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ADVANCEMENT OF CREW RESOURCE MANAGEMENT BEYOND AVIATION Abstract Crew resource management (CRM) is an essential tool within the aviation industry. Its value and effectiveness in the advancement of safe operations has been widely acknowledged by academia, industry, and regulators alike. Similarities exist between aviation and other high-risk industries such as medicine, nuclear power plants, and offshore oilrigs. Acknowledging these similarities, these organisations have adopted aviation CRM to improve safety and enhance threat and error mitigation.
This article will investigate the application of CRM and its variants within these organisations and discuss the benefits and limitations of its application. It is evident that CRM is an essential tool in improving the reliability of high-risk industries. Key words: CRM, RRM, ACRM, error, teamwork, communication Advancement of Crew Resource Management beyond Aviation Introduction Crew resource management (CRM) is now a widely accepted philosophy across many aviation organisations as an effective threat and error mitigation strategy in team performance.
Following several catastrophic aviation accidents, CRM was introduced in the aviation industry with the objective of improving coordination and corporation between crewmembers. Since then, through the evaluation of effectiveness of programs, CRM has now evolved as a counter measure to error propagation by promoting teamwork, coordination, situational awareness, good decision-making, and effective communication.
The success of CRM in the aviation industry has not gone unnoticed; other organisations that rely on teamwork for production outputs, particularly in the medical industry, have attempted to adopt aviation CRM within the context of such organisations as an error mitigation strategy. This assignment will focus on other high-risk organisations and there approach to threat and error mismanagement through the implementation of CRM type programs.
The paper will first discuss the characteristics of high hazard organisations (HHO) and its move towards high reliability organisations (HRO). Normal Accident Theory and High Reliability Theory will be explained in the context of HHO and HRO respectively. The assignment will then discuss the proliferation and the need for CRM in other HHOs. In doing so, it will present examples of accidents where the effective use of CRM principles may have prevented the occasioning of such accidents.
NOTECH skills, error management, and organisational influences will be discussed as drivers of CRM type training; the influences of each of these drivers in the advancement of CRM will be discussed. The limitations of CRM and its variants in high-risk environments will be briefly discussed. This paper will articulate that the adoption of CRM in high-risk environments outside the aviation industry, have advanced organisations from high-hazard to high-reliable organisations. From HHO to HRO
HHOs are by definition extremely complex systems that, through the very process of performing its core business, pose a significant threat to its employees and the communities it serves. According to Carroll, Rudolph and Hatakenaka (2002), the operations of HHOs are such that a single event can cause catastrophic outcomes leading to multiple fatalities, severe injuries, and equipment failure. Organisations within industries such as aviation, nuclear power plants (NPP), offshore oilrigs, rail systems, and health are all high-risk organisations with significant threat to humans.
The Pan American Airways and KLM crash at Tenerife on Mar 27th 1977 killing 549 passengers and crew (National Transportation Safety Board 1977); the Chernobyl nuclear reactor incident on Apr 26th 1986 that accounted for 30 fatalities and many more radiation injuries (United Nations Scientific Committee on the Effects of Atomic Radiation 2008); the Deepwater Horizon accident on Apr 20th 2010 which accounted for 11 fatalities, 17 injuries, the total loss of the rig, and the flow of Hydrocarbons into the ocean for 87 days (BP 2010); the Clapham Junction rail collision that accounted for 35 deaths and over 500 injuries (Reason & Hobbs 2003) are all examples of failures resulting in multiple fatalities and injuries. Further, in the health industry, 350 patients die in Australia each fortnight due to preventable adverse events (Richardson cited in Medew 2011). Typically, HHO espouse unique characteristics that place them in categories of high threat and risk. The most obvious of these is the nature of business it undertakes. The aviation industry is involved in mass transport of passengers and goods, both the offshore drilling and nuclear industries are involved in the production of mass energy, and the health industry is involved in the care of patients.
Delivering these objectives involves teamwork at all levels, interaction with highly technical and sometimes complex equipment, and decision making sometimes under sever time pressure. Centralised decision-making, product maximisation, organisational complexities, and competing priorities are other factors that are common in HHO that may lead to unintended safety threats (International Atomic Energy Agency 2005). However, the most fallible, the most significant contributor to threats, and one which is most relied on within the high hazard organisation is the human element. Statistics indicate that human error is identified as a causal or contributing factor to 80% of all accidents (Aas & Skramstad 2010).
