Transcript LM21 Operating Excellence Leadership Training Introduction

AERONAUTICAL DECISION MAKING
+
SINGLE PILOT RESOURCE MANAGEMENT
=
OPERATIONAL RISK MANAGEMENT
CGAP Decision Making/Risk Management Definitions
• Aeronautical Decision Making (ADM): systematic approach to consistently determine the
best course of action to a given set of circumstances
• Automation Management (AM): demonstrated ability to control and navigate an aircraft by means of the
automated systems installed in the aircraft
• Operational Risk Management (ORM): decision-making tool to systematically help identify operational
risks and benefits and determine the best courses of action for any given situation.
• Single Pilot Resource Management (SRM): art and science of managing all the resources (onboard
aircraft and outside sources) available to a single pilot (prior to and during flight) to ensure
the successful outcome of the flight is never in doubt.
• Situational Awareness (SA): the accurate perception and understanding of all factors and conditions
within the four fundamental risk elements (pilot, aircraft, environmental, external pressures)
that affect safety before, during and after the flight.
• Task Management (TM): process by which pilots manage the many concurrent tasks that must be
performed to safely and efficiently fly a modern aircraft.
CGAP Decision Making/Risk Management Acronyms
• AOE: Areas of Evaluation
• CFIT: Controlled Flight Into Terrain
• D-E-C-I-D-E: Detect-Estimate-Choose-Identify-Do-Evaluate
• I-A-D-E: Identify-Analyze-Decide-Execute
• I-A-A-D-E: Identify-Analyze-Assess-Decide-Execute
• IFR: Instrument Flight Rules
• IMC: Instrument Meteorological Conditions
• I-M-S-A-F-E: Illness-Medication-Stress-Alcohol & drugs-Fatigue-Eating
• MEA: Minimum Enroute Altitude
• P-A-V-E: Pilot In Command-Aircraft-enVironment-External Pressures
• T-E-A-M: Transfer-Eliminate-Accept-Mitigate
CGAP Decision Making/Risk Management "Tools"
• The following Risk Management/Decision Making "Tools" are FAA AOE's for future pilot
certification tests:
-
SRM
ADM
ORM
TM
CFIT Awareness
• CGAP has incorporated some of these "tools"
in its Decision Making/Risk Management Model
- ADM/SRM/ORM
Using versions of or the actual "tools" below:
D-E-C-I-D-E; PPP's, 5P's, PAVE, I-M-S-A-F-E, T-E-A-M
How does it all fit together?
CGAP Decision Making/Risk Management TREE
SINGLE PILOT RESOURCE MANAGEMENT
(SRM)
AERONAUTICAL DECISION MAKING (ADM)
5P’s
I-A-D-E
OPERATIONAL RISK MANAGEMENT
I = IDENTIFY
A=ANALYZE
D=DECIDE
E=EXECUTE
(D-E-C-I-D-E)
I-A-A-D-E
PLAN
PLANE
PILOT
PASSENGERS
PROGRAMMING
CGAP Aeronautical Decision Making: "I-A-D-E Loop"
AERONAUTICAL DECISION MAKING (ADM)
I = IDENTIFY
A = ANALYZE
D = DECIDE
E = EXECUTE
I-A-D-E
IDENTIFY
FINISH
HAZARDS,
PROBLEMS,
PITFALLS,
YES
SUCCESSFUL?
ANALYZE
NO
RISK
POTENTIAL
SEVERITY OF
OUTCOME
DETERMINE
COURSE OF ACTION
EXECUTE
ACTION PLAN
TRANSFER
ELIMINATE
ACCEPT
MITIGATE
CGAP Decision Making/Risk Management TREE
SINGLE PILOT RESOURCE MANAGEMENT
(SRM)
AERONAUTICAL DECISION MAKING (ADM)
5P’s
I-A-D-E
OPERATIONAL RISK MANAGEMENT
I = IDENTIFY
A=ANALYZE
D=DECIDE
E=EXECUTE
(D-E-C-I-D-E)
I-A-A-D-E
PLAN
PLANE
PILOT
PASSENGERS
PROGRAMMING
CGAP Decision Making/Risk Management: SRM & "5P's"
SINGLE PILOT RESOURCE MANAGEMENT
(SRM)
5P’s
PLAN: Mission or Task
PLANE: Systems, complexity, design
PILOT: I-M-S-A-F-E
PASSENGERS: Status, behavior
PROGRAMMING: Navigation; Automation
SRM and the "5P's"
"5P's"- a scheduled review at key points in the flight where decisions are most
likely to be effective:
- pre-flight
- before takeoff
- midpoint cruise
- before descent
- before initial approach segment or pattern entry
- anytime an emergency or abnormal situation occurs
• PLAN- mission or task: weather, route, fuel, publications, ATC, nature of flight
• PLANE- status/condition: mechanical, database currency, automation, backup systems
• PILOT: I-M-S-A-F-E
Illness: symptoms, do I feel well?
