the learning never stops!

Crew Resource Management


  • A Little History — To understand where we are today (and where we need to go) we need to understand from where we've come.
  • The Problem — The problem is that we continue to teach CRM as an integral part of the rest of our training. On the surface that would seem like a good thing: we have CRM in everything we do. But it makes it too easy for our problem captains and crewmembers to slip under the radar because we aren't looking for them.
  • A New Training Method — There is a better way to train in the simulator that doesn't depend on chance to provide you with the exposure you need to identify any weaknesses and the experience to realize how things should be done.

Of course you may want the fundamentals or a few examples of mishaps caused by breakdowns in CRM. Those follow in an appendix on the bottom of the page.

  • Case Studies — You can learn a lot CRM by studying mishaps involving pilots who thought they were ideal CRM pupils (but were not).
  • The Fundamentals — The fundamentals, as currently taught, are fine and should be studied before tackling some serious simulator training.



Photo: Struggle for control, from "The High and the Mighty"

A Little History

"Single Pilot Resource Management"
When cockpit disputes were short-lived, and so were the pilots

In the beginning: the single-pilot tradition in aviation


Photo: World War I pilot, from the public domain.

[Crew Resource Management (Kanki, Helmreich, Anca), Chapter 1] The evolution of concern with crew factors must be considered in the historical context of flight. In the early years, the image of a pilot was of a single, stalwart individual, white scarf trailing, braving the elements in an open cockpit. This stereotype embraces a number of personality traits such as independence, machismo, bravery, and calmness under stress that are more associated with individual activity than with team effort. It is likely that, as with many stereotypes, this one may have a factual basis, as individuals with these attributes may have been disproportionately attracted to careers in aviation, and organizations may have been predisposed to select candidates reflecting this prototype.

You find pilots of this stereotype littered over the pages on many NTSB accident reports. These are pilots who think of their crews as appliances to be trusted only with the most rudimentary tasks. When the chips are down, these pilots fly the aircraft, make the decisions, and even find the time to give an ice-cold report to the radio and the public address system. These pilots used to be exclusively produced by the military, but those days are long gone. (The Air Force and the Navy embraced crew resource management early on.) You still find these single-seat-brained pilots out there, many of whom have no military experience at all. No matter the source, pilots like this need to be educated or disposed of.

And then: two or three pilots meant more than one opinion on the flight deck

"First Pilot Resource Management"
When the captain's word was final, dissent was mutiny


Photo: Boeing 314 Clipper, from the Library of Congress.

[Fallucco, pg. 9] Another major player of the time and contributor to the aviation industry was Juan Trippe. As a young entrepreneur, this enterprising former Naval flight instructor used his energy and creative mind as well as the backing of some wealthy Yale schoolmates to first form Eastern Air Transport. Two years later, after acquiring two smaller companies, he merged them all into Pan American Airways. As a young 30-year-old, he and Lindbergh became friends. They began working together sharing a global vision for aviation. Within months of his signing with TAT [Transcontinental Air Transportation, later to become TWA], Lindbergh also became the technical advisor to Pan American Airways (Pan Am). It is Juan Trippe who is credited with first using the name captain in place of first pilot. He saw the amphibian airplanes he used in his new airline as flying boats. Trippe reasoned that boats have captains. Since his amphibians operated on the water and in the air why not call the first pilot — captain? The name stuck.

Despite the two- and three-pilot cockpits, the captain was the unmistakable person in charge and each pilot strove to retain the aura of the single, stalwart individual. There used to be a certain understanding among pilots that the less said in the cockpit the better. One need only read books from that era, such as the 1961 classic by Ernest K. Gann, "Fate is the Hunter," for examples of pilots scared to death about some noise, vibration, or other abnormality, and waiting to see which pilot would admit to it first. It is important to realize that shared information multiplies in value.

And then: the first generation of CRM


Figure: Eastern Airlines 401, from anonymous (GNU Free Documentation License)

[Cortés, Cusick, pp. 128-129]

  • In 1972, a Lockheed L-1011 operating as Eastern Airlines Flight 401 flew into the Everglades in Florida as all members of the flight deck crew were focused on a burned-out light bulb. During the troubleshooting, no pilot had been assigned the task of flying the aircraft and, although an altitude discrepancy was noticed by air traffic control, the flight gently descended without the crew noticing the critical controlled flight into terrain (CFIT) problem.
  • For more about this accident, see: Eastern Air Lines 401.