With regard to HHOs, Perrow advanced the Normal Accident Theory (NRT) which suggests that, by its very nature of business, accidents in HHOs are inevitable (International Atomic Energy Agency 2005). An opposing view is the High Reliability Theory (HRT). This theory suggests that, while functioning in high hazard environments, organisations strive for safety reliability through the pursuit of error-free performance (Weick, Sutcliffe & Obstfeld 2008). Also known as HROs, such organisations advances learning from mistakes through a robust error reporting system, acknowledges that error is a by product of the human process, supports decentralised and flexible decision-making, and nurtures a strong safety culture (International Atomic Energy Agency 2005 ; Weick, Sutcliffe & Obstfeld 2008).
Contemporary organisations involved in high-risk activity are now applying principles of HRT to move towards high reliability. Organisations in industries such as nuclear power, aviation, health, and offshore oil platforms are moving towards high reliability through effective error management initiatives (Crichton & Flin 2004 ; Defense Nuclear Facilities Safety Board 2004). Embedded within organisational reliability is the acknowledgement of organisational influences in accident causation (Bourrier 2005). Complimenting this view is the systems approach to error management suggested by Reason (Reason & Hobbs 2003). In this approach, Reason argues organisational influences are, more often than not, a significant contributing factor to system failures.
Therefore, a move from high hazard to high reliability requires organisations to acknowledge that errors are as a result of organisational function, and effective management principles must be employed to prevent such errors from resulting in catastrophic failure. Because of the significance of the human factor as either a causal or contributing factor to accidents, focus on the mitigation and management of human error has earned prominence in the move towards a HRO. The training in and the application of human factors principles is leading the way as an effective systemic approach to safety management. Crew Resource Management (CRM) is on such tool used across many HROs (Crichton & Flin 2004).
Initially, developed for flight crews following aviation accidents that resulted in significant organisational, societal, and political impact (Salas et al. 1999), the application of CRM is supported across many other high reliability industries such as medical, shipping, offshore rigging, and NPP (Flin, O’Connor & Mearns 2002). Why CRM? In most cases, the human operator is competent and capable to adopt and adjust to various situations as a response to environmental stimuli; following effective training, mastery in technical skills can be achieved. However, as research suggests, non-technical (NOTECH) skills such as leadership, decision-making, communication, and teamwork are seen as significant contributors to accident causation.
According to the Federal Aviation Administration (FAA) (n. d. ), 66% of air carrier, 79% of commuter, and 88% of general aviation accidents were attributed to NOTECH skills such a those mentioned above. CRM was introduced to train operators in the NOTECH skills required to perform tasks safely (United States Department of Transportation 2006). In the aviation industry CRM is used to train aircrews in human performance limitations and the use of behaviours such as good communication, leadership, and interpersonal relations as error countermeasures (Helmreich 2000). NOTECH skills such as teamwork, leadership, and communication are not exclusive to aviation.
The use of these skills is evident across many other high-risk environments where group interaction is required to perform complex tasks (Flin, O’Connor & Mearns 2002). As such, industries such as NPP, rail, offshore oil rigs, and health have adopted CRM principles to avoid and mitigate error (United States Department of Transportation 2006). The rest of this paper will discuss the application of CRM beyond the aviation industry. Proliferation of CRM or equivalent in other industries The adoption of CRM principles in industries outside of aviation was as a result of the recognition that the human element was subject to similar operational dynamics and complexities which leads to the precipitation of human error. According to the U. S.
Department of Transport (2006), the requirement to perform high-stress, high-risk activities in team environments led to the adoption of CRM type training in industries outside aviation. CRM training was targeted at teams such as surgical teams, tank crews, oil platform crews, maritime bridge crews, and nuclear power plant operating crews (United States Department of Transportation 2006). In the health industry, surgical teams were provided with “Team Training” and Anaesthetists were provided with “Anaesthesia Crisis Resource Management” (Musson & Helmreich 2004). Similarly “Bridge Resource Management (BRM)” and Engine Room Resource Management (ERRM)” was the CRM equivalent in the maritime industry (Hetherington, Flin & Mearns 2006 p. 07-08), while “Rail Resource Management (RRM)” represented CRM in the rail industry (Rail Safety and Standards Board 2009 p. 2). Further, “Emergency Resource Management (ERM)” in the Oil and Gas industry (Flin & O’Connor 2001 p. 220) and “Human Performance Foundation (HPF)” course in the NPP (Flin, O’Connor & Mearns 2002) served as CRM training Need for CRM Case 1: an 8 year old boy who was admitted for elective eardrum surgery died during the surgery due to the anaesthetist failure to monitor and recognise patient complications during the surgery (Helmreich 2000). The investigation in to the incident found poor teamwork, communication, professional attitude and organisational factors as contributing factors (Helmreich 2000).
