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IATA CRM Course Threat and Error Management Captain Zhou Yizhi IATA CRM Course Threat and Error Management Captain Zhou Yizhi

Introductions Ø Name Ø Airline Ø Position Ø Flying experience Ø Previous CRM experience Introductions Ø Name Ø Airline Ø Position Ø Flying experience Ø Previous CRM experience IATA CRM: TEM 2

Course Schedule 0900 - Start 1030 -1045 Break (approximate) 1200 - Lunch 1330 – Course Schedule 0900 - Start 1030 -1045 Break (approximate) 1200 - Lunch 1330 – Return 1515 -1530 Break (approximate) 1700 - Finish IATA CRM: TEM 3

Course Outline DAY 1 Introduction to Threat and Error Management - TEM Countermeasure (CRM) Course Outline DAY 1 Introduction to Threat and Error Management - TEM Countermeasure (CRM) Skills DAY 2 Review Error Avoidance Threat Management Error Management Undesired Aircraft State Management DAY 3 Review Threat and Error Management Model Safety Management Systems Test IATA CRM: TEM 4

Objectives of the course Ø To understand the concept of threats. Ø To understand Objectives of the course Ø To understand the concept of threats. Ø To understand that operational errors are normal, expected and a consequence of mismanaged threats. Ø To develop strategies to: Recognize and manage threats Identify and manage errors Minimize the consequences of errors Ø To recognise that the safety system can be improved by the application of the TEM model to events. Ø At the end of this course students will be able to apply the TEM process to their area of operation. IATA CRM: TEM 5

Module 1 Overview History of CRM IATA CRM: TEM 6 Module 1 Overview History of CRM IATA CRM: TEM 6

Our Job is to fly from point “A” to point “B” safely and efficiently. Our Job is to fly from point “A” to point “B” safely and efficiently. IATA CRM: TEM 7

To accomplish this we must deal with threats and errors from the real world… To accomplish this we must deal with threats and errors from the real world… IATA CRM: TEM 8

… and the mistakes we make as pilots. . . IATA CRM: TEM 9 … and the mistakes we make as pilots. . . IATA CRM: TEM 9

. . . while maintaining productivity. IATA CRM: TEM 10 . . . while maintaining productivity. IATA CRM: TEM 10

How are Pilots made safe? ØProficiency ØTechnical knowledge ØPhysical and mental well being ØCRM How are Pilots made safe? ØProficiency ØTechnical knowledge ØPhysical and mental well being ØCRM IATA CRM: TEM 11

Crew Resource Management Crew Resource Management

Evolution of CRM ØNASA research inspired this response to non-mechanical accidents ØGoal to reduce Evolution of CRM ØNASA research inspired this response to non-mechanical accidents ØGoal to reduce Human Error IATA CRM: TEM 13

First Generation CRM Ø Derived from corporate management development training Ø Focus on individual First Generation CRM Ø Derived from corporate management development training Ø Focus on individual management style/interpersonal skills Ø Insure captain accept input from F/O Ø Addressed lack of assertiveness by F/O “Cockpit Resource Management” IATA CRM: TEM 14

Second Generation CRM Ø More team based Ø Use of team building exercises Ø Second Generation CRM Ø More team based Ø Use of team building exercises Ø Focus on concepts Ø Situational Awareness Ø Stress Management Ø Modular Ø Teach the error chain Ø Train individual decision making, briefing strategies, team building “Crew Resource Management” IATA CRM: TEM 15

Third Generation CRM Systems approach Ø Focus on specific skills/behaviours Ø Integration with technical Third Generation CRM Systems approach Ø Focus on specific skills/behaviours Ø Integration with technical performance Ø Emphasis on evaluating human factors Ø Special training for Instructor/Check pilots Ø Broadened perspective Ø Flight attendants, dispatchers, maintenance “Advanced CRM” IATA CRM: TEM 16

Fourth Generation CRM Ø Performance data guide training Ø Integration of CRM into technical Fourth Generation CRM Ø Performance data guide training Ø Integration of CRM into technical Training Ø Proceduralization of CRM ØChecklists include CRM issues Ø Specialized curriculum topics ØAutomation, etc. Ø Reinforcement of human factors in full mission simulation (LOFT) “Integrated CRM” IATA CRM: TEM 17

Problems with past CRM Ø Adaptation of business models Ø Confusing Ø Industry has Problems with past CRM Ø Adaptation of business models Ø Confusing Ø Industry has evolved and matured Ø Diluted Ø Separation of technical and CRM training Forgot the primary objective of CRM… IATA CRM: TEM 18

…Reduce Human Error IATA CRM: TEM 19 …Reduce Human Error IATA CRM: TEM 19

Error Error

NTSB Study Conclusions - When flying the aircraft, captains appear to have difficulty in NTSB Study Conclusions - When flying the aircraft, captains appear to have difficulty in monitoring their own performance - Many new on the line crewmembers have difficulty in voicing concerns about the captain’s decision making, particularly if they have not flown together before. IATA CRM: TEM 21

IATA CRM: TEM 22 IATA CRM: TEM 22

Error environments Ø Increasing workload Ø Undo time pressure Ø Fatigue Ø Procedural non-compliance Error environments Ø Increasing workload Ø Undo time pressure Ø Fatigue Ø Procedural non-compliance Ø Poor crew coordination Ø Interruptions/distractions IATA CRM: TEM 23

Error Actions or inactions by the crew that lead to deviations from organizational or Error Actions or inactions by the crew that lead to deviations from organizational or flight crew intentions or expectations. Errors in the operational context tend to reduce the margin of safety and increase the probability of incidents or accidents. IATA CRM: TEM 24

Fifth Generation CRM Cannot totally eliminate error Ø Avoid errors being made Ø Manage Fifth Generation CRM Cannot totally eliminate error Ø Avoid errors being made Ø Manage errors by trapping or mitigating their consequences “Error Management” IATA CRM: TEM 25