  • [In 1978] A Douglas DC-8 operating as United Airlines Flight 173 crashed near Portland, Oregon, after running out of fuel, killing 10 occupants. The accident resulted from the captain focusing too heavily on preparing the cagin for an emergency landing due to a gear malfunction, while neglecting both the fuel state and the increasing concerns of the other flight crewmembers who were rightfully worried about running out of gas.
  • For more about this accident, see: United Airlines 173.

  • NASA decided to host a series of conferences in 1979 out of which the CRM concept was officially born. At that time the term stood for Cockpit Resource Management and was narrowly focused on flight deck crewmembers, often comprised of two pilots and a flight engineer in those days.
  • The first generation of CRM in 1979 focused on changing individual behavior, primarily that of the captain, so that input would be incorporated from other flight deck crewmembers when making decisions.

[Crew Resource Management (Kanki, Helmreich, Anca), §1.4.4] A 1979 NASA study placed 18 airline crews in a Boeing 747 simulator to experience multiple emergencies. The study showed a remarkable amount of variability in the effectiveness with which crews handled the situation. Some crews managed the problems very well, while others committed a large number of operationally serious errors. The primary conclusion drawn from the study was that most problems and errors were introduced by breakdowns in crew coordination rather than by deficits in technical knowledge or skills. The findings were clear: crews who communicated more overall tended to perform better and, in particular, those who exchanged more information about flight status committed fewer errors in the handling of engines and hydraulic and fuel systems and the reading and setting of instruments.

And then: the second generation of CRM


Figure: Air Florida 90, from

[Cortés, Cusick, pp. 129-130]

  • As airline accidents with CRM components continued to happen, such as the very dramatic crash of a Boeing 737 operated as Air Florida flight 90 during a winter storm in Washington, D.C. in 1982, the industry and government continued to cooperate to shape and evolve CRM.
  • For more about this accident, see: Air Florida 90.

  • As a result of these efforts, around 1984 the second generation of CRM took shape. Instead of changing individual behaviors, CRM now went deeper in an attempt to change attitudes and focus more on decision making as a group.
  • Special emphasis was placed on briefing stragies and the development of realistic simulator training proviles known as Line-Oriented Flight Training (LOFT).
  • By 1985 only four air carriers in the United States had full CRM programs; United, Continental, Pan Am, and People's Express. American and the U.S. Air Force Military Airlift Command soon introduced CRM programs, and the U.S. Navy and Marine Corps were on the verge of starting CRM programs.
  • In 1989, a very serious accident happened that provided irrefutable proof that CRM principles worked. A DC-10 operating as United Airlines Flight 232 experienced the uncontained failure of its #2 engine, resulting in a loss of normal flight controls. The captain ably coordinated flight deck and cabin resources to perform a controlled crash of the aircraft at Sioux City, Iowa. The resulting crash killed 111, but there were 185 survivors who likely would have not survived at all had it not been for the CRM prowess of the crew.
  • For more about this accident, see: United Airlines 232.

The United States military and most commercial airline businesses embraced Cockpit Resource Management early and the improvements were dramatic. As more and more of the world embraced CRM, the accident rates fell accordingly. One need only examine the hold outs to fully understand just how far we've come. Examine Korean Airlines for a thirty-seven year look at a country's airlines ignoring the call for CRM, being forced into it, and then working their way around it. It isn't an Asian culture thing. The Japanese realized early on that crashing airplanes and killing passengers was a bad business model.

And then: the third generation of CRM


Photo: Army medicine, from Jim Bryant, NW Guardian, (Creative Commons.)

[Cortés, Cusick, p. 131]

  • In the early 1990s the third generation of CRM took hold, which deepened the notion that CRM extended beyond the flight deck door. That generation saw the start of joint training for flight deck and cabin crewmembers, such as for emergency evacuations.
  • Around 1992 CRM also saw itself being exported to the medical community to address similar group dynamics events associated with medical error in both routine and emergency care at hospitals.

[Crew Resource Management (Kanki, Helmreich, Anca), §6.1] The term non-technical skills (NTS) is used by a range of technical professions (e.g. geoscientists) to describe what they sometimes refer to as "soft" skills. In aviation, the term was first used by the European Joint Aviation Authorities (JAA) to refer to CRM skills and was defined as "the cognitive and social skills, of flight crewmembers in the cockpit, not directly related to aircraft control, systems management, and standard operating procedures." They complement workers' technical skills and should reduce errors, increase the capture of errors and help to mitigate when an operational problem occurs.

[Crew Resource Management (Kanki, Helmreich, Anca), §6.2] As concern about the rates of adverse events to patients by medical error grew, medical professionals began to look at safety management techniques used in industry. One technique that has attracted their interest is the training and assessment of non-technical skills.

