Crew Resource Management Improves Decision Making

INSIGHT | ASK MAGA ZINE | 11
Crew Resource Management

Improves Decision Making
By JERRy MULENBURG
People make decisions, and people are fallible. So how can we make the best decisions in a particular
situation given the information available? Crew resource management techniques designed for
aircraft emergencies can help.
12 | ASK MAGA ZINE
DECISIoNS ArE oFTEN Poor ChoICES

MADE For ExPEDIENCy or oUT oF
IGNorANCE oF ALTErNATIvES.
Some think of decision making as a logical, well-defined Crew Resource Management

process and teach it that way in management courses and The best example of CRM in use may be the safe landing on
elsewhere. The evidence of practical experience shows, January 15, 2009, of U.S. Airways flight 1549 by Captain Chesley
however, that decision making is seldom a precise, rational (Sully) Sullenberger in New York’s Hudson River. Hitting a
activity. In reality, it is often plagued with bias, misconception, flock of geese on takeoff from New York’s LaGuardia Airport
and poor judgment. Decisions are often poor choices made completely shut down both engines on his Airbus A320. With
for expediency or out of ignorance of alternatives. In my own more than 19,000 hours of flight time, including flying gliders,
experience, the person at the top in the hierarchy in most Captain Sullenberger’s experience and training helped prepare
organizations is expected, or assumed, to be in the best him for the once-in-a-lifetime decision he faced. In less than three
position to make the important decisions. Having served in minutes, this is what Captain Sullenberger did:
several different NASA Ames Research Center divisions, and
as the head of two of them, I experienced firsthand the fallacy • Requested permission to return to LaGuardia—approved
of this expectation. (normal procedure)
As managers, we get in our own way sometimes because • Performed engine restart procedure—engines didn’t restart
we don’t think enough and sometimes because we think too (multiple attempts would have resulted in the same outcome
much. Thinking hard about the decision is not enough; we need and time was short)
to think about it in the right way. Rather than make us better • Asked for alternate airport-landing location in New
decision makers, a lot of experience in an area can sometimes Jersey—granted (wanted to avoid densely populated area
blind us to alternatives because of our investment in what we’ve near LaGuardia)
done before. In his book, How We Decide, Jonah Lehrer describes • Made final decision to land in the Hudson River—
the need to embrace uncertainty and new ideas in decision successful in saving all onboard (copilot provided airspeed
making: “There is no secret recipe for decision making … only and altitude readings for pilot to glide aircraft in)
… commitment to avoiding those errors that can be avoided.
There’s not always time to engage in a lengthy cognitive debate. As Sully put it: “I was sure I could do it. I think, in many
But whenever possible, it’s essential to extend the decision- ways, as it turned out, my entire life up to that moment had been
making process [to] entertain competing hypotheses [and] a preparation to handle that particular moment.”2 During a talk
continually remind yourself of what you don’t know.”1 Lehrer about his experiences, Captain Sullenberger mentioned that he
also warns that we are often most ignorant of what is closest owed a lot to the CRM training he went through.
to us. These ideas have special relevance to high-risk and other The CRM training Sully refers to is a program Ames
complex decision-making situations. developed in the 1970s in response to a number of flawed in-
For instance, what if you were piloting an aircraft full flight decisions that resulted in aircraft crashes. CRM is now
of passengers and suddenly ran out of fuel? How would you widely used in military and civilian aviation throughout the
go about making the decision about what to do first, next, world. So what is CRM, and how can its lessons about decision
and, if none of these efforts solved the problem you’re facing, making apply to complex project situations?
then what? This type of situation is so out of the ordinary, The driving idea behind CRM is to train aircrews in
fortunately, that few people have experienced it, but such communication skills to maximize coordination and minimize the
emergencies can and do happen. Thanks to a program called chance for errors. According to AirlineSafety.com, CRM is “… one
crew resource management, or CRM, decision makers can of the most valuable safety tools we have today. It has contributed
learn how to handle them. significantly toward the prevention of ‘pilot error’ accidents; it has
ASK MAGA ZINE | 13
DESPITE ALL ThE SEASoNED vETErANS worKING oN A

