The Loss Of Situation Awareness Management Essay

2540 words (10 pages) Essay

1st Jan 1970 Management Reference this


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Crew resource management or cockpit resource management (CRM) is a management system that uses non – technical knowledge to make optimum use of all information that they can get from people, Equipment and other to make sure the safety and efficiency of the flight. CRM has been existing for over 2 decades; it was developing as a responded to the increase of accident that occur in aviation world. There are 9 elements in CRM we need to know such as crew fatigue, leadership, situational awareness, teamwork, crew stress, crew personality, decision making, communication and workload management. It is also about reduce or decrease human error and optimum human performance.

CRM is needed in aviation world because it can increase the ability of flight crew to prevent and manage if error happens. Flight crew can be appointing to pilot, flight officer, flight attendance and flight engineer. In CRM they will have to understand and apply the relationship between pilot and cabin crew can ensure the safety of the flight and passengers. The training also focuses on interpersonal communication, leadership and decision making.

Major accident will happen if error chain happens between pilot and cabin crew. Error chain or chain of event refers to the relationship or a good communication between all the flight crew. Error chain means factors that lead to accident (mishap). It is typically base on human factor, rather than machine failure. The fact is 70% of accident cause by human error, while 20% cause by machine failure and 10 % cause by nature environment. The links of this error chain can be recognize and prevent to ensure the error chain remains intact.

Many accident cause not from technical failure but cause by the ability of the crew to aware and make a decision making fast. This is where the training takes place. The first generation of CRM or cockpit resource management is about the relationship and communication between the pilot and co- pilot. The pilot needs to hear what the co- pilot have to say and not to take control all the time. Because when the pilot does that, the co- pilot might get scared to say if anything wrong. That may lead to aircraft crash. So they trying to change the wrong stuff and increase the relationship between the pilot and co- pilot.

The second generation of CRM is changing the training course from cockpit to crew resource management. Because before they change the mane, the training only focus on the environment inside the cockpit only not the whole aircraft. When they change the name, they want to focus and organize the role of flight crew members to make sure the accident will be reduce, it also can break the error chain between the crews. For this second generation they will conduct team building, situational awareness and briefing about stress management.

The third generation of CRM or broadening the scope is about the broadening the flight crew function or ability. It is to make sure that when the time emergency the fight know what to do. They also train pilot to have leadership skill. The fourth generation is about the development of specific organization culture. They introduced Line Oriented Training (LOFT) a simulator that have the possibility accident or failure that can happen when the crew in flight, with the simulator they will learn how to solve and make a decision for the particular cases.

The fifth generation of CRM is focus on error management and how to solve it. There are three lines of defence the error. Firstly is, we have to try to minimise the error. Secondly is, we can try to trap the error and lastly we can reduce the error. The sixth and last generation of CRM is to reduce human error and optimum the human performance. In this generation they cover the whole thing that they want the flight crew to learn such as communication, decision making and other element.

Cases study

As for my case study, I will take aircraft accident that happen on 10 January 1954, British Overseas Airways Corporation, flight 781 a de Havilland DH.106 comet 1 registered G-ALYP, figure 1.

Figure 1

The comet is the first jet in the world, to make as jet airliner. It was built in British and it was consider as landmark for British aeronautical design. This comet jet does bring a new revolution to aviation world. Its bring world closer to the high speed transport than before. At that time in Europe, aviation is moving, by the new technological that has been experiment and invent during World War 2 that make the number of passenger twice in two year.

The comet designed base of military expertise and power by four turbo jet engines, carry 42 passenger and crew. The size is about Boeing 747 and the speed is 800 km per hour, almost twice the speed of other aircraft at that time. The type of the aircraft is De Havilland DH-106 Comet 1. The air craft name is Yoke Peter. The flight origin is from Kallang airport, Singapore and stopover at Ciampino airport, Rome, Italy and fly to the last destination at London Heathrow airport, London, England, United Kingdom.

The accident happens at about 10:40 GMT, the aircraft suffered an explosive decompression at altitude and crashed into the Mediterranean Sea island of Elba, no survivor were found, refer to figure 3. At first, it was hard to find what the causes of the accident are; it is because at that time the black box, cockpit voice recorders or flight data recorders. There is no way they can understand what was going on. So they have to take out the aircraft body from the sea, to investigate what was the real cause. Figure 4.

Figure 3 figure 4

The accident show that the aircraft suffer from the ‘Metal Fatigue’. ‘Metal Fatigue’ is a structural damage that occurs when aircraft fly at certain altitude, it also because of the type of the metal that they use to make the aircraft is too thin. The stress around pressure cabin is higher than had been expected, especially a round window. Figure 5 show the part where the damage and the crack started.

Figure 5




Communication is very important to human being. Communication can be defined as transferring information using transmitter (deliver) and receiver (listener) so, in aviation every flight crew and ground staff must learn and apply the communication skills it is because, to avoid miscommunication that can lead to unwanted event. It is a must for Pilot and Air Traffic Controller to adapt these communication skills, so that the ATC can give simple and easy instruction to the pilot, and pilot can give a quick feedback to the ATC.

Other than that, flight crew also have to communicate with the passenger in simple and understandable conversation. So they understand what the flight crew want, and the flight crew understand what the passenger wants. As we know, 70% of the accident happen because of the human error, especially because of poor communication between pilot, ATC and ground staff.

