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You are the First Officer on United 173. Tell me an exact assertive statement you would use.
Explain when you would need to use each of the five different types of leadership styles (ie. autocratic, minimal etc) Be detailed, give examples of each one.
Explain what communication barriers were present in United 173 and KLM 4807. Be detailed.
Using the SHELL interface, which accident, we discussed in class, is a prime example of a poor interface? Be detailed
What is the difference between an assertive statement and being assertive? Give a detailed explanation.
In class we discussed synergy. Explain in detail what that means in terms of how humans work together in a group (ie. flight crews)
What hazarous attitudes were present in American 1420? (do not list, explain in detail)
What hazarous attitudes were present in KLM 4805 and Pan Am? (do not list, explain in detail, both crews, not just KLM)
What hazarous attitudes were present in Eastern 401? (do not list, explain in detail)
In regards to Northwest 255, describe in detail exactly the system wide culture which possibly lead to the accident.
Crew
Resource
Management
INTRODUCTION TO CRM
Before CRM…
https://www.youtube.com/watch?v=
qh42k3Kvxck
Crew Resource Management John
Wayne (708 folder)
Learning Outcomes
The student shall…
Define and describe the concept
of Crew Resource Management
Identify key accidents that resulted
in the formation of CRM
List and identify key components of
CRM
What is CRM?
Crew Resource Management: A set of training procedures for
use in environments where human error can have devastating
effects. Used primarily for improving air safety, CRM focuses on
interpersonal communication, leadership, and decision
making in the cockpit.
– wikipedia.org
CRM Objectives
To enhance crew and management awareness
of human factors which could cause or
exacerbate incidences which affect the safe
conduct of air operations.
CRM Objectives
To enhance knowledge of human factors and
develop skills and attitudes, which when applied
appropriately could extricate an aircraft
operation from incipient accidents and incidents
whether perpetrated by technical or human
factor failings.
A History of CRM
Landmark accidents:
United Airlines Flight 173
Douglas DC-8 – Crashed in Portland, OR
Ran out of fuel
Captain was occupied with troubleshooting faulty
landing gear indication
Other crewmembers noticed the fuel issue and
seemed to express concern
Captain did not respond to the fuel concerns
A History of CRM
Landmark accidents:
The Tenerife Disaster
Collision of two 747 aircraft in Tenerife
KLM 747 began takeoff roll while Pan Am 747 was
back-taxiing on the runway
Poor communication between ATC and aircraft
resulting in much confusion
KLM crewmembers expressed concern regarding the
Pan Am 747, but Captain disregarded their concerns
Deadliest aviation accident in history
A History of CRM
Landmark accidents:
Eastern Airlines Flight 401
Lockheed L-1011 – Controlled flight into terrain in
Florida Everglades
Entire three-member crew was distracted by a faulty
landing gear indication
No crewmember noticed autopilot had disconnected
and the airplane had begun a slow descent
Captain failed to delegate the task of monitoring the
aircraft
A History of CRM
In 1979, as a result of United 173, NTSB
recommends airlines begin training and
practicing CRM
Originally called “Flightdeck Resource
Management” and later “Cockpit Resource
Management”
Current term “Crew Resource Management”
incorporates all crewmembers, whether in the
cockpit, cabin, or outside the aircraft.
A History of CRM
Crew Resource Management is now an industrywide standard
Crewmembers are evaluated on their CRM skills
during initial and recurrent training and during line
observations
Components of CRM
Effective communication
Effective leadership, followership, and crew
coordination
Delegation
Assertiveness
Crewmember roles and responsibilities
Workload management
Remember…
CRM is much easier to discuss than to practice
Knowledge of the concepts is only the
beginning…
Must continuously exercise these practices
Experience improves skills and confidence
Learning Outcomes
The student shall…
Define and describe the concept of
Crew Resource Management
Identify key accidents that resulted in
the formation of CRM
Identify key accidents where effective
CRM created favorable outcomes
List and identify key components of
CRM
Questions?
Crew
Resource
Management
COMMUNICATION
Communication
https://www.youtube.com/watch?v=
NfDUkR3DOFw
Roger Roger video (708 folder)
Learning Outcomes
The student shall…
List and define the key elements of the
communications process
List and define the five essential
communication skills
Apply the concept of assertive
statements
Apply the concept of closed-loop
communication
Describe the process of conflict
resolution
Learning Outcomes
The student shall…
Describe the process of effective critique
List and define barriers of communication
Apply the concept of effective feedback
Define sterile cockpit in a Part 121
environment
List and describe briefings used in a Part
121 environment
Analyze the Tenerife Disaster and
distinguish CRM failures
Communication
Exchange of messages between two or more
individuals
Essential to CRM
Crewmembers must exchange ideas, opinions,
concerns, comments, instructions, callouts,
commands, etc…
The Communication
Process
Key Elements
Source: The message sender
Symbol: The message itself
Receiver: The message recipient
The Communication
Process
The Source
Selects and utilizes language for transmitting
meaningful information to listeners.
Consciously or unconsciously reveals attitudes
towards themselves, their ideas, and the receiver
when communicating.
Attitudes must be positive towards the ideas being
communicated and towards their receiver.
The Communication
Process
The Source – Language
How would you respond to…
Bonjour, monsieur! Je voudrais voler l’avion à la Fargo,
s’il vous plaît.
Hello, sir! I want to fly the plane to Fargo, please.
The Communication
Process
The Source – Attitude
How would you respond to…
HEY STUPID, GO GET THOSE DAMN CHOCKS!
Excuse me, could you get the chocks when you have
a chance?
The Communication
Process
The Symbol
Words
Signs
Motions/Movements
Symbols are used to compose and transmit
messages.
Choose symbols that are best for explaining,
clarifying, or emphasizing.
The Communication
Process
The Symbol
What symbols do you use during a flight?
Speech
Motions
Signs
Hand Signals
The Communication
Process
The Receiver
Effective communication depends upon the
source’s knowledge of the receiver’s abilities,
attitudes, and experiences.
Your CFI’s debrief after your first ever flight compared
to now
The receiver must have the appropriate knowledge
and experience for the situation.
Ex: If the receiver doesn’t know the phonetic
alphabet, they are not an effective receiver in the
cockpit
Effective Communication
Skills
Five Essential Skills:
Inquiry
Advocacy
Listening
Conflict Resolution
Critique
Effective Communication
Skills
Inquiry
Obtaining information from relevant sources
Obtaining clarification on procedures
Don’t be afraid to ask questions!
Just like your Flight Instructor, your Captain will have
more experience than you. USE THEM AS A RESOURCE!
