Transcript PIEDMONT AIRLINES - Aviation Human Factors

SINGLE PILOT CRM
Sun-N-Fun
FAA Safety Center
Lakeland, Florida
April 17, 1999
Downloaded from www.avhf.com
WHY ARE WE HERE?
FLY-IN
FUN
FUTURE
A/C
RAIN?
7/17/2015
Sun-N-Fun 1999
2
IT WON’T HAPPEN TO ME!

“WHEN ANYONE ASKS ME HOW I CAN BEST DESCRIBE MY
EXPERIENCE IN NEARLY FORTY YEARS AT SEA, I MERELY SAY,
UNEVENTFUL. OF COURSE THERE HAVE BEEN WINTER GALES,
AND STORMS AND FOG AND THE LIKE, BUT IN ALL MY
EXPERIENCE I HAVE NEVER BEEN IN AN ACCIDENT OF ANY
SORT WORTH SPEAKING ABOUT. I HAVE SEEN BUT ONE
VESSEL IN DISTRESS IN ALL MY YEARS AT SEA....I NEVER SAW
A SHIPWRECK AND HAVE NEVER BEEN SHIPWRECKED, NOR
WAS I EVER IN ANY PREDICAMENT THAT THREATENED TO END
IN DISASTER OF ANY SORT.”
E.J. SMITH

ON 14 APRIL 1912 RMS TITANIC SANK WITH THE LOSS OF 1500
LIVES - ONE OF WHICH WAS IT’S CAPTAIN....... E.J. SMITH
7/17/2015
Sun-N-Fun 1999
3
WHAT IS CRM?
“THE EFFECTIVE USE OF ALL
AVAILABLE RESOURCES…
 HUMAN
 HARDWARE
 INFORMATION
7/17/2015
Sun-N-Fun 1999
4
WHY CRM?
1. OPTIMIZE HUMAN
PERFORMANCE
2. REDUCE HUMAN
ERROR
7/17/2015
Sun-N-Fun 1999
5
QUICK HISTORY...





1940’S - MILITARY
1970’S - ACCIDENT STUDIES/ASRS
1980’S - GENERAL AVIATION - PILOT
JUDGMENT TRAINING
1980’S - AIRLINES - “COCKPIT
RESOURCE MANAGEMENT”
1990’S - INTEGRATION AND
APPLICATION
7/17/2015
Sun-N-Fun 1999
6
CHANGES IN ACCIDENT CAUSAL
FACTORS OVER TIME
RELATIVE
PROPORTION
OF
ACCIDENT
CAUSES
(HUMAN VS
MECHANICAL)
HUMAN FACTORS CAUSES
MECHANICAL CAUSES
TIME (31 YEARS)
7/17/2015
Sun-N-Fun 1999
7
HUMAN FACTORS
DEFINITION
HUMAN FACTORS
“A MULTIDISCIPLINARY FIELD
DEVOTED TO OPTIMIZING
HUMAN PERFORMANCE AND
REDUCING HUMAN EROR”
(OOOPS!)
7/17/2015
Sun-N-Fun 1999
8
HUMAN ERRORS LEADING
TO ACCIDENTS...
HOW MANY
ERRORS
NEED TO
OCCUR
BEFORE WE
HAVE AN
ACCIDENT?
7/17/2015
Sun-N-Fun 1999
9
TOTAL ACCIDENT RATE FOR AIRCRAFT
1959-1998
AIRCRAFT ACCIDENTS PER MILLION DEPARTURES
70
60
50
40
30
20
10
7/17/2015
Sun-N-Fun 1999
95
92
89
86
YEAR
83
80
77
74
71
68
65
62
0
59
A
N
N
U
A
L
R
A
T
E
S
10
PRIMARY CAUSAL FACTORS OF
AIRCRAFT ACCIDENTS
Cockpit Crew
Airplane
Maintenance
Weather
Airport/ATC
Misc
0
1987-98
7/17/2015
20
40
60
80
1959-98
Sun-N-Fun 1999
11
PROBABLE CAUSE IN 80% OF ALL
ACCIDENTS (NTSB)
UNPROFESSIONAL
ATTITUDES
47%
VISUAL PERCEPTION
MISJUDGMENT
19%
PILOT TECHNIQUE
21%
INFLIGHT JUDGMENT OR
DECISION
5%
IMPROPER OPERATION OF
EQUIPMENT
6%
4%
UNKNOWN CAUSES
7/17/2015
0
5
10 Sun-N-Fun
15
20
1999
25
30
35
40
45
12
50
LET’S TAKE A CLOSER
LOOK...
CRM
INTEGRATION
AND
APPLICATION
7/17/2015
Sun-N-Fun 1999
13
PRACTICAL TEST STANDARDS
REQUIREMENTS
“CRM is not a single TASK.
CRM is a set of skill
competencies which must be
evident in all TASKS in this
PTS as applied to the single
pilot or the multicrew
operation.”
7/17/2015
Sun-N-Fun 1999
14
WHAT MAKES A PILOT?
“A PILOT MUST HAVE A MEMORY; BUT THERE ARE TWO
HIGHER QUALITIES WHICH HE MUST ALSO HAVE. HE
MUST HAVE GOOD AND QUICK JUDGMENT AND
DECISION, AND A COOL, CALM COURAGE THAT NO PERIL
CAN SHAKE. GIVE A MAN THE TRIFLE OF PLUCK TO
START WITH, AND BY THE TIME HE HAS BECOME A PILOT
HE CANNOT BE UNMANNED BY ANY DANGER…BUT ONE
CANNOT QUITE SAY THE SAME FOR JUDGMENT.
JUDGMENT IS A MATTER OF BRAINS, AND A MAN MUST
START WITH A GOOD STOCK OF THAT ARTICLE OR HE
WILL NEVER SUCCEED AS A PILOT.”
MARK TWAIN
7/17/2015
“LIFE ON THE MISSISSIPPI”
Sun-N-Fun 1999
15
CRM MARKERS
 COMMUNICATION
 DECISION
MAKING
 PLANNING
 WORKLOAD MANAGEMENT
 SITUATION AWARENESS
7/17/2015
Sun-N-Fun 1999
16
CRM MARKERS
COMMUNICATION
 WORDS
 TONE
 BODY
LANGUAGE
 TWO EARS, ONE MOUTH
7/17/2015
Sun-N-Fun 1999
17
CRM MARKERS
DECISION MAKING