Threat Threat

The Real World What is a normal flight? Ø What hazards do pilots have The Real World What is a normal flight? Ø What hazards do pilots have to deal with on the line? IATA CRM: TEM 27

Threats Are situations external to the flight deck, that must be managed by the Threats Are situations external to the flight deck, that must be managed by the cockpit crew during normal, everyday flights. Such events increase the operational complexity of flight and pose a safety risk to the flight at some level. IATA CRM: TEM 28

Types of Threat Weather Distractions Ground Crew error Missed Approaches Flight Diversions Heavy Traffic Types of Threat Weather Distractions Ground Crew error Missed Approaches Flight Diversions Heavy Traffic Similar call signs Passenger Events Cabin Crew error Maintenance error System Malfunctions Time Pressures Automation Events ATC error IATA CRM: TEM Unfamiliar Airport 29

Types of Threat Weather Distractions Ground Crew error Missed Approaches Flight Diversions Heavy Traffic Types of Threat Weather Distractions Ground Crew error Missed Approaches Flight Diversions Heavy Traffic Similar call signs Passenger Events Cabin Crew error Maintenance error System Malfunctions Time Pressures Automation Events ATC error IATA CRM: TEM Unfamiliar Airport 30

What groups are responsible for the safety of a flight? IATA CRM: TEM 31 What groups are responsible for the safety of a flight? IATA CRM: TEM 31

Safety Defenses Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: Safety Defenses Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: TEM 32

Safety Defenses - Errors Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production Safety Defenses - Errors Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: TEM Errors 33

Threat Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: TEM Threat Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: TEM Threat 34

Threat Not Captured Incident / Accident Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Threat Not Captured Incident / Accident Pilots Safety Barriers Company/ Organization Aircraft Manufacturer Government Regulations Production IATA CRM: TEM Threats 35

Pilots are the last line of defense! IATA CRM: TEM 36 Pilots are the last line of defense! IATA CRM: TEM 36

What do Pilots have to do to fly safely from A to B? Avoid What do Pilots have to do to fly safely from A to B? Avoid committing errors Manage operational complexity Manage their own errors Safe = Flight Manage aircraft deviations IATA CRM: TEM 37

Perception Crew Invulnerability Ø Pilots perceive themselves as unbreakable under pressure, that they can Perception Crew Invulnerability Ø Pilots perceive themselves as unbreakable under pressure, that they can handle all problems Reality Ø Pilots are affected by various factors which influence their ability to perform, their personal limitations IATA CRM: TEM 38

Sixth Generation of CRM Ø Focuses on CRM as set of countermeasures against threat Sixth Generation of CRM Ø Focuses on CRM as set of countermeasures against threat and error Ø Error avoidance Ø Threat and error management Ø Undesired aircraft state management “Threat and Error Management” TEM IATA CRM: TEM 39

Countermeasures to Threat and Error Avoid committing errors Error Avoidance Manage operational complexity Threat Countermeasures to Threat and Error Avoid committing errors Error Avoidance Manage operational complexity Threat Management Manage their own errors Error Management Manage aircraft deviations Undesired Aircraft State Management IATA CRM: TEM 40

Our Goal Ø Need to refocus CRM towards error reduction and threat recognition Ø Our Goal Ø Need to refocus CRM towards error reduction and threat recognition Ø Adaptation of existing skills towards countermeasures in the real world IATA CRM: TEM 41

Module 2 Countermeasures Skill Groups to be used as Countermeasures to Threat and Error Module 2 Countermeasures Skill Groups to be used as Countermeasures to Threat and Error

CRM Skill Groups Four groupings of CRM skills are threat and error countermeasures 1. CRM Skill Groups Four groupings of CRM skills are threat and error countermeasures 1. 2. 3. 4. IATA CRM: TEM Team building and climate Planning Execution Review / modify 43

CRM Skill ① Team Climate Countermeasures CRM Skill ① Team Climate Countermeasures

Ø In a large number of incidents, one person knew something was wrong and Ø In a large number of incidents, one person knew something was wrong and did not speak up! Ø Least errors made by crews who communicated the most! IATA CRM: TEM 45

Team Climate How do you create an atmosphere for constructive TEM? Ø develop and Team Climate How do you create an atmosphere for constructive TEM? Ø develop and maintain a good communication environment Ø effective leadership Important in all aspects of safety ( CRM/TEM) IATA CRM: TEM 46

Communication Environment Communication channels established and maintained Ø Be assertive, yet respectful Ø Ask Communication Environment Communication channels established and maintained Ø Be assertive, yet respectful Ø Ask for information and advice Ø Create climate for critique – give and take IATA CRM: TEM 47

Some Communication Skills Inquiry – asking questions Active listening - acknowledge message Clarity - Some Communication Skills Inquiry – asking questions Active listening - acknowledge message Clarity - clear communication Appropriate assertiveness – proper level for situation IATA CRM: TEM 48

What qualities make a good leader? -In command -Decisive -Encourages participation -? IATA CRM: What qualities make a good leader? -In command -Decisive -Encourages participation -? IATA CRM: TEM 49

Leadership Skills Purpose -Explain reason for task -Do what is right for the group Leadership Skills Purpose -Explain reason for task -Do what is right for the group Direction -Define crewmembers responsibilities -Good influence Motivate -Build the team -Give and receive feedback -Maintain focus on objective IATA CRM: TEM 50

“ The Captain demonstrates responsibility for the operation of the flight, is the final “ The Captain demonstrates responsibility for the operation of the flight, is the final authority and decision maker” IATA CRM: TEM 51

Conflict Management How do you deal with conflict in the flightdeck? IATA CRM: TEM Conflict Management How do you deal with conflict in the flightdeck? IATA CRM: TEM 52

