Matthias D. Wunderlin
Adapting Crew Resource Management for Aerospace Original Equipment Manufacturers to Increase Efficiency
Submitted as part of the requirement for the award of
MSc in Air Safety Management
At City, University of London
I certify that this project is wholly my own work and in accordance with the project regulations.
All material that has been extracted from others has been clearly referenced.

This Project complies with the Project Regulation and Guidelines.

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Executive SummaryThe aim of this project is to propose methods of Crew Resource Management (CRM) for the employees of original equipment manufacturers (OEM) in the aerospace industry. CRM is a method for dealing with Human Factors (HF) originally intended for and used by pilots for safety improvements. The process of this project is to review the literature and carry out empirical research into aerospace OEMs, through four different objectives.

The first objective was to research CRM and HF. The findings confirmed that CRM is not generally used by aerospace OEMs, but by aircraft technicians. Additionally, ambiguities were apparent in the use of the terms HF and CRM, and the hoped for, additional motivation anticipated for CRM use, by aerospace OEM employees, could not be positively confirmed.

The second objective was to research efficiency and safety benefits. The findings were vague and did not offer enough proof to support the aim of the project; more work is required.

The third objective looked into current legislation, and additionally why CRM should be legislated for. The findings suggested that legislating for CRM may provide helpful stimuli and that there are already thorough legislations for aircraft technicians.The fourth objective looked into the adaptation of CRM for OEMs. A introductory CRM lesson was designed including a new HF model, the ‘SRH Circle-Model.’
This project was non-conclusive as there was a lack of evidence of extra motivation to support CRM and not enough proof of its benefits. This project proposed a new name to be used instead of CRM for aerospace OEMs, that is ‘Staff Resource Handling’ (SRH), to prevent ambiguities.

The conclusions recommend that CRM methods should be adopted for OEMs, and that future research should involve CRM courses to measure acceptance.

TOC ;Chapter Title, 1,Section, 2,Sub-Section, 3;
Executive Summary PAGEREF _Toc h ii
List of Figures PAGEREF _Toc1 h v
List of Tables PAGEREF _Toc2 h vi
Glossary PAGEREF _Toc3 h vi
List of Abbreviations PAGEREF _Toc4 h vii
Chapter One – Introduction PAGEREF _Toc5 h 1
1.1 Overview and Structure of the Paper PAGEREF _Toc6 h 1
1.2 Human Factors and Crew Resource Management PAGEREF _Toc7 h 1
1.3 Project Objectives PAGEREF _Toc8 h 2
1.4 Problem Formulation PAGEREF _Toc9 h 3
1.5 Applicable Countries and Cultural Limitations of the Research PAGEREF _Toc10 h 6
1.6 Participating Companies for the Empirical Research PAGEREF _Toc11 h 7
1.7 Author’s Background PAGEREF _Toc12 h 8
Chapter Two – Objective 1: Human Factors and CRM Research PAGEREF _Toc13 h 9
2.1 Source and Criteria used for the Literature Review PAGEREF _Toc14 h 9
2.2 HF and CRM Literature Review PAGEREF _Toc15 h 10
2.2.1 Human Factors, Human Performance and Ergonomics PAGEREF _Toc16 h 10
2.2.2 Human Factors; the SHELL Model PAGEREF _Toc17 h 13
2.2.3 ‘Human Error’ PAGEREF _Toc18 h 16
2.2.4 CRM and Threat/Error Management (TEM): Pilots PAGEREF _Toc19 h 17
2.2.5 HF and CRM in Context PAGEREF _Toc20 h 24
2.2.5 Automation; Men and Machine PAGEREF _Toc21 h 25
2.2.6 Usage of CRM in other Industries/Domains PAGEREF _Toc22 h 28
2.2.7 Human Factors Engineering: Methods in Design PAGEREF _Toc23 h 28
2.2.8 Punishment for Mistakes; Just-Culture PAGEREF _Toc24 h 29
2.3 Empirical Research Methods PAGEREF _Toc25 h 32
2.3.1 Research Strategy PAGEREF _Toc26 h 32
2.3.2 Ethics Review PAGEREF _Toc27 h 33
2.3.3 Data Collection PAGEREF _Toc28 h 33
2.3.4 Framework for Data Analysis PAGEREF _Toc29 h 34
2.3.5 Limitations of the Empirical Research PAGEREF _Toc30 h 34
2.4 Empirical Research Findings; Description and Analysis PAGEREF _Toc31 h 36
2.4.1 Survey; Interview Description PAGEREF _Toc32 h 36
2.4.2 Survey; Questionnaire Description PAGEREF _Toc33 h 39
2.4.3 Surveys Analysis PAGEREF _Toc34 h 45
2.5 Synthesis: HF/CRM Literature Review and Empirical Research PAGEREF _Toc35 h 49
Chapter Three – Objectives 2 and 3: Benefits and Legislation PAGEREF _Toc36 h 52
3.1 Objective 2: Benefits PAGEREF _Toc37 h 53
3.1.1 Safety and Efficiency PAGEREF _Toc38 h 53
3.1.1 Safety Improvements in Civil Aviation PAGEREF _Toc39 h 54
3.1.3 HFE and CRM Benefits PAGEREF _Toc40 h 56
3.2 Objective 3: Legislating for CRM for OEMs PAGEREF _Toc41 h 61
3.2.1 Why to Legislate? PAGEREF _Toc42 h 61
3.2.2 CRM Regulations and Legislation PAGEREF _Toc43 h 62
3.2.3 Legislation Section Analysis PAGEREF _Toc44 h 64
Chapter Four – Objective 4: Adaptation of CRM for OEMs PAGEREF _Toc45 h 66
4.1 Design Brief PAGEREF _Toc46 h 67
4.2 Design Methodology PAGEREF _Toc47 h 67
4.3 CRM/HF Introductory Lesson PAGEREF _Toc48 h 68
4.3.1 Introduction PAGEREF _Toc49 h 68
4.3.2 What are Human Factors? The SHELL model PAGEREF _Toc50 h 69
4.3.4 Supportive Company Structure PAGEREF _Toc51 h 71
4.3.5 Purpose of Supportive Company Structure and CRM Training PAGEREF _Toc52 h 72
4.3.6 Multiple Causes for Mishaps PAGEREF _Toc53 h 73
4.3.7 Situational Awareness and Error in Context PAGEREF _Toc54 h 74
4.4 Chapter Summary PAGEREF _Toc55 h 75
Chapter Five – Summary of Findings, Conclusions, Recommendations PAGEREF _Toc56 h 76
5.1 Findings and Conclusions PAGEREF _Toc57 h 76
5.1.1 Objective 1: HF and CRM Research PAGEREF _Toc58 h 76
5.1.2 Objective 2: Benefits of Implementation PAGEREF _Toc59 h 77
5.1.3 Objective 3: Legislating for CRM for aerospace OEMs PAGEREF _Toc60 h 77
5.1.4 Objective 4: Adaptation of CRM for aerospace OEMs PAGEREF _Toc61 h 78
5.1.5 Findings and Conclusions Summary PAGEREF _Toc62 h 78
5.2 Recommendations PAGEREF _Toc63 h 79
8 References PAGEREF _Toc64 h 80
9 Bibliography PAGEREF _Toc65 h 88
10 Appendices PAGEREF _Toc66 h 93

List of Figures TOC "Figure, 1"
Figure 1: Recent innovative aeroplane developments compared PAGEREF _Toc h 4
Figure 2: Simplified aircraft lifecycle in terms of HF and CRM PAGEREF _Toc1 h 5
Figure 3: Interpretation of the field of Human Factors PAGEREF _Toc2 h 11
Figure 4: Components of the SHELL model PAGEREF _Toc3 h 13
Figure 5: The error troika PAGEREF _Toc4 h 20
Figure 6: Swiss-cheese model PAGEREF _Toc5 h 22
Figure 7: The tunnel model PAGEREF _Toc6 h 30
Figure 8: Just-culture culpability model PAGEREF _Toc7 h 31
Figure 9: Portion of answered questionnaires in relation to languages PAGEREF _Toc8 h 39
Figure 10: Questionnaire: Diagram illustrating the answers to question 1 PAGEREF _Toc9 h 40
Figure 11: Questionnaire: Diagram illustrating the answers to question 2 PAGEREF _Toc10 h 40
Figure 12: Questionnaire: Diagram illustrating the answers to question 3 PAGEREF _Toc11 h 41
Figure 13: Questionnaire: Diagram illustrating the answers to question 4 PAGEREF _Toc12 h 41
Figure 14: Questionnaire: Diagram illustrating the answers to question 5 PAGEREF _Toc13 h 42
Figure 15: Questionnaire: Diagram illustrating the answers to question 6 PAGEREF _Toc14 h 42
Figure 16: Questionnaire: Diagram illustrating the answers to question 7 PAGEREF _Toc15 h 43
Figure 17: Questionnaire: Diagram illustrating the answers to question 8 PAGEREF _Toc16 h 43
Figure 18: Questionnaire: Diagram illustrating the answers to question 9 PAGEREF _Toc17 h 44
Figure 19: University graduates’ and non graduates’ communications training PAGEREF _Toc18 h 46
Figure 20: University graduates’ and non graduates’ HF/CRM training PAGEREF _Toc19 h 46
Figure 21: Current HF applications in the context of the proposed SRH PAGEREF _Toc20 h 51
Figure 22: World jet fleet accident rates and onboard fatalities (1959-2015) PAGEREF _Toc21 h 54
Figure 23: Main cause* of hull loss (jet fleet 1991-2000) PAGEREF _Toc22 h 55
Figure 24: Safety evolution PAGEREF _Toc23 h 56
Figure 25: HF effort is better made in the early stages of the design process PAGEREF _Toc24 h 57
Figure 26: Return of investment equation and example PAGEREF _Toc25 h 58
Figure 27: Perceived usefulness of CRM amongst pilots PAGEREF _Toc26 h 59
Figure 28: Crew performance ratings in the context of CRM training PAGEREF _Toc27 h 60
Figure 29: The SHELL model, as generally known, and illustrated using symbols PAGEREF _Toc28 h 69
Figure 30: Distinguishing between CRM and HF using the SHELL model PAGEREF _Toc29 h 70
Figure 31: CRM; Supportive company structure PAGEREF _Toc30 h 71
Figure 32: ‘SRH circle-model’ in the context of a supportive company structure PAGEREF _Toc31 h 72
Figure 33: SA in context with TEM PAGEREF _Toc32 h 74

List of Tables TOC "Table, 1"
Table 1: Educational backgrounds, NASA-Ames PAGEREF _Toc h 12
Table 2: Components of the SHELL model PAGEREF _Toc1 h 14
Table 3: JAA and FAA CRM curricula recommendations for flight crew PAGEREF _Toc2 h 23
Table 4: The principles of the Fitts list PAGEREF _Toc3 h 26
Table 5: Comparison of the three automation philosophies PAGEREF _Toc4 h 27
Table 6: Most frequently identified causal factors in the 589 fatal accidents PAGEREF _Toc5 h 55

GlossaryAerospace – Original Equipment Manufacturer (OEM):
Aerospace may be defined as the joint effort of aeronautics and astronautics.

There are different definitions about what an OEM is, depending on the industry/application. Aerospace OEM generally refers to the manufacturer doing the assembly of air/space-crafts.

Crew Resource Management (CRM):
A method originally designed for pilots; the original intent was to use all available resources to conduct efficient and safe flights. CRM has, however, evolved over time; the application of CRM involves wider aspects, commonly known as Human Factors (HF). The Introduction chapter has a short discussion about CRM (‘1.2 Human Factors and Crew Resource Management’) and a more thorough discussion can be found in Chapter 2 (‘2.2.4 CRM and Threat/Error Management TEM: Pilots’).

Ergonomics (ERG):
Ergonomics emerged along side HF, and is very similar; however, the differences are discussed in Chapter 2 (‘2.2.1 Human Factors, Human Performance and Ergonomics’).

‘Human Error’ (‘HE’):
Human Error may be defined as: ‘human action with unintended consequences’. The reasons for ‘HE’ may be complex and multiple factors can contribute such as poorly designed systems, hardware and software (for more, see 2.2.3 ‘Human Error’).

Human Factors (HF):
Briefly, Human Factors refers to the Integration of the Human into systems with the aim of improvement. The Introduction chapter has a short discussion about HF (‘1.2 Human Factors and Crew Resource Management’) and a more thorough discussion can be found in Chapter 2 (‘2.2.1 Human Factors, Human Performance and Ergonomics’).

