Editing Crew resource management (section)

== Case studies ==

===United Airlines Flight 173===

When the crew of [[United Airlines Flight 173]] was making an approach to [[Portland International Airport]] on the evening of Dec 28, 1978, they experienced a landing gear abnormality. The captain decided to enter a holding pattern so they could troubleshoot the problem. The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply, and only realized the situation when the engines began flaming out. The aircraft crash-landed in a suburb of Portland, Oregon, over {{Convert|6|mi|0|spell=in}} short of the runway. Of the 189 people aboard, two crew members and eight passengers died. The [[NTSB]] Air Safety Investigator Alan Diehl wrote in his report:

{{blockquote|Issue an operations bulletin to all air carrier operations inspectors directing them to urge their assigned operators to ensure that their flightcrews are indoctrinated in principles of flightdeck resource management, with particular emphasis on the merits of participative management for captains and assertiveness training for other cockpit crewmembers. (Class II, Priority Action) (X-79-17)<ref name="ReferenceA" />}}

Diehl<ref name="ReferenceA" /> was assigned to investigate this accident and realized it was similar to several other major airline accidents including the crash of [[Eastern Air Lines Flight 401]]<ref>NTSB report: Eastern Airlines, Inc, L-1011, N310EA, Miami, Florida, December 29, 1972, NTSB (report number AAR-73/14), June 14, 1973</ref> and the runway collision between [[Tenerife airport disaster|Pan Am and KLM Boeing 747s at Tenerife]].<ref>International Civil Aviation Organization, Circular 153-An/56, Mortreal, Canada, 1978)</ref>

=== United Airlines Flight 232 ===

[[Alfred C. Haynes|Captain Al Haynes]], pilot of [[United Airlines Flight 232]], credits CRM as being one of the factors that saved his own life, and many others, in the Sioux City, Iowa, crash of July 1989:

{{blockquote|&nbsp;... the preparation that paid off for the crew was something&nbsp;... called Cockpit Resource Management&nbsp;...  Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said, goes. And we lost a few airplanes because of that. Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about. And we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced [under those failure conditions], any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn't used [CRM], if we had not let everybody put their input in, it's a cinch we wouldn't have made it.<ref>{{cite web|url=http://yarchive.net/air/airliners/dc10_sioux_city.html |title=The Crash of United Flight 232 |author=Capt. Al Haynes |date=May 24, 1991 |access-date=2013-06-04 |url-status=dead |archive-url=https://web.archive.org/web/20131026210937/http://yarchive.net/air/airliners/dc10_sioux_city.html |archive-date=October 26, 2013}} Presentation to [[NASA]] [[Dryden Flight Research Facility]] staff.</ref>}}

=== Air France 447 ===

One analysis blames failure to follow proper CRM procedures as being a contributing factor that led to the 2009 fatal crash into the Atlantic Ocean of [[Air France Flight 447]] from Rio de Janeiro to Paris. The final report concluded the aircraft crashed after temporary inconsistencies between the airspeed measurements—likely due to the aircraft's [[pitot tube]]s being obstructed by ice crystals—caused the [[autopilot]] to disconnect, after which the crew reacted incorrectly, causing the aircraft to enter an aerodynamic stall from which it did not recover.<ref name=popmech>{{Cite web|url=https://www.popularmechanics.com/technology/aviation/crashes/what-really-happened-aboard-air-france-447-6611877|title=What Really Happened Aboard Air France 447|first=Jeff|last=Wise|date=June 1, 2020|website=Popular Mechanics}}</ref>

Following recovery of the black box two years later, independent analyses were published before and after the official report was issued by the [[Bureau of Enquiry and Analysis for Civil Aviation Safety|BEA]], France's air safety board. One was a French report in the book "Erreurs de Pilotage" written by Jean-Pierre Otelli,<ref>{{Cite web|url=https://www.lepoint.fr/societe/af447-pas-de-diffamation-pour-erreurs-de-pilotage-15-02-2012-1431836_23.php|title=AF447, pas de diffamation pour|first=Thierry|last=Vigoureux|date=February 15, 2012|website=Le Point}}</ref><ref>{{Cite news|url=https://www.economist.com/gulliver/2011/10/14/a-controversial-look-at-the-crash-of-flight-447|title=A controversial look at the crash of flight 447|newspaper=The Economist|date=14 October 2011}}</ref><ref>{{Cite web|url=https://www.telegraph.co.uk/news/worldnews/europe/france/8825264/Final-words-of-Air-France-passenger-jet-emerge-whats-happening.html|title=Final words of Air France passenger jet emerge: 'what's happening?'|first=Peter|last=Allen|date=October 13, 2011|via=www.telegraph.co.uk}}</ref><ref>{{Cite news|url=https://www.nytimes.com/2011/11/21/world/europe/when-disaster-threatens-instinct-can-be-a-pilots-enemy.html|title=When Disaster Threatens, Instinct Can Be a Pilot's Enemy|first=Nicola|last=Clark|newspaper=The New York Times|date=November 20, 2011}}</ref> which leaked the final minutes of recorded cockpit conversation. According to ''[[Popular Mechanics]]'', which examined the cockpit conversation just before the crash:
 