CRM Skill ② Planning Countermeasures CRM Skill ② Planning Countermeasures

Planning Preparation in dealing with threat and avoiding error by using; - Good Briefings Planning Preparation in dealing with threat and avoiding error by using; - Good Briefings - Stating Plans - Workload assignment - Contingency management IATA CRM: TEM 54

Briefings Ø What is a briefing? Ø Why is it important to give good Briefings Ø What is a briefing? Ø Why is it important to give good briefings? Ø How do we accomplish this? IATA CRM: TEM 55

Briefing Points Ø Must be short, less than 10 ideas to be fully understood Briefing Points Ø Must be short, less than 10 ideas to be fully understood Ø Better to split the briefing into two parts if longer Ø Individually prepared for each flight, automatic briefings used as routine activate none of the memory and are ineffective Ø Must be understood by all crew members, better to have a simple well understood plan than a brilliant misunderstood one! IATA CRM: TEM 56

Plans Stated Develop plan - Solicit input from other sources - Responsibility of all Plans Stated Develop plan - Solicit input from other sources - Responsibility of all crewmembers to contribute to the decision making process State plan - Make plan known to crew, company and others as appropriate - Communicating decisions clearly reduces confusion and misunderstandings Shared Mental Model - constructing and maintaining a common image of the situation - synchronization of ideas IATA CRM: TEM 57

Workload Assignment Evaluate -Determine work to be completed -Calculate resources and time required Prioritize Workload Assignment Evaluate -Determine work to be completed -Calculate resources and time required Prioritize -Match abilities with available time -Avoid distractions Assign Work -Assign actions based on crewmember experience and workload -Issue clear and concise instructions or guidance IATA CRM: TEM 58

Workload Assignment One pilot is always monitoring during low workload and both pilots are Workload Assignment One pilot is always monitoring during low workload and both pilots are monitoring as much as possible during high workload Strategically plan workload to maximize monitoring during those areas of vulnerability i. e. stowing charts, approach briefing, PA’s IATA CRM: TEM 59

Contingency Management Contingency Planning - Anticipate potential outcomes - Alternate plan is initiated when Contingency Management Contingency Planning - Anticipate potential outcomes - Alternate plan is initiated when limits are exceeded Establish Limits - Assess time available - Assess capability to complete task - Set limits IATA CRM: TEM 60

Missed Approach Policy Back-up plan – to reduce stress in busy time What is Missed Approach Policy Back-up plan – to reduce stress in busy time What is your policy? IATA CRM: TEM 61

Planning for Known Threats How do you plan for known threats? Ø Diagnose- identify, Planning for Known Threats How do you plan for known threats? Ø Diagnose- identify, knowledge, memory, problem solving skills Ø Generate solutions – find alternatives, hard to do under stress Ø Assess risks – predict consequences and success rate IATA CRM: TEM 62

CRM Skill ③ Execution Countermeasures CRM Skill ③ Execution Countermeasures

Execution Application of countermeasures to threat and error - Monitor / Crosscheck - Workload Execution Application of countermeasures to threat and error - Monitor / Crosscheck - Workload Management - Vigilance - Automation Management IATA CRM: TEM 64

One way of assessing your current monitoring ability is to ask: “How often have One way of assessing your current monitoring ability is to ask: “How often have I missed making the 1, 000’ before altitude callout? ” IATA CRM: TEM 65

Monitor/Crosschecking of systems and actions such as; - aircraft trajectory - automation systems and Monitor/Crosschecking of systems and actions such as; - aircraft trajectory - automation systems and mode status - Aircraft systems and/or components Inadequate flight crew monitoring has been cited by a number of sources as a problem for aviation safety IATA CRM: TEM 66

Monitoring for Error Pilots must actively monitor the aircraft. Consider changing title of “Pilot-Not-Flying” Monitoring for Error Pilots must actively monitor the aircraft. Consider changing title of “Pilot-Not-Flying” (PNF) to “Pilot Monitoring” (PM) Describes what the pilot should be doing, (monitoring), versus what he/she is not doing, (not flying) IATA CRM: TEM 67

Monitor / Crosscheck This means mentally flying the aircraft, even though the autopilot or Monitor / Crosscheck This means mentally flying the aircraft, even though the autopilot or other pilot is flying. - monitor the flight instruments as when hand flying - if the aircraft or Pilot Flying is not doing what it is supposed to do, the take appropriate actions to rectify IATA CRM: TEM 68

BARRIERS to Effective M/C - Ego - Complacency - New in seat - Fatigue BARRIERS to Effective M/C - Ego - Complacency - New in seat - Fatigue IATA CRM: TEM 69

Fatigue Less reliable memory – items missed Reduced attention- tunnel vision, reduced visual scan Fatigue Less reliable memory – items missed Reduced attention- tunnel vision, reduced visual scan Withdrawn mood - more accepting of own errors Rough motor skills – poor timing IATA CRM: TEM 70

Workload Management Ability to manage required tasks. - Know the capabilities and reliability of Workload Management Ability to manage required tasks. - Know the capabilities and reliability of crew - Detect work overload - Initiate assistance when required IATA CRM: TEM 71

WM Countermeasures Ø Speak up when overloaded Ø Change level of automation Ø Ask WM Countermeasures Ø Speak up when overloaded Ø Change level of automation Ø Ask for more time - hold, delay vectors IATA CRM: TEM 72

BARRIERS to Effective W/M - Stress - Fatigue - Distractions IATA CRM: TEM 73 BARRIERS to Effective W/M - Stress - Fatigue - Distractions IATA CRM: TEM 73

Stress Curve Performance Peak Overload Bored Stress IATA CRM: TEM 74 Stress Curve Performance Peak Overload Bored Stress IATA CRM: TEM 74