Human Performance (HP):
This term refers to human limitations and capabilities which contribute to efficiency and safety, e.g. for operations in aerospace (for more see: ‘2.2.1 Human Factors, Human Performance and Ergonomics’).

Maintenance Technicians:
Different terminology is used for people who repair/maintain airplanes. That includes mechanics, technicians, maintainers and engineers (Kinnison and Siddiqui, 2013). For this paper the expression ‘Maintenance Technicians’ will be used to prevent ambiguities with e.g. design engineers with university degrees. A ‘maintenance technician’ will have an aviation authority issued license, when the term is used in this paper.

List of AbbreviationsANCAviate Navigate Communicate
AOCAir Operator Certificate
AQPAdvanced Qualification Program
CAACivil Aviation Authority
CRMCrew Resource Management
CSCertification Specification
DOADesign Organisation Approval
EASAEuropean Aviation Safety Agency
ERGErgonomics
FAAFederal Aviation Administration (United States)
GMGuidance Material
HCDHuman Centered Design (also known as UCD)
HE’Human Error’
HFHuman Factors
HFEHuman Factors Engineering
HFIHuman Factors Integration
HFMHuman Factors Methods
HFPHuman Factor Principles
ICAOInternational Civil Aviation Organisation
LOFTLine Orientated Flight Training
MABA-MABAMen Are Better At – Machine Are Better At
NTSNon Technical Skills
OEMOriginal Equipment Manufacturer
SASituational Awareness
SARPStandards and Recommended Practices
SRHStaff Resource Handling
SOPStandart Operating Procedure
TCType Certificate
TEMThreat and Error Management
UCDUser Centered Design (also known as HCD)
UAVUnmanned Arial Vehicle
Chapter One – IntroductionThe aim of this project is to implement ‘Crew Resource Management’ (CRM) for aerospace OEMs, argue the benefits, why/how to legislate and how to adapt CRM. This chapter discusses ‘Human Factors’ (HF) and CRM, to get a broad overview of what these are. Furthermore, the original project objectives of the proposal are shown followed by a discussion of ‘Problem Formulation’, involving a discussion of what this project tries to tackle. Next, the cultural limitations of the research are stated. Furthermore, an introduction to the companies participating in the empirical research is included, and a brief summary of the author’s background is shown. The first section involves an overview of the project and the structure of this paper.

1.1 Overview and Structure of the PaperThe four objectives of the project proposal are shown in Section 3 (below). The first objective is considered in Chapter 2, and Chapter 3 includes objectives two and three. The fourth objective is considered in Chapter 4. The chosen method used for the secondary research (literature review) is discussed at the beginning of Chapter 2, and is applicable to all four objectives/chapters. The empirical research method section is located before the empirical research findings section in Chapter 2. Chapter 5 includes the conclusions and recommendations. Appendices are located at the end of the paper.

1.2 Human Factors and Crew Resource ManagementThe science and the definition of HF may not be widely known and there may be ambiguities about what it is. ICAO (1998) advises of a persistent misconception, that HF is a branch of medicine. HF is based on several scientific disciplines including psychology and engineering according to Harris (2011). There are several different definitions of what HF refers to; one of the definitions is from the Human Factor Society (2015):’ … a multidisciplinary science that includes research from the fields of psychology, biology, sociology and engineering.’ Furthermore, Widdowson and Carr (2002) describe HF as: ‘… a professional discipline concerned with improving the integration of human issues into the analysis, design, development, implementation, and the operational use of work systems’. Furthermore, HF and Ergonomics (ERG) have aspects which are similar, if not identical; therefore, the next chapter will offer a brief discussion about HF and ERG in context.

Crew Resource Management (CRM) is an HF method originally designed for pilots using available resources to prevent incidents/accidents. Lauber (1984) describes CRM as: ‘… using all the available resources — information, equipment, and people — to achieve safe and efficient flight operations.’ CRM has evolved over time, and more aspects of HF are being used in CRM, not just the use of available resources; however, the name CRM has been kept.

1.3 Project ObjectivesThis project has four objectives which are listed below (Wunderlin, 2017b):
(1) To research HFM and CRM. This will involve secondary research (literature) of current HFM used in aerospace OEMs and other domains in addition to secondary research of CRM in different domains (e.g. air traffic control, aviation maintenance, flight operations and space development/operations). Furthermore, primary research with an OEM in the form of interviews and/or observations to compare and verify the secondary research will be undertaken. Remark: primary research of CRM is not intended as the author has CRM experience. Information gained will be presented in the form of a report with relevant aspects.

(2) To research the potential benefits of implementing CRM in OEMs: financial, safety and efficiency benefits in order to make a business case.

(3) To examine how CRM training may be legislated for, e.g. in EASA Part 21 for Design Organisations Approval (DOA). CRM practitioners (e.g. pilots) have recurrent training which is necessary in order for them to retain their, unlike an OEM employee who may have an academic degree which does not require renewal (a degree does not expire, unlike most pilot licenses).

(4) To explore how CRM could be adapted for aerospace OEMs; to design and propose a broad training outline, and perhaps a new HF approach.

1.4 Problem FormulationThis section aims to give an understanding of the reason for the project and identify what it is trying to tackle. Chapter 3 (benefits) supplements this section, showing evidence of ‘why’ this problem should be addressed.

Major recent developments in aeroplanes have been delayed considerably, that includes the development of the Boeing 787, Airbus 350 and the Bombardier CSeries airliners (Airbus A220) (see Figure 1 below).

Several different reasons for the delays have been identified. One notable issue was the involvement of many suppliers, not only for the production, but also in the design process for the aeroplanes. For example, for the CSeries Aircraft, the total number of suppliers exceeded 90 (Bombardier, 2009).

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Figure 1: Recent innovative aeroplane developments compared (Source: Wunderlin, 2016a – adapted from: Airbus, 2016; Boeing, 2016; and Read, 2016)
Furthermore, difficulties in the development of innovative technologies also contributed to delays. For example, the CSeries aircraft has new materials (Bombardier, 2016), new engines (Read, 2016) and a new fly-by-wire system according to Dewar (cited in Warwick, 2013). These very new technologies have, to some extend, contributed to the delays (Hemmendinger, 2016; Bullis, 2013; Dewar, cited in Warwick, 2013), not only in terms of the development of the aircraft, but also new certification methods which have had to be adapted/developed (Zhang et al., 2011 and TCCA, 2015). Therefore, this project proposes CRM for aerospace OEMs to reduce the delays, by increasing efficiency.

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Figure 2: Simplified aircraft lifecycle in terms of HF and CRM(Adapted from: Cross, 2009; CAA, 2016; ICAO, 1998; Koopman, 1999; Sandom and Harvey, 2009)
Efficiency may be achieved as CRM methods successfully improve safety in airline operations. These safety improvements through CRM may be transferred to OEM employees in the form of safety and efficiency improvements. Research, later in this paper, shows the link between safety and efficiency.

CRM and Human Factors Methods (HFM) are used in the lifecycle of an aircraft to some extent. Figure 2 shows the lifecycle of an aircraft in terms of HF and CRM; this figure is a simplified illustration. Nevertheless, there are also some HFM used in the design process, though they may not be considered to be thoroughly applied throughout the process, and are not applied by all people involved. The same applies to CRM which is used by some involved in the flight operations and servicing, e.g. pilots and maintenance technicians. This is supported by the CAA (2016), which argues that the application of CRM in flight operations is inconsistent.

Furthermore, CRM and HFM in the lifecycle of an aircraft are also regulated to some extent. More details about these regulations are presented in Chapter 3 (Legislation). Moreover, the difference between HF and CRM in this lifecycle, is that HF applications are deemed relevant for design purposes, whereas CRM applications are used in operations/maintenance, focusing on the affected person who uses CRM (see Chapter 2 for more). Additionally, the justification for using HFMs in aerospace design are vague in general. This is, perhaps, because the ‘added-value’ may not be visible and it is difficult to present an argument which convinces people to invest in HF according to Harris (2007).

This concludes the problem formulation. The proposed introduction of CRM for all aerospace OEM employees, may help improve the efficiency of OEMs as is discussed in Chapter 3 (Benefits).

1.5 Applicable Countries and Cultural Limitations of the ResearchThe researcher of this project is based in Swizerland, Europe, working through a university in the United Kingdom. The empirical research was conducted in two European countries, Germany and Switzerland. Furthermore, most of the literature used for the research is from Europe and North America. It is important to acknowledge that the application of the ‘Western’ approach to CRM may not be as successful in other regions of the world, e.g. east Asia, according to Harris (2011), as such regions have a high power-distance culture, unlike Western countries, . In Western countries, people are less inhibited about speaking up, and challenging other people. Therefore, this project is considered to be culturally valid for Western countries, such as the United States, Canada, EU member countries, the United Kingdom, Norway and Switzerland. Additionally, for simplicity, most of the legislation and regulations discussed in this paper are limited to Europe. Some regulations from the United Nations aviation unit, ICAO, are also shown.

1.6 Participating Companies for the Empirical ResearchFour companies participated in the empirical research. The author is very grateful for the opportunity to carry out research in these companies. It has been helpful, in terms of getting aspects about HF/CRM used in the real world.

The results of the empirical research are presented as a whole, not distinguishing between companies. More information about anonymity is given in the empirical research methods section in the next chapter. One German and three Swiss companies were used for the empirical research. Below is an introduction to the companies, to give the reader an overview of the companies involved in the research:
The German company, Comco-Ikarus, is an OEM producing ultralight aircraft; it has world-wide sales and a long successful history in this market (Comco-Ikarus, 2018).

RUAG Aviation is a Swiss company and is part of the RUAG Holding. The latter consists of five different divisions including aviation, aero structures, defense, space and ammotec. RUAG Aviation is an OEM and owns the type certificate (TC) of the Dornier 228 aircraft. Furthermore, RUAG also develops/produces aircraft parts e.g. for Airbus; therefore, it is also a supplier. Additionally, the company also services (maintenance) both, military and civil airplanes (RUAG, 2018).

The second Swiss company, Universal Dynamics, produces CNC parts for aerospace companies and is, therefore, a supplier. Additionally, the company has recently developed a UAV (Universal Dynamics, 2018a and 2018b).

The third Swiss company, Aventura AG, is a startup, currently developing an innovative gyrocopter (Aventura AG, 2018).

1.7 Author’s BackgroundThe author has worked for more than eighteen years as an airline pilot, in European and world-wide operations, and has instructed new pilots aspiring to become airline pilots. Furthermore, the author has completed an apprenticeship as a design engineer in an aerospace company, and worked thereafter for other engineering firms, before beginning a career as an airline pilot. The author has worked part-time in order to allow time for study. A university diploma in design and innovation was completed prior to the air safety management studies.

This concludes Chapter 1. Chapter 2, which follows, involves the research, discussions and arguments about HF and CRM with the aim of proposing how to adapt CRM for aerospace OEM employees.

Chapter Two – Objective 1: Human Factors and CRM ResearchThe intention of this chapter is to give an outline of what Human Factors (HF) and Crew Resource Management (CRM) are. This chapter also represents the basis for the next three chapters; the findings of this chapter will be used and researched further to allow for further exploration of the other objectives of this study. Furthermore, the empirical research methods used to conduct the primary research are discussed followed by the findings themselves. And finally, the last section of this chapter is the discussion.

2.1 Source and Criteria used for the Literature ReviewThis section states the methods used for the literature review, which are applied in all four chapters, for each objective.

Criteria used for Searches
Many different sources were used in the research, in order to achieve a thorough picture of the subject, and to find relevant information. Recent books and academic journals were searched (not older than 10 years), and older literature was used to supplement this evidence when deemed necessary.

Internet
The internet was used as an initial source to research the subject. The City University online library and Google Scholar were the two main search tools used. That led to text books and academic journals which were further researched.

Textbooks
The majority of textbooks were acquired from Amazon and Google Play; additionally, the City University library was used to read some textbooks online.

Academic Journals
Many journals were researched; these were accessed from the City University library. Additionally, some journals were found on the internet.

Legislations and Regulations
ICAO and EASA legislations and regulations were researched. Some of the information was found through internet searches, from the respective websites of the regulatory authorities and information was also found in text books and academic journals.