Effective Communication
Skills
Advocacy
Promoting a course of action that you feel is best,
even when it involves conflict with others.
Requires CONFIDENCE
State what you know, and stick to it
Overcome the intimidation factor
Make your thoughts and feelings known!
Effective Communication
Skills
Advocacy
The Assertive Statement: Best method to express
concern on the flight deck and promote your idea.
Five steps:
1.
Get the listener’s attention
2.
Express emotion
3.
Clearly state the problem
4.
Propose a solution
5.
Insist on feedback
Effective Communication
Skills
Advocacy
Assertive Statements
1.
Captain
2.
I am concerned
3.
We do not have enough fuel to continue holding
4.
We must divert to our alternate
5.
What do you think?
Effective Communication
Skills
Advocacy
Assertive Statements – When is it necessary?
Captain is flying the approach 10 knots fast?
Captain is still flying the approach 10 knots fast after
two callouts, is not making any corrections, and is
below 1,000 feet AGL?
Effective Communication
Skills
Listening
Active listening is not passive
Requires structured listening and responses that are focused on the
speaker.
What is the difference between HEARING and LISTENING?
A good listener must provide feedback
The source must verify the message was received and understood
Effective Communication
Skills
Listening
When have you heard something, but not listened?
First landing in AVIT 102. Were you listening to ATC on final?
Are you listening now?
Effective Communication
Listening
Closed-Loop Communication
A method of effective listening that ensures the source
is aware the receiver understood the message.
Receiver must acknowledge the message with a
readback or appropriate response.
When do we do this?
ATC communication
Checklist responses
Effective Communication
Listening
Pre-planning
Actively planning your next statement while the other
person is still talking.
DO NOT DO THIS: You cannot pre-plan and listen at
the same time! You will only be hearing the person.
The human mind cannot process this.
“Sioux 37, cleared to the Grand Forks Airport as
filed…”
Effective Communication
Skills
Conflict Resolution
Conflict: To come into collision or disagreement; be
contradictory, at variance, or in opposition.
Are conflicts always bad?
Effective Communication
Skills
Conflict Resolution
Conflict can be destructive when outside factors
come into play.
Focus on WHAT is right, not WHO is right
DO NOT make it personal
Effective Communication
Skills
Conflict Resolution
Resolve or prevent conflicts in the cockpit
Are some conflicts dangerous in a crew environment?
How can you resolve conflicts?
Each viewpoint must be allowed to be presented with an
explanation of why they think it is the best choice
Each party must be prepared to compromise
DO NOT MAKE IT PERSONAL OR TAKE IT PERSONALLY!
Effective Communication
Skills
Critique
Critique: A detailed analysis and assessment of
something.
When have you been critiqued?
Professional pilots should be able to accept critique
throughout their career
Critique should not be a reprimand
Discussion of positive and negative performance
What did you do well?
What do you need to improve?
Effective Communication
Skills
Critique
Effective critique is necessary for improvement
Should occur at the appropriate moment
Consider workload environment
Should be specific, objective, usable and
constructive.
Effective Communication
Skills
Communication barriers
Personal
Physical
Communication Barriers
Personal barriers
Lack of common experiences
Your experiences vs. other crewmembers’ experiences
Symbol confusion
Non-standard communication
Personality conflicts
Introvert vs. extrovert
Communication Barriers
Personal barriers
Emotions
Positive vs. negative
Stress
Acute vs. chronic
Fatigue
Acute vs. chronic
Performance at 5 AM vs. 11 AM
Communication Barriers
Physical barriers
External noise and volume
Airflow, propellers, communication, etc.
Static
Multiple people keying the frequency at once
Communication Barriers
Physical barriers
Multiple communications
Flight attendants
ATC
Other crewmembers
Oxygen requirements
Mask capabilities
Pressure-demand/Emergency oxygen
Communication
Feedback
Closed-loop communication is essential for
effective communication.
Effective feedback
Non-threatening
Should promote ideas and alternatives
Communication
Feedback
Avoid non-definite statements
“Naw, I don’t think that’s right. Ah, maybe it is.” – Air
Florida 90
Avoid statements that lack clarity (e.g. hints)
“That is weird with no lights” – Comair 5191
“How much fuel you got now?” – United 173
Be alert for “hints” that others may be giving you
and insist on clarification.
Sterile Cockpit
Must avoid non-essential communication and
actions during critical phases of flight
Any operation below 10,000 feet, not including
cruise flight (14 CFR 121)
Taxi
Takeoff
Climb
Descent
Approach
Landing
Sterile Cockpit
Below 10,000ft: May I……
Give a PA to passengers regarding company
information and promotions?
Give a PA to passengers regarding an engine
failure?
Eat a sandwich?
Sterile Cockpit
FAR 121.542
No flight crewmember may perform, any duties
during a critical phase of flight except those
required for the safe operation of the aircraft.
No flight crewmember may engage in any activity
during a critical phase of flight which could distract
any crewmember from the performance of his or
her duties. (e.g. eating meals, nonessential
conversation, reading the newspaper)
Briefings
Briefings
Establish plans and goals
Ensure all team members understand expectations
and responsibilities
Keep people informed
What type of briefings have you conducted?
Briefings
Briefings
Crew briefing
Captain leads
Crewmember introductions
Essential information regarding the flight
Crewmember responsibilities and expectations
Passenger briefing
Flight Attendant leads – Cockpit crew may provide
supplementary information
Information about flight and emergency procedures
Briefings
Briefings
Departure briefing
Pilot Flying leads
Outlines the entire flight and establishes a
plan
Takeoff briefing
Pilot Flying leads
Establishes a takeoff plan
Approach briefing
Pilot Flying leads
Establishes a plan for the approach and
landing
Briefings
Briefings
ACM (observer) briefing
Any cockpit crewmember leads
Briefs authorized flightdeck jumpseat observers on
emergency procedures and expectations
Authorized jumpseat occupants are considered CREW!
Online or offline pilots
Air traffic controllers
Check airmen
FAA/government inspectors
Cabin Communication
Cockpit-to-Cabin
Departure/Arrival Preparation
PA announcement or phone call to
the cabin
Delays
Double-chime (DING-DONG)
Convey important safety
information
Security concerns
Passenger/crew medical
concerns
Aircraft discrepancies,
failures, malfunctions
Turbulence
“Flight attendants, please prepare
the cabin for departure/arrival”
Sterile Cockpit signal
Cabin-to-cockpit
PA announcement or phone call to
the cabin
Emergencies
Nature of emergency, time
available, special instructions,
brace signal
Provide information to passengers?
