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'Knock It Off' before someone gets hurt

CANNON AIR FORCE BASE, N.M. -- If you ask any flight crew member or aircraft maintainer what "Knock It Off" (KIO) means, they will probably tell you that whatever is going on ceases until the concerns of whoever called it are satisfied. The procedures are taught in Crew Resource Management (CRM) and now in Maintenance Resource Management (MRM), but it wasn't always so.

According to the Federal Aviation Administration's on line Human Factors course the first CRM training programs were adaptations of management training courses developed for corporations. Early courses included psychological testing in addition to seminars on individual communication styles, leadership, and behavior modification. Within this context, the need for airline captains to be less authoritarian and for junior crew members to be more assertive was emphasized.

This emphasis was the result of the National Transportation Safety Board (NTSB) analysis of a 1978 aircraft accident in Portland, Ore. This crash occurred because the captain was preoccupied with a landing gear malfunction and preparation for an emergency landing, and failed to monitor fuel level. The aircraft ran out of fuel and crashed on initial approach six-tenths of a mile from the airport after circling for 23 minutes trying to resolve the landing gear problem.

The first officer and the flight engineer had both warned the captain of the aircraft's fuel state but did not stress the urgency of the situation. The crash resulted in 10 fatalities and 23 serious injuries; in addition, two homes (fortunately unoccupied) were destroyed.

CRM was adopted by the airlines in the early 1980's as "Cockpit Resource Management", but was changed in the 1990's to the current definition of CRM when they realized that flight attendants and others on the flight team had valuable inputs toward safety as well.

The Air Force started implementing CRM in the early 1990's, but due to our rank structure, it took about 10 years to become fully accepted as a culture where a junior member of the crew could tell a senior member they didn't feel safe about a situation.

In September of 2000, based upon the success of CRM in saving aircraft and lives, the FAA issued Advisory Circular number 120-72 which set the objective as: "This Advisory Circular presents guidelines for developing, implementing, reinforcing, and assessing MRM training programs for improving communication, effectiveness, and safety in maintenance operations. These programs are designed to become an integral part of training and maintenance operations."

The Air Force was behind industry, and it took a fatality to implement MRM. In July 2004, we needlessly lost an individual at Charleston Air Force Base, S.C., because a member of the team, much like the crew in the 1978 Portland crash, was not assertive enough to stop a process. While troubleshooting a spoiler malfunction on an aircraft, a junior team member stated many times that they didn't want anyone crawling under the spoiler with hydraulic power applied. Unfortunately, their concerns were ignored. The spoiler eventually closed on a fellow teammate, fatally crushing him.

Whenever a major accident occurs, two separate investigative bodies are usually convened. A Safety Investigation Board meets to find the root cause and learn how we can prevent future incidents of the same type, while an Accident Investigation Board determines legal liability for the incident. Both boards -- working completely independent of each other -- came up with the recommendation that the Air Force should institute MRM.

With these recommendations in hand, several bases independently, and with no standard format implemented a MRM program. In 2007, a team of major commands met at Dover AFB, Del., to carve out an Air Force baseline MRM course. As a template, they used a course designed for the National Guard by Lt. Col. Doug Slocum. This year it was approved at the Pentagon and will be written into AFI 21-101.

Since the concept has proven so beneficial to the flying and maintenance communities, the 27th Special Operations Wing Commander, Col. Timothy Leahy, has directed anyone on base to call "KNOCK IT OFF" when an unsafe situation might be developing. Work should cease until the safety concerns are addressed. If it can't be resolved, base personnel are encouraged to continue bringing the concerns up the chain of command until the best course of action is chosen.

KIO is not a "get out of work free" card. Its purpose is to prevent injury and property damage. Calling Knock It Off won't just protect you it will protect us all!

Do you have a KIO story? If so, send your story to 27sowvpp@cannon.af.mil. If it's unique and may help others, I will get your message out. It could help save even more lives than you thought!