Introduction
The origins of Crew Resource Management (CRM) are usually traced back to a workshop sponsored by the National Aeronautics and Space Administration (NASA) in 19791.Over time the key concepts in CRM have evolved via a series of generations.The lessons learnt from each generation were incorporated into CRM.There have been six distinct generations of CRM to date.CRM initially evolved, and was applied to, the aviation industry.More recently, CRM has been applied to a variety of other industries including nuclear power facilities, surgical teams and obstetric care2.
Background considerations
Aircrew and AME Aeromedical Evacuation personnel both operate in hazardous environments.Their duties involve interaction with complex technologies and with other people.Aircraft accidents occur infrequently, with a current average accident rate of one to two per million departures3.When accidents do occur they are widely reported in the media and attract considerable public attention.As a result there is usually considerable investigation into any accident, and most nations have investigating bodies charged with the task of aircraft accident investigation4.NASA research has found that up to 70% of aviation accidents involve human error5.
Aeromedical crew are at considerable occupational risk, with an occupational death rate 15 times the average.This risk is especially pronounced for helicopter EMS (Emergency Medical Services); however the accident rate and the occupational fatality rate are also higher amongst small fixed-wing EMS providers6.
Whilst aircraft accidents receive much publicity, adverse events in the medical sphere usually involve just one individual and receive minimal, if any, publicity.It would appear though that far more people die each year from medical error than from aircraft accidents, with figures from the USA estimating upwards of 100,000 deaths each year from medical error7.Clearly there would appear to be much more work to be done in decreasing medical error than errors relating to aircraft accidents.
When humans reach their physiological and psychological limitations, error may occur.Typical causes of error include workload, fatigue, poor communication, flawed decision making, imperfect information processing and fear.Aviation and medicine both require teamwork.Team error can be defined as action or inaction leading to deviation from team or organisational intentions.
The use of error management in aviation has become commonplace.Error management is based on changing the conditions that induce error, understanding the nature and extent of error, determining behaviours that prevent or mitigate error and training personnel in their use8.
Aviation training is now recognised as requiring a team approach with the aircrew being considered part of a system.This approach is less frequently utilised in medicine, with emphasis placed on individual responsibilities.The challenge for medical operators is to incorporate the lessons learnt from the aviation industry by adopting a team approach9.This is the theoretical basis for recommending CRM training for aeromedical personnel.
Aeromedical accident rates – the current state of play
The US National Transportation Safety Board (NTSB) conducted a study into aviation emergency medical operations between Jan 2002 and Jan 20056.During this interval there were 55 crashes amongst air ambulances in the USA.Given that there were approximately 750 helicopters and 150 fixed wing air ambulances; this represents a staggeringly high accident rate of six per cent of all airframes within this interval. Analysis of the three-year moving average accident rate for air ambulances shows a steady increase in the accident rate from 1991 to 200410.The air ambulance accident rate rose to 5 per 100,000 flying hours and the fatality rate rose to 2 per 100,000 flying hours.This accident rate should be compared to the rate for air taxis (operating under the same flight rules) which had rates of 2.52 for accidents and 0.67 for fatalities.The causes for this are complex, and are often due a chain of circumstances involving poor CRM [Cockpit Resource Management], pilot aeronautical decision making (ADM) and flight conditions, including adverse weather conditions and terrain. (See figure 1)
The evolution of CRM
First generation CRM
The 1979 NASA meeting heralded the first use of the term Cockpit Resource Management (CRM).This term was applied to the process of training aircrew to reduce pilot error by improved utilisation of the human resources on the flight deck.
The first major CRM program was initiated by United Airlines in 1981.The training was delivered in a seminar setting.The first generation of CRM emphasised changing individual styles and correcting deficiencies such as authoritarian behaviour by captains and submissive behaviour by junior flight crew8.The failure of captains to accept input from junior co-pilots was labelled the “Wrong Stuff” (see figure 2).
Even with the first generation of CRM it was realised that it should not be delivered as a once only session, and that it required recurrent training.Training was delivered in the classroom and also in simulator settings called Line Orientated Flight Training (LOFT).The simulator setting allowed cockpit crew to practice their interpersonal skills without jeopardy (from aircraft accident).