In this comet flight 781 case, the accident may cause by the lack of understanding of the engineer that designed the aircraft. He or she may not know that when the aircraft is at the high speed, the pressure is increasing because of the high speed and the gravity, and also we know that the aircraft body are made from thin and light metal. This combination can cause the crack of the aircraft when it reaches at certain altitude.×307.jpg

Figure 6 figure 7

So, to avoid this poor communication from happening in the future, all the flight crew and ground staff must apply the communication skill to each other.


Nowadays, as we read in newspaper, there is always an aircraft accident happen. As we know 70% of accident cause by human error and half of that are cause by loss or lack of situation awareness. Situation awareness means the actual perception of all the factors that included technical, environment and human that can affect the flight and the crew. Every crew must be aware and alert about the situational awareness. So, the aircraft can avoid loss control or mishap during its operation.

As in this case, the pilot not pays any attention to the indicator that displays the cabin pressure. Before the ATC give the comet to increase the flight level, the captain already, take the action to increase the flight level to 23000 ft. when he realize that the cabin pressure increase, it was too late to do anything and its crash.

Other example, which is flight eastern L-1011 was crashed during approach in Miami airport. In this case, the flight crew fail to monitor the flight instrument during a malfunction of the landing gear position indicator that time, the crew realized that it was too late to do anything. In this accident, 163 people on board, only 112 were killed in the crash.

Figure 8


Most of the aircraft accidents happen in the aviation world cause by the crew stress and fatigue. Crew Fatigue is defined as the state where the air crew is having difficulties in handling any situation caused by the loss of energy from their body. When this occurs, the personnel will have difficulties in performing any critical thinking, to make any decision as well as performing any heavy physical task.

While, Crew Stress is defined as the state human of body’s reaction, to a change that requires a physical, mental or emotional adjustment or response. Stress can come from any situation or thought that makes you feel frustrated, angry, nervous, or anxious. As for the comet, the pilot and the co-pilot failed to monitor the entire instrument. Maybe the pilot is to excite to meet his family at the airport or maybe he had a fight with his wife just before he takes off. After all, the cabin crew also do not inform the pilot about the passenger had problem with breathing.

So, to avoid pilot’s stress and fatigue, they can get some restful and quality sleep. It is to ensure the safety of flight during flight hours or maybe they had a fight with each other, which will make poor communication and stress.

Figure 9 figure 10


Leadership can be defined as a person who has been given a task to guide all the c workers that work under him or she. The workers must inform the leader if they want to make any change or anything else, they must get approvable from the leader to do any action. With this leadership procedure, all the work will be easy and organize. As for aviation world, pilot will be captain or leader in the aircraft, so that all the crew have to inform anything that they see or hear about the passenger or the aircraft. As the captain, he or she must apply the leadership during the flight operation. Figure 11

Figure 11

In the comet flight 781, the captain didn’t really care about the crew. He only communicated with the co-pilot. So, the crew didn’t aware of the environment in the aircraft. Leadership is really important to every company that sell service and product. It will increase the profit.


Teamwork is really important to achieve any objective. Teamwork can be defined as a group of people works together to achieve the goal in effective and efficient way as possible. Other that teamwork we also can use synergism. Synergism can be defined as efforts of each member in the crew acting in isolation. In synergism we have to apply good communication, situation awareness and good decision making. We can achieve excellent teamwork, if the member of the team applies synergism and greater achievement.

In teamwork, we must have leader and follower so that the teamwork can be performed. Leader is a person who has ideas that can influence other in easy way, while follower can be defined as a group of people that can take order from the leader without complaining. In aviation world, all crew members must apply the leadership role, it is because when the emergency case happen, one of the crew must perform the role, to make sure all the passenger are safe.

In the comet flight 781, all the flight crew are not apply the teamwork and synergism, each of the member are not doing the task given, that the reason why the they didn’t aware that the cabin pressure is increasing. That why all the aviation crew or flight crew must learn and adapt the teamwork and synergism. Figure 12 show the teamwork. Figure 13 shows what will happen if teamwork fails.

Figure 12 figure13


The fact is, human error can’t be completely vanish or gone from aviation world, ever. But, we still can reduce it by combine all the thing that we study in Crew resource Management, which is situation awareness, fatigue, decision making, teamwork and few other things. Because we know that the aircraft accident percentage are increasing each year. What we can do to decrease the aircraft crash is, do a better training for the flight crew and ground staff, shorter the work hour, so that the entire aviation worker can rest, because, we know that the aviation industry is a fast organization, sometimes the worker do work more that they could possible to do ,overload work.

Other than that, the company must increase the salary, so that they will do a good work and will show their talent in doing work. Also, the organization must monitor all the worker work, so that we can stop the bad thing from happen, the organization can review the pilot habit during flight operation.

To do all of this, it will cost money. So airlines won’t do it voluntarily.  Which means it needs to be mandated–so all airlines have to do it the same way and are on the same playing field.


As My Conclusion, Study Crew resource management is very important to ensure the safety of aircraft. Many aircraft accident happen in this world is caused by the human error. So, to avoid this thing happens, every air crew need to complete CRM or crew resource management Training. It is including, the training how to handle aircraft during emergency. Every pilots and Flight attendant must demonstrate the safety demonstration to the passengers during flight.

There are many major causes of aircraft accident. Such as poor communication, poor decision making, Engine failure or malfunction, and others. So to avoid aircraft accident happen again, the pilot and also the air crew must have a good communication each other during flight hours. The pilot also must have skill to make the best decision making if any emergency happen. Other than that, checking the engine before flight is very important to avoid the aircraft engine is malfunction. This is the job by the aircraft maintenance in the ground.

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