Backgrounder–A11H0002 (Resolute Bay)

Crew resource management

Occurrence

On 20 August 2011, a Boeing 737-210C aircraft operated by First Air was being flown as a charter flight from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. At 1142 Central Daylight Time, during the approach to Runway 35T, the aircraft struck a hill about 1 nautical mile east of the runway. The aircraft was destroyed, and all 4 crew members and 8 passengers suffered fatal injuries. The remaining 3 passengers suffered serious injuries.

Crew resource management

The cockpit, or flight deck, of a multi-crew aircraft is a dynamic, challenging workplace where flight crews are constantly interacting with the aircraft, the environment, and each other. Crew resource management, or CRM, is about making effective use of the resources available—human, hardware, and information—to manage the threats and challenges that can arise during any flight.

Poor weather or mechanical malfunctions, for example, are external threats – they originate outside the flight crew’s control. Errors such as an incorrect instrument setting or an unintended deviation from a flight profile are internal.

Some of the subjects addressed in CRM training for crews are the following:

  • Decision making: recognizing when problems arise, and then devise and implement a plan to deal with them.
  • Human factors: understanding the individual elements that can affect performance, such as a person’s fatigue or stress level.
  • Standard operating procedures (SOPs): knowing what to expect from each other. SOPs also provide pre-determined solutions to many common situations.
  • Situational awareness: knowing what’s going on around you, and how it will affect you in the future.
  • Crew communication: being comfortable providing, and receiving feedback. This lets teams build—and maintain—group situational awareness.
  • Workload management: ensuring tasks are completed within the available time, so vital cues aren’t missed.
  • Team performance: making sure crew members have a good understanding of their roles and responsibilities.

Used effectively, these elements combine to make CRM a powerful tool, one that helps flight crews identify and manage threats and errors that can jeopardize safety.

This investigation found that if initial CRM training does not develop effective CRM skills and if there is inadequate reinforcement of these skills during recurrent training, flight crews risk not managing activities on the flight deck adequately. Furthermore, if operators do not take steps to ensure that flight crews routinely apply effective CRM practices during flight operations, risk to aviation safety will persist.

Safety concern

Therefore, the Board is concerned that, without a comprehensive and integrated approach to CRM by Transport Canada and aviation operators, flight crews may not routinely practise effective CRM.