CRM: FROM THE INSTRUCTOR VIEWPOINT
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:
- FLAPS 8 DEPARTURE: Not verifying flap position. I have seen flaps
either not being selected at all, or takeoffs with full flaps (usually after
- FLY RUNWAY HEADING TO 3000 FEET: Normally, this is not a problem.
However, I have observed significant course deviations after a V1 cut
because they PF had a hard time “keeping it under control.” Just because
you are flying on a single engine, you are not relieved of your ATC
clearance. And why is the PF not making a significant deviation callout
before it gets to 40º? A 40º course deviation is NOT acceptable because
you've lost an engine. If you don't believe me, try it on a checkride!
- 80 KNOTS CROSSCHECK: What are we crosschecking? The primary purpose
of this callout is to verify that both airspeed indicators are alive and
indicating approximately the same speed. This is done by the PNF, since the
PF has his head out the window during the takeoff roll. What amazes me is
how many times I have failed the PF's airspeed indicator to 0, and the PNF
has made the callout “80 knots crosschecked!”
- BETWEEN 80 KNOTS AND V1, WE WILL ONLY ABORT FOR ENGINE FAILURE, ENGINE
FIRE, CATASTROPHIC FAILURE, OR LOSS OF DIRECTIONAL CONTROL: Such a
critical part of the brief, yet, in the scheme of things, I've seen quite
a variety of deviations. There is a good reason we don't abort for
“non-critical items” above 80 knots, particularly if your runway is on
the shorter side. The risk of running off the end of the runway is most
likely going to be greater than the problems we have to deal with after
takeoff for a single GEN (generator) light. The same is true for an
illumination of the ALC AI (alcohol anti-ice) light at high speeds. Would
you really want to abort a takeoff for this? On the other side of the coin,
I have seen pilots lose an engine well before V1 and continue the takeoff!
Didn't we brief that that was one of the high-speed abort scenarios? The
point is, this is a very critical area and pilots need to make sure that
they execute the plan exactly as it was briefed.
- THE ABORT CALLOUT: The actual ABORT callout itself is another
area worth mentioning. Once again, in the PF's takeoff briefing (which may
delegate the ABORT callout to the PNF), I have seen too many pilots perform
an aborted takeoff but failed to make the ABORT callout! (this callout
should actually be made three times, ABORT, ABORT, ABORT). Let's say the
PF decides to ABORT for an engine failure. He is the first one to notice it
and decides to reject the takeoff. The PNF, doing his duties inside the
cockpit, has no idea what is happening. He is simply along for the ride. If
the PF had actually called the ABORT, the PNF would have known what was
expected of him, since that was part of the takeoff briefing! Maybe the PNF
was supposed to deploy the drag chute or arm the thrust reversers on the
ABORT callout, but since there was no callout, he had no clue as to what was
going on. I think you get my point.
- 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:
after V1, we are dedicated to go flying, whether we like it or not! Even
though V1 is referred to as “takeoff decision speed,” our decision has
been made for us. That is why we are gently (sometimes not so gently)
reminded to remove our hand from the throttle when the V1 callout is made.
Occasionally, I see a pilot decide to ABORT after V1. As you may have
guessed, their logic is that they have a long runway. And although a
10,000-foot runway may physically give you that comfort, legally we need to
follow the rules, regardless of runway length. The second part of this
problem lies in what should (or shouldn't be done) during our climb to a
“safe altitude, clear of obstacles, and stabilized.” There is a huge
amount of ambiguity here and here lies an area that can turn ugly, fast!
Let's break this down further:
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
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
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.
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.
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
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The Editor of this Web Page, now retired, was an
airline pilot for 33 years and holds 6 specific Captain's type-ratings
on Boeing Jet Airliners.