Much of the rest of the world, especially that which deals with life and death issues, adopted CRM (or NTS) and have had to do the hard sell to obtain "buy in" from their professionals. Doctors, for example, may reacted just as early airline captains did thirty to forty years ago. Meanwhile, we in the aviation world have seen decades of progress and it is a rare crewmember these days who attempts to push back.

And then: the fourth generation of CRM

[Cortés, Cusick, p. 131]

  • Around the mid-1990s the fourth generation of CRM was introduced, which promoted the FAA's voluntary Advanced Qualification Program (AQP) as a means for "custom tailoring" CRM to the specific needs of each airline and stressed the use of Line Oriented Evaluations (LOEs).

And then: the fifth generation of CRM

[Cortés, Cusick, p. 131]

  • Around 1999 the fifth generation of CRM took hold, which reframed the safety effort under the umbrella of "error management" modified the initiatives so as to be more readily accepted by non-Western cultures, and placed even more emphasis on automation and, specifically, automation monitoring. Three lines of defense were promoted against error: the avoidance of error in the first place, the trapping of errors that occur so that they are limited in the damage they create, and the mitigation of consequences when errors cannot be trapped.

And then: the sixth generation of CRM

[Cortés, Cusick, pp. 131-132]

  • At the start of the 21st century, the sixth generation of CRM was formed, which introduced the Threat and Error Management (TEM) framework as a formalized approach for identifying sources of threats and preventing them from impacting safety at the earliest possible time.
  • Threats can be any condition that makes a task more complicated, such as rain during ramp operations or fatigue during overnight maintenance. They can be external or internal. External threats are outside the aviation professional's control and could include weather, a late gate change, or not having the correct tool for a job. Internal threats are something that is within the worker's control, such as stress, time pressure, or loss of situational awarenes.
  • Errors come in the form of noncompliance, procedural, communication, proficiency, or operational decisions.
  • To assess the Threat and Error Management aspects of a situation, aviation professionals should:
    • Identify threats, errors, and error outcomes.
    • Identify "Resolve and Resist" strategies and counter measures already in place.
    • Recognize human factors aspects that affect behavior choices and decision making.
    • Recommend solutios for cahnges that lead to a higher level of safety awareness.

The Problem . . .

. . . is that we in aviation are training crews as if we've made zero progress in the last thirty-plus years. Take a look at the 1990 FAA text and notice there is very little change from what came before and after. They are still teaching this.

The statistical lie about accident rates


Figure: US/Canadian Operators Accident Rates by Year to 1990, from CRM Handbook, figure 1.

[Crew Resource Management: An Introductory Handbook, pg. 1] From the 1950s to the 1990s we have witnessed a steady decline in aviation accidents. This decline in aviation accidents has been attributed to better equipment, better training, and better operating procedures.

More about this: Accident Rates.

Notice the chart looks pretty flat from 1986 on.

The statistical lie about accident causes


Figure: Changes in accident causal factors over time, from CRM Handbook, figure 2.

[Crew Resource Management: An Introductory Handbook, pg. 1] As Figure 2 illustrates, as accidents related to equipment weaknesses have decreased, accidents attributed to human weaknesses have increased.

That is what the chart suggests, but it is a lie.

[Crew Resource Management: An Introductory Handbook,pg. 2] Figure 1 and Figure 2 suggests two points. First, Figure 1 indicates that after a sharp drop in the 1960s, accident rates have leveled off from 1970 through 1990. Second, the trends in causes of accidents illustrated in Figure 2 show that human error has remained a major contributing factor in aviation accidents during these latter years.

The statistical lies exposed


Figure: US/Canadian Operators Accident Rates by Year 1993 to 2012, from Boeing Statistical Summary.

The first chart seems to show the accident rate has leveled off and we aren't getting any better. This is a distortion caused by the constant scale of the left axis. It is hard to see a trend when the changes are small relative to the scale. If you zoom in you will see the trend continues, as shown by the updated chart here.

The second chart is a lie of improperly used statistics. The chart clearly says "Relative proportion of accidents cause." In plain English:

  1. The number of accidents has gone down, way down.
  2. The number of accidents caused by machines has gone down, way down.
  3. The number of accidents caused by humans has gone down, but not as far down as those cause by machines.

