARRIVAL

  The flightcrew sets up and briefs the ILS approach. The weather is reported as 200 overcast and ½ mile visibility (minimums). The PNF performs the APPROACH checklist, and the PF shoots a picture perfect ILS! Both needles are crossed right down to Decision Height! And then…they crash! What happened? At Decision Height, the PNF called “lights in sight,” the PF looks up away from his instruments and sees nothing but an array of white flashing lights. He gets vertigo (spatial disorientation), loses control of the aircraft, and balls it up in the approach light array. 

        ON LOW VIS APPROACHES, I CANNOT STRESS THE IMPORTANCE OF “STAYING ON THE GAUGES” UNTIL THE PNF CALLS RUNWAY IN SIGHT! This applies to the real aircraft as much as it applies to the simulator. If the PF transitions from the instruments to the outside without the actual runway in sight, there is a good chance he will become disoriented. I have seen this happen over and over again in the simulator and it either ends as a crash or a missed approach! To preclude this from happening, I highly recommend that the PF waits until the PNF calls out “RUNWAY IN SIGHT, ? CLOCK POSITION” before going visual.
        On the Missed Approach, there are also problems lurking. First and foremost, there is a saying that I want to reiterate: Always treat a takeoff as if you are going to lose an engine, and always think your approach will be a missed approach! This is pretty good advice, considering it keeps your thought logic a few steps ahead (mental preparedness). That said, it amazes me how many times I've observed a pilot having to “go missed” and just losing control (with no emergency or abnormal problems!).
        Remember, at Decision Height, one of two things will happen: We are either going to continue the approach to land (barring loss of visual clues or not in a position to land without aerobatic maneuvers), or we are going to execute a missed approach. Good CRM and communication between the crew at this critical phase is absolutely necessary!
        Standard callouts are another weak area. The importance of making callouts during the approach cannot be overemphasized. Although many operators have their own Standard Operating Procedures on what should be called out and when, the important part is that the callouts are actually being made. The callouts should be helpful and timely, but not overdone. I have seen many PNF's try to really impress the PF by making callouts every second! This just becomes a distraction to the PF.

THE CONCLUSION

        Hopefully, I have provided some insight into the real-life world of Crew Resource Management. Obviously, this is only the tip of the iceberg in my numerous observations. There is no place for a single-pilot operation in a two-pilot aircraft!
        CRM is no longer just for the “121 guys.” Any flight operation, Part 91 or Part 135, can benefit from a formal CRM training program. 

April, 2002

See also, CRM: The Missing Link


Robert Baron is the president and chief consultant of The Aviation Consulting Group, an aviation consulting firm with a core specialization in CRM/Human Factors training and research, and expert witness support for aviation law firms. He holds an Airline Transport Pilot Rating and has over 16 years of aviation experience, including a Line Captain, Instructor and Check Airman in Learjet aircraft. He's also type-rated in the Cessna Citation and holds a Flight Engineer Rating for Turbojet aircraft. His academic achievements include a Bachelor's Degree in Professional Aeronautics/Aviation Safety, a Master's Degree in Aeronautical Science with dual specializations in Aviation Safety/Human Factors, and is currently working towards a PhD in General Psychology with an emphasis on Aviation/Aerospace Psychology. Mr. Baron is also an adjunct professor at Everglades University, where he teaches Graduate and Undergraduate courses in Aviation Safety and Human Factors.  Mr. Baron can be reached at 1-954-803-5807. Company website is http://www.tacgworldwide.com.


Robert J. Boser    
Editor-in-Chief 
AirlineSafety.Com

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