Requests
Cabin environmental
control
Information for passengers
Service requests upon
arrival
Learning Outcomes
The student shall…
List and define the key elements of the
communications process
List and define the five essential
communication skills
Apply the concept of assertive
statements
Apply the concept of closed-loop
communication
Describe the process of conflict
resolution
Learning Outcomes
The student shall…
Describe the process of effective
critique
List and define barriers of
communication
Apply the concept of effective
feedback
Define sterile cockpit in a Part 121
environment
List and describe briefings used in a
Part 121 environment
Questions?
Crew
Resource
Management
HUMAN FACTORS
Learning Outcomes
The student shall…
Describe the concept of human factors
List and define the components of the
SHELL model and describe the interfaces
Describe the concept of automation
management
List and define methods of information
presentation
Describe effective signal detection
methods
Learning Outcomes
The student shall…
Describe the concept of memory
and methods to improve memory
Describe the concept of critical
thinking
List and describe each taxonomy
level
Human Factors
Human Factors: The applied science that studies
people working together in concert with
machines in order to optimize human
performance and reduce human error.
Behavioral and social sciences
Physiology
Engineering
Human Factors
“…the probable cause of the crash was pilot
error”
The term “pilot error” only indicates WHERE the
failure occurred, but not WHY it occurred. Human
factors is the study of “why”.
Human Factors in Crew
Performance
SHELL model
Organization of interactions between you and other
aspects of the flight
H
Where did the error occur?
Software
Hardware
Environment
Liveware (others)
Liveware (self)
S
L
L
E
Human Factors in Crew
Performance
Software
Policies, regulations and instructions that guide
crewmember actions.
Framework for operations
Standardization
Checklists
FOM/SP&P
POH/AFM
FAR/AIM
Human Factors in Crew
Performance
Hardware
How information is perceived
Physical equipment or systems
Design of displays and controls
Flight deck layout
Human Factors in Crew
Performance
Human Factors in Crew
Performance
Environment
External factors
Temperature
Noise
Vibration
Light levels
Weather
Human Factors in Crew
Performance
Liveware (others)
People whom you must interact with in order to
perform duties
Captain
First Officer
Flight Attendant(s)
ATC
Ramp personnel
Dispatcher
Others?
Human Factors in Crew
Performance
Liveware (self)
Your physical health, personal experience and
attitudes will affect the way you perceive
information and the decision making process.
Any factor attributed to an individual
Physical health
Emotional stability
Personal biases
Attitudes
Human Factors in Crew
Performance
SHELL Interfaces
Liveware-Software
Liveware-Hardware
Liveware-Environment
S
H
L
L
Liveware-Liveware
Each interaction may influence crew behavior
with another interaction.
Liveware-Software interactions may influence
Liveware-hardware interactions when strict rules
and harsh punishments affect how a crew utilizes
aircraft operation and systems.
E
Automation Management
What is automation? (Liveware-Hardware)
The allocation of functions to machines that would
otherwise be allocated to humans.
Examples of automation:
Autopilots
Flight management systems
Electronic flight instrument systems (EFIS)
Warning and alerting systems
Automation Management
What should you know about your automation?
Policies and Procedures
What are the limitations of your automation?
Minimum altitudes
Max/min airspeeds
Engagement limits
Approved operations
Automation Management
What should you know about your automation?
Practices
Should automation always be used?
Automation is very useful for high-workload situations
Crewmembers become over-reliant on automation over
time
Reduce levels of automation when appropriate
Hand-fly visual approach?
What will you do if automation does something
unexpected?
Human Factors
What should you know about your automation?
Practices
Crew coordination
Both crewmembers are expected to monitor and verify
each other’s automation inputs
Crewmembers should verbally state inputs
Automation monitoring
Automation transfers workload, it DOES NOT transfer
responsibility
Human Factors
What should you know about your automation?
Mode confusion
Occurs when a crewmember incorrectly interprets
autopilot modes
Understand each mode
Understand mode transitions
MONITOR
Human Factors
What should you know about your automation?
Mode confusion
Asiana Flight 214
Boeing 777 – crashed in San Francisco, CA
Crew became unstabilized on a visual approach
Pilot Flying changed AP mode – This mode results in
disconnection of autothrottles – Crew was not aware
Aircraft crashed short of runway
Human Factors
https://www.youtube.com/watch?v=QVaQYhd_Q
y0
Types of Information
Presentation of information
Quantitative
Qualitative
System status
Caution and warning
Representational
Types of Information
Quantitative
Provides a numeric value
Faster interpretation for obtaining an exact value
Difficult to read when values change quickly
Types of Information
Qualitative
Approximate or relative value,
rate or trend information
Engine parameters
System information
Can provide the pilot with a pre-
set range value to base
decisions (green is good/red is
bad)
Types of Information
System Status
Indicates the condition of a
system
Anti-ice
De-ice
AFCS
Landing Gear
Types of Information
Caution and Warning
Alerting Systems
Warning Systems
Categories of Information
Representational
Pictures
Graphics
Examples
Weather RADAR
Moving map
Terrain mapping
Overlaid navigational charts
Signal Detection
Consider situations that are loud and busy. What
senses should be triggered?
Use of stick shakers can utilize sense of touch to
convey information no matter how loud or busy.
Auditory information can bring a pilot “back into
the loop” without the pilot always having to
interpret (e.g. altimeter vs. “100ft to minimums”)
Signal Detection
Auditory information
Good for messages:
Visual Information
Good for messages:
Short and simple
Long and complex
Information is not
referred to later
Information will be used
later
Immediate action is
required
Used when auditory
systems are
overburdened (you
can’t hear it)
Signal Detection
Auditory Intensity
Sufficient to overcome background noise
Shouldn’t create a distraction
Increasing intensity is preferred over a sudden onset
of full intensity
Frequency
Phase shifts enable better detection (siren)
Complex noises are better than pure tones (fire bell)
Signal Detection
Caution and Warning System principles
Disruptive alarms should be downgraded after
acknowledgement
Ex: Engine Fire
Initially has 2 warnings (visual + audio)
After acknowledgement only a visual warning
remains.
After fire is extinguished all warnings disappear
Be cautious for alarms that cascade.
One alarm triggers subsequent alarms causing
confusion and poor performance.
Human Performance
Why learn about human performance?
Improves how humans interact, reason, adapt, and
respond to situations, technology and the
environment.
Human Performance
Memory
The ability of the brain to organize, store and
retrieve information.