So why is overplaying the problem a problem when it comes to training? Because the problem has changed. The problem in aviation used to be a culture that gave the captain complete authority and discouraged any kind of resistance to that authority. We are over that. While it may be true that not every pilot fully embraces CRM, the vast majority of them say they do. That word, "say," is important here. Because the new problem is that we have a culture that expects all flight crews to embrace CRM and that we have some pilots that may not know how to do that, or are doing that in thoughts only. We have a new problem:

  • Some captains think they follow CRM conventions but have never really been tested to see if they "walk the talk."
  • Some captains do not embrace CRM conventions, but play act the role in training that does not test their convictions.
  • Some captains do not know how to foster a good CRM environment among unfamiliar crews.
  • Some captains do not know how to deal with unfamiliar crews that may fall short of the standards set by the crews they are familiar with.
  • Some crewmembers do not know how to deal with these captains in a "live" situation, that is, a situation outside the classroom or with captains other than those they are very familiar with.

Notice there is a common factor to all these problems. That leads us to a new training paradigm . . .

A New Training Method


Photo: Antoinnette Aircraft Company Simulator, 1909, from Creative Commons.

How we train CRM today

The current philosophy is that CRM is a part of everything we do so there is no specific block of training called "CRM." We simply complete our training and if the instructor happens to see an instance of exceptional CRM or where CRM has failed, that gets brought up and discussed.

The problem with that

The problem with this method of training is that students are not systematically exposed to CRM pitfalls and may not ever be exposed to problems they could face in the airplane. If the captain and first officer pair are from the same flight department, they may have enough pre-existing synergy so as to make things run smoothly under most conditions. Likewise, if the captain or first officer are very good either technically or with CRM, the other pilot may not be exposed to potential CRM problems. So if things are going well why worry about potential CRM problems? Because a weakness can lie hidden until the right circumstances and it is better to correct those in the simulator than an airplane. Similarly, crew pairings cannot always guarantee the synergy a pilot would prefer.

A new idea


Photo: Link trainer, Freeman Field, US Army, from Creative Commons.

A better way to teach CRM is to induce problems during simulator sessions by asking one pilot to play act a specific scenario under the instructor's supervision.

While it may be more comfortable to train with a member of the same flight department or someone you know, it is counterproductive for optimal CRM training. You should look for opportunities to train with someone you don't know; someone who's every action in the cockpit isn't easily predicted.

Instructor notes

  1. Let each pilot know there will be one CRM exercise for each during the day's session in which one pilot will be instructed to do something contrary to good CRM practice as a test of the other pilot.
  2. After the session is underway, during time on the ground as the pilots are busy resetting the cockpit for the next takeoff, hand one pilot an index card with the special instructions.
  3. Allow the scenario to play out, ensuring the instigating pilot plays the correct role and watching for the target pilot's reaction.
  4. If the target pilot handles the situation well, allow it to conclude naturally. Once back on the ground, fully debrief and congratulate everyone for a job well done.
  5. If the target pilot mishandles the situation, stop the scenario and discuss with both pilots what has happened and how things could have been handled better. Do not allow the situation to continue to the point the aircraft crashes or the pilots become overly frustrated. Debrief it as a learning exercise and point out the scenario is realistic and could have happened in real life.

Sample Scenarios


    Photo: N121JM wreckage, from NTSB.

  1. Scenario card. Capt: when the first officer calls for the flight control check, say "not required." If he tactfully says that it is, say "we can skip it." If he then comes back and insists, agree to do it.
    • Target pilot. First officer should use Inquiry / Advocate / Assert. "Why don't we need to do this?" "I really think we should do a complete flight control check." "I am very uncomfortable skipping this check. We need to do it."
    • Instructor notes. There have been many crashes over the years because the crew decided to skip the flight control check, the most recent being GIV N121JM at KBED, 31 May 2014. CRM is a useful tool to prevent one pilot's complacency from causing a serious lapse in standard operating procedures.


    Photo: Crash site of G-OBME, from Accident Report, figure 1.

  2. Scenario card. First officer: there will be an engine fire just after V1, as soon as the gear is retracted reach for the applicable fire switch and say, "Fire on engine ___, standing by to pull the fire switch!"
    • Target pilot. Captain should tell the first officer to wait until the aircraft is at a safe altitude.
    • Instructor notes. Getting the wrong engine happens more often than you might think.
    • Consider: British Midland Airways 092 (1989), SA Airlink 8911 (2009), to name just two. For many more examples see: Panic.


    Figure: Air Illinois 710, from Aviation Safety Net.