2.2 HF and CRM Literature ReviewThe literature review in this section is used not only for the preparation of the empirical research, but also to explain HF/CRM, and to get an insight into its application in other industries/domains. Furthermore, HF will be explained using the SHELL model, followed by a discussion about CRM. Also, ‘Human Error’ and automation/men-machine will be discussed. Additionally, Human Factors Engineering is also discussed followed by ‘just-culture’. Initially, however, HF, Human Performance and Ergonomics will be considered.

2.2.1 Human Factors, Human Performance and ErgonomicsThere are many different definitions of what HF are; some of the definitions are mentioned above in the introduction chapter. The integration of the human into systems with the aim of improvement, may be used as a brief description of the term. Eurocontrol summarised (Figure 3) the interpretations of HF to include the interaction of men-machine, organisation/staffing, training/development, procedures/roles/responsibilities, teams/communication and the recovery from failures. Furthermore, human limitations and capabilities are studied in HF, with the intention to design systems with a minimised mismatch between the requirements and capabilities of the human.

Figure 3: Interpretation of the field of Human Factors(Source: Eurocontrol, cited in Dahlström et al., 2008)
By doing so, Human Performance (HP) is not only improved, but optimised according to Rodrigues et al. (2012). Additionally, HF also include the relationship and interaction between humans according to Hawkins (2016). That is one important aspect, as the original concept of CRM is to use all available resources, e.g. the communication between pilots, thus maximising the benefits of the interaction aspect. Moreover, HP describes how well humans’ carry out assigned tasks, and measures how quickly and how accurately these are performed. HP may be split into seven different categories: physical, physiological, psychological, psychosocial, hardware, task and environmental factors (Rodrigues et al., 2012).

9713201260475
Table 1: Educational backgrounds, NASA-Ames(Source: NASA, 1992, cited in Hawkins 2016)
Psychology 32 Computer Science 1
Experimental psychology 8 Aviation Medicine 1
Cognitive psychology 5 Behavioral Sciences 1
Psychophysiology/Clinical psychology 2 Biology 1
Cognitive/Mathematical psychology 1 Business Management 1
Cognitive engineering 1 Education 1
Aeronautics and Astronautics 4 Formal Systems 1
Mathemathics 3 Industrial Engineering 1
Electrical Engineering 4 Law 1
Electr. Eng. and Computer Sience 2 Nursing 1
Aeronautical Engineering 2 Physics 1
Architecture 3 Social Sciences 1
Communications 2 Sociology 1
Computer Music 1 Spanish 1
HP and HF may be thoroughly discussed using these seven categories; this paper will, however, use a simpler approach; the SHELL model will be used not only to explain and discuss HF, but also as a reference to illustrate the context for the other objectives of this project.

Moreover, psychology may be considered the predominant science in HF. That is, as many HF practitioners have a psychology background and most of the HF literature is authored by psychologists according to Hawkins (2016), Table 1 shows the backgrounds of HF practitioners.

Moreover, HF and Ergonomics (ERG) are closely related or may even be almost identical sciences. Hawkins (2016), however, argues that HF have a wider meaning than ERG; the aspects of HP and system interfaces are not generally considered in ERG, unlike in HF. Furthermore, the origins of ERG predominately take physiological aspects into account, whereas psychology is the basis for HF, according to Noyes (2009). HF developed in the United States, and ERG emerged in Europe initially (Sandom and Harvey, 2009). The expression HF will be used in this paper, to include aspects which some literature may refer to as ERG. For the direct associations of the human-hardware integration, however, the term ERG will be used, as ERG may be understood by the general public and the empirical research involves related questions.

2.2.2 Human Factors; the SHELL Model-6349212119Figure 4: Components of the SHELL model(Source: Wunderlin, 2017a – adapted from: ICAO 2013a; Hawkins 2016)
The SHELL model was chosen to explain HF in more depth, as it shows the different interactions/influences, of humans in a simplistic way. The SHELL model emerged in the early 1970s and was originally called SHEL (Edwards, 1972); the second ‘L’ was added later to illustrate the interaction between people. The model has the following different components: Lifeware, Sofware, Hardware and Environment. Figure 4 shows the SHELL model according to Hawkins (2016) including explanations of the interfaces between the components.

Table 2: Components of the SHELL model(Adapted from: ICAO 2013a; Hawkins 2016)
A simple explanation of the SHELL model in practical terms is as follows: the human at the centre of the SHELL model may be a pilot. A pilot flies an aeroplane and is using procedures (software) to operate the airplane (hardware) and low air density (environment) may be a performance-influencing factor. The pilot will communicate and interact with other humans (lifeware) e.g. cabin crew and air traffic controllers. The individual components are listed in Table 2, and explanations and/or examples are shown to get a better understanding of the different components.

to explain in great10928351636395Component Explanations/Examples
Lifeware (L) Humans in the workplace
Software (S) Procedures, training, support, manual/checklist layout, computer programs, symbology
Hardware (H) Machines, equipment, e.g. aircraft controls
Environment (E) Working environment where the other components operate in
Component Explanations/Examples
Lifeware (L) Humans in the workplace
Software (S) Procedures, training, support, manual/checklist layout, computer programs, symbology
Hardware (H) Machines, equipment, e.g. aircraft controls
Environment (E) Working environment where the other components operate in
er depth, the Lifeware component in the middle of the model is the human, and may be called the hub; it is the most flexible and valuable component according to Hawkins (2016). The other components need to be matched or adapted to the central human component. The connections between the components are not straight or simple; a careful match is necessary to avoid suboptimal performance and prevent stress in the system according to Abbott (2001).
Therefore, good products/services will be designed to make the hub (the human) work as effectively as possible. This effective design of components is also called Human Centered Design (HCD) and will be discussed later.

The four different connections between the components are discussed in more detail below, according to Abbott (2001), Rodrigues et al. (2012), ICAO (2013a) and Hawkins (2016):
Lifeware-Lifeware (L-L)
The L-L interface, is the interaction between people and is concerned with teamwork, inter-personal cooperation, leadership, and personality. The L-L interface was the main focus of CRM when it first appeared, ‘using all available resources’ in the form of other people in the means of communications. Additionally, when people work in groups, their performance and behaviour can be affected by group influences, which is addressed with CRM training.

Lifeware-Software (L-S)
The interface between lifeware and software includes aspects which are non-physical. Computer software is an obvious one, as the name suggests. Furthermore, the layout of checklists and manuals are other software components. Symbology is also considered software; this can be seen, for example, at airports, where different signs with symbols help passengers find their way. Symbols are also shown on instrument screens in the cockpit illustrating flight information. Software problems are often more difficult to solve compared to L-H problems and, as such, are less tangible.

Lifeware-Hardware (L-H)
The interface between lifeware and hardware, commonly refers to, and is most concerned with, the expression man-machine. A good adaptation of hardware to the human is also sometimes called good ERG. Nevertheless, all four interfaces (not only L-H) are addressed in HF and ERG (see Section ‘2.2.1 Human Factors, Human Performance and Ergonomics’). The design of a seat is one example of the L-H interface. A good seat design will prevent the Human from having an uncomfortable experience, and in some cases even prevent injury in the case of an accident or spinal issues from long-term usage.

Lifeware-Enviroment (L-E)
Environmental aspects can have an influence on HP. Notably, the air (pressure, moisture levels, temperature, …) and the noise can adversely influence the human. Measures to reduce/avoid these effects for people on board aeroplanes have been designed and implemented. That includes pressurised cabins in aircraft and noise cancelling headsets. Furthemorer, another aspect which has gained importance is the disturbance of biological rhythms such as sleep disturbances due to air travel and crossing time zones.
2.2.3 ‘Human Error”Some believe that they need to keep beating the «human» until the «human error» goes away.’ (Dekker, 2014)
There are several different definitions of what ‘Human Error’ (‘HE’) is, and the expression is even considered inappropriate in some literature. Above is a quote from Sidney Dekker, which sums up in a few words, the misconception of how ‘HE’ may be removed. Additionally, Dekker (2012) suggests that ‘HE’ may be considered the symptom and not the cause of mishaps. Nevertheless, McFarland and McRandal (2016) describe ‘HE’ as: ‘… defined as a human action with unintended consequences’, or: ‘Any action, performed by a person, which exceeds a system’s tolerance’. Furthermore, ICAO (2013a) argues that contributions to ‘HE’ involve:'”… a mismatch between the liveware and the other four components …’, referring to the SHELL model.

Moreover, ‘HE’ may be considered an expression which is misleading and wrong. If determined to be more critical, a particular ‘HE’ may have a connection to an organisation, meaning the error happened because of decisions within the organisation, resulting in the operator taking actions leading to the particular ‘HE’. That is supported by Dekker (2014), who argues that more complex stories about organisations are behind stories of ‘HE’. Dekker (2014) also states: ‘… errors are symptoms of trouble deeper inside a system’. Furthermore, Hawkins (2016) argues, in the context of the SHELL model, that badly designed equipment (hardware) and/or badly designed procedures (software) may induce ‘HE’. Improvements in hardware/software may be helpful in such cases, as the ‘HE’ may be repeated by other humans. Furthermore, Hawkins (2016) also argues that accidents arising due to ‘HE’ may lack appropriate HFM in the working environment. Therefore, HF and CRM may be considered an ‘instrument’ for preventing ‘HE’. The preferred management of error will be discussed below (Just-Culture).

Nevertheless, the expression ‘HE’ will be used in this paper in spite of the debate about terminology outlined above. As much of the HF and CRM literature uses the expression ‘HE’ and it may be considered helpful for educational purposes, it will be used in a simplistic way. The next sub-chapter will give some examples.

2.2.4 CRM and Threat/Error Management (TEM): PilotsThis sub-section illustrates Crew Resource Management (CRM) used by pilots; it also addresses Threat and Error Management (TEM). Additionally, CRM is also used by other professions and will be discussed below.

CRM Definition and History
CRM originally emerged in the 1970s, and its intention was to prevent incidents and accidents in airlines, caused by pilots (Rodrigues et al., 2012). Similarly to HF, CRM doe snot have one clear definition. The definition from Lauber (1984) is given in the introductory chapter: ‘… using all the available resources — information, equipment, and people — to achieve safe and efficient flight operations.’ The original name of CRM was ‘Cockpit Resource Management’ and it was introduced by NASA; the name was eventually changed to ‘Crew Resource Management’, as other crew members, outside the cockpit, were also included, according to Helmreich and Foushee (2010).

CRM Evolution
CRM has undergone evolution according to Salas et al. (2001). The focus of the first evolution was on the individual styles and behaviours, focusing on psychological testing. Group dynamics in the cockpit was the focus of the second evolution. The broadening of the scope was central to the third evolution, when factors outside the cockpit were taken into account, training CRM for cabin crew and maintenance technicians. The fourth evolution integrated CRM with technical training. Concepts such as Advanced Qualification Program (AQP) and Line Orientated Flight Training (LOFT) which led to proceduralisation and integration of CRM were included. The fifth evolution has acknowledged the inevitable existence of ‘HE’, and managing ‘HE’ is its predominant focus (Flin et al., 2008).

Present CRM
HF may be considered a better expression of the respective CRM training and methods, because of the evolution of CRM. While the original intention of CRM was ‘to use all available resources’ referring mainly to the ‘L-L’ interface in the SHELL model, HF looks at all the components in the SHELL model. Nevertheless, the name CRM has stayed and is used in several domains and industries, referring to the HFMs of operating personnel like pilots and air traffic controllers. The CAA (2016) supports the idea that CRM has a wider scope nowadays: ‘… Although retaining the title «CRM», such training now covers a much wider scope that is often referred to under the umbrella terms of «non- technical skills» and «human factors».’
Threat and Error Management
Threat and Error Management (TEM), similarly to CRM, is conceived for pilots. It can be described as safety management activities oriented for the cockpit, according to Harris (2011). In practical terms, TEM may be defined as predicting/avoiding operational threats and errors by thinking ahead (CAA, 2016). The fifth generation of CRM acknowledges the inevitable existence of ‘HE’. As mentioned above, TEM is concerned with the management of error in general. Furthermore, all pilot training events should cover TEM according to EASA-FCL (CAA, 2016). In this paper, the expression CRM will combine CRM and TEM, for simplicity.

CRM Applications, Methods and Models
This short section illustrates some examples of the practical use of CRM. Firstly, inevitable ‘HE’ will be addressed in the form of the ‘error-troika’ in connection with TEM and Situational Awareness (SA). Additionally, ‘ANC’ and the Swiss cheese model will be shown.

‘Error Troika’: three different levels of managing ‘HE’ are suggested in TEM: avoiding the error, trapping the error and mitigating the consequences of errors (CAA, 2016), as illustrated in Figure 5 below.