Storage capacity is vast and impressive, but
retrieval of information is imperfect.
Human Performance
Two types of memory
Short-Term
Used for remembering things you will only need for a
short time.
ATC vectors
Capacity is approximately 5 to 9 items
Meaningful information is easier to remember
Human Performance
Long Term Memory
Used for remembering things that you will use over
and over.
How to fly the vector
Organized and correctly learned information will
help memorization
Mnemonics can help you transfer information to
long term memory
TOMATO FLAMES or BCGUMP
Human Performance
•
Memory is:
–
The result of nerve stimulation and;
–
Will fade without efforts to transfer this knowledge
into long term memory.
Human Performance
•
Engrams
–
Well developed nerve pathways that are created
by repeated use
–
Have greater retrieval capability
–
This type of information can be recalled without a
lot of cognitive effort
–
Ex. What is your name?
Human Performance
Motor skills
Learning motor skills requires significant
reinforcement over a period of time to strengthen
nerve pathways.
Common factors that interfere with learning motor
skills:
Distractions in the early learning phases
Inadequate time to develop basic skills
Human Performance
Memory process
Encode
Store
Retrieve
Your ability to encode and store information is
affected by many things such as:
Noise
Distractions
Fatigue
Information overload
Human Performance
Critical Thinking
The ability to use judgment in the management of
information resulting in greater utility of your
knowledge
Critical Thinking Levels
(Bloom’s Taxonomy)
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Knowledge
Individual is able to recall information
Select and recognize information
Characterized by simple memorization of
information
Most basic level of critical thinking
Comprehension
Individual knows the material well enough to
explain it
Characterized with being able to defend,
summarize and give examples of knowledge used
What your flight instructor does with you on most
flights
Application
Individual can apply knowledge to new situations
Characterized with the ability to solve complex
problems in the cockpit
Emergency procedures are put “to the test”
Analysis
Individual is able to look at components and
break them down, understanding what the
problem involves and how to solve it
What has failed?
What systems are affected?
How do I fix it?
Synthesis
Individual can develop new methods to new
problems
Characterized by the ability to develop or
combine solutions to problems
Is there a checklist for a bird strike?
Evaluation
Individual’s ability to evaluate possible choices
with outcomes
Characterized by a person’s ability to judge,
relate, weigh, criticize and compare possible
solutions to problems
Requires more than memorization of material
What choices do we have?
What are the outcomes of each choice?
Which should we choose?
Learning Outcomes
The student shall…
Describe the concept of human factors
List and define the components of the
SHELL model and describe the interfaces
Describe the concept of automation
management
List and define methods of information
presentation
Describe effective signal detection
methods
Learning Outcomes
The student shall…
Describe the concept of memory
and methods to improve memory
Describe the concept of critical
thinking
List and describe each taxonomy
level
Questions?
Crew
Resource
Management
THE CREW CONCEPT
Learning Outcomes
The student shall…
List and identify crewmembers
Describe the concept of crew
coordination
List and describe skills required for crew
proficiency
List the four qualities of an effective
leader
List and describe the five leadership styles
Describe the concept of followership
Learning Outcomes
The student shall…
Define assertiveness and describe
appropriate levels of assertiveness
Describe effective methods of conflict
management
Describe the components and
purpose of crew briefings and
debriefings
Describe the concept of synergy and
cross-checking
Crew Concept
“Emphasis on the crew concept is important
because experience has proven emergency
situations are handled best by well-coordinated
crew actions.” – FAA
The Flight Crew
Pilot-in-Command
Flight Attendant
Second-in-Command
Check Airman
Flight Engineer
Flight Deck Observer
Dispatcher
Non-pilots
Weather Briefer
Air Traffic Control
Ramp Personnel
Flight Service/Watch
Chief Pilot
The Flight Crew
Crew Cooperation Statistics (AC 120-48)
63% of flight attendants and 40% of pilots thought
that communication between the cabin and the
flight deck is not adequate.
51% of flight attendants and 24% of pilots did not
cover each other’s duties prior to takeoff and
landing during training.
The Flight Crew
Crew coordination
Each crewmember should be aware of each others
duties so that they can be sensitive to the other’s
level of workload
Knowledge helps to avoid miscommunication,
unrealistic expectations, and inappropriate requests
During emergencies, each crewmember should
know exactly what to expect from the other
crewmembers
Crew Concept
Crew roles
Proficiency is required in both technical skills and
interpersonal skills
Technical
Motor skills
Procedural skills
Information base/knowledge
Interpersonal
Communications processes and decision making
Team building
Workload management and situational awareness
Crew Concept
Technical proficiency
Motor skills
System control
Aircraft control
Visual acquisition and interpretation of hazards
Crew Concept
Technical proficiency
Procedural skills
Emergency and Abnormal procedures
Flight maneuvers
System knowledge
Crew Concept
Technical proficiency
Information base/knowledge
Company policies
Regulations
ATC procedures
Airspace
Weather
Aircraft limitations & performance
Crew Concept
Interpersonal proficiency
Communications processes and decision making
Briefings
Inquiry/Advocacy/Assertion
Crew self-critique
Communications
Conflict resolution
Crew Concept
Interpersonal proficiency
Team building
Leadership/followership
Concern for tasks
Relationships and group climate
Automation management
Crew Concept
Interpersonal proficiency
Workload management and situational awareness
Preparation/planning/vigilance
Workload distribution
Distraction avoidance
Crew Concept
Leadership
An effective leader establishes a clear
understanding of roles, responsibilities and
expectations
Leadership styles must be adjusted according to
operational constraints and the abilities and
confidence of their followers
Leadership
Qualities of an effective leader
Have respect from and for the people with whom
you work
Able to delegate responsibilities, when appropriate
Able to admit when they are wrong
Able to make a decision
Leadership
Leadership Styles
Autocratic
Minimal
Consensus
Directive
Consultative
Leadership
Autocratic
A leader makes a decision and expects it to be
carried out without questions
Authoritarian
Leadership
Minimal
A leader is present but everyone is expected to
make decisions without supervision
Not authoritative
Leadership
Consensus
A leader actively seeks consensus before a decision
is made and accepts the majority viewpoint
Not authoritative
Leadership
Directive
A leader makes a decision and explains the
rationale and the group is free to ask questions
Leadership
Consultative
A leader who consults with the group before
making a decision
Followership
The ability to contribute to task and goal
accomplishment through supportive technical,
interpersonal, and cognitive skills
Followership is not a challenge to the captain’s
authority, but neither is it blind compliance with
directives
Followership
Who acts as a follower?
