HUMAN FACTORS. Part 1 -The Genesis of Cockpit Resource Management

Captain Bob Henderson has been a staunch supporter of the Scholarship. As well as providing articles for this webpage, he has regaled us with marvelous stories of his time flying the C130 for the RNZAF.

He also happens to have been Air New Zealand’s Training Manager for the A320. In fact - he is also a whole lot more when it comes to Human Factors!

Here’s his FULL title - Captain (airline), Wing Commander (Air Force), A320 Training Manager (airline), Human Factors Manager (airline), HF researcher (University of Auckland Medical School), MSc (1st class hons) human factors, MNZM, AFC 😲

So we can comfortably say the pedigree of the author of this series of 4 articles on Human Factors is impeccable!

Every CPL student studies HF now and this training continues throughout a pilot’s career and we recommend this series (being published consecutively over the next three fortnights) be read to deepen understanding on why it is essential for aircraft safety.

Captain Bob Henderson

In 1977 two Boeing 747 aircraft collided on the runway at Tenerife airport. Both aircraft were fully serviceable; both crews were experienced; Air Traffic controllers were on duty; the radios in the aircraft and the tower were all working.

How was it that 583 people lost their lives?

This question troubled accident investigators and NASA.

The history of aviation is plagued with fatal accidents. Early aircraft were prone to mechanical failures, engines were unreliable, engineering practices were (by today’s standards) primitive. And even when aircraft had two engines, their ability of continue to fly on one only was marginal.

Over time aircraft engineering practices and engine technology improved, especially with the development of the turbine powered engine.

Then in the mid-1970’s a trend became apparent – that perfectly serviceable aircraft were crashing and this suggested something other a mechanical basis for the event - albeit with the beauty of hindsight one can’t help but wonder why this concern was not raised earlier.

In 1972, there were two sentinel accidents. The first, on 18 June 1972, killing all 118 people on board, involved a Hawker Siddeley Trident and became known as the Staines air disaster. The aircraft suffered a deep stall in the second minute of its flight and crashed to the ground, narrowly missing a busy main road, following the premature retraction of the leading edge devices. Recommendations from the inquiry led to the mandatory installation of cockpit voice recorders (CVR) in British-registered airliners.

Staines Air Disaster news headline.

The second was a scheduled flight from John F. Kennedy International Airport to Miami International Airport, Florida. Shortly before midnight on December 29, 1972, the Lockheed L-1011-1 TriStar crashed into the Florida Everglades, causing 101 total fatalities. All three cockpit crew members, two of the ten flight attendants, and ninety-six of the 163 passengers were killed; seventy-five people survived. The crash occurred while the three cockpit crew were preoccupied with a burnt-out landing gear indicator light. The captain bumped the yoke on the aircraft, causing it to turn off the autopilot. Due to the focus on the landing gear and the minimal changes in the cockpit, the pilots did not notice. Because of this, the aircraft gradually lost altitude and crashed. The sequence of events leading up to this accident were visible to the aviation world because the aircraft was fitted with a CVR. It was proof that a fully serviceable aircraft came down through, what became euphemistically know as “pilot error”.

Lockheed Tristar Crash, Florida Everglades

The 1977 Tenerife accident followed. The collision occurred when a KLM flight initiated its takeoff run in dense fog while a Pan Am flight was still on the runway. and, again, due to CVR tapes, it was apparent that there were miss-communications and miss-understandings between the pilots on both 747 flight decks and the tower controller while the aircraft manoeuvred on the ground. The airport had become congested with parked airplanes blocking the only taxiway, due to multiple diversions from Gran Canaria Airport as a result of a bomb explosion. Departing aircraft had to taxi on the runway while patches of thick fog were drifting across the airfield reducing visibility for pilots and the control tower.

Worst Air Disaster in History. Tenerife Airport. Two B747s

Cockpit Resource Management (CRM), as a concept, grew out of the Tenerife accident, when, a few weeks later, NASA held a workshop on the topic, endorsing this training, based on a study that showed crews that communicate competently usually managed in-flight simulated emergencies better than crews who had a strongly hierarchical structure.

Then in 1978 a United Airlines DC8 Flight 173 crashed when it ran out of fuel over on a fine night in clear weather at Portland, Oregon, while troubleshooting a landing gear problem. A recommendation by the National Transportation Safety Board (NTSB), following the investigation, resulted in CRM being formally adopted in the USA.

Portland, Oregon DC8 crash

The term "cockpit resource management"—which was later generalized to "crew resource management"—was coined in 1979 by NASA psychologist John Lauber, who for several years had studied communication processes in cockpits.] While retaining a command hierarchy, the concept was intended to foster a less-authoritarian cockpit culture in which co-pilots are encouraged to question captains if they observed them making mistakes.

United Airlines was the first airline to launch a comprehensive CRM program, starting in 1981. By the 1990s, CRM had become a global standard.

United Airlines also trained their flight attendants to use CRM in conjunction with the pilots to provide another layer of enhanced communication and teamwork. Studies have shown the use of CRM by both work groups reduces communication barriers and problems can be solved more efficiently, leading to increased safety. CRM training concepts have been modified for use in a wide range of activities including air traffic control, ship handling, firefighting, and surgery, in which people must make dangerous, time-critical decisions.

 TO COME

Part II – Slips, Lapses, Mistakes, and Violations (Prof Jim Reason)

Part III – The Evolution of Threat and Error Management (Prof Bob Helmreich)

Part IV – The Science of Human Factors (Rasmussen, Reason, Helmreich, Hollnagel)