  3. Scenario card. Captain: you have a heart patient and a medical team on board determined to go to your destination, two hours away, where a very good hospital awaits. The weather there is at IFR minimums, your departure airport is VFR. After takeoff you will lose half of your electrical system leaving you with only your flight instruments, your first officer's flight instruments will be inoperative. Announce to the crew you have enough to make it to the destination and are determined to press on for the good of the patient. If the first officer complains, dismiss these concerns as less important than the life of the heart patient. If the first officer insists, ask for options. You will end up having to return to your departure point, but the patient will find another ride.
    • Target pilot. First officer should object to the captain's plan, first asking why the decision was prudent, then advocating a return to the departure airport, and finally insisting.
    • Instructor notes. There are many examples of captains being so mission oriented they lose the forest for the trees. It rarely makes sense to endanger the lives of the crew to save the life of one passenger. Another consideration is that if the airplane crashes short of the runway, there are more lives in danger from the impact.
    • See the 1983 case of Air Illinois 710 where everyone was killed by a pilot's insistence about getting to the destination despite survivable malfunctions.


    Figure: Eastern Airlines 401, from anonymous (GNU Free Documentation License)

  4. Scenario card. First officer: You will have a problem with an electrical, hydraulic, or fuel system while on radar downwind. Pretend to be confused by the procedure in an attempt to have the captain take over the troubleshooting. The captain should initiate a positive exchange of aircraft control. If he or she does not, fully engage with the captain to help with the trouble shooting. If the captain does give you control of the aircraft, acknowledge but place most of your attention on trouble shooting until the captain reminds you someone has to actively monitor the aircraft at all times.
    • Target pilot. The Captain should leave no doubt as to who will be flying the airplane and who will be trouble shooting. If the first officer appears to be disregarding this imperative, the captain should be assertive.
    • Instructor notes. There have been many perfectly flyable aircraft lost over the years because the entire cockpit crew got wrapped up in the problem and forgot to fly the airplane.
    • See the 1972 case of Eastern Airlines 401, for example.


    Figure: Southwest 1455, from NTSB Accident Docket.

  5. Scenario card. Captain: attempt to fly the approach just under the limiting final flap speed and then try to salvage the landing on this shorter than average runway. If the first officer tells you to go around say, "What? Huh?" If he repeats the command, go around. If the first officer is quiet throughout the landing attempt, go around on your own.
    • Target pilot. The first officer should provide approach call outs, stabilized approach reminders, and should eventually command a go around.
    • Instructor notes. The first officer has many monitoring duties during an approach and landing. Many landing mishaps could have been prevented by a first officer insisting on stabilized approach criteria.
    • For examples, see Allegheny Airlines 453 and Southwest 1455 (Stabilized Approach).


    Figure: N777TY, from

  6. Scenario card. First officer: The gear will fail to retract and you want to land as soon as possible. Get immediate clearance and tell the captain you think you forgot the pins but if you land immediately you can get them and you won't be too delayed. Don't initiate any checklists until called and even then do them from memory until the captain tells you to slow down and be more methodical.
    • Target pilot. Captain should take control of the situation and remind the first officer that there is no rush.
    • Instructor notes. This lesson applies to all aircraft but more so for aircraft with safety systems keyed to the landing gear weight on wheels system. In most Gulfstreams, for example, the same issue that can prevent the gear from retracting could cause the ground spoilers from activating in flight.
    • See GV N777TY West Palm for an example.


    Figure: Fuel Pipe Crack, from Portugal Accident Investigation Final Report, Figure 4.

  7. Scenario card. Captain: you will have a fuel leak from one of the engines while flying oceanic. It will first manifest itself as a fuel imbalance. Take the appropriate measures to balance the fuel. The instructor will attempt to distract both pilots by asking about drift down procedures (or something else appropriate to an oceanic crossing). Allow the first officer to troubleshoot. If the first officer concludes it is a fuel leak, express doubt and offer another fuel balancing technique. The first officer should attempt to convince you to stop the fuel transfer.
    • Target pilot. The first officer should realize there is a fuel leak and should attempt to first convince the captain to terminate fuel transfer and later insist.
    • Instructor notes. Structure the scenario so it is possible to stop the fuel transfer and still maintain control of the aircraft for while diverting to the nearest airport. But if the fuel transfer is not stopped, make it obvious they will run out of fuel. Don't let it get that far, it will become an academic exercise at that point.
    • This scenario happened to Air Transat 236 in 2001.


