The CRM Syndrome known as "the Hawthorne Effect"
Narrowing the human factor

April 02, 2004

SAFETY is no accident - so the saying goes - and in aviation at least there couldn't be a more accurate statement.

With aviation headlines focused on low-fare airlines, trans-Tasman competition and the Qantas/Air New Zealand equity alliance, it is easy to overlook the significant strides made by some of the region's more accident-prone airlines in improving their poor safety performance.

There have been hiccups - and worse - but the trend is moving in the right direction.

Nevertheless, avoiding complacency is crucial to preventing disaster, and this is no time for resting on laurels.

Within the past 12 months there have been calls by local pilots to sack expatriate pilots - a sure sign of cockpit disharmony, at odds with

 a culture of safety.

There was also a severe tail strike in Auckland - the plane's tail hit the runway during takeoff - and reports from "human factors" experts that significant challenges remain in the cultural areas of implementing crew resource management (CRM), particularly as it pertains to Asia-Pacific carriers.

The failures of crew performance documented in the investigation into the tail strike - by Singapore Airlines - illustrate one of the challenges facing airlines in implementing CRM: how to ensure that what is learned in the classroom actually becomes part of the cockpit routine.

The New Zealand Transport Accident Investigation Commission report found that in that incident on March 12, 2003, there was a transcription error between the captain and the first officer. The first officer wrote down and computed the takeoff speed for 247 tonnes, instead of 347 tonnes.

The "excessively slow takeoff speed" was not queried by the captain, who had just come from a A340-300 -- a much lighter aircraft.

TAIC found that the crew programmed in a takeoff speed 33 knots below the 163 knots required and on rotation the tail struck the runway and scraped for 490m until the 747 clawed its way into the sky.

The report said that "system defences did not ensure the errors were detected" and recommended that SIA use the incident as a flight simulator scenario for pilot recurrent training - which the airline has done.

Human factors expert Najmedin Meshkati warns that "some CRM courses may be perceived as effective but that may be more the 'Hawthorne Effect' rather than a long-term cultural and CRM change."

The syndrome gets its name from a five-year efficiency study conducted at Western Electric Hawthorne Works in Chicago in the first half of the 20th century. It found that the study itself contributed to a change in individual behaviour - but that it was not necessarily long-lasting. Translated into aviation, this means that pilots may perform perfectly in CRM training scenarios but revert to old ways and cultural habits on the line.

Mr Meshkati, who lectures on human factors in aviation at the University of Southern California. observes: "It may be that CRM training is less effective than we think."

Mr Meshkati also warns about the absence of CRM culture beyond the cockpit at many Asian airlines.

"In my human factors classes I talk to over 40 pilots from Asian airlines every year and too many voice concerns that the CRM lessons they are learning are not supported by the airline's management."

While acknowledging that his evidence was not very scientific, Mr Meshkati says there were too many voices of concern for the problem to be treated as isolated.

"Many airlines are planting the seed in CRM training but outside the cockpit the harsh winds of reality are a negative force," he declares.

"I am also concerned that many airlines have hired outside consultants to rectify safety attitudes and CRM issues, but once their contracts

expire the old ways will creep back.

"Clearly, for CRM training to be effective the entire airline must embrace the team-building culture and respect that is at the core of the program."

While conceding problems still exist in an imperfect world, Association of Asia Pacific Airlines Technical Director Leroy Keith lauds the progress of the past 10 years.

"Look at the statistics. Member airlines are putting a great effort into training."

He also says most Chinese airlines are making significant strides. "I meet with safety officials and my sense is that there has been a lot of progress but, of course, there is always room for further improvement. From what I see, there is an awareness that it is essential to keep up with the rest of the world."

Organisations such as Flight Safety Foundation, Alteon, Lufthansa Flight Training and Delta Air Lines have played major roles in the improvement of the safety record among Asia-Pacific airlines.

According to Keith, a host of safety programs have been implemented, including long-term contracts with major internationally

 recognised training organisations, use of specialised consultants and staff from other airlines, recognition of "softer" critical knowledge skills such as English-language training and CRM, including the critical role cabin crews play in safety.

Importantly, he notes that some airlines are including human factors training for employees and management involved in maintenance activities.

"They are also measuring trends to identify root causes of errors and at the same time are moving away from laying blame to fixing problems, so both pilots and engineers will be inclined to report their own mistakes."

Meshkati warns that no airline is an island and neither is any department within that airline. "I am very concerned that CRM is not being institutionalised into some Asia-based airlines and quite often there is no reward-based incentive program. You must constantly energise the program for it to keep working."

privacy            The Australian

to Hot off the PRESS