ProJECT (AND SoMETIMES bECAUSE ThEy TrUST ThEIr
ExPErTISE Too MUCh), MISTAKES ArE MADE, oMISSIoNS
oCCUr, AND CLEAr ThINKING IS oFTEN DISPLACED by A
FALSE SENSE oF KNowING whAT IS GoING oN.
saved airplanes and lives.”3 The basic tenets of CRM are to avoid, errors, and helps ensure that the four CRM steps—recognizing
trap, or mitigate the consequences of errors resulting from poor that a problem exists, defining the problem, identifying probable
decisions. To do this, according to CRM, it is essential to solutions, and taking appropriate action—will be carried out
effectively. “Integration” describes the need to integrate the whole
1. recognize that a problem exists, team’s knowledge and skill into a final solution. TRIM also stands
2. define what the problem is, for terms that emphasize communication:
3. identify probable solutions, and
4. take appropriate action to implement a solution. • Talk with each other
• Respect each other
CRM techniques have been applied to other high-risk • Initiate action
situations, including the high-stress environment of the operating • Monitor results
room. Poor decisions are not simply due to surgeon error but also to
the processes and systems that allow errors to remain undetected. CRM is already a mature discipline with clear benefits in
CRM in the operating room has shown positive results due to high-risk situations that can translate to complex projects. Using
improved communication, teamwork, error reduction, and better its successful training methods, CRM seems ideal for application
training of the whole team, reducing avoidable mortality rates. to project management decision making. I believe it is important
One CRM trainer describes the CRM process as “see it, that the project management community recognize the benefits
say it, fix it.” This is a good approach to problems on complex gained by the application of the CRM/TRIM technique to
projects, including NASA projects. reduce decision errors and the consequences of those errors. CRM
is a systematic way of helping us use our collective cognitive
Applying CRM at NASA skills to gain and maintain situational awareness and develop
Flawed decision making was one of the root causes of the loss of our interpersonal and behavioral skills to establish relationships
the Challenger and Columbia Space Shuttles and their crews. It also and communicate with everyone involved, to achieve accurate
contributed to the loss of the Mars Climate Orbiter, Mars Polar and robust decisions. ASK readers responsible for managing
Lander, and problems on other projects. Despite all the seasoned complex projects can take the initiative to begin implementing the
veterans working on a project (and sometimes because they trust CRM/TRIM processes and provide feedback on their results. ●
their expertise too much), mistakes are made, omissions occur,
and clear thinking is often displaced by a false sense of knowing
what is going on. For most complex projects, the decisions are Jerry muleNburG retired from NASA in 2006 with more than twenty-five years of
not as monumental as for in-flight emergencies or surgery. But distinguished service. He held positions as assistant division
the mistakes matter and sometimes lead to the expensive and chief for Life Sciences, and division chief of the Ames Aeronautics
and Space Flight Hardware Development Division and of Wind
disappointing loss of mission or, tragically, loss of crew. Tunnel Operations. A former air force officer, he is a Project
NASA would benefit greatly from applying CRM-like Management Institute Project Management Professional and
techniques to its complex projects. One of the things CRM does a trained MBTI administrator, and he currently teaches project
management at the university graduate and undergraduate
is integrate the knowledge and experience of all team members levels. He also provides training in project management as an
to arrive at a wise and robust decision. The acronym TRIM, independent consultant.
which stands for team resource integration management, clearly
describes the process. TRIM embraces the three CRM tenets 1. Jonah Lehrer, how We Decide (New york: houghton Mifflin, 2009).
2. Alan Levin, “Pilot: ‘I was sure I could’ land in river,” usa today, February 9, 2009.
of avoid, trap, or mitigate the consequences of decision-making 3. robert J. boser, “CrM: The Missing Link,” November 1997, www.airlinesafety.com/editorials/editorial3.htm.

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INSIGHT | ASK MAGA ZINE | 11

Crew Resource Management

DECISIoNS ArE oFTEN Poor ChoICES

Some think of decision making as a logical, well-defined Crew Resource Management

DESPITE ALL ThE SEASoNED vETErANS worKING oN A

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