Second generation CRM
By the mid 1980’s many airlines had commenced CRM programs.At this time it was thought that CRM training would disappear as a single entity and that it would be incorporated into all aspects of aircrew cockpit training.The name changed from Cockpit to Crew around this time, as it was realised that involving the entire aircrew produced better outcomes.Second generation programs included such concepts as team building, briefing strategies, situation awareness and stress management for aircrew.The aim was to break the chain of errors that could precipitate an accident.
Third generation CRM
In the 1990’s CRM analysed the system in which crews functioned, including analysis of the organisational culture.There was increased effort at incorporating CRM into specific crew training; with a focus on specific skills and behaviours.The increasing use of flight automation began to occur around this time and CRM incorporated this topic.Human factors began to be analysed and more intensive training was provided for the CRM instructors.CRM was broadened to involve training with flight attendants, dispatchers and maintenance personnel.
Fourth generation CRM
The US Federal Aviation Administration introduced its Advanced Qualification program for aircrew in 1990.This program permitted airlines to tailor CRM to their specific needs.As part of this broadening, airlines had to analyse the specific training needs for each aircraft and to list the CRM factors in training.The lessons learnt from fourth generation CRM are that there needed to be specific behaviour associated with checklists.These standards were to be applied in all situations, and were of greatest use in non-standard situations.The introduction of what Helmreich termed “bottom lines” was expected to decrease the effect of human error8.
Fifth generation CRM
Fifth generation CRM accepted that human error was both ubiquitous and inevitable8.CRM was viewed as error management.Helmreich and Merritt et al. were the main proponents of this concept, and stated that they were much influenced by the work of Professor James Reason11,12.CRM began to be seen as a series of error counter-measures with three lines of defence. The first line is the avoidance of error.The second is the trapping of errors, and the third is error mitigation before they occur.This became known as the error troika (See Figure 3).
Organisations were encouraged to state that errors would inevitably occur, and to adopt a non-punitive approach to error.Incident reporting was introduced to help identify the sources of error.From here steps could be taken to minimise the recurrence of error.CRM programs would include formal instruction in human behaviour, human performance limitations, error management and adaptability, communication and assertiveness, teamwork, leadership and followership, situational awareness, decision making, workload management and automation, and task and mission planning13.
Sixth generation CRM
The current generation of CRM has added the concept of threat recognition and management.The threat of error can not only arise from within the aircraft, but also from external sources such as ground maintenance staff and flight controllers.
CRM benefits
To prove that CRM reduces accident rates and improves efficiency is difficult.The use of accident rates per million flights as a measure is not realistic as the rate is so low.In addition, the lack of standardisation of CRM programs makes the validity of any measurements questionable14.The most realistic method in measuring the benefits of CRM is by analysis of flightdeck behaviour and attitudes during LOFT. i.e. under realistic conditions8. (See figure 4)
Another method that gives indirect evidence that CRM is beneficial is to audit crews as they complete CRM training.Data from 15,000 crew members from 12 airlines and military organisations in the US revealed that the majority rated CRM training as very or extremely useful, with similar data showing that the majority agreed that CRM had the potential to increase safety15.
Another study completed over a 12 month interval on aeromedical crew involved in rotary and fixed wing aeromedical retrieval demonstrated that CRM training increased crew awareness and promoted team concepts.The authors concluded that CRM training for aeromedical crew should provide a safer operating environment16.
Unfortunately CRM does not reach everyone, with a small subset of candidates refractory to the benefits of training.Another important aspect of CRM training is that it is viewed as less important over time – meaning that aircrew viewed CRM as less important as time elapsed since their initial CRM training.The corollary of this is that CRM needs to be incorporated into recurrent training.Further, CRM training does not transfer between different countries and even different organisations within each country7.(See figure 4)
CRM training – flight crew and medical crew
Whilst airline crews must submit to compulsory CRM training, there is currently no recommendation that this occur for aeromedical operators.The more progressive operators have taken the initiative; conducting CRM training for all crew in their aeromedical aircraft and sourcing the training through commercial providers17.However, this does not reflect the majority of operators.The National Transport Safety Bureau, USA (NTSB) has stated that CRM training is not tailored to the specific operational conditions and pressures of the air ambulance pilot.This point is very cogent as CRM needs to be specifically targeted, otherwise it is less successful18. Specific training is also recommended for air ambulance flight dispatchers, who typically do not receive formal training in aviation operations or aviation weather10.The practical significance of this is that CRM training for aeromedical training must be adapted to suit the unique operating environment that aeromedical crew work in.
