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Crew Resource Management (CRM) Accidents

12 investigationsFrom the official reportsUpdated Sep 2026

Crew resource management (CRM) is the effective use of every resource available to a crew, including each other, air traffic control, the cabin crew and the aircraft's systems, to operate safely. It grew directly out of accident investigations.

In the 1970s several airliners were lost with serviceable aircraft and experienced crews, and the reports found failures of communication, leadership and decision-making rather than of flying skill: a captain who did not listen, a first officer who hinted at a problem but did not challenge, a crew so absorbed in one fault that nobody was flying the aircraft. A NASA workshop in 1979 gave the discipline its first name, cockpit resource management, and airlines built training on it through the 1980s. CRM training is now compulsory for airline crews under EASA and FAA rules and has grown to include threat and error management. The reports below show what happens when CRM fails, and what a crew working well together can achieve under pressure.

The investigations

The Boeing 767 freighter N1217A.
NTSB · 2019

Atlas Air Flight 3591

· Boeing 767-375BCF (converted freighter)
A 767 freighter's go-around mode engaged by accident in turbulence; the first officer, disoriented, pushed the aeroplane into a steep dive, and 32 seconds after the mode change it struck the bay.
Loss of controlSpatial disorientationAutomationCRMHuman factors
An Asiana Airlines Boeing 777-200ER, registration HL7742.
NTSB · 2013

Asiana Airlines Flight 214

· Boeing 777-200ER
A 777 crew on a visual approach to San Francisco unintentionally left the autothrottle in HOLD at idle, noticed the decaying airspeed only at about 200 ft and struck the seawall after a late go-around.
Approach and landingAutomationCRMFatigueHuman factors
A Qantas Airbus A380 registered VH-OQA climbing away after take-off.
ATSB · 2010

Qantas Flight 32

· Airbus A380-842
How a manufacturing flaw in an oil pipe led to a turbine disc burst on an A380, and how a five-pilot crew worked through the damage and landed at Singapore.
Engine failureFireCRM
An Air France Airbus A330-200, registration F-GZCP, on the ground at Paris Charles de Gaulle airport.
BEA · 2009

Air France Flight 447

· Airbus A330-203
A temporary loss of airspeed indications at FL350 led to inappropriate control inputs, a stall that the crew never identified and the loss of all 228 people on board.
Loss of controlStallAir dataAutomationCRM
A Bombardier Dash 8 Q400 twin turboprop airliner, registration N208WQ, in Continental Connection colours.
NTSB · 2009

Colgan Air Flight 3407

· Bombardier DHC-8-402 (Q400)
A Q400 slowed into its stick shaker on a night approach in icing conditions; the captain's aft column inputs stalled the wing and he pulled against the stick pusher.
Loss of controlStallIcingFatigueCRM
A US Airways Airbus A320, registration N106US.
NTSB · 2009

US Airways Flight 1549

· Airbus A320-214
Both engines of an A320 ingested Canada geese at 2,818 ft above ground; the crew glided to a ditching on the Hudson River and all 155 people on board survived.
Engine failureDitchingCRMSurvival
A Delta Air Lines Boeing 717 landing on runway 22 at Blue Grass Airport, Lexington, Kentucky.
NTSB · 2006

Comair Flight 5191

· Bombardier CL-600-2B19 (CRJ-100)
Cleared for runway 22 at Lexington, a CRJ crew lined up in the dark on runway 26, less than half as long, and crashed beyond its end.
Runway incursionHuman factorsCRM
The Helios Airways Boeing 737-300 5B-DBY.
AAIASB · 2005

Helios Airways Flight 522

· Boeing 737-31S (737-300)
A 737 left Larnaca with its pressurisation in manual; the crew mistook the cabin altitude horn, lost consciousness from hypoxia, and the aircraft flew on autopilot until its fuel ran out.
PressurisationIncapacitationMaintenanceCRMHuman factors
A DHL Boeing 757 freighter at Brussels Airport.
BFU · 2002

Überlingen Mid-Air Collision

· Tupolev Tu-154M and Boeing 757-200 freighter (757-23APF)
Two jets cleared at FL360 collided near Lake Constance at night after a late ATC descent instruction to one crew contradicted its TCAS climb advisory; all 71 people on board died.
Mid-air collisionHuman factorsCRM
The United Airlines McDonnell Douglas DC-10-10 registered N1819U, a three-engined wide-body airliner with one engine in the tail.
NTSB · 1989

United Airlines Flight 232

· McDonnell Douglas DC-10-10
A DC-10's tail engine fan disk burst in cruise and cut all three hydraulic systems; the crew steered it to Sioux City using engine thrust alone.
Engine failureFlight controlsMaintenanceCRMSurvival
The British Midland Boeing 737-400 G-OBME at London Heathrow.
AAIB · 1989

British Midland Flight 92 (Kegworth)

· Boeing 737-400
After a fan blade failure in the left engine, the crew of a Boeing 737-400 shut down the right engine; the damaged engine failed on final approach and the aircraft crashed beside the M1.
Engine failureCRMHuman factorsSurvival
Recovery of the tail section of the Air Florida Boeing 737 from the Potomac River.
NTSB · 1982

Air Florida Flight 90

· Boeing 737-222
A Boeing 737 took off in continuing snow with contaminated wings and far less thrust than its iced EPR gauges showed, could not sustain flight after liftoff and struck a bridge over the Potomac.
IcingStallCRMHuman factors

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Picture credits

  1. Atlas Air Flight 3591: Orlando Suarez · CC BY-SA 4.0 · Wikimedia Commons
  2. Asiana Airlines Flight 214: Tomás Del Coro from Las Vegas, Nevada, USA · CC BY-SA 2.0 · Wikimedia Commons
  3. Qantas Flight 32: Adrian Pingstone ( talk ) · Public domain · Wikimedia Commons
  4. Air France Flight 447: Pawel Kierzkowski · CC BY-SA 3.0 · Wikimedia Commons
  5. Colgan Air Flight 3407: DearEdward from New York, NY, USA · CC BY 2.0 · Wikimedia Commons
  6. US Airways Flight 1549: Edmund Seeger · CC BY-SA 2.0 · Wikimedia Commons
  7. Comair Flight 5191: Checkerberry · CC0 · Wikimedia Commons
  8. Helios Airways Flight 522: Mila Daniel · CC BY-SA 4.0 · Wikimedia Commons
  9. Überlingen Mid-Air Collision: Koen Gladines · CC BY-SA 4.0 · Wikimedia Commons
  10. United Airlines Flight 232: Paul Seymour · CC BY-SA 4.0 · Wikimedia Commons
  11. British Midland Flight 92 (Kegworth): Leslie Snelleman · CC BY-SA 4.0 · Wikimedia Commons
  12. Air Florida Flight 90: FAA · Public domain · Wikimedia Commons

Crash Investigations pages summarise official investigation reports for study and exam preparation. The investigating body's report is the authoritative account and prevails wherever it differs from this page. Under ICAO Annex 13, an investigation exists to prevent accidents, not to apportion blame or liability.