In stressful situations, the captain will be better able to manage the problem when In stressful situations, the captain will be better able to manage the problem when not flying the aircraft! IATA CRM: TEM 75

Distractions Interruptions can form holes in defenses What can be done to prevent distractions? Distractions Interruptions can form holes in defenses What can be done to prevent distractions? Ø Sterile cockpit Ø Locked cockpit door IATA CRM: TEM 76

Distractions Identify the interruption Ask what was I doing before. . . being interrupted Distractions Identify the interruption Ask what was I doing before. . . being interrupted Decide what action to take to get back on track IATA CRM: TEM 77

Work as a CREW One pilot is always monitoring during low workload and both Work as a CREW One pilot is always monitoring during low workload and both pilots are monitoring as much as possible during high workload Perform non-essential duties/activities during lowest workload periods such as cruise Strategically plan workload to maximize monitoring during those areas of vulnerability i. e. stowing charts, approach briefing, PA’s IATA CRM: TEM 78

Vigilance Is being alert to the situation, not only what is happening, but what Vigilance Is being alert to the situation, not only what is happening, but what may happen Ø Anticipate problems Ø Gives you the ability to think about options without being under the stress of an emergency Ø Cannot be expected to be 100% vigilant during low workloads ie long haul flights, take turns monitoring Ø Particular attention must be devoted to altitude and course changes IATA CRM: TEM 79

Vigilance - Situational Awareness Is being alert and applying knowledge of what is normal Vigilance - Situational Awareness Is being alert and applying knowledge of what is normal Ø Anticipating what will happen Ø Prepare for problems that may arise Ø What skills are used to maintain SA? IATA CRM: TEM 80

SWA 1455 IATA CRM: TEM 81 SWA 1455 IATA CRM: TEM 81

Automation Management Balance of automation and workload Ø During high workload, FMS inputs made Automation Management Balance of automation and workload Ø During high workload, FMS inputs made by PM, below 10, 000 or within 1000 ft of transition altitude Ø Confirm FMS input with the other pilot Ø Activate the input Ø Monitor mode announcements to ensure autoflight system performs as desired Ø Intervene if necessary IATA CRM: TEM 82

CRM Skill ④ Review / Modify Countermeasures CRM Skill ④ Review / Modify Countermeasures

Review/Modify Countermeasures Use against unexpected threat or when aircraft is in an undesired state. Review/Modify Countermeasures Use against unexpected threat or when aircraft is in an undesired state. Evaluation of plans – review and modify plans when necessary Inquiry – ask questions to clarify Assertiveness – state critical information with persistence IATA CRM: TEM 84

Evaluation of plans Review and modify plans when necessary - Review plan to asses Evaluation of plans Review and modify plans when necessary - Review plan to asses if course of action appropriate to the conditions - Consider alternatives - Consider time available - Establish options IATA CRM: TEM 85

Inquiry Ask questions to clarify – nothing taken for granted - Actively seek information Inquiry Ask questions to clarify – nothing taken for granted - Actively seek information - Question ambiguous or difficult situations until there is understanding Better to have questioned information before, than to have to ask for help later! IATA CRM: TEM 86

Assertiveness Ø Making sure your viewpoint is understood Ø State critical information with persistence Assertiveness Ø Making sure your viewpoint is understood Ø State critical information with persistence Ø Make position known when safety is in question Ø Sense persons concern IATA CRM: TEM 87

Specific Phrases to Use Ø Are you ready for…? Ø What heading did he Specific Phrases to Use Ø Are you ready for…? Ø What heading did he give us? Ø I'm uncomfortable. Ø We are off our heading/altitude. Ø I thought he gave us…. IATA CRM: TEM 88

Decision Making for an Unexpected Threat Perceive situation - gather and process information - Decision Making for an Unexpected Threat Perceive situation - gather and process information - vigilant – alert to situation - knowledge- variation from the norm What is the risk? Is it time critical? Select a course of action IATA CRM: TEM 89

Error Avoidance Module 3 Error Avoidance Module 3

Preventing Error Ø Maintaining your health Ø High levels of training and proficiency Ø Preventing Error Ø Maintaining your health Ø High levels of training and proficiency Ø Following SOP’s Ø Proper use of Checklists Ø Minimizing distractions Ø Planning ahead Ø Open two-way communication Ø Maintaining situational awareness IATA CRM: TEM 91

Barriers to Help Prevent Error Avoidance Planning Team Climate Checklists / SOP’s Training / Barriers to Help Prevent Error Avoidance Planning Team Climate Checklists / SOP’s Training / Proficiency Health IATA CRM: TEM 92

Health Your health affects everything you do. Thorough awareness of one’s own limitations is Health Your health affects everything you do. Thorough awareness of one’s own limitations is a vital prerequisite for adapting to our flying environment. the following affects our ability to perform Ø Noise Ø Medication Ø Diet Ø Stress Ø Fatigue - greatest workload is at the end of the flight, when one is most fatigued - be aware IATA CRM: TEM 93

Technological Proficiency Ø An expert pilot must constantly train. No expertise without training and Technological Proficiency Ø An expert pilot must constantly train. No expertise without training and expertise is lost if training is not maintained, need to practice Ø Technical proficiency is important to TEM / CRM IATA CRM: TEM 94

Standard Operating Procedures Ø Establish a repeatable sequence or rhythm, so that all items Standard Operating Procedures Ø Establish a repeatable sequence or rhythm, so that all items can be covered in a logical manner, easy to pick up where it was left off if interrupted Ø Standard use of phraseology – standard calls Ø Increased margin of safety – confirming actions by other pilot Ø Workload management is improved by specifying and prioritizing the duties each person is responsible for Ø Sets limits Ø Teamwork is standardized - can work with any crew IATA CRM: TEM 95