What are the responsibilities associated with
followership?
Support
Goal and/or task accomplishment
Commitment to cause
The responsibility of followership is no less
important than that of leadership, in fact it
enables good leadership.
Crew Concept
Crew support
Encourage and consider crew member input
Crewmembers should contribute their own ideas
and recommendations
Crewmembers show sensitivity and ability to adapt
to the personality of others
Assertiveness
Assertiveness
Confidently aggressive and self assured
How could this be used in a crew environment?
Could assertiveness prevent an accident?
Assertiveness
Assertiveness
How assertive should I be?
Depends upon your evaluation of the situation. Be sure your
response is proportionate to the risk involved
Assertiveness
You are the PM during a visual approach. The PF
appears to be flying towards a cloud while
aligning with the localizer
How assertive will you be? What will you say or
do?
Assertiveness
Required assertiveness
Service related
Point it out
Policies
Give rationale
Operating procedures
Discuss
Regulations
Insist
Safety
Take control
Conflict Management
•
Conflict management methods
–
Integration: find ways to allow both parties to meet
their original goals
–
Compromising: parties give up parts of their goals to
get what they need.
–
Dominating: One party controls the other to get its
goals.
–
Obliging: One party give into demands to achieve
its goals.
–
Avoiding: Ignoring conflict
Conflict Management
–
Crewmembers must recognize and manage
conflict.
–
Utilizes assertiveness and listening skills to create
a mutual understanding of perspectives and
ideas.
–
Crew should focus on common goals.
–
Crew should NOT focus on “who is right” but
rather “what is right”
–
Functional conflict can raise new issues,
viewpoints, and inspire creativity.
Crew Concept
Crew Briefing
Use to ‘form the crew’
Utilized to set the tone
Encourage participation; and
To communicate anticipated operational problems
and differences. (Turbulence, MELs, ATC delays…)
Introduces each crewmember to each other
Outlines the chain-of-command
Crew Concept
Debriefings
Was the goal achieved?
What obstacles did we successfully overcome?
What can we do to improve future performance?
Synergy
The interaction of two or more crewmembers
whose combined effect is greater than the sum of
their individual efforts.
How can you foster synergy in the cockpit?
Crew Concept
Crew Monitoring and Cross-Checking
Each crewmember should carefully monitor the
aircraft’s flight path, systems and flight
crewmember actions.
May be the last line of defense that prevents an
accident or incident.
Learning Outcomes
The student shall…
List and identify crewmembers
Describe the concept of crew
coordination
List and describe skills required for crew
proficiency
List the four qualities of an effective
leader
List and describe the five leadership styles
Describe the concept of followership
Learning Outcomes
The student shall…
Define assertiveness and describe
appropriate levels of assertiveness
Describe effective methods of conflict
management
Describe the components and
purpose of crew briefings and
debriefings
Describe the concept of synergy and
cross-checking
Questions?
Crew
Resource
Management
WORKLOAD, FATIGUE, AND STRESS
Learning Outcomes
The student shall…
Define workload and task load
Describe the effects of workload on
performance
Describe the concept of workload
management
Describe effective automation management
and workload management techniques
Define and describe the concept stress
Describe effective stress management
techniques
Learning Outcomes
The student shall…
Define and describe the concept
of fatigue
Define Circadian Rhythm
Describe effective fatigue
management techniques
Workload Management
Definition of workload
Term used to describe the relationship between an
individual’s capacity to perform a task (mental
and/or physical), and the level of system and
situational demands associated with the
performance of that task. –AC 23.1523
Workload Management
Workload vs. Task load
Task load: A result of system and situational
demands
Workload: A result of system and situational
demands compared with operator abilities
Workload Management
Performance vs. workload
Follows an inverted U-Shape relationship such that
performance suffers when workload is too low or
too high.
Why?
PERFORMANCE
WORKLOAD
Workload Management
Manage external or self-imposed time constraints.
Adequate time should be allowed to accomplish
tasks.
Recognize and manage situations when externally
or self-imposed time constraints might adversely
affect performance.
Workload Management
Recognizing high workload
Prioritize tasks to prevent interference with primary duties.
Less essential tasks are prevented from interfering with primary flight
duties.
Speak up when you recognize overloads.
Delegate tasks to avoid overload
Crew distributes the workload so that NO crewmember is overloaded.
Recognize and report task overload in self and others.
Workload Management
Is automation a solution to workload
management?
Automation can increase OR decrease workload
Autopilot mode confusion
Autopilot performs unintended maneuver
Remember humans do what computers cannot:
Interpret incomplete or ambiguous information
Consider implications
Make appropriate value judgments and decisions
Workload Management
Select the appropriate degree of automation to
reduce workload.
There are multiple levels of automation
Hand flown aircraft (raw data)
Hand flown with the use of a flight director
AP flown with the use of VOR/ILS/HDG modes
AP flown aircraft coupled to FMS (horizontal & vertical)
Verbalize and acknowledge automation system
changes.
Workload Management
Recognizing low workload
Is a low workload dangerous?
Causes boredom and inattentiveness
Check in with other crewmembers to see how they
are doing.
Good time for social conversation, preparation and
planning.
Workload Management
Preparation and planning
Crew anticipates contingencies and various actions
that may be required.
Monitor weather and traffic
Share relevant information with the entire crew
Avoid tunnel vision caused by stress & fatigue
Ask for the big picture if you need it.
Allow enough time before maneuvers for
programming of the flight management computer.
Pull back the “event levers”
Workload Management
Preparation and planning
Workload Management
Dealing with distractions and interruptions
What is a distraction?
An unexpected event that causes a pilot’s attention
to be momentarily diverted.
Pilots must determine whether or not a distraction
warrants further attention or action on their part.
Workload Management
Dealing with distractions and interruptions
What is an interruption?
Unexpected event for which the pilot voluntarily
suspends the performance of one task in order to
complete a different task.
Interruptions are a significant source of errors. Why?
Workload Management
Countermeasures for interruptions
1.
Pause when interrupted and make an explicit
intention to resume the interrupted task.
2.
Identify cues that may be available to remind you
after the interruption to continue.
3.
Pause after the completion of ALL tasks to
evaluate which task should be performed next.
4.
Periodically pause to search memory for deferred
intentions.
Stress Management
Stress
A specific response by the body to a stimulus, as
fear or pain, that disturbs or interferes with the
normal physiological equilibrium of an organism.
Stress Management
Is stress good or bad?
Certain amounts of stress keeps you alert and
prevents complacency.
Too much stress can be detrimental to optimal
performance.