SA is used by pilots to prevent and handle errors. The CAA (2016) describes SA as ‘knowing what is going on’; additionally, Weiner (2016) suggests that the same method is also used by healthcare practitioners. Tools like SOP checklists, planning, drills and more are used in practical terms.

5485231260475
Figure 5: The error troika(Adapted from: Helmreich et al., 1999b)
For example, planning a flight, e.g. in connection with weather, may be considered thinking ahead (avoid). Using the weather radar of an aircraft in order to detect and avoid CBs may be considered understanding (trapping). Noticing entry into a turbulent area, turning on the fasten seatbelt sign and changing the aeroplane’s lateral and/or vertical flight path may be considered noticing (mitigating), according to Dahlström et al. (2008). Figure 33 below illustrates the connection between SA and TEM. Figure 33 appearing here is a copy of the original in Chapter 4 (‘Objective Four: Adaptation of CRM for OEMs’).

Figure 33: SA in context with TEM-63501260475
(Adapted from: CAA, 2016; Dahlströhm et al., 2008; Helmreich et al., 1999a; Weiner, 2016)
Furthermore, ‘ANC’ is a CRM method, which stands for ‘Aviate Navigate Communicate’. ANC is a very simple but an important tool used by pilots, as it contributes to flight safety in a effective way. The application is a prioritisation tool: flying the aircraft is most important, next is navigation and third is any communication, that includes with air traffic control, cabin crew and passengers (CAA, 2016). As an example, a functional Lockheed Tristar crashed in the 1970s in the Everglades, United States. It only had an inoperative light bulb, which indicates the position of the landing gear. The flight crew tried to solve that minor problem; however, while doing so, nobody was flying the plane and it crashed (NTSB, 1973).

Moreover, several models are used in CRM training and one of those is the ‘Swiss cheese model’ (see Figure 6, below). According to Reason (2000), the system and the person approach can be used to determine error causation. The system approach looks deeper into the system including processes from organisations.

Figure 6: Swiss-cheese model(Source: Wunderlin, 2016b — adapted from Reason, 1990)
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In contrast, the person approach blames humans for ‘HE’ . Nevertheless, the systems approach sees errors as consequences from deeper inside the system and considers that multiple causes contribute to error. That is reflected in the Swiss-cheese model (Figure 6) and shown as an analogy, with objects flying through cheese slices (barriers). Holes move and change in size, and a mishap happens when all the layers are aligned (Reason, 1990). Moreover, protective layers can be added for error prevention, e.g. a third or fourth engine of an aircraft would give more back up, in the face of potential engine failures. Nevertheless, Dekker (2014) appreciates the simplicity of the model and suggests that finding contributors to accidents and categorising them is a strength of the model. However, Dekker (2014) also states shortcomings of the model: a ‘linear’ perception of barrier models may be dangerous; it is difficult to predict accidents; explanation of the organisational, bureaucratic and social context is difficult; systems are complex – just adding barriers may not work.
CRM Training Content
It is not practical to state a full pilot CRM program in this paper, as that would take too long. Therefore, the previous sub-section illustrates the practical application of CRM with a few examples. Additionally, Table 3 is added to give an overview of what both Europe (JAA) and the United States (FAA) recommend for pilot CRM training. It is worth mentioni10928354541590JAA FAA
-human error and reliability, error chain,
error prevention and detection
-company safety culture, standard
operating procedures, organisational
factors
-stress, stress management, fatigue and
vigilance information acquisition and
processing, situation awareness, and
workload management
-stress, stress management, fatigue and
vigilance
-information acquisition and processing,
situation awareness, and workload
management
-decision-making
-communication and co-ordination inside
and outside the cockpit
-leadership and team behavior synergy
automation (for type of aircraft)
-specific type-related differences
-case-based studies 1.Communications processes and
decision behavior:
-briefings
-safety, security
-inquiry/advocacy/assertion
-crew self-critique (decisions and actions)
-conflict resolution
-communication and decision-making
2. Team-building and maintenance:
-leadership/followership/ concern for task
-interpersonal relationships/ group climate
-workload management and situation
awareness:
-preparation/planning/vigilance
-workload distribution/distraction
avoidance
-individual factors/stress reduction
JAA FAA
-human error and reliability, error chain,
error prevention and detection
-company safety culture, standard
operating procedures, organisational
factors
-stress, stress management, fatigue and
vigilance information acquisition and
processing, situation awareness, and
workload management
-stress, stress management, fatigue and
vigilance
-information acquisition and processing,
situation awareness, and workload
management
-decision-making
-communication and co-ordination inside
and outside the cockpit
-leadership and team behavior synergy
automation (for type of aircraft)
-specific type-related differences
-case-based studies 1.Communications processes and
decision behavior:
-briefings
-safety, security
-inquiry/advocacy/assertion
-crew self-critique (decisions and actions)
-conflict resolution
-communication and decision-making
2. Team-building and maintenance:
-leadership/followership/ concern for task
-interpersonal relationships/ group climate
-workload management and situation
awareness:
-preparation/planning/vigilance
-workload distribution/distraction
avoidance
-individual factors/stress reduction
ng that although the wording is different, both regions have a similar approach to pilot CRM training. Additionally, the table also illustrates the wider scope of CRM and more HF aspects are addressed than in the original CRM concept, e.g. fatigue, automation and stress reduction.

Table 3: JAA and FAA CRM curricula recommendations for flight crew(Source: Flin et al. 2008)
Acceptance of CRM and Motivation
The acceptance of CRM and motivation may be considered crucial factors. Hawkins (2016) even argues that motivation of the lifeware component is the most significant characteristic, referring to the SHELL model. Additionally, according to ICAO (1998) advice, flight safety is affected significantly by behaviours and attitudes. Furthermore, motivation may be a reflection of what a person actually does and could do (ICAO, 1998). CRM training acceptance can be linked directly to better crew performance and attitude changes (Chidester et al., 1991). Additionally, a resistance to CRM training existed when it first emerged and sometimes the expression ‘charm schools’ was used by attendees (Flin, 2010).

More literature is available on this subject, confirming the issue of acceptance and required motivation; in addition, Section ‘3.1 Benefits’ will supplement this argument.

2.2.5 HF and CRM in ContextHF and CRM have been discussed in the previous sub-sections to give an understanding of the context and application of the two subjects. CRM is considered to be the application of HF; additionally, it was stated above that CRM has evolved and has a wider usage compared to HF than the original intention. The name, however, stayed, and it may be considered to be HF as used by pilots. This is supported by Dahlström et al. (2008) who argue that CRM is an applied form of HF. Pilots are operational staff, following procedures, and they judge how tasks can be accomplished successfully as such, and when necessary, they deviate from procedures in order to reach the intended and safe outcome (Harris 2011; Hawkins 2016; Rodrigues et al., 2012). The project proposal (Wunderlin, 2017b) states that an introduction of CRM for aerospace OEMs require an adaptation of CRM; a transfer of existing CRM training is not sufficient according to Flin et al. (2008). Aerospace companies have many different jobs and some may be considered ‘operational’ jobs, some may not. An aerospace design engineer’s job may have some ‘creative’ aspects; therefore, certain CRM methods used by pilots may be little or no help for design engineers. There are, however, certain HF aspects which are valid for many jobs and domains.

2.2.5 Automation; Men and Machine’Getting technology to replace unreliable people is an attractive idea, and is wide-spread. But technology introduces new problems as well as new capacities.’ (Dekker, 2014)
Humans make mistakes, and when they happen, often the expression ‘HE’ is used. One tempting approach to prevent ‘HE’ is to remove the ‘human’, and replace it with a machine; it is, unfortunately, not that simple. The quote at the beginning of this sub-chapter is shown, as it illustrates in a few words the challenge of automation and the men/machine problematic/opportunity. Additionally, Dekkers’ quote is supported by Abbott (2001), who argues that new technology often introduces other problems while solving some. This sub-section is a discussion about automation/men-machine in anticipation of the aspects concerning CRM and HF.

One approach to address this issue is called the ‘compensatory principle’. This approach is also called ‘MABA-MABA’ in some literature, meaning Men Are Better At – Machine Are Better At (Dekker and Woods, 2002). Reduction of ‘HE’ is done by determining ‘MABA-MABA’ and allocating tasks to men or machines respectively, according to the strengths, guided by the compensatory principle (Sandom and Harvey, 2009).

Table 4: The principles of the Fitts list(Source: Sandom and Harvey, 2009)
The compensatory principle has been addressed and used for a long time, and a considerable amount of knowledge about the characteristics of man-machine is available. The application of the compensatory principle may be performed using lists comparing men/machine characteristics. One list was published as early as the early 1950s by Fitts (1951) (see 10801351916430Attribute Machine Operator/human
Speed Much superior Comparatively slow, measured in seconds
Power output Much superior in level and consistency Comparatively weak, about 1500 W peak, less than 150 W during a working day
Consistency Ideal for consistent, repetitive actions Unreliable, subject to learning (habituation) and fatigue
Information capacity Multi-channel. Information transmission in megabits/sec. Mainly single channel, low rate <10 bit/sec.
Memory Ideal for literal reproduction, access restricted and formal Better for principles and strategies, access versatile and innovative
Reasoning, computation Deductive, tedious to program. Fast, accurate. Poor error correction Inductive. Easy to ‘programme’. Low, inaccurate. Good error correction.
Sensing Specialised, narrow range. Good at quantitative assessment. Poor at pattern recognition. Wide energy ranges, some multi-function capability
Perceiving Copes poorly with variations in written/spoken material. Susceptible to noise. Copes well with variation in written/spoken material. Susceptible to noise.
Attribute Machine Operator/human
Speed Much superior Comparatively slow, measured in seconds
Power output Much superior in level and consistency Comparatively weak, about 1500 W peak, less than 150 W during a working day
Consistency Ideal for consistent, repetitive actions Unreliable, subject to learning (habituation) and fatigue
Information capacity Multi-channel. Information transmission in megabits/sec. Mainly single channel, low rate <10 bit/sec.
Memory Ideal for literal reproduction, access restricted and formal Better for principles and strategies, access versatile and innovative
Reasoning, computation Deductive, tedious to program. Fast, accurate. Poor error correction Inductive. Easy to ‘programme’. Low, inaccurate. Good error correction.
Sensing Specialised, narrow range. Good at quantitative assessment. Poor at pattern recognition. Wide energy ranges, some multi-function capability
Perceiving Copes poorly with variations in written/spoken material. Susceptible to noise. Copes well with variation in written/spoken material. Susceptible to noise.
Table 4). Nevertheless, there is also opposition to the compensatory principle.

Dekker and Woods (2002) question the compensatory principle based lists, as the false assumption is made that machines/computers and people have fixed weaknesses and strengths. Furthermore, Dekker and Woods (2002) argue that for human-automation, ‘get along together’ may be the preferred approach rather than refining/re-inventing compensatory based methods.
Moreover, there are also other principles which address the men-machine problematic/opportunity; two additional principles are the ‘left-over’ and the ‘complementary’ principles. Firstly, the left-over principle lets the machine do as much work as is feasible; the rest will be done by the human according to Hollnagel (2009). The complementary principle looks for guidelines to compliment the human, instead of replacing the human with machines according t10928354023545Automation principle Residual function
(‘left-over’) Fitts list Complementary/
Congruence
Function allocation principle Leave to humans what cannot be achieved by technology Avoid excessive demands to humans (juxtaposition) Sustain and strengthen human ability to perform efficiently
Purpose of function allocation Ensure efficiency of process by automating whatever is feasible Ensure efficiency of process by ensuring efficiency of human–machine interaction Enable the joint system to remain in control of process across a variety of conditions
School of thought
Classical human factors Human–machine interaction, human information processing Cognitive systems engineering
View of humans (operatiors) None (human as a machine) Limited capacity information processing system (stable capabilities) Dynamic, adaptive (cognitive) system, able to learn and reflect
Automation principle Residual function
(‘left-over’) Fitts list Complementary/
Congruence
Function allocation principle Leave to humans what cannot be achieved by technology Avoid excessive demands to humans (juxtaposition) Sustain and strengthen human ability to perform efficiently
Purpose of function allocation Ensure efficiency of process by automating whatever is feasible Ensure efficiency of process by ensuring efficiency of human–machine interaction Enable the joint system to remain in control of process across a variety of conditions
School of thought
Classical human factors Human–machine interaction, human information processing Cognitive systems engineering
View of humans (operatiors) None (human as a machine) Limited capacity information processing system (stable capabilities) Dynamic, adaptive (cognitive) system, able to learn and reflect
o Grote et al. (1995). Table 5 is illustrated to show a comparison between the three discussed men-machine principles.