Accident Cause Factors Source: Boeing (1982 -1991) Primary Factor Percentage of Accidents 10 20 Accident Cause Factors Source: Boeing (1982 -1991) Primary Factor Percentage of Accidents 10 20 30 40 50 Flying pilot non-adherence to procedure Other operational procedural considerations Non-flying pilot non-adherence to procedure Embedded piloting skills Design improvement Captain or instructor exercise of authority Maintenance or inspection action Approach path stability ATC system performance First officer’s cross check performance as non-flying pilot Go-around decision Runway hazards eliminated IATA CRM: TEM 96 60

Accident Cause Factors Source: Boeing (1982 -1991) Primary Factor Percentage of Accidents 10 20 Accident Cause Factors Source: Boeing (1982 -1991) Primary Factor Percentage of Accidents 10 20 30 40 50 Flying pilot non-adherence to procedure Other operational procedural considerations Non-flying pilot non-adherence to procedure Embedded piloting skills Design improvement Captain or instructor exercise of authority Maintenance or inspection action Approach path stability ATC system performance First officer’s cross check performance as non-flying pilot Go-around decision Runway hazards eliminated IATA CRM: TEM 97 60

How SOP’s relate to error Ø data show that crews who intentionally erred by How SOP’s relate to error Ø data show that crews who intentionally erred by not following SOP’s were 1. 8 times more likely to commit another error with consequential results Ø Intentional crew non-compliance was a factor in 39. 5% of accidents IATA CRM: TEM 98

Checklists Proper checklist usage is. . . a basic strategy for error avoidance. . Checklists Proper checklist usage is. . . a basic strategy for error avoidance. . essential for safe flight operation of complex equipment. . a countermeasure to mistakes. IATA CRM: TEM 99

Checklists Ø Helps prioritize items Ø Frees up brainpower for other tasks Ø Reminds Checklists Ø Helps prioritize items Ø Frees up brainpower for other tasks Ø Reminds us of items when under pressure Ø Good reminder when we are fatigued Ø Standardization IATA CRM: TEM 100

What is Checklist abuse? - Memorizing - Self-initiating - Ignoring, not completing - Not What is Checklist abuse? - Memorizing - Self-initiating - Ignoring, not completing - Not getting any responses - Accepting incorrect response - Crew failed to verify settings visually How do you handle the pilot who abuses checklists? IATA CRM: TEM 101

Checklist Errors Fatigue and stress – increase chance of overlooking or missing item when Checklist Errors Fatigue and stress – increase chance of overlooking or missing item when fatigued we prioritize tasks in order of perceived importance Interruptions – lose place Do not put checklist down in its normal spot during interruption IATA CRM: TEM 102

Error Avoidance Using CRM skills as countermeasures Error Avoidance Using CRM skills as countermeasures

Things you can do to help avoid error Ø Create a positive team climate Things you can do to help avoid error Ø Create a positive team climate Ø Develop planning strategies IATA CRM: TEM 104

Team Climate How do you create an atmosphere for constructive TEM? Ø by developing Team Climate How do you create an atmosphere for constructive TEM? Ø by developing and maintaining a good communication environment Ø effective leadership Important in all aspects of safety ( CRM/TEM) IATA CRM: TEM 105

Error Avoidance - Planning What/why is planning? How accomplished Ø Briefings Ø Plans stated Error Avoidance - Planning What/why is planning? How accomplished Ø Briefings Ø Plans stated Ø Workload assignment – distractions Ø Contingency management? IATA CRM: TEM 106

Module 4 Threat Management Module 4 Threat Management

What was a threat on a recent flight? IATA CRM: TEM 108 What was a threat on a recent flight? IATA CRM: TEM 108

Ø What is threat? Are situations external to the flight deck, that must be Ø What is threat? Are situations external to the flight deck, that must be managed by the cockpit crew during normal, everyday flights. Ø Why is it a problem? Such events increase the operational complexity of flight and pose a safety risk to the flight at some level – increase error potential Ø How do we respond to threat? Countermeasures IATA CRM: TEM 109

Threats which originate outside the cockpit. Ø expected or unexpected things like mechanical failures, Threats which originate outside the cockpit. Ø expected or unexpected things like mechanical failures, adverse weather conditions, and ill passengers. Ø errors made by the people we deal with during our flight, ground crew, air traffic control, maintenance Ø oversight in decisions made by those responsible for our working environment (latent). IATA CRM: TEM 110

Threats which originate outside the cockpit. Ø expected or unexpected things like mechanical failures, Threats which originate outside the cockpit. Ø expected or unexpected things like mechanical failures, adverse weather conditions, and ill passengers. Ø errors made by the people we deal with during our flight, ground crew, air traffic control, maintenance Ø oversight in decisions made by those responsible for our working environment (latent). IATA CRM: TEM 111

Threats Adverse weather Terrain Airport conditions Aircraft malfunctions Automation events Communication events IATA CRM: Threats Adverse weather Terrain Airport conditions Aircraft malfunctions Automation events Communication events IATA CRM: TEM Operational time pressures Non-normal operations ATC command events/errors Cabin events/errors Maintenance events/errors Dispatch events/errors Ground crew events/errors 112

Threats by Phase of Flight Threats by Phase Pre-Departure / Taxi 30% Takeoff / Threats by Phase of Flight Threats by Phase Pre-Departure / Taxi 30% Takeoff / Climb 22% Cruise 10% Descent / Approach / Land Taxi / Park 36% IATA CRM: TEM 2% 113

Latent Threats Factors that affect our ability to operate safely without our prior knowledge Latent Threats Factors that affect our ability to operate safely without our prior knowledge of their consequences. People unwillingly create conditions for crews to commit error by negligence in; - design - manufacture - regulations - procedures IATA CRM: TEM 114