Case 2: On the 25th Mar 1998, a Norfolk Southern Corporation train 255L5 collided with Consolidated Rail Corporation train TV220. The investigation highlighted poor teamwork, communication, and coordination as contributing factors (National Transportation Safety Board 1999). As a result of this accident the NTSB (1999) recommended that CRM type training be adopted in the rail industry. Based on the above cases the need for CRM outside of the aviation industry was just as important as it was within. The objective of such training and adoption of principles was to avoid and mitigate human error using all available resources (Helmreich, Merritt & Wilhelm 1999).
The adoption of CRM in industry was to address key NOTECH skills such as situational awareness (SA), decision-making, leadership, communication, teamwork, and crew coordination (Hetherington, Flin & Mearns 2006 ; United States Department of Transportation 2006). The following paragraphs will discuss NOTECH skills, error management, and organisational influence as drivers for the adoption of CRM training. NOTECH skills NOTECH skills refer to those behaviours and attitudes that are not directly related to the technical and procedural aspects of performing the tasks but those which, when executed properly, are positively correlated with the successful outcome of the task (Klampfer et al. 2001). Further O’Connor and Flin (2003 p. 92) describe NOTECH as ” a prescribed set of behaviours which have been identified as indicative of some aspects of skilled human performance”. In understanding the criticality of training crews in NOTECH skills, BRM, ERRM, ERM, RRM and other alternatives to CRM training have all adopted NOTECH training in to the program (O’Connor & Flin 2003). Among others, Communication and teamwork were observed to be common and critical NOTECH skills delivered across many resource management programs (Flin, O’Connor & Mearns 2002 ; Helmreich 2000 ; O’Connor & Flin 2003 ; United States Department of Transportation 2006). Communication is an essential element in the effective and safe operation of teams, particularly in high-risk environments.
For example, in NPP, communication is vital because of the “distributed communication” and the communication gaps between hand-over/take-over activities (Fukuda & Strater 2004). Indeed the latter was identified as a contributing factor in the Cullen report of the Piper Alpha disaster (Flin & O’Connor 2001). Further, by the very nature of its operation, high-risk activities can place crews in elevated threat and error levels within a short space of time narrowing the capability to communicate and interact effectively; if not anticipated and communicated effectively, such situations can lead to fatal accidents (Hausler et al. 2004). Research indicates that, in the medical field, lack of communication between members of a surgical team has led to medical error (Kao & Thomas 2008).
Therefore the need to improve communication skills within and between teams is paramount and, as assessed by Chidester, Helmreich, Gregorich and Geis (cited in Helmreich & Sexton 2004 p. 13), CRM type training has produced “measurable improvements in communication skills and practices”. Hetherington, Flin and Mearns (2006) identify communication as a core skill in the effective and safe operation of teams in high-risk environments and one that must be addressed within the variants of CRM training. Focused within this core skill were sub-skills that included assertiveness, questioning, listening, feedback, and non-verbal signals (O’Connor & Flin 2003).
Further, in systems such as NPPs and medicine where a requirement to interpret data from technological interfaces exist, operators must also be trained to develop the skill of anticipatory planning to maintain safe systems and predict system state based on the information presented (Kontogiannis 2011). Because it is intrinsic within many other NOTECH skills such as leadership, problem solving, and decision-making, communication training must be integrated within other CRM outcomes rather than a stand-alone version (Kanki & Smith 2001). That is, when discussing training outcomes such as leadership, team coordination, and threat analysis the development of communication skills must be integrated within these modules.
Teamwork is an important skill because in most cases operations in NPP, Oilrigs, Medical and aviation requires groups of people to work together to achieve an objective. A study conducted by the Canadian Transportation Safety Board (CTSB) found that, in the maritime industry, teamwork was “often” or “always” considered an important NOTECH skill (Hetherington, Flin & Mearns 2006). Acknowledging the findings of the CTSB, the National Transportation Safety Bureau (NTSB) has recommended that BRM include team-training competencies for maritime personnel. Teamwork is a core competency within the CRM domain across many industries; RRM, BRM, ERM all include team training within the program (United States Department of Transportation 2006).
One might also suggest that team training is analogous to communication skills and one without the other is an orphaned competency. This is evident in research conducted by NASA where it was found that poor team attitude towards communication had direct affect on safety performance (Gordon 1998). In its application in the offshore oil industry, Flin (1997) views CRM training as Team training, and decision-making, communication, and leadership etc are seen as subsets of team training. Error Management Error is a by product of human operations in complex systems (Reason & Hobbs 2003) and yet the human is also the champion of error management and mitigation.