<blockquote>The men are utterly failing to engage in an important process known as crew resource management, or CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, and who is doing what.<ref name=popmech /></blockquote>

=== First Air Flight 6560 ===

The [[Canadian Transportation Safety Board]] (CTSB) determined a failure of crew resource management was largely responsible for the crash of [[First Air Flight 6560]], a [[Boeing 737-200]], in [[Resolute, Nunavut]], on August 20, 2011. A malfunctioning compass gave the crew an incorrect heading, although the [[instrument landing system]] and [[Global Positioning System]] indicated they were off course. The first officer made several attempts to indicate the problem to the captain but a failure to follow airline procedures and a lack of a standardized communication protocol to indicate a problem led to the captain dismissing the first officer's warnings. Both pilots were also overburdened with making preparations to land, resulting in neither being able to pay full attention to what was happening.

First Air increased the time dedicated to CRM in their training as a result of the accident, and the CTSB recommended regulatory bodies and airlines to standardize CRM procedures and training in Canada.<ref>{{cite web | title=First Air captain ignored co-pilot's warnings before Nunavut crash |publisher=CBC News | date=2013-10-03 | url=https://www.cbc.ca/news/canada/north/first-air-captain-ignored-co-pilot-s-warnings-before-nunavut-crash-1.2584641 | access-date=2020-06-27}}</ref><ref>{{Cite web|url=https://nunatsiaq.com/stories/article/65674poor_training_miscommunication_and_a_simple_accident_lead_to_nunavuts_/|title=Poor training, miscommunication, simple accident led to 2011 Nunavut air disaster|agency=Nunatsiaq News|date=March 26, 2014}}</ref><ref>{{Cite web|url=https://www.aptnnews.ca/uncategorized/co-pilot-suggested-twice-change-course-deadly-first-air-flight-6560-crash-tsb/|title=Co-pilot suggested at least twice to change course before deadly First Air flight 6560 crash: TSB|agency=APTN National News|date=March 25, 2014}}</ref><ref>{{Cite web|url=https://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/A11H0002/A11H0002.html|title=Aviation Investigation Report A11H0002|author=[[Transportation Safety Board of Canada]] |publisher=Government of Canada|date=March 5, 2014|website=www.tsb.gc.ca}}</ref><ref>{{Cite news|url=https://www.theglobeandmail.com/news/national/combination-of-factors-blamed-for-fatal-resolute-bay-plane-crash/article17657641/|title=Combination of factors blamed for fatal Resolute Bay plane crash|newspaper=The Globe and Mail|date=25 March 2014|last1=Carlson|first1=Kathryn Blaze}}</ref>

=== Qantas Flight 32 ===

The success of the [[Qantas Flight 32]] flight has been attributed to teamwork and CRM skills.<ref>{{Cite web|url=https://livingsafelywithhumanerror.wordpress.com/2017/01/09/crm-at-its-best-qantas-flight-32-learning-from-the-recent-past/|title=CRM at its best: Qantas flight 32, learning from the recent past|date=January 10, 2017}}</ref> Susan Parson, the editor of the [[Federal Aviation Administration]] (FAA) Safety Briefing wrote; "Clearly, the QF32 crew's performance was a bravura example of the professionalism and airmanship every aviation citizen should aspire to emulate".<ref>{{cite web |url=https://www.faa.gov/news/safety_briefing/2013/media/SepOct2013.pdf |title=aviation citizenship|date=2013 |website=www.faa.gov |access-date=2020-06-27}}</ref>

Carey Edwards, author of ''Airmanship'' wrote:

<blockquote>Their crew performance, communications, leadership, teamwork, workload management, situation awareness, problem solving and decision making resulted in no injuries to the 450 passengers and crew. QF32 will remain as one of the finest examples of airmanship in the history of aviation.<ref>{{Cite web|url=https://qf32.aero/book-reviews-summary/|title=Book Reviews|date=December 1, 2012}}</ref><ref>{{Cite book|url=https://books.google.com/books?id=-bodGgAACAAJ|title=Airmanship|first=Carey|last=Edwards|year=2008|publisher=Crowood Press UK|isbn=9781861269805|via=Google Books}}{{page?|date=June 2023}}</ref></blockquote>