Table 5: Comparison of the three automation philosophies(Source: Hollnagel, 2009)
Furthermore, automation and the interaction between men and machine may be a considerable part of CRM and HF. Two of the four interfaces of the SHELL model may be considered men-machine interfaces to some extent (Lifeware-Hardware and Lifeware-Software). Flight safety can be affected in an adverse way and accidents may happen when the automation/men-machine interaction breaks down. As an example, an aircraft crashed and all 264 occupants were killed in 1994, because of inputs given to the autopilot by the pilots. The aircraft stalled because of a combination of high engine thrust, out-of-trim condition and too great a flab retraction (Abbott, 2001). The interactions between man and machine need to be addressed to prevent such accidents. Human limitations and capabilities need to be considered in the design process (HFE) and humans need to be trained (CRM).

2.2.6 Usage of CRM in other Industries/DomainsCRM was introduced originally for pilots, and over time, more industries and domains have adopted CRM. Fields where safety is deemed a high priority use CRM nowadays, such as rail and sea transportation, also nuclear/chemical industries and medicine (Dahlström et al., 2008). Furthermore, other airline employees, e.g. cabin crew, were eventually also CRM trained; additionally, maintenance technicians and air traffic controllers are now trained in CRM as well (Rodrigues et al., 2008).

2.2.7 Human Factors Engineering: Methods in DesignA discussion about Human Factors Engineering (HFE) will be presented in this sub-section. Aerospace companies use HFE for the design of their vehicles. There is, unlike CRM for pilots, not much standardisation, nor are there many regulations. Chapter 3 will state some regulations currently in place for aerospace OEMs.

HFE, like other previously mentioned HF disciplines, addresses aspects concerning humans, and HFE used in design may neither have a simple nor clear definition. Nevertheless, Cardosi and Murphy (1995) consider engineering psychology to be a close cousin of HFE. Furhermore, Cardosi and Murphy (1995) define HFE as: ‘… the discipline that applies knowledge of human capabilities and limitations to the design of technological systems.’ Additionally, Harris (2007) describes HFE as how performance can be optimised, in the system of men-machine, by integrating the human into the system. In addition, Human Centered Design (HCD), also known as ‘User Centered Design (UCD)’, is where the design process places the end-user at the centre. HCD may be considered another name for HFE according to Harris (2007).

HFM are used in HFE; nevertheless, Stanton et al. (2013) argue that HFMs are sometimes only used by the very person who designed them, and a limited use in general may apply. Furthermore, the process for designing, e.g. aircraft cockpits, may be considered nonstandard, complex, largely unwritten and variable according to NASA (1995b). That may be, as several disciplines are required in the process, not only HFE (Abbott, 2001).

2.2.8 Punishment for Mistakes; Just-CultureCRM training itself may not be sufficient for the successful implementation of CRM; a supportive company structure may also be required. Such a supportive structure may be achieved by implementing a ‘just-culture’. Reducing and preventing mistakes has been discussed in several sections above. It was stated that ‘HE’ may be considered inevitable, and methods used to avoid, trap and mitigate consequences are being used, e.g. by pilots.

Not many human actions that result in mishaps are deliberate. Additionally, judging in hindsight and drawing conclusions is easy according to Dekker (2014). Figure 7 below, the tunnel model, shows the lead up to and implications of a mishap. Pilots come to work to do a good job and their decision-making is influenced by several factors, when safety critical events happen. Furthermore, a continuous pace and ‘being inside the tunnel’ adds further difficulties.
Therefore, a simple judgment in hindsight is considered inappropriate according to Dekker (2014). Additionally, Dekker states: ‘To understand error, take the view from inside of the tunnel and stop saying what people failed to do or should have done” and “Don’t ask who is responsible, ask what is responsible!’
Nevertheless, sometimes deliberate actions do lead to mishaps, and not all actions are tolerated in a just-culture. An intended action which leads to an intended consequence may be considered sabotage; however, an intended

-6349-152400
Figure 7: The tunnel model(Adapted from: Dekker, 2014)
action which leads to an unintended consequence may be tolerated (Marx, 2014).

Culpability models, such as those shown in Figure 8 below, are used in support of the management in just cultures. A line must be drawn to distinguish between acceptable and not acceptable actions according to Reason (1997). Additionally, Dekker (2012) advises that who draws the line is more important than where to draw the line.

Moreover, an effective reporting environment is a key aspect of a just-culture. That is: learning from mistakes is practiced in a just-culture and that is only possible if people do the reporting. In a just-culture, reporting is encouraged as there is no retribution in most cases (Dekker, 2014).

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Figure 8: Just-culture culpability model(Adapted from: Baines Simmons, 2008)
2.3 Empirical Research MethodsThis section illustrates the methods used for the empirical research, and relates mainly to the first objective (HF and CRM research). This project proposes CRM for all employees of aerospace OEMs, and the gathered information from the literature review shows that some areas of HF and CRM are being used, in such companies. The following areas will be researched: HF/CRM training/applications, communications training, employee motivation, ERG and working hours. The literature review led to the decision to research these areas, and the purpose is to be able to suggest/adjust/adapt CRM for companies, using the findings. Furthermore, the data collection process and how it was conducted will be discussed. Then, the framework for the data collection followed by a limitations sub-chapter will be presented. Nevertheless, the research strategy, followed by an ethics review sub-section, will be shown first.

2.3.1 Research StrategyThe research strategies are surveys, in the form of questionnaires and interviews. The intention is to conduct interviews with superiors in several management positions, and questionnaires to be answered by all employees and people in a variety of job positions, in aerospace OEMs. The interviews may be considered qualitative research, whereas the questionnaire may be considered mainly quantitative research, as nine out of ten questions are multiple choice. Nonetheless, the tenth question may be considered qualitative, as participants are able to comment openly by writing feedback. This question was included to give additional (qualitative) information and feedback concerning the questionnaire itself, as suggested by Cardosy and Murphy (1995). The questionnaire was designed to be short and simple and the questions asked are very basic. Biggam (2015) argues that too many questions may deter people from completing questionnaires. Additionally, Cardosi and Murphy (1995) advise creating questions which are direct and simple.

2.3.2 Ethics ReviewThe university has an approval process concerning ethics for empirical research. A procedure has to be followed, and depending on the research, documents have to be submitted for approval. The author has followed this process for the surveys. A confirmation from the university was received, stating that the research proposal does not require an ethics review. This approval letter is shown in Appendix B, together with the research proposal in Appendix A.

2.3.3 Data CollectionSurvey Languages
The surveys are made available in three languages: English, German and French. The official language of the location of all four companies is German. English was added in anticipation of foreign employees and French was added as three companies are located in Switzerland, since French is the second most used, official language after German, of the four official languages in Switzerland (Swiss Confederation, 2018). Multiple languages were used to increase the chance of more precise results, if participants were able to use their mother tongue, or a language they have more fluency in, e.g. English instead of German or French for non Swiss nationals. Only the English research proposal was reviewed by the university; the German and French versions are translations of the original English version. The translations were made and certified by a translation service. The German translation is shown in Appendix C and the French translation is shown in Appendix D; both appendices also have the translation certificates attached.

Anonymity of Participants
It was decided to disclose the company names (with their permission) to support the validity of the empirical research. The participating companies are introduced in Chapter 1. The author is not employed by any of the participating companies and the information sought may be considered confidential in many cases. Therefore, all information gathered will be treated as a whole, and there will be no comparison between companies. The questionnaire results (shown in Appendix F: Questionnaire Answers) are given as one, with all companies combined. The interview transcript (Appendix E: Interview Transcript) shows answers to the questions randomly; therefore, it does not disclose from which company the answer came.

Interviews
Face-to-face interviews were planned, and as an alternative, telephone interviews. The author intended to ask questions according to the interview topic guide (Appendix A) and notes were taken, which are given in the interview transcript (Appendix E).

Questionnaires
The questionnaires were submitted by email, stating links, which led to the online questionnaires (Survey Monkey). The emails included all the information relating to the survey, that is the information which was reviewed for ethics, and can be found in Appendix A.

2.3.4 Framework for Data AnalysisThe actual collected data is shown in Appendix E (Interview Transcript) and in Appendix F (Questionnaire Results). The next section will show the results (interview) and graphic illustrations (questionnaire). Additionally, a survey analysis is presented followed by a synthesis of the gathered information of the empirical research in the context of the literature review.

2.3.5 Limitations of the Empirical ResearchIt has been a long and difficult task to get access to companies to conduct the empirical research. Nonetheless, it was decided to involve several companies in the research. Not all the companies work to the same regulations (e.g. EASA Part-21). Therefore, the application of HF in some companies may well be considered different, as the HF legislation is different, or there may even be no legislation at all. In spite of this, the findings will not show which regulations particular companies have to work to, as the results are randomised (see: ‘2.3.3 Data Collection; Anonymity of Participants’). Therefore, it is not possible to show findings in relation to applicable regulations.

Moreover, the research was only conducted in two different countries and cultural differences may apply (see also Chapter 1, ‘1.5 Applicable Countries and Cultural Limitation of the Research’). Therefore, the findings may be considered applicable for Europe and North America; however, there may still be some differences, if the research were to be conducted in different countries in the same region.

Additionally, personal opinions are included in some of the answered questions in interviews; these may be open to inaccuracy and bias.

2.4 Empirical Research Findings; Description and AnalysisThis section consists of the findings from both the interviews and the questionnaires. The next two sub-chapters consist of descriptions of the findings, and the third sub-chapter is an analysis of both, in the form of a discussion. Additionally, a synthesis of the empirical research in the context of the literature review will be included in the next section.

2.4.1 Survey; Interview DescriptionFive people were interviewed on four different occasions, through two company visits, one interview during an exhibition and one telephone interview. The job positions of the interviewees included: safety manager, company directors, human resources person and human factors trainer. The full interview transcript is located in Appendix E. The line number of a statement in Appendix E will be added when referring to a statement from an interviewee, e.g. Appendix E, line 13; for a later mention in the same context, only the line number will be included, e.g. line 18. This is due to the fact that the interviewed people and companies are not identified (anonymity) and the answers are listed randomly under each question in the interview transcript. More information on the anonymity of the surveys is given above in Section 2.3.3. The findings from the interviews are given below and each is preceded by the question from the interview topic guide.

Question one:
‘Does the company have practical Human Factors applications? If yes, please give a broad overview.’
Some of the companies do not have practical HF applications (Appendix E, lines 4, 7 and 9). Maintenance technicians are CRM trained according to EASA Part-145, that includes a two day initial training and recurrent training every two years (line 5). Additionally, there is a CRM training manual (Part-145 technicians) (line 8). A safety management manual and a just-culture is in place covering all employees (line 3).

Question two:
‘Do you have a Safety/HF department/person?’
Some companies answered the question with a ‘No’ (lines 11, 13 and 14). HF is part of the safety and quality department (line 12). A safety and quality (SQ) department has a matrix structure, meaning that workers of SQ can work in other departments, but are still subordinate to the SQ department (lines 15 and 16).

Question three:
‘Ergonomics (ERG); does the company have procedures in place to review individual working places and improve these accordingly?’
One company advises that both workshop and office make an effort to provide adequate ERG (line 21). Some companies answered the question with a ‘No’ (lines 20 and 22). Another company stated that a mandatory question during the two-yearly employee meeting concerns ERG (lines 23 and 24). It was also mentioned that it is a part of audit management (Part-145) (line 19).

Question four:
‘Do the employees get communications training? If yes, please give more details.’
Some companies answered the question with a ‘No’ (lines 26, 28 and 29). Communications training is part of certain job positions, e.g. for leaders and trainers (line 27).

Question five:
‘How are the working hours and breaks regulated, please explain.’
One company has fixed working hours (line 32). The yearly working hours are based on 40 hours per month, hours are bankable with a maximum and minimum amount (line 31). Work is given to contractors and the mandates have deadlines (line 34). Some have flexible working hours with a mandatory presence time (line 33).