Acknowledging that error exists and that, for the most part, accidents are as a result of a series of continuous and sequential errors is the first step in managing error (Reason & Hobbs 2003). In using CRM principles to manage error, Helmreich, Merritt, and Wilhelm (1999) advanced three mechanisms by which CRM type training can be used as a defence against error. The first mechanism is to prevent the error from occurring, the second is trapping the error when it was not avoided, and the third is mitigating the consequence of the error when it was not avoided or trapped. The medical industry as well has advocated a systems approach to error management (Dain 2002).
In acknowledging the systemic influence in error propagation, Dain (2002) postulates medical personal be trained in error avoidance and mitigation skills. The application of CRM in the medical industry addresses error management as a core competency within the program (Davies 2001). In NPP Crichton and Flin (2004) suggests that the use of CRM type training for emergency response teams will aid in the mitigation of error, through improved NOTECH skills in team performance. As with many other high-risk industries, poor NOTECH skills will exacerbate and magnify human error, which may lead to unwanted outcomes. Training personnel to manage and mitigate error, particularly during high-stress situations, will enhance teamwork and reduce error thereby promoting safer outcomes (Crichton & Flin 2004).
The CRM equivalent in the maritime industry, BRM and ERM, promote the management of human error as a critical element in positive safety outcomes (Hetherington, Flin & Mearns 2006). Similar to NPP operations, BRM addresses training NOTECH skills as the method by which error management is promoted (Hetherington, Flin & Mearns 2006). Organisational Influence Safety is an organisational imperative, and CRM is a tool used to improve organisational safety outcomes. The success of CRM or its variant largely depends on the acceptance and support of the organisation. Based on the Federal Aviation Administration (Seamster et al. 1998), to be successful, CRM training requires complete organisational involvement, from it initiation through to its delivery as well as its ongoing provision.
Further, in presenting guidelines for a CRM program in the medical field, Davies (2001) suggests that CRM programs must be integrated within organisational culture and organisations must allocate the necessary resources to promote the successful implementation if such programs. Organisational attitude towards safety is closely correlated to employee’s attitude toward safety. According to Helmreich and Sexton (2004), poor organisational safety attitude sets the preconditions for inadequate crew safety performance. Similarly, a study conducted by Rudmore (cited in O’Dea & Flin 2001) found that greater positive organisational influences in safety resulted in elevated employee safety attitudes. Across many high-risk environments, the influence of organisational culture on error production is increasingly evident (Helmreich et al. 2001).
A positive organisational safety culture enhances error management and mitigation through appropriate training, open communication, efficient reporting culture and reinforcing safe practices (Helmreich et al. 2001). CRM programs delivered on the foundation of positive organisational safety culture will have wider impact and higher acceptance among the intended participants. Limitations of MRM, BRM, and ERM etc As has been validated throughout this assignment, academia and regulatory bodies strongly support the implementation and application of resource management training to improve overall performance of crews operating in high-risk, high-stress environments. Organisations involved in high-risk activity as well, support the application of CRM type training within their domains.
Despite this, a key area of concern common across literature is the measurement of the effectiveness of CRM in preventing accidents and improving safety (Helmreich, Merritt & Wilhelm 1999). According to Helmreich, Merritt and Wilhelm (1999), The low accident rate in the aviation industry makes it very difficult to ascertain the validity of CRM against the improved efficiency in the flight deck. Similar measurement difficulties apply in the medical field. According to Pizzi, Goldfarb and Nash (n. d), while the application of CRM in the medical industry has been well received by the professionals in the field, its success in relation to increased patient safety is largely unknown. In the offshore oil industry, the valuation of the application of CRM is largely limited to the effectiveness in training delivery (O’Connor & Flin 2003). According to O’Connor and Flin (2003), much like the aviation and medical industries, difficulties exist in linking improved safety outcomes with the successful application of CRM. Conclusion This assignment has discussed high-hazard organisations and the application of CRM within these organisations to improve safety outcomes. The assignment first introduced the concept of high-hazard organisations and it move towards high-reliability organisations. In doing so, it discussed NRT and HRT as accident theories defining HHO and HRO respectively.
The paper then discussed CRM and the proliferation of CRM in other industries; NPP, offshore oilrigs, rail, maritime, and medicine have all adopted variances of the aviation CRM model in preventing, managing, and mitigating error. Improving NOTECH skills, enhancing error management, and organisational influences were identified as three key needs for the application of CRM across industries; communication and teamwork were identified as two key NOTECH skills. Finally, the assignment discussed the limitations of CRM within industry and identified the difficulty in measuring the effectiveness of CRM in the reduction of accidents as a key limitation. Overall, this assignment postulates that the successful application of CRM has had a positive impact on organisational moves towards high-reliability settings. References
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