Crew Resource Management free essay sample

In another fifty seconds, the plane was at half its assigned altitude. The CVR recorded the last few moments of conversation between the crew, acknowledging the change in altitude: Stockstill: We did something to the altitude. Loft: What? Stockstill: Were still at 2,000 feet, right? Loft: Hey  Ã¢â‚¬â€ whats happening here? (NTSB, 1973) Official observations find a probable cause of this accident to be the insufficiencies of flight crew to properly monitor flight instruments (especially during the final few minutes of flight). This lead to a failure in detecting the unplanned descent soon enough to prevent controlled flight into terrain. The cause, after thorough official investigation, was due to a burned-out light bulb (i. e. there was no fault with the nose gear position, only an apparent fault). The landing gear could have been manually lowered either way with standard pilot procedures. The captain had the landing gear recycled however, the confirmation light still did not illuminate and this became the driving force of the overpowering distraction within the cockpit. To summarise this synopsis, the crew lost perspective of situation awareness (caused by an apparent fault of the landing gear) to the extent that autopilot de-activation and flight status was not sufficiently recognised nor was it corrected after deviation. The crew, though rightfully working together to fix the malfunction, failed to positively manage the flight as a team and utilise all resources available to meet the higher demands of the flight. The aircraft gradually lost altitude with the pre-occupied flight crew, which did not prioritise the golden rules of the air: Aviate, Navigate, Communicate. In its time the causes of Flight 401 made this accident to be one of the most pivotal wide-bodied, controlled flight into terrain (CFIT) crashes creating the need for real solutions that will prevent such an occurrence. CRM-related issues: According to the National Transport Safety Board, investigations found that the aircraft was free from all mechanical faults, was certified appropriately and deemed applicable to all regulations. This finding automatically thrusts investigations to question the effectiveness (and contribution) of the air crew, and continued to magnify the inevitable occurrences of ‘pilot-error’. Kanki, Helmreich and Anca (2010), resurface the idea that effective CRM does not only optimise the person-machine interface, but goes far beyond and includes interpersonal activities among crew which tends to manifest as positive team-building qualities (this was a strong focus especially in the first generation of CRM). Typical examples certainly include; leadership, team formation and maintenance, decision making, problem-solving and, of course, the maintenance of situation awareness. These few examples are some of the fundaments of crew resource management (from a contemporary view-point) and are factors which often determine the making or breaking of operationally effective CRM. Modern day programmes (particularly airline crew resources management) strongly emphasise the need of such specific qualities investing much resources for the flight crew to recognise and practice these qualities within a cohesive team-environment. A large portion of CRM revolves around maintaining optimum situation awareness for operators. In the cockpit, maintaining high and positive levels of situation awareness (SA) is deemed to be a fundamental yet challenging role for pilots (Garland, Wise Hopkin, 1999). The flight crew in this example predominantly compromised such standards, and according to findings this compromise became one of the primary causes. The official NTSB report states the preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew’s attention from the instruments and allowed the descent to go unnoticed (NTSB, 1973, p. ) The crew exemplified poor situation awareness by initially losing awareness of instrument readings and basic aircraft statuses, which consequently lead to impaired judgement and wrong expectations between the required flight path verses the perceived flight path. It was uncovered by reports that the autopilot had been inadvertently switched from ALTITUDE HOLD to CWS mode in the pitch control. Investigators interpret that the switch in autopilot modes would likely have occurred when Captain Loft turned around to speak to the Second Officer (inadvertently leaning against the yoke). In the CWS mode, any slight forward pressure placed on the yoke would have certainly caused a subtle descent to the flight profile. The false expectation that the instruments were always maintained in the ideal status (or the lack of being aware of current positioning) consequently lead into a downward spiral of other errors including delayed decision-making and poor crew communication- with regards to aircraft heading and altitude. The birth of such errors may have been prevented by the use of appropriate leadership and teamwork skills. Although leadership is not only for the Captain to posses, Loft did not execute the appropriate leadership required for the task at hand. As the report states, Loft instructed First Officer, Stockstill a task which diverted his attention from monitoring the instruments. A more appropriate ‘leadership’ response would be to delegate someone else (or even himself) to take charge of flying the aircraft, and execute usual flight duties such as ‘scanning’ the instruments. The NTSB report concludes the cause of the crash to be solely based on pilot-error. In relation to the causes, it was specifically documented to have been the failure of the flight crew to monitor the flight instruments during the final four minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground (NTSB, 1973). In conclusion, with the shortcomings of Eastern Airlines Flight 401 focussed on operator error and more specifically, insufficient levels of situation awareness, crew resource management actively combats such errors (to this day) in attempting to shape sound leadership that strongly emphasises the use of teamwork among crew members. Also as a response, specific training programmes relating to the development of teamwork or CRM techniques are regularly practiced. One key example readily used by airlines is training to encourage genuine assertiveness with the First Officer (behaviour training), and to minimise steep gradient authorities between crew members; between the Captain and First Officer. Such programmes initially consisted of simulated-type training, known as Line-Oriented Flight Training (LOFT). Part of this programme, in first generation CRM, highlights correcting individual behaviours and identifying individual styles. Good practice of teamwork in the cockpit enhances situation awareness as it envelopes the interpersonal activities, as earlier discussed and highlighted by Kanki, Helmreich and Anca (2010). Interpersonal activities are over and above the person-machine interface. This includes and influences the crews decision-making and constructive communication, both of which were not appropriately used in the case of Captain Loft and First Officer Stockstill. Without sound situation awareness, even the best trained crew are susceptible to poor decision making. Garland, Wise Hopkin (1999) predicted improved cockpit designs and implementing enhanced training- programs to be pivotal toward improving situation awareness for all flight crew. Kanki, Helmreich Anca (2010) redefines effective teamwork as a focus on the proper response towards threats to safety, and appropriate management of crew error; which is the very heartbeat of crew resource management and what it attempts to achieve.