Has stress ever prevented you from doing your best
in the cockpit? Stage checks?
Stress Management
Stress Management
Stress Management
Types of stress
Acute
A short term phenomenon that triggers the “fight or
flight” reaction.
Usually arises from an immediate danger.
Chronic
Long term stressors or on-going acute stress.
Has a cumulative effect on the body.
Can exceed the individual’s ability to cope.
Stress Management
Stages of Stress
Alarm (1st stage)
Occurs when the stressor is identified.
Fight-or-flight response is activated.
Body releases adrenalin, increases heart and
breathing rate
Stress Management
Stages of Stress
Resistance (2nd stage)
If the stressor continues your body will attempt to some
means of ‘coping’ with the stress.
Bodily resources for coping with stress are gradually
depleted.
Stress Management
Stages of Stress
Exhaustion (3rd stage)
Body is unable to maintain normal function.
Problems with digestive system, cardiovascular system
and other illness.
Stress Management
Stress is insidious
Stress has a gradual and cumulative effect that
develops slowly, so slowly that a pilot may not be
able to recognize the signs of him/her being
beyond their ability to respond appropriately.
Stress Management
Stress is cumulative
There is a limit to a pilot’s adaptive nature.
If the number or intensity of the stressors becomes
too great, the pilot is susceptible to an
environmental overload.
Stress Management
Effects of Stress
Reduces working memory capacity (Tunneling)
Narrowing of human attention
Restricts scanning of environmental cues
Yields poor diagnosis of situation
Stress Management
Effects of Stress
Working Memory
Capacity and length of time information can be held
decreases
When exceeded, difficulty performing mental
calculations, problem solving, making sense of pieces
of information, shifting mental sets (concurrent task
management)
Stress Management
Life Stress Management
Become knowledgeable about stress
Take a realistic assessment of your self
Take a systematic approach to problem solving
Develop a lifestyle that will buffer against the
effects of stress
Practice behavioral management techniques
Establish and maintain a strong support network
Stress Management
•
Cockpit Stress Management
–
Maintain good life stress management
–
Condition yourself to relax and think rationally
–
Avoid situations that distract you from flying
–
Reduce your workload. This will create an
environment that supports decision making.
–
If an emergency occurs, think for a moment and
weigh the alternatives, then act.
–
Maintain proficiency in your aircraft.
–
Don’t let little mistakes bother you until they build
into a big thing.
Stress Management
Reducing stress
Include relaxation time in busy environment
Maintain a program of physical fitness
Learn to manage time effectively
Increase confidence by engaging in
comprehensive recurrent training which can
increase self confidence and reduce stress.
Fatigue Management
Fatigue and commercial aviation
“Operator fatigue is one of the most persistent hazards in all travel
modes, including commercial aviation…Recognizing and
managing fatigue is one of the most important elements
recommended for inclusion in CRM training.”—FAA
NASA study finds 88% of 1,424 airline pilots reported fatigue was a
common occurrence.
NASA study find 92% of these same pilots reported fatigue as a
moderate or serious safety concern.
Time of Day (24 hour)
1000
0900
0800
0700
0600
0500
WORST
0400
0300
0200
0100
2400
2300
2200
2100
2000
1900
1800
1700
1600
OPTIMAL
1500
1400
1300
1200
1100
SLEEPINESS
PERFORMANCE
Circadian Rhythm
PEAK
ALERT
Circadian
Trough
NADIR
SLEEPY
Fatigue Management
Fatigue Management
Fatigue is an expected and unavoidable aspect of
being a commercial pilot. So….
How much sleep do you really need?
“A minimum of 5 hours of uninterrupted ‘core’ sleep
during the circadian trough is necessary to maintain
80% performance in the lab.”—FAA
Same study finds 8 hours of sleep or more is required
to maintain peak performance.
Fatigue Management
There are many causes of fatigue
Boredom
Circadian rhythm disruptions
Heavy physical exertion
Fatigue leads to a decreased ability to execute
tasks related to dexterity, concentration, and
intellectual processing.
How will this affect you as a pilot?
Fatigue Management
Can you tell when you’re too fatigued to fly?
The worst person to judge your level of fatigue is
you, the person who is fatigued!
Why?
Impaired judgment
Requires critical thinking skills that may be impaired
Biases and vicarious learning
Fatigue Management
Types of Fatigue
Acute Fatigue
Occurs after some significant physical or mental
activity.
Chronic Fatigue
Fatigue that occurs over a long period of time.
Long duty days.
Circadian disruptions from night flying or time zone
changes and/or scheduling changes.
Fatigue Management
Preventive countermeasures
Obtain sufficient sleep at home, while off duty
Understand how to plan sleep and naps
Naps should be taken when you “feel” sleepy
Short naps should be limited to 45 minutes
Long naps should be at least 2 hours to allow for a
complete NREM/REM cycle.
Fatigue Management
Reactive countermeasures
Stretching or other physical activities can battle
fatigue
Social interactions can help mask the symptoms
Use caffeine when sleepy, or 10-15 minutes before a
predicted period of vulnerability (approach and
landing)
Maintain good nutrition and hydration
Remember: The only way to reverse sleepiness is to
get SLEEP!
Fatigue Management
Antidotes while on trips
Obtain adequate sleep!
Can you sleep in the cockpit during flight?
Should you notify other crewmembers if you’re
fatigued?
Don’t consume alcohol or caffeine 3-4 hours before
a required rest period.
Exercise is great! Don’t do it 2-3 hours before
attempting to sleep.
Fatigue Management
Fatigue Management
Signs of fatigue
Unable to respond to critical items in a timely
fashion.
Indecisive (prolongs decisions or unable to make
them)
Inattentive (fails to respond to events)
Consistently asks for verbal communications to be
repeated.
Unfocused attention (unable to concentrate on a
single task to completion)
Learning Outcomes
The student shall…
Define workload and task load
Describe the effects of workload on
performance
Describe the concept of workload
management
Describe effective automation management
and workload management techniques
Define and describe the concept stress
Describe effective stress management
techniques
Learning Outcomes
The student shall…
Define and describe the concept
of fatigue
Define Circadian Rhythm
Describe effective fatigue
management techniques
Analyze Colgan Air Flight 3407 and
distinguish CRM failures
Questions?
Crew
Resource
Management
SITUATIONAL AWARENESS
Learning Outcomes
The student shall…
Define situational awareness
Define and describe the 3 levels of
situational awareness
Identify equipment designed to
improve situational awareness
Describe common situational
awareness failures
Describe methods of improving
situational awareness
Situational Awareness
“The accurate perception of the elements in the
environment within a volume of time and space, the
comprehensions of their meaning, and the projection
of their status in the near future.”
