Palm 90 tragedy Solace: CRM as an aviation safety advance

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37 Years Ago- The horror and Heroism of Air Florida

SIC warned PIC about thrust problem

Cockpit Resource Management

Improves Communications

Iterations of CRM


Palm 90 received a tremendous amount of attention- a dramatic crash, incredible rescue action and its location. The regulatory landscape in 1982 was dramatically different than today’s more preventative approach. This tragedy’s prominence probably helped move forward an important safety initiative—cockpit (now crew) resource management. Fortunately that momentum did not die then; CRM has continued to increase its didactic elements and to expand these disciplines in pilot training around the globe.

[The NTSB report on AF90 was found a number of predicates to the crash.

The CRM determination had the greatest long term impact.]

First, it is important to recite the NTSB’s Probable Cause findings (Boeing 737-222 (N62AF) NTSB Number: AAR8208):

“The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to use engine anti-ice during ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and the captain’s failure to reject the takeoff during the early stage when his attention was called to anomalous engine instrument readings. Contributing to the accident were the prolonged ground delay between deicing and the receipt of ATC takeoff clearance during which the airplane was exposed to continual precipitation, the known inherent pitchup characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice, and the limited experience of the flightcrew in jet transport winter operations.”

With that predicate, what has been the development of CRM:







The aegis of CRM was a NASA 1979 conference report called Resource Management on the Flightdeck sponsored by the National Aeronautics and Space Administration.

The next active developer was United Airlines in 1981 and its Denver Flight Training Center. There with the help of consultants, an approach called “Managerial Grid” was taught to crew members in intensive seminars setting. The pilots were instructed how to diagnose their own managerial style.

About 1987, a “second wave” of CRM began; one of the signals of the shift in the classes was renaming it as “Crew Resource Management” in which the focus was placed on the personal interactions. This new wave, led by Delta, was to teach using more real cockpit situations specific aviation concepts related to flight operations. From a pedagogical standpoint, the pilots were exposed to more team building, briefing strategies, situational awareness, stress management. decision making strategies and breaking the chain of errors that are frequently causes for accidents.

The next step in the evolution involved automation. CRM, here, emphasized the importance of cross-checking data inputs and choice of system. Seeing the value of this training, airlines added CRM to flight attendant, mechanic and flight dispatchers. The concepts were integrated into many curricula for pilots being upgrades, particularly the PIC seat.

The FAA’s Advanced Qualification Program (AQP), a voluntary alternative, encouraged airlines to develop alternative means of training. The trainers used this freedom from the prescripted lesson plans to devise scenarios relevant to the class members.

[These 4 stages were identified in The Evolution of Crew Resource Management Training in Commercial Aviation

by Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm ;Department of Psychology; Aerospace Crew Research Project

The University of Texas at Austin.]

The authors made the following observations about CRM in aviation:

CRM does not reach everyone.

Acceptance of basic concepts may decay over time.

CRM did not export well.

They postulate that there is a 5th iteration in which CRM is used to address to address specific errors.


The article includes a lot more useful commentary.







The literature on CRM is quite robust; here are some further references:






















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