Latent Threats Ø ATC practices Ø Scheduling practices that result in fatigue Ø Organizational, Latent Threats Ø ATC practices Ø Scheduling practices that result in fatigue Ø Organizational, national, professional culture Ø Aircraft characteristics Ø Qualification standards Ø Regulatory practices IATA CRM: TEM 115

Locked Cockpit Door Ø Ambiguous regulations – government Ø Untested aircraft systems – manufacturer Locked Cockpit Door Ø Ambiguous regulations – government Ø Untested aircraft systems – manufacturer Ø Flawed procedures – SOP’s - Ø Inadequate training – company IATA CRM: TEM 116

Runway incursions Ø Both pilots have taxi charts available Ø Both pilots monitor taxi Runway incursions Ø Both pilots have taxi charts available Ø Both pilots monitor taxi clearance Ø Captain will verbalize any hold short instructions, FO to request confirmation from Captain if not received IATA CRM: TEM 117

Singapore Airlines SQ 006 IATA CRM: TEM 118 Singapore Airlines SQ 006 IATA CRM: TEM 118

Threat Management IATA CRM: TEM 119 Threat Management IATA CRM: TEM 119

Barriers to Manage Threat Management Review / Modify (Unexpected Threat) Planning (Expected Threat) Team Barriers to Manage Threat Management Review / Modify (Unexpected Threat) Planning (Expected Threat) Team Climate Training / Proficiency External Alerting Systems Aircraft Warning Systems IATA CRM: TEM 120

What are countermeasures for Expected Threat? Unexpected Threat? IATA CRM: TEM 121 What are countermeasures for Expected Threat? Unexpected Threat? IATA CRM: TEM 121

Team Climate Ø Why is communication and leadership important to threat management? Ø Review Team Climate Ø Why is communication and leadership important to threat management? Ø Review skills relevant to threat management with examples IATA CRM: TEM 122

Planning Ø Used for expected threat Ø Brief, state plans, assign work and contingency Planning Ø Used for expected threat Ø Brief, state plans, assign work and contingency strategies IATA CRM: TEM 123

LOSA Data Ø In complex or high threat conditions, performance is better when First LOSA Data Ø In complex or high threat conditions, performance is better when First Officer is pilot fling Ø Captain can manage situation Ø Use automation to decrease workload IATA CRM: TEM 124

Review/Modify Unexpected threat Ø Evaluation of plans – reviewed and modified plans when necessary Review/Modify Unexpected threat Ø Evaluation of plans – reviewed and modified plans when necessary Ø Inquiry – asked questions to clarify Ø Assertiveness – stated critical information with persistence IATA CRM: TEM 125

Module 5 Error Management Module 5 Error Management

Why do we make errors? Ø Ø Ø Lack of experience Rushed Distractions Stress Why do we make errors? Ø Ø Ø Lack of experience Rushed Distractions Stress Crews make mistakes several times during each flight, most of which are unimportant Ø However it can be beneficial to recognize and learn from errors, since it will help manage your resources better during the next flight IATA CRM: TEM 127

Distractions Ø How do you manage distractions? Ø Prioritize Ø Tell intruder to be Distractions Ø How do you manage distractions? Ø Prioritize Ø Tell intruder to be quiet Ø Sterile cockpit Ø Look in books IATA CRM: TEM 128

Professional culture Ø Pilots have a strong professional culture with positive and negative aspects Professional culture Ø Pilots have a strong professional culture with positive and negative aspects Ø Positive Ø Strong motivation to do well Ø Pride in profession Ø Negative Ø Training that stresses the need for perfection Ø Sense of personal invulnerability IATA CRM: TEM 129

Personal Invulnerability The majority of pilots agree that Ø Their decision-making is as good Personal Invulnerability The majority of pilots agree that Ø Their decision-making is as good in emergencies as in normal situations Ø Their performance is not affected by personal problems Ø They do not make errors under high stress Ø True professional can leave behind personal problems ALL FALSE IATA CRM: TEM 130

Areas of Vulnerability Cruise / Descent transition Within 1, 000 ft of level off Areas of Vulnerability Cruise / Descent transition Within 1, 000 ft of level off Descent, approach and landing Transition Alt. 10, 000 ft Taxi-in Taxi-out IATA CRM: TEM 131

Flight Safety Foundation Ø Ø Ø Many of the accidents raise questions about pilot Flight Safety Foundation Ø Ø Ø Many of the accidents raise questions about pilot training Most accidents occur during the approach & landing phase Ø The approach is only 11% of the flight time Ø The landing is only 4% of the flight time 55% of all commercial aviation deaths are caused by controlled flight into terrain IATA CRM: TEM 132

Errors by Phase of Flight Errors by Phase Mismanaged Errors Pre-Departure / Taxi 24% Errors by Phase of Flight Errors by Phase Mismanaged Errors Pre-Departure / Taxi 24% 18% Takeoff / Climb 22% 16% Cruise 6% 17% Descent / Approach / Land 44% 35% Taxi / Park 4% 24% IATA CRM: TEM 133

Highlighting CRM in the Blue Box Brief TOD 18000 ft 10000 ft Slow and Highlighting CRM in the Blue Box Brief TOD 18000 ft 10000 ft Slow and Configure Stabilized Approach FAF/OM Bottom Line Flare / Touchdown IATA CRM: TEM 134

Blue Box Ø Most crew errors (LOSA) Ø Most consequential crew errors (LOSA) Ø Blue Box Ø Most crew errors (LOSA) Ø Most consequential crew errors (LOSA) Ø Most accidents worldwide (ALAR) Ø CFIT Ø Errors dealing with automated systems represent the largest source of error IATA CRM: TEM 135