Achieving SA
3 levels of situational awareness
Perception of the elements in the environment
Comprehension of the current situation
Projection of future status
Situational Awareness:
Level 1
•
Perception of elements in the environment
–
•
The first step to achieving SA requires the pilot to
accurately perceive the status and dynamics of
relevant elements in the environment.
Relevant elements
–
–
–
–
–
Aircraft Systems
Aircraft Condition (airspeed, altitude, direction of
flight)
Weather
ATC clearances
Geography (terrain and location)
Aircraft Design and Level
1 SA
Technology designed to improve a pilot’s
perception of relevant elements in their
environment:
EICAS
Warning Tone Generator (WTG)
Heads-Up Display (HUD)
Multi-Functional Display (MFD)
EGPWS
Synthetic Vision
Weather Radar
EICAS
Engine Indication and Crew Alerting
System
Display engine instruments
Provide visual and aural crew-alert
messages
Provide real time interpretation of
aircraft system operation
EICAS
Four levels of priority
Warning = Aural triple chime
Caution = Aural single chime
Advisory = Status
How would this improve SA?
Warning Tone Generator
Compute and provide warning tones
which alert the flight crew to specific
abnormalities or system failures.
Engine fires
Take off warning
Autopilot disengagement
Pitch trim in motion
Overspeed warning
Master cautions/warnings
Heads-Up Display
•
•
Purpose
–
Provides essential flight performance and navigation
data to the pilot in a heads up mode of information
gathering.
–
Allows lower takeoff and landing minimums (improved
Cat I, Cat II, Cat III)
HGS 5 modes of operation
–
Takeoff Mode (low visibility takeoffs)
–
Primary (all phases of flight)
–
AIII (CAT III approach and landing)
–
IMC (CAT I approach and landing)
–
VMC (visual approaches)
Enhancing Situational
Awareness
MFD system displays
Provide crewmembers a real-time depiction of
aircraft system status.
Fuel
Electrical
Doors
Pneumatic
Many others
Enhancing Situational
Awareness
MFD Map Displays
•
CFIT and approach-and-landing accidents
accounted for approximately 80% of fatal
accidents in commercial transport aircraft during
the 1980’s.
•
Provide the pilot with a real time depiction of
proximity to terrain.
–
•
Terrain data base combined with GPS location
Interfaced with EGPWS, TCAS II and weather
radar
–
Pilot can detect traffic location, proximity to
weather and terrain.
MFD Map Displays
1.
Color
Solid Red
Indication
(meaning)
2.
Solid Yellow
1.
3.
50% Red dots
Terrain/Obstacle warning
area
4.
50% Yellow dots
2.
Terrain/Obstacle caution
5.
25% Yellow dots
3.
Terrain >2000ft above
6.
Solid Green
4.
Terrain 1,000-2000ft above
7.
50% Green dots
5.
Terrain 500-1000ft above
8.
16% Green dots
6.
9.
Black
Terrain less than 500ft
above
7.
Terrain 500-1,000ft below
8.
Terrain 1,000-2,000ft below
9.
No significant terrain
MFD Map Displays
Enhanced Ground Proximity
Warning
•
Controlled flight into terrain
–
•
Occurs when an airworthy aircraft, under
control of a flight crew is flown unintentionally
into terrain, obstacles, or water with no prior
awareness.
EGPWS
Accepts a variety of aircraft parameters (e.g.
baro altitude, radar altitude, vertical speed,
GPS location, aircraft systems), and applies
alerting algorithms.
– Provides the crew with aural and visual
annunciations in the event envelops are
exceeded.
–
•
EGPWS general operation
Enhanced Ground
Proximity Warning
•
7 modes of operation
Excessive descent rate
1.
Outer boundary (“sink rate” “sink rate” w/
warning lights)
Inner boundary (“Pull UP” “Pull UP”)
Excessive terrain closure rate
2.
•
Mode 1: “Terrain” “Terrain” w/warning
lights
•
Mode 2: “Pull UP” “Pull UP”
Altitude loss after takeoff or go-around
3.
•
“Don’t Sink” “Don’t Sink” w/warning lights
Enhanced Ground
Proximity Warning
4.
Unsafe terrain clearance
Mode 4A: (approach and landing w/gear up)
Aircraft configuration = gear up “TOO LOW
TERRAIN”
Below 500ft alert changes to “TOO LOW
GEAR”
Mode 4B: (approach and landing w/ flaps not in
landing config.)
“TOO LOW FLAPS”
Mode 4C: (both gear and flaps not in the
landing configuration)
Alerts the crew when terrain is rising more
steeply than the aircraft’s rate of climb.
Enhanced Ground
Proximity Warning
5.
Excessive glideslope deviation
Soft alert
Below G/S switch lights illuminate
“glide slope” “glide slope”
Hard alert (aircraft continues below g/s)
6.
“GLIDE SLOPE” continues at a faster rate and louder
volume
Advisory callouts
“Minimums, Minimums” (Cat III approaches)
“Bank Angle” “Bank Angle” (excessive bank angles at
various altitudes)
Enhanced Ground
Proximity Warning
7.
Windshear protection
Monitors airspeed, radar altitude, angle of attack,
acceleration and many other parameters to
guard against wind shear at or below 1,500ft.
“Caution Windshear” (generalized wind shear)
“Wind Shear” “Wind Shear” “Wind Shear”
Back to Technology
Indicates rapidly increasing tail wind or decreasing
headwind
Synthetic Vision
Synthetic Vision
Synthetic vision features
Utilizes heads-up-display symbology
EGPWS terrain database displayed in 3-D perspective
Absolute altitude terrain color coding
Contains approach database (high-way in the sky)
Contains airport and taxiway information
SVS benefits
Reduced technical flight errors
Enhances operational flexibility (lower approach minimums)
Eliminates poor visibility as a safety factor for CFIT
Videos
Back to Technology
Airborne Weather Radar
Provides pilots an aid to detouring severe
weather, not penetrating.
4 levels for radar return
Level 1 (drizzle, light rain)
Level 2 (moderate rain/snow)
Level 3 (moderate to heavy rain showers)
Level 4 (heavy rain w/ possible hail)
Airborne Weather Radar
Back to Technology
Situational Awareness:
Level #1
Common Level 1 SA failure
Failure to correctly perceive information
Data is not available
Not having correct information displayed
Not available due to failure in the communication
process
Example: Crew forgets to retract the landing gear
because PM forgets to call positive rate.
