Transcript CREW RESOURCE MANAGEMENT

AERONAUTICAL
DECISION MAKING
The Theory Behind
The Practice
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Definition of Aeronautical
Decision Making (ADM)
“ADM
is a systematic approach to
the mental process used by all
involved in aviation to
consistently determine the best
course of action in response to a
given set of circumstances.”
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PRIMARY CAUSAL FACTORS OF
AIRCRAFT ACCIDENTS
Cockpit Crew
Airplane
Maintenance
Weather
Airport/ATC
Misc
0
1987-98
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40
60
80
1959-98
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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%
UNKNOWN CAUSES
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4%
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10
20
30
40
4
50
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. CRM competencies,
grouped into three clusters of observable
behaviors are....”
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ADM SKILL MARKERS
(“Observable Behaviors”)
COMMUNICATION
 SITUATION
AWARENESS
 WORKLOAD
MANAGEMENT
 PLANNING
 DECISION
MAKING

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CRM DEFINITION
“THE EFFECTIVE
USE OF ALL
AVAILABLE
RESOURCES”
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CREW...
Pilot-in-Command
 Second-in-Command
Flight Instructor
 Aircraft Scheduler
 Weather Briefer
 Ramp Personnel
 Chief Instructor

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Flight Attendant
 Check Airman/ Pilot
Examiner
 Flight Engineer
 Non-pilot
 Air Traffic Control
 Flight Service/Watch

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RESOURCES...
 Time
 Information
 Workload
 Prioritization
 Strategies/Plans
 Scheduling
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MANAGEMENT...
 Situation Assessment
 Risk Assessment
 Planning/Strategizing
 Prioritizing
Tasks
 Allocating Responsibilities
 Problem Solving
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ENHANCED CREWMEMBER
PERFORMANCE
ENHANCED CREWMEMBER PERFORMANCE
CREWMEMBER NON-TECHNICAL SKILLS
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CREWMEMBER TECHNICAL SKILLS
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ENHANCED CREWMEMBER
PERFORMANCE
ENHANCED CREWMEMBER PERFORMANCE
CREWMEMBER NON-TECHNICAL SKILLS
COMMUNICATIONS
PROCESSES AND
DECISION MAKING
CLUSTER
Briefings
Inquiry/Advocacy/Assertion
Crew Self-Critique
Communications/Decisions
Conflict Resolution
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TEAM BUILDING
AND MAINTENANCE
CLUSTER
WORKLOAD MANAGEMENT
AND SITUATIONAL
AWARENESS
CLUSTER
Leadership/Followership/
Concern for Tasks
Interpersonal Relationships/
Group Climate
Automation Management
Preparation/Planning/
Vigilance
Workload Distributed/
Distractions Avoided
CREWMEMBER TECHNICAL SKILLS
MOTOR
ACTIVITIES
SKILLS
Visual Acquisition/
Interpretation of
Hazards
System Control
Aircraft Control
PROCEDURAL
ACTIVITIES
SKILLS
Emergency/
Abnormal
Flight Maneuvers
ATC Communications
System Operation
Aeronautical Decision Making - The Theory Behind the Practice
INFORMATION BASE/
KNOWLEDGE
Company Policies/
Laws/Rules/
Regulations
ATC/Airspace
Weather
Aircraft Limitations/
Performance
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ENHANCED CREWMEMBER
PERFORMANCE
ENHANCED CREWMEMBER PERFORMANCE
CREWMEMBER TECHNICAL SKILLS
MOTOR
ACTIVITIES
SKILLS
Visual Acquisition/
Interpretation of
Hazards
System Control
Aircraft Control
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PROCEDURAL
ACTIVITIES
SKILLS
Emergency/
Abnormal
Flight Maneuvers
ATC Communications
System Operation
INFORMATION BASE/
KNOWLEDGE
Company Policies/
Laws/Rules/
Regulations
ATC/Airspace
Weather
Aircraft Limitations/
Performance
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ADM Focus
Non-Technical Skills
CREWMEMBER NON-TECHNICAL SKILLS
*COMMUNICATIONS
PROCESSES AND
*DECISION MAKING
CLUSTER
Briefings
Inquiry/Advocacy/Assertion
Crew Self-Critique
Communications/Decisions
Conflict Resolution
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TEAM BUILDING
AND MAINTENANCE
CLUSTER
*WORKLOAD MANAGEMENT
AND *SITUATIONAL
AWARENESS
CLUSTER
Leadership/Followership/
Concern for Tasks
Interpersonal Relationships/
Group Climate
Automation Management
Preparation/ *Planning/
Vigilance
Workload Distributed/
Distractions Avoided
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ADM SKILL MARKERS
(“Observable Behaviors”)
COMMUNICATION
 SITUATION
AWARENESS
 WORKLOAD
MANAGEMENT
 PLANNING
 DECISION
MAKING