Question six:
‘Motivation; from your personal experience, if you have worked for non aerospace companies before, would you consider aerospace company employees and/or people who apply, in general, more motivated compared to workers in non aerospace companies? If you can, please give examples or details.’
The motivation of aerospace employees has declined over the last few decades (line 39); this may be in connection with low salaries (line 40). The new generation is expecting to learn new things, otherwise, high fluctuations (line 44) and it may be a societal problem (line 46). One interviewee answered with an overwhelming ‘Yes’ (line 41). A perceived higher motivation (in a start up company) (line 48).

Question seven:
“If you want, please comment on the proposed implementation of CRM for OEMs and any other comments are welcome.”
Just-culture is already implemented (part 145) (lines 51, 52 and 53). No, it is not desired to have CRM (line 56). More legislation is not desired and people have different levels of IQ; CRM may not work for all (line 60). Interdisciplinary job knowledge is welcome (line 57). Designers are working in the workshops together with mechanics for new developments (line 59).

2.4.2 Survey; Questionnaire DescriptionThis sub-section illustrates the results of the questionnaires in the form of graphs and, additionally, Appendix F (Questionnaire Result) includes all the results.
In total, 1012 questionnaires were distributed, and 341 were answered, giving a return of 33.7%. The questionnaire was available in three languages (see also: 2.3.3, Survey Languages). Figure 9 shows the answered questionnaire in relation to the languages. German questionnaires were the most answered, followed by English and French.362013389751
Figure 9: Portion of answered questionnaires in relation to languagesQuestion 1198659342368
‘What is the highest level of education you have completed?’
Figure 10: Questionnaire: Diagram illustrating the answers to question 1Question 2374864390144
‘Have you ever received communications training?’
Figure 11: Questionnaire: Diagram illustrating the answers to question 2Question 3
‘Do you know what Human Factors (HF) and/or Crew Resource Management (CRM) is?’397319329771
Figure 12: Questionnaire: Diagram illustrating the answers to question 3362013575949
Question 4
‘Have you received any HF/CRM training?’
Figure 13: Questionnaire: Diagram illustrating the answers to question 4Question 5
‘Are you using HF methods at work?’
Figure 14: Questionnaire: Diagram illustrating the answers to question 5Question 6
‘Do you prefer to work fo10801351783651r a company involved in aerospace, than for a362013527114 company not involved in aerospace?’
Figure 15: Questionnaire: Diagram illustrating the answers to question 6Question 7
‘Do you have interests in aerospace outside work, for example flying model planes or do you follow developments in aerospace, like reading aerospace344360473932 magazines?’
Figure 16: Questionnaire: Diagram illustrating the answers to question 7Question 8
‘Are you satisfied with the infrastructure at work (ergonomics) or would you362013492316 welcome improvements?’
Figure 17: Questionnaire: Diagram illustrating the answers to question 8Question 9362013434975
‘Are your working hours fixed or do you have some flexibility?’
Figure 18: Questionnaire: Diagram illustrating the answers to question 9Question 10
‘Please write in this box any comments concerning questions 1-9, and/or you may write any comments about Human Factors and/or Crew Resource Management at work.’
This is the only question which is not multiple-choice. A short discussion is added of comments considered worth noting, and all the answers to Question 10 are located in Appendix F (Questionnaire Answers).

Feedback concerning the design of the questionnaire was about Question 1 and also included general comments. It was said that the options for Question 1 were too limited –education other than apprenticeship and university should have been made available (Appendix F, lines 2, 5, 18, 28, 41). Additionally, some answers will be added in the discussion section of the chapter (‘2.5 Synthesis: HF/CRM Literature Review and Empirical Research’).

2.4.3 Surveys AnalysisThe surveys, interviews and questionnaires, will be analysed in this sub-section. The questionnaires were given to all employees no matter what job positions they held, whereas the interviews were conducted with superiors only. Some of the questions for both (interviews/questionnaires) have some similarities and the following areas will be discussed in context where applicable: communications training, HF/CRM training/applications, employee motivation, ERG, working hours and questionnaire design. Furthermore, the analysis will include comparisons between university graduates and non graduates; for that, people with bachelors and masters/doctorate degrees will be considered university graduates.

Communications Training
A considerable number of people have received communications training (the ‘Lifeware-Liveware’ interface in the context of the SHELL model), about two thirds. One third received communications training in either schools or universities. Some companies do provide communications training, but only for certain, mainly superior positions (Appendix E, line 27). Nevertheless, there seems to be no evidence for standardisation and the necessity for communications training in aerospace OEMs. Furthermore, the majority of university graduates tend to have received some form of communications training, whereas a larger number of non university graduates have not received communications training compared to the graduates (see Figure 19, below).

610009618566
Figure 19: University graduates’ and non graduates’ communications trainingHF/CRM Training/Applications
The majority of employees do know what either HF or CRM is (83%) according to the questionnaire. All five interviewees (superiors) did know what HF/CRM is. The proportion of questionnaire participants who received HF/CRM training was almost identical for the graduates and non graduates (see Figure 20).610009972805
Figure 20: University graduates’ and non graduates’ HF/CRM trainingThe use of HF/CRM, does as well, not differ much between graduates (79%) and non graduates (84%) according to the questionnaire. This survey suggests that HF methods are used but not in a consistent way.

Motivation
It may not be clear if motivation of aerospace OEM employees is considered higher than for other working groups, although the majority in the questionnaire stated a preference for working for aerospace OEMs (74%) and having some outside interest related to aerospace (65%). Nevertheless, the findings from the interviewees were less promising, suggesting mostly no higher motivation (Appendix E, lines 39-48). It is therefore questionable if these findings are proof enough for a higher motivation among aerospace OEM employees compared to non aerospace workers.

Ergonomic Aspects
ERG aspects (the ‘Lifeware-Hardware’ interface in the context of the SHELL model) may be considered quite consistently addressed. About two thirds of the answers in the questionnaire stated satisfaction. Additionally, procedures are in place in the majority of companies to address ERG aspects (Appendix E, lines 19-24).

Working Hours
Different companies have different ways of regulating working hours (the ‘Lifeware-Environment’ interface in the context of the SHELL model) (Appendix E, lines 31-34). That was also reflected in the answers to the questionnaire. Nevertheless, there were some discrepancies between the interviews and questionnaires. The answers did not match completely, and that may be down to the understanding of working agreements. However, the working hours in general may be perceived to be quite sophisticated, as there is a lot of flexibility for the individual worker, supporting HF aspects in regard to working hours.

Questionnaire Design and Shortcomings
The questionnaire was designed before the companies were contacted, in order to be able to give answers about the interview/questionnaire to companies when they were contacted. Therefore it was not anticipated that a significant number of licensed maintenance technicians would take part. It is not clear how many of the questionnaires were answered by licensed maintenance technicians. The answers may well have been considerably different, if only design and production personnel had participated, as CRM is a requirement for licensed maintenance technicians (see also: ‘3.2 Objective 3: Legislating CRM for OEMs’).

Furthermore, the questionnaire had the following four education options available: No, apprenticeship, bachelor and masters/PhD. That was criticised by several questionnaire participants (Appendix F, lines 2, 5, 18, 22, 28, 41). In hindsight it would have been helpful to have the following options: No, apprenticeship, licensed technicians, non-university higher education and university higher education.

2.5 Synthesis: HF/CRM Literature Review and Empirical ResearchThe aim of this project is to introduce CRM for aerospace OEM employees and the first objective (addressed in this chapter) was to research HF and CRM. The purpose of this section was to synthesise the literature review findings with the empirical research results. Additionally, the literature review illustrates and explains HF/CRM, and areas like man-machine, human-error, ergonomics and HFE. The purpose of the empirical research is to show the actual HF/CRM application in aerospace OEMs.

The problem formulation section in the introduction chapter addresses the lack of CRM in aerospace OEMs. No evidence of CRM training for aerospace OEM employees was found in either the literature review or the empirical research. The only exception was for licensed maintenance technicians (See Chapter 3). There is, however, some evidence of HF being trained for and used, but not consistently.

Ambiguity and confusion surrounding HF and CRM may exist. That was confirmed by both the literature and empirical research (ICAO, 1998; Appendix E lines 61 and 62; Appendix F lines 8, 35 and 45).

HF may involve all aspects of the SHELL model; therefore, it is concerned with hardware, software, environment and liveware, whereas CRM is mainly concerned with ‘the hub’, the liveware component in the middle of the model. The human is being trained to perform safely and efficiently with the other given components, preferably with a supportive company structure. See Figure 30 below which illustrates this in an simplified way. Remark: this figure is copied from Chapter 4 ‘Objective 4: Adaptation of CRM for OEMs’.

-6349208725
Figure 30: Distinguishing between CRM and HF using the SHELL model
(Adapted from: Hawkins, 2016)
Moreover, the expression CRM may also be confusing. CRM was originally mainly concerned with using all available resources, hence the name. However, CRM has evolved and has a wider use for most HF aspects, though the name has remained the same. Additionally, the ‘C’ of CRM refers to crew which may be inappropriate for aerospace OEM employees. It is, therefore, proposed that a different name should be used, and one possibility is ‘None Technical Skills’ (NTS) according to Flin (2010) and in-pilot training known as NOTECHS (Van Avermaete, 1998) used to assess CRM. The author proposes the name ‘Staff Resource Handling’ (SRH) as an alternative to NTS.

SRH may have aspects which are the same as CRM for pilots and maintenance technicians. Therefore, some parts of the proposed SRH training may be identical for all personnel in aerospace OEMs. Figure 21 below illustrates this. General SRH may be supplemented with customised SRH for different jobs.

Figure 21: Current HF applications in the context of the proposed SRH-63501260475Furthermore, motivation and CRM acceptance have been addressed in both the literature review and empirical research. The CRM literature review is mainly concerned with pilots. An introduction to CRM for aerospace OEM employees would need to take account of vast differences in education and skill levels, unlike pilots who normally have to go through a thorough selection process and standardised training. Helmreich and Foushee (2010) support the idea that the selection process for pilots contributes to better performance. The motivation aspects in the empirical research represented an attempt to see if increased motivation levels may support the acceptance of CRM. The findings from the questionnaire may support this, but with limitations, and the findings from the interviews are not considered proof enough; further research is required.

Chapter Three – Objectives 2 and 3: Benefits and LegislationBoth, Objectives 2 and 3 will be addressed in this chapter. Whilst Objective 1 (‘Human Factors and CRM Research’) is the basis for this paper, Objectives 2 and 3 are supplementary in supporting the aim of introducing CRM for aerospace OEM employees. The aim of the benefits sections is to state ‘why’ it should be done. The legislation section, and the aims of the next chapter (‘Objective 4: Adaptation of CRM for OEMs’) are to state ‘how’ it should be done.

3.1 Objective 2: BenefitsThe purpose of this section is to explore and illustrate the benefits of the proposed introduction of CRM for aerospace OEM employees. Section 1.4 (‘Problem Formulation’) may be regarded as an addition to this section, as it illustrates ‘what’ the issue is, and this section argues for ‘why’ it should be addressed. The research in this section is based on the literature review; it looks at current applications (HF/CRM) and seeks to illustrate the benefits for aerospace OEM employees in the form of a discussion in the last sub-section. Furthermore, the sources and criteria used for the research are discussed above, in Chapter 2 (‘2.1 Source and Criteria used for the Literature Review’).

3.1.1 Safety and EfficiencyThe second objective, discussed in this section, considers: ‘… Financial, safety and efficiency benefits in order to make a business case’. The wording may not be considered optimal, and the author regrets using this sentence. It may be confusing, as increasing efficiency may relate to financial benefits. Therefore, the research will concentrate on safety and efficiency only, in anticipation that improved efficiency may lead to financial benefits.

Efficiency may be a description of how something works well and promptly. The Cambridge Dictionary (2018) states that efficiency in connection with business is: ‘a situation in which a person, system, or machine works well and quickly’. Whereas safety may be described as protection from injury. The Cambridge Dictionary (2018) states that safety in connection with business is: ‘The condition of not being likely to cause damage or harm’.

The ICAO (1998) states two areas for which HF is needed, namely the wellbeing of personnel and the system’s effectiveness; the latter is divided into two areas: safety and efficiency. Therefore, the areas to be addressed (safety and efficiency) may be considered core parts of HF in essence. The next two sub-chapters will discuss both the safety and efficiency benefits of current aviation applications respectively.