Medication: am I taking medication which is not approved for flying?
Stress: am I under emotional stress or psychological pressure? Are there personal distractions?
Alcohol & drugs: have I consumed alcohol within the last 8, 12, 0r 24 hours; do I use controlled
substances?
Fatigue: have I had sufficient rest; am I sleepy?
Eating: am I adequately nourished; do I have too low a blood sugar level or too high a caffein
level?
SRM and the "5P's"
"5P's"- continued
• PASSENGERS- pilot, non-pilot, experienced vs nervous flyer, quiet vs disruptive
• PROGRAMMING- avionic, navigation management systems, flight control systems, EFIS,
powerplant management systems
CGAP Decision Making/Risk Management TREE
SINGLE PILOT RESOURCE MANAGEMENT
(SRM)
AERONAUTICAL DECISION MAKING (ADM)
5P’s
I-A-D-E
OPERATIONAL RISK MANAGEMENT
I = IDENTIFY
A=ANALYZE
D=DECIDE
E=EXECUTE
(D-E-C-I-D-E)
I-A-A-D-E
PLAN
PLANE
PILOT
PASSENGERS
PROGRAMMING
Operational Risk Management Elements
OPERATIONAL RISK MANAGEMENT
I-A-A-D-E
A = ASSESS RISK
I = IDENTIFY HAZARD
E = EXECUTE ACTION PLAN
A = ANALYZE HAZARD
D = DEVELOP ACTION PLAN
RISK VS BENEFITS
P = PILOT IN COMMAND
A = AIRCRAFT
V = ENVIRONMENT
E = EXTERNAL PRESSURES
T = TRANSFER
E = ELIMINATE
A = ACCEPT
M = MITIGATE
TASK
MANAGEMENT
HAZARD Definition
• Condition, or circumstance which can lead or contribute to
an unplanned or undesired event such as a mishap.
• Examples: thunderstorms; wet or icy runways; obstacles in
approach or departure path; FOD
Operational Risk Management Elements
OPERATIONAL RISK MANAGEMENT
I-A-A-D-E
A = ASSESS RISK
I = IDENTIFY HAZARD
E = EXECUTE ACTION PLAN
A = ANALYZE HAZARD
D = DEVELOP ACTION PLAN
RISK VS BENEFITS
P = PILOT IN COMMAND
A = AIRCRAFT
V = ENVIRONMENT
E = EXTERNAL PRESSURES
T = TRANSFER
E = ELIMINATE
A = ACCEPT
M = MITIGATE
TASK
MANAGEMENT
Analyze Hazard: P-A-V-E
• PILOT: certificate level, competency in aircraft, currency, experience
• AIRCRAFT: performance, equipment, airworthiness, condition
• ENVIRONMENT: weather, airport condition
• EXTERNAL PRESSURE: purpose of flight, job, family, commitments
Operational Risk Management Elements
OPERATIONAL RISK MANAGEMENT
I-A-A-D-E
A = ASSESS RISK
I = IDENTIFY HAZARD
E = EXECUTE ACTION PLAN
A = ANALYZE HAZARD
D = DEVELOP ACTION PLAN
RISK VS BENEFITS
P = PILOT IN COMMAND
A = AIRCRAFT
V = ENVIRONMENT
E = EXTERNAL PRESSURES
T = TRANSFER
E = ELIMINATE
A = ACCEPT
M = MITIGATE
TASK
MANAGEMENT
Risk Vs Benefits Analysis
• LEVEL OF RISK: in terms of hazard severity and probability of occurrence
- Severity: catastrophic, critical, marginal, negligible
- Probability: frequent, probable, possible, remote, improbable
• ACCEPTANCE OF RISK: accept no unnecessary risk
• WEIGHT/AMOUNT OF BENFITS VS RISK: accept risk only when benefits outweigh risks
Example:
Flight Instructor turns off fuel selector/fuel shutoff in flight
in a single engine airplane to simulate loss of engine
power
Risk Vs Benefits Analysis
• WHAT IS THE HAZARD?
