CRM Refresher 2002 Downloaded from www avhf com

CRM Refresher 2002 Downloaded from www. avhf. com

Rules of Engagement Participation is Key Non-Attribution No Names – What Not Who Downloaded from www. avhf. com

CRM – What is the Goal? To achieve Optimal Performance from a team executing multiple, complex tasks. Downloaded from www. avhf. com

CRM – What is the Goal? Does Optimal Performance Equate to Perfection? Downloaded from www. avhf. com

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? Downloaded from www. avhf. com

Absolutely We Manage Our Errors We Incorporate Error Management into Every Aspect of CRM Downloaded from www. avhf. com

GOAL: OPTIMAL PERFORMANCE Error Management is the “What” Intervention/Prevention CRM is the “How” Trap, Mitigate, Avoid Downloaded from www. avhf. com

Downloaded from www. avhf. com

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 Downloaded from www. avhf. com

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. Downloaded from www. avhf. com

Error Management Error does not, has not, and will not cause an incident, an accident, or a fatality So, what does? Consequence Downloaded from www. avhf. com

Error Management Consequences are not universal or inevitable. Errors happen all of the time. Incidents, accidents, and fatalities do not. EM targets the GAP between Error and Consequence! Downloaded from www. avhf. com

Where Error Lives l LATENT – present but not visible…hidden in the things we do routinely l ACTIVE – present, in use…individual error Downloaded from www. avhf. com

The Swiss Cheese Model (REASONS) Latent Errors in System Organizational Filters: Training/Stan/CRM/ORM Latent Errors at Mgt Level Trajectory of Accident/Error Unchecked 1 2 3 Individual Error (Active Error) Downloaded from www. avhf. com 4 5 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 Downloaded from www. avhf. com

6555 Aug ‘ 94 Practice Auto Latent & Active Errors What was EM Outcome Downloaded from www. avhf. com

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. Downloaded from www. avhf. com

CRM Principle - S. A. l 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 Downloaded from www. avhf. com

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! Downloaded from www. avhf. com

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” Downloaded from www. avhf. com

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 Downloaded from www. avhf. com Ambiguity Failure to meet targets Not addressing discrep’s Preoccupation

CRM Principle - S. A. What do you do when you suspect you have lost S. A. ? èReact è è Downloaded from www. avhf. com Regain Reconstruct

ROADBLOCKS l The common obstructions to good CRM! l A combination of negative human factors, ingrained habits, and our own personal attitudes and those of the crew-members we are working with. Downloaded from www. avhf. com

ROADBLOCKS l NORMS: unwritten rules that become pressures that act upon a group, be alert for “Killer Norms. ” l ODD MAN OUT: Ignore input from a particular member of the crew. Results in a loss of total crew effectiveness. l HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew. Downloaded from www. avhf. com

ROADBLOCKS (cont): l CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation. l BREAK THE CHAIN Downloaded from www. avhf. com

ROADBLOCKS (cont): l HAZARDOUS ATTITUDES: Attitudes that impede effective CRM. – Macho - “I can do it. ” – Anti-Authority - “Don’t tell me. ” – Impulsivity - “Do something -quickly!” – Resignation - “What’s the use? ” – Missionitis - “Let’s press on. ” Downloaded from www. avhf. com

FATIGUE Widely recognized enemy of pilots & crewmembers. – A low frustration threshold – Degraded coordination – Slowness in response – Carelessness – Acceptance of low standards of accuracy Downloaded from www. avhf. com

ROADBLOCKS l 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. Downloaded from www. avhf. com

TOOLS Will help in assuring a good balance of; l Effective communication l Personal monitoring l Strong team work skills l Downloaded from www. avhf. com

TOOLS cont: ERROR TRAPS STERILE COCKPIT/CABIN TWO CHALLENGE RULE Downloaded from www. avhf. com

PERSONAL MONITORING “I’M SAFE” ILLNESS MEDICATION SLEEP ALCOHOL FATIGUE EATING/EXERCISE Downloaded from www. avhf. com

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. ” Downloaded from www. avhf. com

CRM Principle - Communication Apply the A-B-C’s of communication Accurate Bold Concise Downloaded from www. avhf. com

CRM Principle - Communication l Understand the communication loop Idea-Encode-Xmit-Receive-Decode-Idea Say what you mean, mean what you say. But, “Have I been understood? ” Downloaded from www. avhf. com

CRM Principle - Assertiveness Elements of Assertive Behavior Authority with Participation Assertiveness with Respect The genuine, complete & direct communication of ideas, wants & needs. Downloaded from www. avhf. com

CRM Principle - Assertiveness The genuine, complete & direct communication of ideas, wants & needs. Downloaded from www. avhf. com

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” Downloaded from www. avhf. com

CRM Principle - Risk Management RISK is a factor of: Probability Severity Exposure Downloaded from www. avhf. com

Risk Management - M 3710. 1 D l What is an acceptable level of Risk? l …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. l “probable loss of an aircrew is not an acceptable risk. ” Downloaded from www. avhf. com

Operational Risk Management (ORM) History: 1996 - multi-dimensional workshop Developed common risk mgmt process Specifically tailored to our size and multi-mission nature. Downloaded from www. avhf. com

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 l Use the “PEACE” Model to remember the 5 risk factors: – Planning – Event Complexity – Asset Selection – Communications – Environmental Conditions Downloaded from www. avhf. com

Step #3: Assess the Risks SPE RISK ASSESSMENT MODEL l 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 Downloaded from www. avhf. com

Step #4: Identify the Options l STAAR – Spread Out – Transfer – Avoid – Accept – Reduce Downloaded from www. avhf. com

Step #5: Evaluate Risk vs. . Gain l Analyze the operation’s degree of risk with the proposed controls in place l Determine if operational benefits exceed the degree of risk the operation presents l Consider cumulative risks l This is the “REALITY CHECK!” Downloaded from www. avhf. com

Step #6: Execute the Decision l The risk control decision is made l Clear communication of decision clarifies rational behind risk management decision. l (Done it a hundred times, been there, etc. ) Downloaded from www. avhf. com

Step #7: Monitor Situation l Monitor situation to ensure controls are effective and in place l Identify and all changes requiring further risk management and act on them l Risk management is a continuous process Downloaded from www. avhf. com

Catastrophic Events Rarely Result From A Single Error Downloaded from www. avhf. com

Crew Resource Management The empowerment of all crewmembers to promote safety and increase overall aircrew performance. Think Error Management Execute CRM Skills Downloaded from www. avhf. com