Types of Error Intentional Noncompliance – violations Ex) Checklist from memory Procedural – followed Types of Error Intentional Noncompliance – violations Ex) Checklist from memory Procedural – followed procedures with incorrect execution Ex) Wrong altitude setting dialed Communication – Missing information or misinterpretation Ex) Miscommunication with ATC Proficiency – Lack of knowledge or skill Ex) Lack of knowledge with automation Decision – Crew decision unbounded by procedures that unnecessarily increased risk Ex) Unnecessary navigation through adverse wx IATA CRM: TEM 136

Barriers to Manage Error Management Execution Team Climate External Alerting Systems Aircraft Warning Systems Barriers to Manage Error Management Execution Team Climate External Alerting Systems Aircraft Warning Systems IATA CRM: TEM 137

Managing Errors Ø Once an error is committed, it is difficult to catch (trap) Managing Errors Ø Once an error is committed, it is difficult to catch (trap) your own error Ø Other people are more likely to catch your error Ø Therefore redundancy is one strong defense against error IATA CRM: TEM 138

Managing Error Topics Ø Pilot invulnerability? Ø Culture? Ø Team Climate is important also Managing Error Topics Ø Pilot invulnerability? Ø Culture? Ø Team Climate is important also Ø Distractions? Execution Ø Monitor crosscheck Ø Workload management Ø Vigilance Ø Automation management IATA CRM: TEM 139

Guidelines and Techniques for EFFECTIVE CHALLENGING - Timely - With respect - Constructive intent Guidelines and Techniques for EFFECTIVE CHALLENGING - Timely - With respect - Constructive intent - Specific - Use questions IATA CRM: TEM 140

Summary Ø What error management is Ø Why we need it Ø How are Summary Ø What error management is Ø Why we need it Ø How are we going to accomplish this Ø Team Building Öleadership ÖCommunication environment Ø Execution ÖMonitor / crosscheck ÖWorkload management ÖVigilance ÖAutomation management IATA CRM: TEM 141

NWA 1482 IATA CRM: TEM 142 NWA 1482 IATA CRM: TEM 142

Module 5 A Undesired Aircraft State Management Module 5 A Undesired Aircraft State Management

Undesired Aircraft State Management UAS - Aircraft deviations at edge of the safety envelope Undesired Aircraft State Management UAS - Aircraft deviations at edge of the safety envelope Incorrect aircraft configurations Vertical deviations Lateral deviations Speed too high Speed too low Abrupt aircraft handling IATA CRM: TEM Path/glide slope deviations Unstable approach Long landing Firm landing Wrong taxiway/runway Runway incursion 144

Barriers to Manage Aircraft Deviations Undesired Aircraft State Management Review / Modify Team Climate Barriers to Manage Aircraft Deviations Undesired Aircraft State Management Review / Modify Team Climate Aircraft Systems (Stick pusher etc. ) External Alerting (ATC) IATA CRM: TEM 145

Countermeasures Ø Team Climate Ø Review/Modify IATA CRM: TEM 146 Countermeasures Ø Team Climate Ø Review/Modify IATA CRM: TEM 146

Module 6 TEM Threat and Error Management Module 6 TEM Threat and Error Management

“The Tip of the Iceberg. . . ” IATA CRM: TEM 148 “The Tip of the Iceberg. . . ” IATA CRM: TEM 148

. . . is a small part of what lies beneath” IATA CRM: TEM . . . is a small part of what lies beneath” IATA CRM: TEM 149

Threat Latent Threats – National Culture, Organizational Culture & Policies Professional Culture Regulation Overt Threat Latent Threats – National Culture, Organizational Culture & Policies Professional Culture Regulation Overt Threats – Environmental Factors Organizational Factors Individual Factors Team / Crew Factors Aircraft Factors External Error IATA CRM: TEM 150

Crew Error Threat Crew Error Crew mismanages threat Error Types - Communication Intentional Non-Compliance Crew Error Threat Crew Error Crew mismanages threat Error Types - Communication Intentional Non-Compliance Procedural Proficiency Decision Error IATA CRM: TEM 151

Undesired Aircraft State Threat Crew Error Undesired Aircraft State IATA CRM: TEM Aircraft is Undesired Aircraft State Threat Crew Error Undesired Aircraft State IATA CRM: TEM Aircraft is not where it is supposed to be due to mismanaged threat and/or error 152

Incident (Accident) Threat Crew Error Undesired Aircraft State Incident IATA CRM: TEM Result of Incident (Accident) Threat Crew Error Undesired Aircraft State Incident IATA CRM: TEM Result of mismanaged threat and error “the tip of the iceberg” 153

Threat Crew Error Threat and Error Model Undesired Aircraft State Incident IATA CRM: TEM Threat Crew Error Threat and Error Model Undesired Aircraft State Incident IATA CRM: TEM 154

Application Ø Apply the TEM model to SQ 006 IATA CRM: TEM 155 Application Ø Apply the TEM model to SQ 006 IATA CRM: TEM 155

Application Ø Apply the TEM model to SQ 006 IATA CRM: TEM 156 Application Ø Apply the TEM model to SQ 006 IATA CRM: TEM 156

How to Manage Threat and Error Avoidance Threat Management Countermeasures Error Management Undesired Aircraft How to Manage Threat and Error Avoidance Threat Management Countermeasures Error Management Undesired Aircraft State Management IATA CRM: TEM 157

Countermeasure Skills Ø Team Climate Ø Planning Ø Task Execution Ø Review and Modify Countermeasure Skills Ø Team Climate Ø Planning Ø Task Execution Ø Review and Modify IATA CRM: TEM 158

How do we apply these skills? How do we apply these skills?

