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CRM Refresher 2002

Rules of Engagement

Participation is Key Non-Attribution No Names – What Not Who

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CRM – What is the Goal?

To achieve Optimal Performance from a team executing multiple, complex tasks.

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CRM – What is the Goal?

Does Optimal Performance Equate to Perfection?

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CRM…..

To Error is Human

You Can Not Engage In Human Activity Without Introducing Human Error

So, Can We Reach The Goal of CRM Without Eliminating Error?

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We Incorporate

Error Management

into Every Aspect of CRM

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Absolutely We Manage Our Errors

GOAL: OPTIMAL PERFORMANCE

Error Management is the “What”

Intervention/Prevention

CRM is the “How”

Trap, Mitigate, Avoid

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Error Management

Overview:

– –

What it is… and, isn’t What Error Management Seeks to Achieve

– –

Where Error Lives Where it Fits in Our Skills as Pilots/Aircrew

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Error Management

Systematic Approach to Determining Common Errors & Contributing Factors Drives Cultural Change to Accept:

Error is Universal. Error is Inevitable.

Shifts Focus from Who to What Teach aircrews to TRAP, MITIGATE & AVOID Error.

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Error Management

Error does not, has not, and will not cause an incident, an accident, or a fatality

So, what does?

Consequence

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Error Management

Consequence

Consequences are not universal or inevitable.

Errors happen all of the time. Incidents, accidents, and fatalities do not.

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EM targets the GAP between

Error and Consequence!

Where Error Lives 

LATENT – present but not visible…hidden in the things we do routinely



ACTIVE – present, in use…individual error

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The Swiss Cheese Model (REASONS)

Latent Errors in System Organizational Filters: Training/Stan/CRM/ORM Latent Errors at Mgt Level

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1 2 Individual Error (Active Error) 3 4 5 Trajectory of Accident/Error Unchecked Result/error

Error Management… The Crux

Mitigating the Consequence of Error

Employ Error Trapping in Every Aspect of: Training Standardization CRM & ORM

Error Trapping = Prevention & Intervention

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6555 Aug ‘94 Practice Auto

Latent & Active Errors What was EM Outcome

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EM & CRM

Error Management must be imbedded in all four principles of CRM (SCAR)

CRM Principle - S.A.

Situational Awareness…

…is the realistic understanding of all factors which affect the safety and effectiveness of your crew and aircraft.

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CRM Principle - S.A.



Elements of Situational Awareness?

Spatial Orientation/attitude Orientation to traffic, geography & time Aircraft status & capabilities Aircrew status & Crew-life cycle Mission concept & Mission-life cycle

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CRM Principle - S.A.

Loss of Situational Awareness

Still the Leading Cause of Aircraft Mishaps (NASA/FAA: causal factor in 65-80% accidents) Rarely is it Instantaneous!

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CRM Principle - S.A.

Why do we lose Situational Awareness?

Mode confusion/Automation Complacency Stress/Fatigue Stimulus Fixation Decision Making/Task Management Inadequate Error Management/Trapping “Roadblocks”

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CG 6541 - Humboldt Bay, 12 Jul ‘94 Downloaded from www.avhf.com

CRM Principle - S.A.

What are the “Loss of S.A.” flags?

Not Communicating No one flying the aircraft Deviating from Standards Violating Minimums Confusion Ambiguity Failure to meet targets Not addressing discrep’s Preoccupation

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CRM Principle - S.A.

What do you do when you suspect you have

lost S.A.?



React

 

Regain Reconstruct

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ROADBLOCKS 

The common obstructions to good CRM!



A combination of negative human factors, ingrained habits, and our own personal attitudes and those of the crew-members we are working with.

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ROADBLOCKS 

NORMS: unwritten rules that become pressures that act upon a group, be alert for “Killer Norms.”



ODD MAN OUT: Ignore input from a particular member of the crew. Results in a loss of total crew effectiveness.



HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.

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ROADBLOCKS (cont): 

CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation.



BREAK THE CHAIN

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ROADBLOCKS (cont): 

HAZARDOUS ATTITUDES: Attitudes that impede effective CRM.