3.1.1 Safety Improvements in Civil AviationThe safety improvement in civil aviation has been a gradual process over the last 60 years. Accident rates have been reduced as illustrated by Figure 22. Additionally, human involvement may be considered the main reason for air accidents. Figure 23 below shows the different causes of accidents, two thirds of which are considered to be the fault of flight crew. Furthermore, the CAA (1998, cited in Harris, 2007) has identified failure in CRM as a casual factor in 17.1% of 589 analysed fatal accidents (see Table 6 below).
Moreover, the ICAO (2013a) differentiates between efforts to reduce accidents over time; firstly, it addresses technical factors, then HF and more recently organisational factors (see Figure 24 below). It is worth mentioning that the HF area shown in that figure, corresponds with when CRM appeared; the ICAO (2013a) also refers to the effort to improve the man-machine interface in the66698389323 same time period.

Figure 22: World jet fleet accident rates and onboard fatalities (1959-2015)(source: Boeing, 2015)
-6350-152400
Figure 23: Main cause* of hull loss (jet fleet 1991-2000)(Source: Boeing, 2001)
Table 6: 10928355823785% of
Casual factor Count accidents
Lack of positional awareness in air 244 41.4
Omission of action or inappropriate action 216 36.7
Flight handling 177 30.1
Poor professional judgment or airmanship 134 22.8
Slow and/or low on approach 113 19.2
Failure in CRM 101 17.1
Press-on-it is 97 16.5
Deliberate non-adherence to procedures 72 12.2
Design shortcomings 67 (11.4)
Post crash fire 63 (10.7)
% of
Casual factor Count accidents
Lack of positional awareness in air 244 41.4
Omission of action or inappropriate action 216 36.7
Flight handling 177 30.1
Poor professional judgment or airmanship 134 22.8
Slow and/or low on approach 113 19.2
Failure in CRM 101 17.1
Press-on-it is 97 16.5
Deliberate non-adherence to procedures 72 12.2
Design shortcomings 67 (11.4)
Post crash fire 63 (10.7)
Most frequently identified causal factors in the 589 fatal accidents(Source: Harris, 2007)
Figure 24: Safety evolution(Source: ICAO, 2013a)
3.1.3 HFE and CRM BenefitsBoth HFE and CRM contribute to safety improvements, and safety may be considered the main impetus for HFE/CRM. Nevertheless, efficiency may also be considered to be of paramount importance in HFE. This is supported by Harris (2011) who states that HF w10801351260475as driven by demands to improve safety in the last half century. Additionally, Harris (2011) states the necessity of making progress in HF towards benefits such as smooth operations and finances.

Human Factors Engineering (HFE) Benefits
Human Factors Engineering (HFE) does contribute to several benefits. Harris (2007) reckons ‘adding value’ is achieved through HFE, since not only operational costs, but also total lifecycle costs, are reduced by the enhanced performance achieved with good HFE. The enhancement of performance through HFE is also supported by Cardosi and Murphy (1995), who argue that this is achieved through good design, whereas poorly designed systems degrade human performance.
Moreover, Human Factors Integration (HFI) is not only needed in the engineering/design process of an aircraft, but also in areas like training. Nevertheless, such factors as training needs to be taken into account during the design of an aircraft. Harris (2007) points out that the skill level of pilots (highly skilled or less experienced) is an aspect which needs to be addressed early in the design phase. Furthermore, it may be considered crucial to focus effort in the design process early on in order to gain benefits from HF. Stanton et al. (2013) advise that the greatest value of HF integration is in the early stages of development as illustrated in Figure 25.524994204219
Figure 25: HF effort is better made in the early stages of the design process(Source: Stanton et al., 2013)
This concludes the ‘HFE Benefits’ section. Since the aim of this paper is to introduce CRM for aerospace OEMs, HFE remains important for aerospace OEMs and it is not the intention to replace HFE with CRM, but to supplement it.

CRM Benefits
Identifying the benefits of CRM may be difficult. This is supported by Helmreich, Merrit and Wilhelm (1999) who argue that the purpose of CRM, increasing safety and efficiency, may not be easily proved. Nevertheless, a proposed equation is available to calculate the return from investment in CRM. Figure 26, by Taylor (2000; cited in CAA, 2002) shows the equation including an example.558353602729
Figure 26: Return of investment equation and example(Adapted from: Taylor, 2000, cited in CAA, 2002)
The costs for the development of a Maintenance Resource Management (MRM) course and delivery to 1,600 employees is $251,660. Long-term injuries were reduced by 80% over the two years post-training, and attitudes improved significantly. The correlation between long-term injuries and improved attitudes was considered to be 0.24^2 (0.0576). The notional reduction in the number of incidents (91) costing $13,465 each ($1,314,150 total) was determined by the 80% reduction in injury. Therefore, in financial terms, the net CRM benefits amounted to $1,062,490 ($1,314,150 – $251,660). The result (ROI) became 24.3% (Taylor, 2000; cited in CAA, 2002).

Moreover, Helmreich and Foushee (2010) researched the effectiveness of different CRM training types, including CRM courses. The findings are considered consistent, and the crew members found the training to be highly effective. Responses from the surveys are shown in Figure 27 below; five airlines participated.

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Figure 27: Perceived usefulness of CRM amongst pilots(Source: Helmreich and Foushee, 2010)
These findings may be considered an indication of acceptance; however, acceptance itself may not be enough of an indicator of effectiveness.

A measurement of the effectiveness of CRM may supplement the acceptance of crew members. Such performance was measured in the form of crew behaviour through checks by airmen and observers. The changes in behaviour have moved in the right direction according to Helmreich and Foushee (2010), as illustrated in Figure 28 below.

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Figure 28: Crew performance ratings in the context of CRM training(Source: Helmreich and Foushee, 2010)
3.1.4 Benefits Section Analysis
This sub-chapter is relatively short and presents the safety/efficiency benefits related to CRM/HF, as well as showing the benefits of HFE, maintenance and flight crew CRM. These safety and efficiency benefits may be translated to aerospace OEM employees; however, both flight crew and maintenance technicians may be considered operational personnel and, therefore, a direct translation may be misleading; further research is required. Moreover, there is not much evidence of the benefits shown above; however, the welfare of personnel as stated by the ICAO (1998) is the first of the two areas covered by HF. The second area is the effectiveness of systems, including safety and efficiency. It has been suggested that CRM contributes to the welfare of personnel, and this anticipated benefit could directly contribute to employee satisfaction. More work in the form of a trial CRM course and structure adjustments to incorporate CRM in an aerospace OEM is suggested to gather more evidence for the proof of benefits. More will be discussed on this in the recommendations section.

3.2 Objective 3: Legislating for CRM for OEMsCRM training is a requirement for the issuance and renewal of most pilot’s licenses. Furthermore, CRM is also included in regulations for other operational staff, like maintenance technicians and cabin crew. This chapter will illustrate current HF and CRM legislation used in aviation. The sources and criteria used for the research are discussed above, in Section ‘2.1 Source and Criteria used for the Literature Review’. However, initially an argument is offered to legitimate the proposal to legislate for CRM for aerospace OEM employees.

3.2.1 Why to Legislate?Good innovative new methods may be used by the industry voluntarily, as they are expected to provide benefits; unfortunately, however, it is not always the case that such measures are adopted. The introduction of new methods requires extra effort from companies and to some extent, new methods may not have proven benefits. Nevertheless, Elliot (2006) argues that new legislation/regulations to change corporate policies can often be powerful stimuli; these set standards which all companies are then required to follow. Furthermore, airlines use contractors for many operations, e.g. ground handling. Such contracts are competitively priced, therefore, there is no room for extra expenses like CRM training. These contractors would not do extra training like CRM, according to a survey conducted by the CAA (2016) unless it is legislated for.

Furthermore, new legislation/regulations may not automatically provide benefits for companies. The introduction of such measures may even produce obstacles which have an adverse effect. It is, therefore, important to judge what legislation/regulations should be introduced. Pelkmans and Renda (2014) suggest that regulations on innovation are considered complex, often ambiguous and multifaceted; therefore, assessment of their worth often ends up as a case-by-case exercise. Additionaly, Pelkmans and Renda (2014) also support the idea that regulation may be considered a strong stimulus for innovation under certain circumstances.

3.2.2 CRM Regulations and LegislationThe legal framework for HF and CRM is covered by several national and international organisations/authorities. This section shows different legal frameworks in the ICAO and Europe. Additionally, a discussion on how the implementation of CRM for aerospace employees may be regulated, is given below.

General
The ICAO offers international standards; these are published in annexes in the form of Standards and Recommended Practices (SARPs) according to the CAA (2016). The ICAO also recommends training associated with HP due to the identification of accidents caused because of HF. This training is intended for flight operations including flight crew, cabin crew, general training, checklists, maintenance personnel, flight dispatch, manual design and airplane instrument/equipment (ICAO, 2010). Furthermore, the ICAO SARPs relating to CRM were introduced to EU-OPS according to the CAA (2016).

Pilots
Relevant European CRM regulations are in place for flight crew (Part-FCL) and for AOC holders (Part-ORO). The following states some of these regulations and Appendix G has a table to clarify the differences between the two and a flow-diagram showing the process to be followed for training courses (CAA, 2016). EASA Part-FCL has regulations for instructors and examiners (subparts J and K respectively); the integration of CRM during training, both practical and theoretical, is regulated, to be trained (EASA, 2016). Furthermore, EU-OPS subparts N and O include training associated with ICAO SARPs, in terms of how the training should be conducted. This includes initial CRM, conversion, recurrent and command training. All major CRM parts need to be covered over a three-year period. The required documentary guidance for training is shown in subpart P, and all relevant items are prescribed in subparts E and N (CAA, 2016).

Cabin Crew
Cabin crew CRM training has similarities to pilot CRM training and joint exercises with pilots are practiced (Hawkins, 2016; CAA, 2016). The required documentary guidance for training is shown in EU-OPS subpart P, and all relevant items are prescribed in subpart O (CAA, 2016).

Maintenance Technicians
EASA has several sections to regulate maintenance; these are Part-M (Continues Airworthiness; EASA 2009), Part-66 (Certifying staff, EASA 2012), Part-145 (Maintenance Organisation Approval; EASA 2008a), Part-147 (Training Organisation Requirements, EASA 2008b).

The majority of HF regulations are in Part-145 and Part-66, ‘Basic Knowledge Requirements’ (66.A.25) states the requirements of HF. The sections concerning HF in Part-145 are listed below:
145.A.30Accountable Executive
145.A.30(e)Initial HF certification; HF Guidance Material (also in Part-66)
145.A.30(d)Fatigue Management
145.A.35(d)Continuation HF training
145.A.45Reporting Requirement of Documentation
145.A.47Tasks, equipment and spares planning; task/shift handover
145.A.60Error Management
145.A.65Safety Culture/Management Systems
145.A.47(b)Capturing errors, e.g. duplicate inspections
145.A.65(c)Non compliance procedure
Aerospace Design/Engineering
Some HF aspects are covered by EASA CS 25 (EASA, 2007), which is the specification for the certification of large aeroplanes. CS-25 refers to HF in the following sections:
25.933In-flight thrust reversal
25.771Controls
25.777(a)Location of controls
25.777(b)Together with 25.779, motion direction and actuation of controls
25.1302Pilot interfaces such as displays, automation and controls
EASA Part-21 also states the requirements for certification procedures according to Chattfield (2016). GM 21.A.3B(b) determination of an unsafe condition acknowledges that HF techniques are under development, but lists preliminary guidance. Multidisciplinary teams may be established, including crews, designers, operators, maintenance and HF experts. Suggested assessments concerning assembly are: operation, alerting systems, previous unsafe conditions, system complexity, manuals/procedures and personnel interactions (EASA, 2012).

3.2.3 Legislation Section AnalysisThis section, like the previous one, is quite short, and the purpose is to show how CRM could be legislated for amongst aerospace OEM employees. The first part of this section argues for why it should be legislated for and the second part shows the current legislation under EASA. Both the literature and empirical research made it clear that maintenance technicians have CRM legislation in place. It is therefore suggested that these regulations should be used as a basis and training material for Part-145 to adapt and integrate it into Part-21. That would mean that OEMs working under a DOA would have a requirement to undertake CRM courses and there would be a CRM-friendly company structure for all employees. Importantly, Part-145 should not be copied into Part-21, it should be used as a basis for adaptations and changes that are required.

Chapter Four – Objective 4: Adaptation of CRM for OEMsThe project proposal’s fourth objective asks: (1) how CRM for aerospace OEMs could be adapted, (2) what a broad training outline should look like, and (3) is there an appropriate new HF method (Wunderlin, 2017b). The expectation during the proposal phase was to be able to identify applicable CRM methods from other domains/industries. The previous section/objective (legislation) suggests using broadly the same CRM structures as Part-145 and integrating them into Part-21 DOAs. This may be guide 1) how it could be adapted and 2) what a broad training outline should look like. These two areas need more research, especially the adaptation, and this paper does not have the scope to cover this, as will be discussed below in the recommendations in Chapter 5. Instead, the author designs and presents an introductory CRM lesson instead, including a new HF model (3).

