The National Aeronautics and Space Administration (NASA) has been intimately involved with the process of crew resource management (CRM) and one of the early innovators of the systematic procedures to eliminate human error in the cockpit. The first effort was the development of the aviation checklist. This was due to the crash of the Boeing Model 229 aircraft on October 30, 1935. The Boeing Model 229 was an extremely complex aircraft for the time. It had many revolutionary design elements incorporated. The pilot, who had never flown the Model 229, had neglected to release the elevator lock prior to takeoff. The Boeing chief test pilot aboard the aircraft, Leslie Tower, realized the error once airborne. He attempted to release the lock, but was too late to save the doomed aircraft. The design was in serious jeopardy after the crash. The press had labeled the aircraft as too complex to fly. Army Air Corps officers pleaded to proceed with the project, and eventually, 12 aircraft were delivered to the second Bombardment Wing at Langley Airfield in Virginia. It was emphasized to the pilots that any further accidents would result in the cancelation of further orders. The pilots came together and developed four checklists. These were the takeoff, flight, pre-landing, and after landing checklists. They eventually proved that the Model 229 was not “too much aircraft for a man to fly”; it had systems more complex than any one man’s memory. These checklists were the assurance that no item was forgotten. These 12 aircraft went on to safely fly 1.8 million miles without a serious accident. The Model 229 went on to be developed as the B-17. It was one of the workhorse bombers of World War II and helped to destroy Nazi Germany’s war industries. The checklist was then integrated into subsequent Air Corps aircraft and then the civilian airline industry.

Human error as a cause for an accident was placed in the public eye again on the night of December 29, 1972. An Eastern Airlines Lockheed L-1011 Flight 401, would be a sentinel event in safety. Flight 401 was en route from JFK Airport, New York, to Miami International Airport. The Lockheed L-1011 had rolled out of the factory only 4 months previously. This particular flight carried 163 passengers and 13 crewmembers. The journey was routine up until 11:32 p.m. The aircraft was on approach to Miami International and the landing gear was lowered. The landing gear indicator was not illuminated, indicating the gear was not down and locked. The landing gear was cycled again and the illuminator still did not light. The light on the indicator was burned out and the cockpit crew began replacing the bulb. The crew discontinued the approach and began a circling pattern to work on this problem. The second officer was sent into the lower avionics bay to view through a small window and confirm the gear was down. The aircraft autopilot was activated to maintain 2,000 ft. During this time, the pilot accidently leaned against the yoke (control column) and changed the modes on the autopilot from altitude hold to CWS (Control Wheel Steering—in which the pilot controlled the pitch of that aircraft). This forward pressure also started the aircraft to descend. After descending 250 ft, a C-cord alarm was sounded in the cockpit. This alarm was designed to alert the crew that they had descended from their assigned altitude. The frustrated, fatigued crew who were concentrating only on the burned out light did not notice the alarm. The engineer was not on the flight deck as well and could not have heard the alarm from the avionics bay. The plane was over the Everglades at night, and therefore, there was no ground references to indicate the plane had descended. In 50 seconds, the aircraft was now down to 1,000 ft. The co-pilot then initiated a 180° turn to maintain a holding pattern and noticed the discrepancy in altitude. This triggered the following conversation.

Ten seconds later, the aircraft impacted the Everglades. This resulted in the deaths of 101 persons and was the first accident of a wide-bodied airliner. At that time, it was the second deadliest single aircraft disaster in the United States [1–4].

Another accident around this same time period highlighted human error in the cockpit. United Airlines Flight 173 (UAL 173) was making its final approach to Portland International Airport after a routine flight on December 28, 1978 [5]. The aircraft ran out of fuel and crashed into a residential area, killing eight passengers and two crew members and seriously injuring 23 others. While circling, the first officer and flight engineer told the pilot that the plane was running low on fuel. The pilot ignored the warnings of his junior officers. These and other accidents aroused the interest publically in accidents due to human error.

In all of the cases, the aircrafts were mechanically sound; the crews were experienced and technically competent. The system at the time simply did not catch mistakes in time to prevent these fatal errors. In 1978, the Military Inspector General determined that poor crew interactions were a major factor in aircraft accidents. NASA then led the way to change the aviation community to prevent these accidents from occurring. In 1979, NASA conducted the Resource Management on the Flightdeck workshop at the Ames Research Center [6, 7]. NASA had for many years been conducting research into human factors and performance in aviation since the early 1970s at the Ames Research Center. In 1973, interviews with aircrews were conducted, and this highlighted the lack of training for airline Captains in leadership. H.P. Ruffel-Smith (1979) conducted a 747 simulator-based study on human behavior [8]. He found that in both routine and emergency simulations, the better the cockpit resources were utilized and using effective crew communications, the better the performance in the cockpit. Several other studies suggested that incorporating “crew resource management” into routine flight operations training would greatly aid in preventing these accidents. During the workshop, it was soon discovered that 60–80 % of aviation accidents were the result of human error. Clearly, the aviation industry had to change. After another NASA/Federal Aviation Administration (FAA) workshop conducted in January 1981, the FAA began incorporating a CRM platform into its regulatory program. United Airlines was the first to add CRM into its training syllabus in 1981.

Crew resource management does not focus on technical aptitude or skills. CRM focuses on cognitive and interpersonal communication needed to organize a complex aviation environment. Cognitive skills focus on situational awareness, planning, and decision-making. Situational awareness provides an organized way to recognize salient factors and conditions that affect the safe operation of the aircraft. Planning takes the decision construction process across all phases of the flight. This also incorporates subordinate input into the decision formation process, but still maintains a hierarchical structure with the Captain retaining authority and responsibility of the flight. Interpersonal skills concentrate on communications and team building. Essential to CRM is communication. Research has proven that good communication not only transfers accurate information but helps to build a unified understanding of the problems at hand. It helps everyone to build a mental model of the environment and enhances situational awareness. Team building incorporates the entire crew’s skills and experience resulting in the combined efforts far exceeding the capability of one individual. Emotional climate and stress management skills are also taught in CRM training. Research showed that the creation of a positive tone on the flight deck enhanced the cognitive and interpersonal proficiencies of the crew. Stress management in the cockpit can be managed by an organizational culture that efficiently assigns tasks and establishes priorities. This also incorporates the empowerment of subordinates by training them in the skills which will enable them to take on additional responsibility when the circumstances demand it.