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Macho “I can do it.”

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Anti-Authority “Don’t tell me.”

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Impulsivity “Do something -quickly!”

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Resignation “What’s the use?”

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Missionitis “Let’s press on.”

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FATIGUE

Widely recognized enemy of pilots & crewmembers .

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A low frustration threshold

–

Degraded coordination

–

Slowness in response

–

Carelessness

–

Acceptance of low standards of accuracy

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ROADBLOCKS 

STRENGTH OF AN IDEA: Tendency to unconsciously make the available evidence fit a preconceived situation; to see or hear what we want to hear, and substitute that for reality. It can take 15 seconds to “break” an idea that has been ingrained, but is incorrect.

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TOOLS 

Will help in assuring a good balance of;



Effective communication



Personal monitoring



Strong team work skills

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TOOLS cont:

ERROR TRAPS STERILE COCKPIT/CABIN TWO CHALLENGE RULE

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PERSONAL MONITORING

“I’M SAFE”

ILLNESS MEDICATION SLEEP ALCOHOL FATIGUE EATING/EXERCISE

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CRM Principle - Communication

Elements of Communication Skills

The most obvious of the CRM principles.

And, the easiest to affect through training.

“Say what you mean, mean what you say.”

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CRM Principle - Communication

Apply the A-B-C’s of communication

Accurate Bold Concise

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CRM Principle - Communication 

Understand the communication loop

Idea-Encode-Xmit-Receive-Decode-Idea Say what you mean, mean what you say. But, “Have I been understood?”

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CRM Principle - Assertiveness

Elements of Assertive Behavior

Authority with Participation Assertiveness with Respect The genuine, complete & direct communication of ideas, wants & needs.

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CRM Principle - Assertiveness

The genuine, complete & direct communication of ideas, wants & needs.

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CRM Principle - Assertiveness

The Assertive Statement

Open-up; get their attention State concern as “owned emotion” State the problem - real or perceived Offer a solution Obtain agreement/closure “Say what needs to be said”

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CRM Principle - Risk

Risk Management RISK is a factor of: Probability Severity Exposure

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Risk Management - M3710.1D



What is an acceptable level of Risk?



…potential risks to the aircraft and crew shall be weighted against risks to the personnel and/or property in distress if the mission is not taken.



“ probable loss of an aircrew is not an acceptable risk .”

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Operational Risk Management (ORM)

History: 1996 - multi-dimensional workshop Developed common risk mgmt process Specifically tailored to our size and multi-mission nature.

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Operational Risk Management (ORM)

Identify Mission Tasks 7 Step Process Identify Hazards Assess Risks Identify Options Eval Risk vs.. Gain Execute Decision Monitor Situation

Step #2: Identify Hazards 

Use the “PEACE” Model to remember the 5 risk factors:

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Planning

–

Event Complexity

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Asset Selection

–

Communications

–

Environmental Conditions

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Step #3: Assess the Risks

SPE RISK ASSESSMENT MODEL

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Risk=Severity x Probability x Exposure

•

Severity - Potential consequences measured in terms of degree of damage, injury, or impact on a mission. Could occur in one of these areas:

•

Injury or death, equip damage, mission degradation, reduced morale, adverse publicity, admin/disciplinary actions

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Step #4: Identify the Options 

STAAR

–

Spread Out

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Transfer

–

Avoid

–

Accept

–

Reduce

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Step #5: Evaluate Risk vs.. Gain 

Analyze the operation’s degree of risk with the proposed controls in place

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Determine if operational benefits exceed the degree of risk the operation presents

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Consider cumulative risks



This is the “REALITY CHECK!”

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Step #6: Execute the Decision 

The risk control decision is made



Clear communication of decision clarifies rational behind risk management decision.



(Done it a hundred times, been there, etc.)

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Step #7: Monitor Situation 

Monitor situation to ensure controls are effective and in place



Identify any and all changes requiring further risk management and act on them



Risk management is a continuous process

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Crew Resource Management

The empowerment of all crewmembers to promote safety and increase overall aircrew performance.

Think Error Management Execute CRM Skills

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