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COMMUNICATIONS
Two-way street
 Information transfer
 Clear, concise,
unambiguous
 Listening
 Repeating
 Clarification
 Understanding

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SITUATIONAL AWARENESS
 THE ACCURATE
PERCEPTION OR
KNOWLEDGE A PILOT MAINTAINS
TO THEIR OPERATIONAL
ENVIRONMENT IN ORDER TO
ANTICIPATE CONTINGENCIES AND
TAKE THE NECESSARY ACTIONS.
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WORKLOAD
MANAGEMENT
PRIORITIZE AND
DELEGATE
 SHARE AND
COMMUNICATE
 ACKNOWLEDGE
PERSONAL LIMITS
 ACTIVELY
MONITOR

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PREPARATION, PLANNING, AND
VIGILANCE
 PREPARING
FOR REQUIRED
ACTIVITIES
 PLANNING FOR ALL POSSIBILITIES
 MAINTAINING AWARENESS FOR
CHANGE
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Decision Making Process
1.
2.
3.
4.
5.
6.
7.
Is there a decision to make?
Gather all available information.
Identify all possible alternatives.
Evaluate alternatives.
Choose an alternative (make a decision).
Act on decision.
Evaluate the results of the decision.
(if necessary, return to the beginning)
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THE EFFECTS OF STRESS
AND FATIGUE
Human
Performance
Error Management
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ADM MODELS AND
PROGRAMS TODAY
 PTS/CRM
 Pilot
Judgment Training Manuals
 Personal Minimums
 FAA’s Model
 DECIDE Model
 Hazardous Attitudes
 Decision Making Process
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The Effects of
Stress & Fatigue
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Stress & Fatigue
Not unique to the airline industry, or the
transportation industry!
Our entire society is now driven by a 24/7
economy and lifestyle
It’s our individual responsibility to implement
alertness management strategies
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Stress & Fatigue
What are causes of “chronic stress”?
What is your chronic stress
level?
How did the pilots surveyed deal with
chronic stress?
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Stress & Fatigue
Stress-Coping Strategies:
About half stated they were physically active to some degree
Remainder were less physically active, but involved in
relaxation-type activities
All strategies provide a welcome diversion from stress.
What is your strategy?
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Human Performance
Stress & Fatigue
12 am
12 noon
3 - 5 am
+
_
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12 am
3 - 5 pm
Performance level
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Stress & Fatigue
AA 1420
Little Rock, AR
June 1, 1999
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Stress & Fatigue
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Human Performance
And Error Management
“You start with a bag full of luck and
an empty bag of experience. The
trick is to fill the bag of experience
before you empty the bag of luck.”
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Human Errors Leading To
Accidents...
How many
errors need
to occur
before we
have an
accident?
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The “Roach Theory” of Errors
Errors are like
roaches...
For every one you see...
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Errors are like roaches
There
are different varieties…
Communications
Procedural
Proficiency
Intentional Non-compliance
Operational Decision
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Errors are like roaches
 There
are different species and sizes
 Slips
- meant to do the right thing but
took incorrect action
 Lapses - omitted an item
 Mistakes - intention was incorrect
 Violations - (procedural noncompliance) i.e. intentionally deviated
from SOP or
accepted procedure
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Error Enhancers
Hurry
Fatigue/excessive
stress
Lack of oxygen/water/food
Distractions/interruptions
“First learned, best learned”
Insufficient situation awareness
Workload -too low or high
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More Error Enhancers
Language barriers
Cultural differences
Inconsistencies in training
Insufficient knowledge and skills
Non-standardized interfaces
Night/weather
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Human Responses to Errors
 Trap
- error is detected and managed
before it becomes consequential
 Exacerbate - error is detected but the
crew’s action or inaction becomes
consequential
 Fail to Respond - lack of a response to an
error (undetected or ignored) that can
either end up being inconsequential or
consequential
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What Do We Do About Errors?
Prevent
as many as possible
Practice detection and recovery
Understand and be vigilant for
potential “error enhancers”
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“Roach Prevention and
Exterminators”
Planning
 Leadership
 Communications
 Decision Making
 Situation Awareness
 Workload
Management

Oh Noooo...
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Error Management
and Roach Control
It
is not possible to prevent all
errors
Error detection, prevention, and
recovery - error tolerance is the
goal.
The goal is met by improving
human performance in all facets
of aviation.
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What about these?
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THE END
 REMEMBER......
MAKE ADM
PART OF YOUR
LESSON PLANS!
 QUESTIONS????
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