A CRM training program for AME staff
Key points for ADF aeromedical CRM training
There are a number of lessons learnt from the collective experience thus far with CRM.Applying these principles to the aeromedical training in the Australian Defence Force, [the CRM training should be:
- Delivered during initial Aeromedical Evacuation (AME) training where possible;
- Incorporated into refresher training;
- Evaluated by entry and exit questionnaires exploring attitudes and awareness;
- Assessed by the equivalent of LOFT for aircrew i.e. assessed during realistic (non-jeopardy) scenario activities;
- Tailored to the needs of the AME duties;
- Reflective of cultural and organisational doctrine;
- Delivered by trainers who scrupulously observe the ADF safety culture;
- Provided by trainers who have received additional and more intensive CRM training (CRM instructors course);
- Delivered in a dynamic and interactive program – incorporating role play, visual presentations and scenarios;
- Able to demonstrate the positive aspects of CRM (and not just give examples of poor outcomes due to CRM breakdown);
- Associated with a non-punitive reporting program to identify and
- mitigate errors.
(See figure 6)
Course guidelines for ADF aeromedical CRM training
Aeromedical CRM ideally should be introduced via an initial one to two day program for all full time and part time medical staff involved in aeromedical operations.A pilot lecture series on Aeromedical CRM will commence during the four week RAAF AME course in February 2008.There should also be refresher training in aeromedical CRM during AME refresher courses.The course framework can be conveniently divided into twelve modules.Visual presentations and training activities are integral to the course.Following the formal aeromedical CRM training, members will be assessed via real-time scenario tasks which will be non-jeopardy and assessed in a non-punitive manner.The twelve modules can be shortened or lengthened depending on ADF needs and time constraints.The twelve modules are:
1.Introduction
2.Human Behavior
3.Human Performance Limitations
4.Error Management and Adaptability
5.Communication and Assertiveness
6.Teamwork, Leadership and Followership
7.Situational Awareness
8.Decision Making
9.Workload Management and Automation
10. Task and Mission Planning
11. Briefing and Debriefing
12. Summary
(See Figure 7)
Each module is accompanied by a PowerPoint presentation with audiovisual material.The PowerPoint material includes multiple scenarios highlighting incidents and accidents involving CRM.
The presentations on CRM are not examinable, however it is recommended that attitudes to CRM be assessed before and after the initial training (entry and exit surveys), as well as assessments during training scenarios.
CRM training should be conducted under the “Chatham House Rule”.The Chatham House Rule originated at Chatham House with the aim of providing anonymity to speakers and to encourage openness and sharing of information19.
Key lessons learnt when applying error management to medical practice
Helmreich analysed error within the aviation and medical spheres and concluded that there are certain areas of medical behaviour that require close attention if one is to recognise and contain error6.Although based on observations in operating theatres, it is worthwhile to repeat his key observations, as they would easily translate to the activities of an aeromedical team.
Firstly, leadership is a key element in his analysis – in particular the identification of a team leader. Secondly it is vital for the team leader to communicate his or her plan to the entire medical team.Thirdly, an alternative plan should be discussed for any likely contingencies.Fourthly, it is vitally important that problematic interpersonal relationships do not interfere with patient care.The final area of emphasis related to preparation, planning and vigilance – contingencies in patient management must be planned for, and the actions of other team members must be closely observed by all the team members.
Conclusion
CRM has been in existence for over 25 years and is a widely accepted component of aircrew training.CRM training for all RAAF Aircrew is compulsory and endorsed by Chief of Air Force (CAF).The success of CRM in improving safety is more difficult to assess, as the number of aircraft accidents per million flights is extremely low, and also because CRM training is so varied between different countries, different airlines and organisations.CRM has also been applied successfully in other highly technical environments such as the operating theatre and deep sea diving habitats.It is a logical extension to recommend CRM training is provided for all members of the flight crew including the AME team
Disclaimer
The views, opinions, and / or findings in this report are those of the author and should not be construed as an official policy of the Royal Australian Air Force or the Australian Defence Force.
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