This introductory lesson will help to offer an understanding of HF/CRM for people new to the subject. For this lesson, the acronym CRM and not SRH will be used, as the SRH acronym is only suggested for now, but may be used in future. The lesson may also be used as pitching material to convince aerospace OEMs to introduce adapted CRM. A design brief followed by a design methodology section is given below which illustrating the design methods used to create the proposed training, followed by a section illustrating the introductory lesson and finally, a summary.
4.1 Design BriefA training lesson will be designed in accordance with the knowledge gained from the research so far. The following design brief is a statement of the opportunity and is based on Cross (2009):
The design goal is to create training material for one introductory CRM lesson. The context is to give a basic understanding of CRM and HF for aerospace OEM employees, with different backgrounds and jobs. The constraints of the training are to teach basic HF/HP and the function of the company structure in relation to CRM. An important criterion is the use of simple understandable methods, preferably visualised in the form of illustrations, as the training could be tough for personnel with different educational backgrounds.

4.2 Design MethodologySeveral design methods were used in order to create the training material according to the design brief. As a first step, brainstorming was used to identify areas which should be addressed in the lesson. Current methods which have already been mentioned in this paper were chosen first. Next, adaptations, transfers and combinations (Roy, 2009) of existing methodologies generated more training material. Furthermore, a Creative Problem Solving method (identification, exploration, incubation, illumination and critical review), according to Roy (2010), helped together with Random Stimuli and Analogies (Roy, 2009) for the creation of the remaining methods of the proposed training material.

4.3 CRM/HF Introductory LessonThis section shows the results of the proposed and designed introductory CRM/HF lesson for aerospace OEM employees. The design process, which was conducted using the methods stated in the design methodology in Section 4.2, and in accordance with the design brief (see Section 4.1), is not shown, only the results. Explanations and some figures of the proposed training material are illustrated below.

4.3.1 IntroductionSummary:This short course is a CRM/HF introductory lesson, including
explanations about what CRM/HF are.

Objectives:When completed, the participant will be able to:
-Identify the basics of Human Factors (HF)
-Understand simple CRM models/methods
-Understand the purpose of CRM, the training, and a supportive
CRM company structure
Outline:1. Introduction
2. What are Human Factors? The SHELL model
3. What is CRM in the context of Human Factors?
4. Supportive company structure
5. Purpose of supportive company structure and CRM training
6. Multiple causes of mishaps
7. Error: prevention, reduction and mitigation
4.3.2 What are Human Factors? The SHELL modelThe SHELL model is used to explain HF, based on the four different interfaces between the human (lifeware): software, hardware, environment and other lifeware, which will be discussed. Figure 29 will be shown.-6349232041
Figure 29: The SHELL model, as generally known, and illustrated using symbols(Adapted from: Hawkins, 2016)
4.3.3 What is CRM in the Context of Human Factors?
HF have many applications including: the interaction of men-machine, organisation/staffing, training/development, procedures/roles/responsibilities, teams/communication and the recovery from failures (Eurocontrol, cited in Dahlström et al., 2008). Therefore, HF may be considered a generic term, and includes all components of the SHELL model. CRM concentrates on the ‘human’ at the centre of the SHELL model, as shown in Figure 30. CRM courses train the ‘human’ at the centre to work efficiently and safely with the other four given components (CAA, 2016). Additionally, behaviour tools have to be provided to the participants in order for them to be able to apply CRM (Helmreich and Foushee, 2010).-6349286617
Figure 30: Distinguishing between CRM and HF using the SHELL model(Adapted from: Hawkins, 2016)
4.3.4 Supportive Company Structure-6349328536Figure 31: CRM; Supportive company structure(Adapted from: CAA, 2016; Dekker 2012 and 2014; Marx, 2014; Appendix E, line 51-55)
An important part of CRM is a supportive company structure. A division between business and CRM/HF is proposed as shown in Figure 31. Reporting should be encouraged, promoted by anonymous reporting, preventing direct consequences and conflicts of interest if, for example, part of the problem is a line manager. This is usually part of a ‘just-culture’ (Dekker, 2012).

4.3.5 Purpose of Supportive Company Structure and CRM Training2630376041-63493533207216803291204Figure 32: ‘SRH circle-model’ in the context of a supportive company structureThis project introduces/proposes the ‘SRH circle-model’ as shown in Figure 32. An employee may work at the centre of a circle, e.g. working hours; nevertheless, the employee may be better placed in a different location in the circle or even outside it (Circle A), e.g. as an early morning person. Circle B illustrates a widening of the circle, e.g. giving more flexible working hours which is achieved through feedback and research by the ‘CRM-division’ and negotiations with the ‘business-division’. Additionally, the ‘CRM-division’ will make sure employees have all the necessary information (e.g. working hours regulations) available, e.g. through an ebook (perhaps made available for mobile devices), which is regularly updated. Such an ebook may include HP information such as solutions for issues such as sleeping. The training will be delivered by the ‘CRM-unit’, as shown in Circle C; how accessing information and CRM will be tough.

4.3.6 Multiple Causes for MishapsThe Swiss-cheese model (Reason, 1990) is used to explain the concept of multiple causes leading to mishaps (see Figure 6). This model is chosen as it is simple and easy understandable. Nevertheless, the shortcomings of this model will be acknowledged, as discussed in Section 2.2.4 (CRM: Pilots — CRM Applications, Methods and Models) and will be mentioned briefly in the training.-6350214051
Figure 6: Swiss-cheese model
(Source: Wunderlin, 2016b — adapted from Reason, 1990)
4.3.7 Situational Awareness and Error in ContextThis example shows a CRM application used by pilots (operational personnel). Avoiding errors requires thinking ahead; trapping errors requires understanding the situation and mitigating requires noticing errors (see Figure 33). This is achieved in different ways, which may include SOPs, checklists, drills, decision-making tools and more. The weather example given in Section 2.2.4 (‘CRM and Threat/Error Management TEM: Pilots’) according to Dahlström et al. (2008) will be used as an example.

-6350241421
Figure 33: SA in context with TEM(Adapted from: CAA, 2016; Dahlströhm et al., 2008; Helmreich, Klinect & Wilhelm, 1999; Weiner, 2016)
4.4 Chapter SummaryThis chapter has addressed Objective 4 of the project which considers how CRM could be adapted for aerospace OEM employees. It is stated that the legislation section (Objective 3) has answered how it could be broadly adapted and given a training outline, by adapting Part-145 CRM and transferring it into Part-21. Additionally, the objective focuses on the possibility of designing a new HF method. It was decided, for the purposes of this study, to design an introductory CRM lesson instead, including a new HF model. A design brief and a design methodology sub-section preceded the introductory CRM lesson. This lesson may also be used as a pitch for aerospace OEMs to convince them of the benefits of introducing CRM. Nevertheless, adaptations are still needed, and this will be further discussed in Chapter 5, since time limitations and the word count for this study restrict the scope of this paper.

Chapter Five – Summary of Findings, Conclusions, RecommendationsThe overall aim of this project was to consider a proposal to implement CRM for aerospace OEM employees to increase efficiency. Findings and conclusions will be shown in this chapter; additionally, recommendations for further research will be stated.

5.1 Findings and Conclusions5.1.1 Objective 1: HF and CRM ResearchThe aim of the first objective was to research both HF and CRM through primary and secondary research. That was conducted in the form of a literature review and empirical research in the form of surveys through aerospace OEMs.

The research started with a literature review; HF, Human Performance and Ergonomics were researched in context. The SHELL model was explained and used in this paper as the basis for HF. ‘Human Error’ and automation/men-machine aspects were explored as these may be considered important aspects of both HF and CRM. Furthermore, CRM was researched, not only in terms of pilots’ CRM but also CRM in other domains. HF aspects for engineers and designers (HF engineering; Human Centered Design) were also presented and ‘Just-Culture’ was discussed, which may be considered supportive for successful CRM. Moreover, empirical research in the form of surveys (interviews and questionnaires) was conducted. The following areas were addressed: HF/CRM training/applications, communications training, employee motivation, ergonomics and working hours.

The findings showed ambiguities in the definitions HF and CRM.
A new acronym for aerospace OEM CRM, ‘Staff Resource Handling’ (SRH), was, therefore, proposed. Furthermore, the research did not offer any proof of a standardised usage of CRM in aerospace OEMs; it is, however, used by maintenance technicians. Nevertheless, many HF aspects were found to be used in aerospace OEMs, but not consistently.

5.1.2 Objective 2: Benefits of ImplementationThe aim of the second objective was to research efficiency and safety benefits.
A literature review addressed the following factors: safety and efficiency in context, safety improvement and its benefits for civil aviation and CRM/HF-engineering.

The findings of the reviewed literature showed some benefits of both efficiency and safety, in other domains, such as flight operations (pilots). Nevertheless, proof was not easily determined, and it may not be possible to project the identified benefits onto aerospace OEMs; more research is required.

5.1.3 Objective 3: Legislating for CRM for aerospace OEMsThe aim of the third objective was to examine how CRM may be legislated for within aerospace OEMs.

An argument was presented to demonstrate why legislation should be introduced. Additionally, current EASA regulations were examined and summarised in this paper, including legislation for pilots and maintenance technicians.

The findings showed that legislating may be a helpful stimulus, but it is crucial to take care in terms of its introduction, as it may also hinder an improvement if not implemented correctly.

It is proposed that the current legislation for maintenance technicians (EASA Part-145) should be used as a basis to be translated into EASA Part-21, requiring aerospace OEMs with DOAs to have SRH. If this proposal were to be followed, however, adaptations would be required, thus necessitating future research.

5.1.4 Objective 4: Adaptation of CRM for aerospace OEMsThe aim of the fourth objective was to explore how CRM could be adapted, to propose a broad training outline and design a potential new HF method.

The suggestion from Objective 3, to transfer and adapt CRM from EASA Part-145 into Part-21, was considered to be too broad an answer to how it could be adapted and to provide a training outline. It was decided to design an introductory CRM lesson instead of working further on adaptations, which would also include a new HF model. It is considered that this introductory lesson may be more helpful than working more on the adaptation and training outline, as this very lesson may be used for pitching to aerospace OEMs to convince them of the importance if introducing SRH and getting access to OEMs for future research. Thus, it was considered that too much work would be involved to continue the research into how the adaptation could take place and the focus switched to work on a training outline, and suggestions for future research.

5.1.5 Findings and Conclusions SummaryThis research may not be considered conclusive, and is limited to some extent. The empirical research did not, for example, positively prove an increased motivation amongst aerospace OEM employees and the benefits found were not sufficient to make a business case. Nevertheless, this project may be considered a basis for future research, and the research and the shortcomings/limitations may be helpful for a larger project. The proposed available time (600 hours), the maximum word count (15,000) and the difficulties accessing aerospace OEMs have contributed to the shortcomings of this research. The extent of the project was, thus, misjudged by the author; however, it has contributed to the author’s knowledge and is considered to have been beneficial in terms of personal gain.

5.2 RecommendationsThe previous section has stated that the findings of this project may not be considered conclusive and more research is required. It is recommended that the research should be continued, and this paper may be used as a basis.

Adaptations of CRM methods are required to be able to provide appropriate training and tools for individuals in different job positions, and considerations for non ‘operational’ employees (e.g. design engineers) will have to be taken into account.

It is recommended that trial SRH courses should be conducted in an aerospace OEM to get feedback to measure the acceptance of SRH. For this, preparation would be required, along with research on the aspects of CRM detailed in EASA Part-145, both from the literature and empirically, to allow guidelines to be transferred and adapted.

Furthermore, the company structures should be researched to see if a similar supportive structure (just-culture), as is already used in Part-145, may be introduced. Other necessary training, such as health and safety, which may be combined with SRH, should be explored to understand synergies and help to make a business case.

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10 AppendicesAppendix A: Survey; Interview Topic Guide and Questionnaire
Appendix B: Ethics Review
Appendix C: German Translation of the Survey
Appendix D: French Translation of the Survey
Appendix E: Interview Transcript
Appendix F: Questionnaire Result
Appendix G: CRM Clarification between FCL – ORO;
Training Diagram

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