Case Studies

  • Air Blue ABQ-202 (2010) — The airplane crashed and killed everyone on board because of the captain's poor airmanship while flying the airplane into a mountain. But on the way to the scene of the accident he beat the first officer down to the point the right seat was occupied by a passenger, unwilling to speak up.
  • Air Florida 90 (1982) — An amiable captain with inadequate experience dealing with icing conditions was paired with a first officer who had the right answer but unwilling to speak forcefully. Most everyone on board was killed.
  • Air Illinois 710 (1983) — A captain with an internal drive to keep the schedule and a reputation of getting angry with first officers with other view points decided to press on to his destination after an electrical failure. His destination was IFR, over 30 minutes away. He could have turned back to his departure airport, which was VFR. All aboard were killed.
  • Allegheny Airlines 453 (1978) — A complete lack of discipline in the cockpit is evidence by sloppy procedures, the absence of required call outs, and stabilized approach monitoring. The lack of crew resource management destroyed the airplane.
  • Eastern Airlines 401 (1972) — The pilots failed to continuously monitor the airplane while troubleshooting a gear position light and allowed the airplane to descend into the Everglades, killing all on board.
  • Galaxy Airlines 201 (1985) — A breakdown in crew coordination following an unexpected vibration shortly after takeoff led to loss of control of the airplane and all but one person on board.
  • Japan Air Lines 8054 (1977) — The crew was unwilling to confront an intoxicated captain who over-rotated into a stall, losing control of the aircraft and killing all on board.
  • United Airlines 173 (1978) — A captain not listening to the crew and a crew not being forceful enough caused the loss of an airplane and many lives.
  • United Airlines 232 (1989) — The mishap was caused by shortsighted aircraft certification rules that led to an engine failure that took out all the airplane's hydraulic systems. Excellent CRM saved many lives that day.
  • A Haskel CRM story: B-707 Depressurization — Just a short story about how I learned a captain must sometimes command as opposed to lead.

The Fundamentals

The CRM fundamentals taught during initial courses are sound and should be understood before moving on to training . . .

Consider the "captain"


Photo: Captain Clarence Over, from the movie "Airplane."

On a routine basis . . .

[CRM Handbook, pg. 25.] Effective leaders perform four primary functions:

  1. Regulating Information Flow. The leader must regulate, manage, and direct the flow of information, ideas, and suggestions within the cockpit crew and between the cockpit crew and outside sources. This function includes the following behaviors:
    • Communicating flight information
    • Asking for opinions, suggestions
    • Giving opinions, suggestions
    • Clarifying communication
    • Providing feedback
    • Regulating participation
  2. Directing and Coordinating Crew Activities. The leader must function as crew manager to provide orientation, coordination and direction for group performance. This function includes:
    • Directing and coordinating crew activities
    • Monitoring and assessing crew performance
    • Providing planning and orientation
    • Setting priorities
    • Delegating tasks
  3. Motivating crewmembers. The leader must maintain a positive climate to encourage good crewmember relations and to invite full participation in crew activities. This function includes:
    • Creating proper climate
    • Maintaining an "open" cockpit atmosphere
    • Resolving/preventing conflict
    • Maintaining positive relations
    • Providing non-punitive critique and feedback
  4. Decision-making. The leader is ultimately responsible for decisions. This function includes:
    • Assuming responsibility for decision making
    • Gathering and evaluating information
    • Formulating decisions
    • Implementing decisions
    • Providing feedback on actions

Preparation/Planning/Vigilance. [Advisory Circular 120-51E, Appendix 1, ¶3.a.]

  • Demonstrating and expressing situation awareness (e.g., the "model" of what is happening is shared within the crew).
  • Active monitoring of all instruments and communications and sharing relevant information with the rest of the crew.
  • Monitoring weather and traffic and sharing relevant information with the rest of the crew.
  • Avoiding "tunnel vision" caused by stress (e.g., stating or asking for the "big picture"). (5) Being aware of factors such as stress that can degrade vigilance, and watching for performance degradation in other crewmembers.
  • Staying "ahead of the curve" in preparing for planned situations or contingencies, so that situation awareness and adherence to SOPs is assured.
  • Ensuring that cockpit and cabin crewmembers are aware of plans. (8) Including all appropriate crewmembers in the planning process.
  • Allowing enough time before maneuvers for programming of the flight management computer.
  • Ensuring that all crewmembers are aware of initial entries and changed entries in the flight management system.

Workload Distributed/Distractions Avoided. [Advisory Circular 120-51E, Appendix 1, ¶3.b.]

  • Tasks are distributed in ways that maximize efficiency.
  • Workload distribution is clearly communicated and acknowledged.
  • Nonoperational factors such as social interaction are not allowed to interfere with duties.
  • Task priorities are clearly communicated.
  • Secondary operational tasks (e.g., dealing with passenger needs and communications with the company) are prioritized so as to allow sufficient resources for primary flight duties.
  • Potential distractions posed by automated systems are anticipated, and appropriate preventive action is taken, including reducing or disengaging automated features as appropriate.