DECISION TO MAKE
GATHER INFORMATION
IDENTIFY ALTERNATIVES
EVALUATE ALTERNATIVES
CHOOSE ALTERNATIVE
EVALUATE CHOICE
RETURN TO THE BEGINNING
7/17/2015
Sun-N-Fun 1999
18
CRM MARKERS
PLANNING
 MAKE
A PLAN
 FOLLOW THE PLAN
 MODIFY THE PLAN, IF
NECESSARY
7/17/2015
Sun-N-Fun 1999
19
CRM MARKERS
WORKLOAD MANAGEMENT
Critical Flight Window
2,000
2,000
CRM MARKERS
SITUATION AWARENESS
THE ACCURATE PERCEPTION
OR KNOWLEDGE A PILOT
MAINTAINS TO THEIR
OPERATIONAL ENVIRONMENT
IN ORDER TO ANTICIPATE
CONTINGENCIES AND TAKE
THE NECESSARY ACTIONS.
7/17/2015
Sun-N-Fun 1999
21
RECOGNIZING THE LOSS OF
SITUATION AWARENESS
(AKA THE ERROR CHAIN)





FAILURE TO MEET
TARGETS
UNDOCUMENTED
PROCEDURES
VIOLATING
MINIMUMS OR
LIMITATIONS
NO ONE FLYING A/C
NO ONE LOOKING
OUT OF THE WINDOW
(HUMAN TCAS)
7/17/2015
Sun-N-Fun 1999
22
RECOGNIZING THE LOSS OF
SITUATION AWARENESS
(AKA THE ERROR CHAIN)






NO CHECKLISTS
INCOMPLETE
COMMUNICATIONS
AMBIGUITY
UNRESOLVED
DISCREPANCIES
FIXATION OR
PREOCCUPATION
EMPTY FEELING OR
CONFUSION
7/17/2015
Sun-N-Fun 1999
23
BREAK
THE ERROR CHAIN
7
No one looking
IMPROVE YOUR CRM
SKILLS...



7/17/2015
ESTABLISH AND
FOLLOW YOUR
SOP’S
COMMUNICATE
YOUR SOP’S
(BRIEF
PASSENGERS)
BE AWARE!
Sun-N-Fun 1999
25
THE END
 QUESTIONS???
 THANK
YOU
FOR YOUR
TIME!
 REMEMBER…..
MAKE CRM
PART OF YOUR
SOP!
7/17/2015
Sun-N-Fun 1999
26