Error Avoidance Proactive strategies to avoid committing errors Ø Planning Ø Following Sop’s and Error Avoidance Proactive strategies to avoid committing errors Ø Planning Ø Following Sop’s and checklists Ø Team climate behaviours such as active leadership and establishing a team environment Ø SMS? Ø Complete avoidance is impossible – errors are inevitable Ø Must look for sources of error to strengthen system defenses IATA CRM: TEM 160

Error Avoidance Human limitations lead to error Ø Limited memory capacity Ø Limited processing Error Avoidance Human limitations lead to error Ø Limited memory capacity Ø Limited processing capacity Ø Multi-tasking capability Ø Limits imposed by stressors Ø Tunnel vision Ø Limits imposed by fatigue or other physiological factors Ø Poor group dynamics Ø Cultural influences Ø Organizational Ø Professional Ø National IATA CRM: TEM 161

Error Avoidance Threat Crew Error Team Climate Planning Undesired Aircraft State Incident IATA CRM: Error Avoidance Threat Crew Error Team Climate Planning Undesired Aircraft State Incident IATA CRM: TEM 162

Threat Management Manage operational complexity, which translates into threat management. Ø Team climate behaviours Threat Management Manage operational complexity, which translates into threat management. Ø Team climate behaviours such as active leadership and establishing a team environment Ø planning Ø Review and modify countermeasures which include evaluation of plans, inquiry and assertiveness IATA CRM: TEM 163

Error Avoidance Threat Management Crew Error Team Climate, Planning Review /Modify Undesired Aircraft State Error Avoidance Threat Management Crew Error Team Climate, Planning Review /Modify Undesired Aircraft State Incident IATA CRM: TEM 164

Error Management Ø Manage crew errors. Ø Error is an inevitable result of human Error Management Ø Manage crew errors. Ø Error is an inevitable result of human limitations such as fatigue and other physiological factors, limited memory and processing capacity, external stressors, poor group dynamics and cultural influences Ø Task execution behaviours such as monitoring and workload management are central to error management IATA CRM: TEM 165

Error Avoidance Threat Management Crew Error Management Team Climate Execution Undesired Aircraft State Incident Error Avoidance Threat Management Crew Error Management Team Climate Execution Undesired Aircraft State Incident IATA CRM: TEM 166

Undesired Aircraft State Management Ø Manage aircraft deviations, wrong configurations, speed etc. Ø Review Undesired Aircraft State Management Ø Manage aircraft deviations, wrong configurations, speed etc. Ø Review and modify countermeasures which include evaluation of plans, inquiry and assertiveness IATA CRM: TEM 167

Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Management Team Climate Review Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Management Team Climate Review / Modify Incident IATA CRM: TEM 168

Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Model Undesired Aircraft State Management Incident IATA CRM: TEM 169

Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Model Undesired Aircraft State Management Incident IATA CRM: TEM 170

AA 1420 IATA CRM: TEM 171 AA 1420 IATA CRM: TEM 171

Safety Management Systems Module 7 Safety Management Systems Module 7

Our Job is to fly from point “A” to point “B” safely and efficiently. Our Job is to fly from point “A” to point “B” safely and efficiently. IATA CRM: TEM 173

Productivity Ø Errors cost money Ø Find out where mistakes are being made and Productivity Ø Errors cost money Ø Find out where mistakes are being made and adjust resources Ø Better use of training IATA CRM: TEM 174

Expose Yourself!!! How can management better understand what is happening on the line? Ø Expose Yourself!!! How can management better understand what is happening on the line? Ø By fostering a culture where crews can confess honest mistakes without fearing reprisal Ø Using your own incidents for training IATA CRM: TEM 175

Management’s Role w establish trust, which includes a commitment to reduce error-inducing conditions. w Management’s Role w establish trust, which includes a commitment to reduce error-inducing conditions. w adopt a non-punitive policy toward error w provide training w collect ongoing data? IATA CRM: TEM 176

Feedback Ø Need a process to identify and feedback threat and error information, not Feedback Ø Need a process to identify and feedback threat and error information, not only from the crew but from the other safety barriers IATA CRM: TEM 177

Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Error Avoidance Threat Management Crew Error Management Undesired Aircraft State Threat and Error Management Model Undesired Aircraft State Management Incident IATA CRM: TEM 178

How does TEM fit into a Safety Management System? Ø TEM supports SMS by How does TEM fit into a Safety Management System? Ø TEM supports SMS by bringing in hard data Ø Linkage between Safety and CRM /TEM Ø Safety change process Ø TEM can be used for a focus group at an airline IATA CRM: TEM 179

TEM at the Organizational level Ø Recognize dangers of threat and error Ø Provide TEM at the Organizational level Ø Recognize dangers of threat and error Ø Provide training in threat and error management Ø Understand limitations of crew Ø Collect data - LOSA and Latent threats Ø Mistakes will be made, reward crew for pointing it out and correcting it IATA CRM: TEM 180

Data Collection Company, industry and regulating authorities get information of the “real” problems that Data Collection Company, industry and regulating authorities get information of the “real” problems that line pilots face Cannot prevent the creation of latent threats but make their adverse consequence visible to those who manage and operate the system IATA CRM: TEM 181

More Realistic Training Ø Focus on Threat and Error Recognition Ø Provide countermeasure More Realistic Training Ø Focus on Threat and Error Recognition Ø Provide countermeasure skills to crews Ø Feedback-help management understand line operation IATA CRM: TEM 182

Tools to Improve Safety Ø SOP’s and Checklists - strategies put forth by the Tools to Improve Safety Ø SOP’s and Checklists - strategies put forth by the company Ø Training - Technical proficiency - Countermeasure (CRM) skills Ø TEM model as an analytical tool of incidents IATA CRM: TEM 183

Line Orientated Safety Audit LOSA Ø Safety data acquisition tool Ø Non-jeopardy, jumpseat observations Line Orientated Safety Audit LOSA Ø Safety data acquisition tool Ø Non-jeopardy, jumpseat observations of flight crews during regularly scheduled flights Ø Provides feedback of threat and error on the line IATA CRM: TEM 184