• WHAT IS LEVEL OF RISK IN TERMS OF SEVERITY AND PROBABILITY OF HAZARD?
- Severity: catastrophic, critical, marginal, negligible
- Probability: frequent, probable, possible, remote, improbable
• IS THERE UNNECESSARY RISK?
• WHAT IS BENEFIT?
• DOES THE BENEFIT OUTWEIGH THE RISK?
Operational Risk Management Elements
OPERATIONAL RISK MANAGEMENT
I-A-A-D-E
A = ASSESS RISK
I = IDENTIFY HAZARD
E = EXECUTE ACTION PLAN
A = ANALYZE HAZARD
D = DEVELOP ACTION PLAN
RISK VS BENEFITS
P = PILOT IN COMMAND
A = AIRCRAFT
V = ENVIRONMENT
E = EXTERNAL PRESSURES
T = TRANSFER
E = ELIMINATE
A = ACCEPT
M = MITIGATE
TASK
MANAGEMENT
Develop Action Plan: T-E-A-M
• Transfer: can the risk be transferred or shared?
• Eliminate:
• Accept:
can the risk be eliminated?
can the risk be accepted? (See Risk Vs. Benefits Analysis)
• Mitigate:
can the risk be mitigated? (Reduced to an acceptable level)
Example:
Planned IFR flight- lowest MEA's along route will be in
IMC with forecast temperatures aloft at or below freezing
Develop Action Plan: T-E-A-M
• WHAT IS THE RISK?
• CAN THE RISK BE TRANSFERRED OR SHARED?
• CAN THE RISK BE ELIMINATED?
• CAN THE RISK BE ACCEPTED?
• CAN THE RISK BE MITIGATED?
Operational Risk Management Elements
OPERATIONAL RISK MANAGEMENT
I-A-A-D-E
A = ASSESS RISK
I = IDENTIFY HAZARD
E = EXECUTE ACTION PLAN
A = ANALYZE HAZARD
D = DEVELOP ACTION PLAN
RISK VS BENEFITS
P = PILOT IN COMMAND
A = AIRCRAFT
V = ENVIRONMENT
E = EXTERNAL PRESSURES
T = TRANSFER
E = ELIMINATE
A = ACCEPT
M = MITIGATE
TASK
MANAGEMENT
EXECUTE- Task Management (TM)
Task Management is an integral part of the EXECUTE phase of ORM.
Task: function performed by human as opposed to machine or system
Task Management (TM): process by which pilots manage concurrent tasks
required to safely and efficiently operate a modern aircraft.
TM entails:
- initiation of new tasks
- monitoring on-going tasks
- prioritization of tasks
- allocation of resources based on priority
- resumption of interrupted tasks
- completion or elimination of tasks
Critical Phases of Flight for TM:
- pre flight preparation & planning
- before take off/departure preparation
- take off & initial departure
- descent/approach preparation
- initial approach/pattern entry phase
- go around/missed approach
EXECUTE- Task Management (TM)
Task Management affected by:
- weather
- stress
- Air Traffic Control
- aircraft condition
- information/data overload
Task Saturation: inability to perform task management due to one or more of
factors above
PRIORITZATION OF TASKS IS KEY TO AVOIDING TASK SATURATION!
AVIATE
NAVIGATE
COMMUNICATE
POST FLIGHT: "Lessons Learned"
•
Successful Operational Risk Management does not end when the flight is
over!
• After each flight the pilot should conduct a "lessons learned" review of
the following:
-
What did I do well/right?
What did I do poorly/wrong?
Did I identify any hazards?
Were the hazards analyzed and the risks assessed?
Did I develop an action plan based on the risk assessment?
Did I execute my action plan? Was that plan successful?
Were there any occurrences which should be reported via an Air Safety
or Hazard Report?
REMEMBER FOUR BASIC PRINCIPLES OF ORM
 ACCEPT NO UNNECESSARY RISK
 MAKE RISK DECISIONS AT APPROPRIATE LEVEL
 ACCEPT RISK ONLY WHEN BENEFITS OUTWEIGH
POTENTIAL OUTCOME
 INTEGRATE ORM INTO ALL PHASES OF FLIGHT
REFERENCES
-
Aviation Instructor Handbook (FAA-H-8083-9A)
FAA System Safety Handbook
CGAP Safety Management System Manual
CGAP EA-500 Training Manual
Industry Standard Practices for Risk Management
Industry Standard Practices for Operating Excellence (Six Sigma)