Decision making

[CRM Handbook, pg. 23.] The decision making process may be broken down into the following five steps:

  1. Recognizing or identifying the problem. Does a problem exist that requires action?
  2. Gathering information to assess the situation. This step requires determining what information is needed, who has the needed information, and whether the information is verified by other crewmembers and resources.
  3. Identifying and evaluating alternative solutions. This step includes evaluating the advantages as well as the risks associated with each alternative identified, and selecting the optimum alternative.
  4. Implementing the decision. This step includes executing the decision and providing feedback on actions taken to crewmembers.
  5. Reviewing consequences of the decision. This step involves evaluating the consequences of the decision and revising the decision if consequences are not as anticipated.

Communications/Decisions. [Advisory Circular 120-51E, Appendix 1, ¶1.d.]

  • Operational decisions are clearly stated to other crewmembers.
  • Crewmembers acknowledge their understanding of decisions.
  • "Bottom lines" for safety are established and communicated.
  • The "big picture" and the game plan are shared within the team, including flight attendants and others as appropriate.
  • Crewmembers are encouraged to state their own ideas, opinions, and recommendations.
  • Efforts are made to provide an atmosphere that invites open and free communications.
  • Initial entries and changed entries to automated systems are verbalized and acknowledged.

When things don't go so well . . .

[Crew Resource Management (Kanki, Helmreich, Anca), Chapter 1] Effective conflict resolution is focused on what is right rather than who is right.

[CRM Leadership & Followership 2.0, Antonio Cortés]

  • Inadequate performance on behalf of a crewmember should be addressed immediately, tactfully, honestly, and privately. It may prove tempting to avoid commenting on inadequate performance in hopes of avoiding interpersonal conflict or damaging someone's feelings, but there is a professional obligation to correct substandard behavior. Of course, a captain's tone of voice can make a great impact in terms of how the feedback is received by the erring crewmember.
  • Good performance should be complimented, but not excessively. The art of leadership lies in knowing what to compliment and how often to do so in order to prevent the devaluation of the compliments. When positive feedback is provided, it should address the specific behavior that was noticed and should explain why the behavior was important.

Consider the "crew"


Photo: Captain Clarence Over, First Officer Roger Murdock, and Second Officer Victor Vostock, from the movie "Airplane."

[Crew Resource Management (Kanki, Helmreich, Anca), Chapter 1] The crew's awareness of operational conditions and contingencies, usually defined as situation awareness, has been implicated as causal in a number of incidents and accidents. However, situation awareness is an outcome rather than a specific set of mission management behaviors. The specific factors that are defined for this cluster are preparation/planning/vigilance, workload distribution, and distraction avoidance.

Preparation/Planning/Vigilance. [Advisory Circular 120-51E, Appendix 1, ¶3.a.]

  • Demonstrating and expressing situation awareness (e.g., the "model" of what is happening is shared within the crew).
  • Active monitoring of all instruments and communications and sharing relevant information with the rest of the crew.
  • Monitoring weather and traffic and sharing relevant information with the rest of the crew.
  • Avoiding "tunnel vision" caused by stress (e.g., stating or asking for the "big picture"). (5) Being aware of factors such as stress that can degrade vigilance, and watching for performance degradation in other crewmembers.
  • Staying "ahead of the curve" in preparing for planned situations or contingencies, so that situation awareness and adherence to SOPs is assured.

Workload Distributed/Distractions Avoided. [Advisory Circular 120-51E, Appendix 1, ¶3.b.]

  • Crewmembers speak up when they recognize work overloads in themselves or in others.
  • Tasks are distributed in ways that maximize efficiency.
  • Task priorities are clearly communicated.
  • Secondary operational tasks (e.g., dealing with passenger needs and communications with the company) are prioritized so as to allow sufficient resources for primary flight duties.
  • Potential distractions posed by automated systems are anticipated, and appropriate preventive action is taken, including reducing or disengaging automated features as appropriate.


[Advisory Circular 120-51E, Appendix 1, ¶1.b.]

  • Crewmembers speak up and state their information with appropriate persistence until there is some clear resolution.
  • "Challenge and response" environment is developed.
  • Questions are encouraged and are answered openly and nondefensively.
  • Crewmembers are encouraged to question the actions and decisions of others.
  • Crewmembers seek help from others when necessary.
  • Crewmembers question status and programming of automated systems to confirm situation awareness.

Characteristics of Effective Followers

[CRM Leadership & Followership 2.0, Antonio Cortés] Show Respect for Fellow Crewmembers. Showing respect to the other members of the crew, naturally including the captain, is not just a matter of courtesy, it is fundamental to fostering a sense of shared purpose that is the building block for teamwork. One of the most important ways of showing respect is by listening to others. This means actively listening for content in what another crewmember is saying, not just "hearing" what is being said.

Another way of showing respect is by offering to help in tasks without being asked to help. This is particularly important if the task is considered undesirable. Granted, a crewmember should always make sure his or her obligations are covered before taking time to help others. Sometimes such a professional obligation to one's own duties will not be noticed by other crewmembers and may be perceived as avoiding helping out. That can present a delicate situation.

Another important way to show respect for those in leadership positions is to always disagree with them in private. Nothing is more corrosive than to have a crewmember disagree with the captain in front of the entire crew.

Be Dependable. A follower has an obligation to the captain and to the employer to be dependable. The captain needs to be able to count on people to fulfill their professional responsibilities and also to complete any tasks that they agree to perform. Part of this "social contract" is showing up early for any scheduled activity. Notice that we are not talking about showing up on-time. Showing up on-time is the same as showing up late! Not only does showing up early show our depth of commitment to the profession, but it shows that we are willing to help pick up the slack for other crewmembers who may be running late.

Adopt a Sense of Ownership. One important quality exhibited through teamwork is a sense of ownership over the profession, the company, and each flight we are involved in. Such a responsibility is a matter of pride and comes from the realization that each of our actions impacts the bottom-line of an operation.

Assertiveness with Respect

[CRM Leadership & Followership 2.0, Antonio Cortés] Regardless of what tone has been set by the captain, crewmembers have an obligation to be assertive and to voice concerns and opinions on matters of importance to the safety of the flight.

What happens when a crewmember needs to convey important information and the captain is not listening, or does not grasp the importance or critical nature of what the crewmember is attempting to convey? To deal with such situations, the industry has adopted a 5-step assertiveness process.

  1. Get the captain's attention (use name or crew position/opposite typical): "Jim, I have a concern I want to discuss with you."
  2. State the concern: "I am not comfortable with this heading that we are on."
  3. State the problem and consequences: "If we continue on this heading, we will be too close to the buildup."
  4. Give solutions:"I think we should turn 20 degrees further west."
  5. Solicit feedback and seek agreement: "What do you think?" or "Don't you think so?"

[CRM Handbook, pg. 20.]

  • Accident reports reveal a number of instances in which crewmembers failed to speak up even when they had critical flight information that might have averted a disaster. In most cases, this hesitancy involved a copilot or flight engineer who failed to question a captain's actions or to express an opinion force fully to the captain. These types of incidents lead to the conclusion that crewmembers are often unwilling to state an opinion or to take a course of action, even when the operation of the airplane is clearly outside acceptable parameters.
  • Assertive behavior includes:
    • Inquiry: inquiring about actions taken by others and asking for clarification when required.
    • Advocacy: the willingness to state what is believed to be a correct position and to advocate a course of action consistently and forcefully.
    • Assertion: stating and maintaining a course of action until convinced otherwise by further information.

Behind the scenes

A reader was asking about the process of turning a rambling topic like this into a magazine article. Well, for me, it all starts with a big sheet of paper and some pens . . .


Photo: Eddie's CRM note board

Book Notes

Portions of this page can be found in the book Flight Lessons 2: Advanced Flight, Chapter 15.


Advisory Circular 120-51E, Crew Resource Management Training, 1/22/04, U.S. Department of Transportation

Aircraft Accident Report 4/90, Department of Transport, Air Accidents Investigation Branch, Royal Aerospace Establishment, Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989

Boeing Commercial Airplanes, Statistical Summary of Commercial Jet Airplane Accidents, Worldwide Operations 1959 - 2012, 2013

Creative Commons

Cortés, Antonio; Cusick, Stephen; Rodrigues, Clarence, Commercial Aviation Safety, McGraw Hill Education, New York, NY, 2017.

Cortés, Antonio, CRM Leadership & Followership 2.0, ERAU Department of Aeronautical Science, 2008

Crew Resource Management: An Introductory Handbook, DOT/FAA/RD-92/26, DOT-VNTSC-FAA-92-8, Research and Development Service, Washington, DC, August 1992

Fallucco, Sal J., Aircraft Command Techniques, 2002, Ashgate, Farnham, England

Flight Safety Foundation, Aviation Safety World, "Pressing the Approach," December 2006

Gann, Ernest K., Fate is the Hunter: A Pilot's Memoir, 1961, Simon & Schuster, New York

Kanki, Barbara; Helmreich, Robert; and Anca, José, Crew Resource Management, Academic Press, Amsterdam, 2010.

Merriam-Webster Dictionary

Portugal Accident Investigation Final Report, All Engines-out Landing Due to Fuel Exhaustion, Air Transat, Airbus A330-243 marks C-GITS, Lajes, Azores, Portugal, 24 August 2001

Revision: 20150411