Failure to monitor or observe information due to
omission, distractions or attention narrowing
Situational Awareness:
Level #2
Comprehension of current situation
(big picture)
Beyond being aware of the elements that
are present, the pilot must understand the
significance of those elements.
Example: [Level 1 SA] Pilot observes OAT
reading of -3° C while flying in icing
conditions.
Example: [Level 2 SA] Pilot becomes aware
that icing conditions exists and there is a
need to either activate anti-ice/de-ice
systems or exit icing conditions.
Situational Awareness:
Level #2
What factors could affect the
transfer from level 1 to level 2 SA?
Training
Experience
Vicarious learning
Proficiency
Others?
Situational Awareness:
Level #2
Common level 2 SA failures
Failure to correctly integrate or
comprehend information.
Poor mental process prevents the combining
of information to meet necessary goals.
Example: Pilot is aware of the aircraft’s
altitude and a necessary crossing restriction,
but doesn’t start a descent when necessary.
Over-reliance on default values in routine
expectations, even though conflicting
information is available.
Situational Awareness:
Level #3
Projection of future status
The ability to project the future actions of the
elements in the environment.
[Level 1 SA] Pilot observes OAT reading of -3° C while
flying in icing conditions.
[Level 2 SA] Pilot becomes aware that icing conditions
exist and there is a need to either activate antiice/de-ice systems or exit icing conditions.
[Level 3 SA] Pilot plans for increased approach speeds
and runway length required at destination.
Situational Awareness:
Level #3
•
Level 3 SA gives the pilot time to decide on the best
course of action and potential conflicts.
–
Why is this important?
–
Achieving level 3 SA required active participation
(cannot be read from an instrument)
–
What actions do you take as a pilot to achieve level
3 SA?
Situational Awareness:
Level #3
Common Level 3 SA failures
Projection is made further into the future than the
information is realistically valid.
Failure to update projections at appropriate
intervals, leading to incorrect plans for the future.
Projection of future events is never made because
of cognitive resource limits.
Situational Awareness
Health and situational awareness
How could an sinus infection affect situational
awareness?
Inaccurate perception of elements in the
environment?
How could fatigue affect situational awareness?
In ability for crewmembers to achieve the “big
picture”
IMSAFE checklist: Does it apply to crewmembers?
Situational Awareness
Attitude and situational awareness
Can your attitude affect your ability to achieve situational
awareness?
Crewmembers should utilize appropriate assertiveness skills to
ensure SA.
UAL 173: How did the FO’s failure to utilize assertiveness contribute to
the accident?
Situational Awareness
Active listening
Used to ensure an understanding of the situation.
UAL 173: Did the captain listen to the ‘hints’
other crewmembers were telling him about
the fuel status?
Have you ever ignored your flight instructor
because you were performing a complex
task?
Is this a sign that your are starting to lose SA?
Is this dangerous? What can you do about it?
Situational Awareness
Group vs. Individual SA
Individual SA is an awareness of the elements in
your environment (volume, space, time) and the
comprehension of their meaning and the projection
of their status.
Group SA is a crew’s understanding of flight factors
that affect or could effect the crew and aircraft at
any given time.
Situational Awareness
Group vs. Individual SA
Is it possible for one crewmember to have
SA and not share it with other
crewmembers?
Has this caused any accidents? (UAL 173)
How does this division of SA occur?
Barriers to communication
Crew conflict
Ambiguous, incomplete or competing
information
How can you prevent a division of SA?
SA in the Cockpit
•
•
Verbalize actions and intended actions
–
Give other crewmembers information they need
per phase of flight… “500ft to minimums”
–
I’m going to start descending now to meet that
crossing restriction.
This procedure will accomplish 2 things.
–
Other crewmember is made aware of what is going
on from your perspective.
–
Gives the other crewmember an opportunity to
help forestall an ill-advised action.
SA in the Cockpit
Preparation and Planning
Personal preparation for a given flight is complex.
(items should be briefed as a crew when necessary)
Taxi routes
Departure plans
Automation to be used
Frequencies to be used
Who will handle emergencies
Failure to be adequately prepared for a flight will
lead to a loss of SA.
SA in the Cockpit
Preparation vs. adaptability
Although developing a plan is crucial, not being
prepared to deviate from this plan may also
interfere with situational awareness.
SA in the Cockpit
Adaptability/Flexibility
Be open to information that suggests your plan is
not working….pilots tend to fall in love with their
plans.
Be ready to alter your own tasks to assist a
crewmember who may be having a problem.
“Would you like the AP in altitude hold?”
“Would you like the gear up?”
“Would you like me to setup your navigation for this
approach?”
SA in the Cockpit
Identify and share (potential) problems
Do increase situational awareness of the entire crew by
verbalizing issues and conditions.
Example: “Number 1 engine fire”
Example: “At this temperature we’ll need to utilize the wing anti-ice
after takeoff.”
DO NOT allow crewmembers to become overly involved with the
same problem…
This may lead to a loss of SA and teamwork.
Eastern 401
SA in the Cockpit
Monitor and anticipate
Continually monitor and anticipate even during
periods of low workload.
You are vulnerable to losing SA if you fail to
continually monitor the aircraft and your workload
suddenly increases.
Unexpected emergency in flight causes crew to miss
crossing restriction.
SA in the Cockpit
Be alert to task performance in other
crewmembers and yourself.
Being alert to crewmember requirements will
enable you to provide essential information before
they have to ask for it…
Why is this be important?
Watch for signs that crewmembers (including
yourself) are overloaded. This is a key indicator that
they may be losing SA.
Situational Awareness
Achieving good SA
Establish shared goals, plans, and status
Seek, evaluate and utilize available resources
Crew members independently monitor and verify
aircraft and crew member performance
Recognize and resist distractions and lapses into
inattention.
Overloads and distractions prevent monitoring
Understand the impact of stress and fatigue on
performance
Situational Awareness
Recognizing the loss of SA
Misinterpretation of readings or events
Failure to observe readings or events
Choice of hypothesis for the situation is irrelevant
Required crewmember actions are omitted
Situational Awareness
4 areas that may lead to loss of SA
Communication
CA is helping new FO with an arrival procedure, the FO is distracted
by CA’s communication and the CA has distracted himself from
adequately monitoring the status of the aircraft while communicating
to the FO.
Aircraft fails to level off from a descent. After ATC alerts the crew, they
are unable to stop the descent.
Both crewmembers failed to realize the speed brakes were still
deployed.
Situational Awareness
4 areas that may lead to loss of SA
Head-Down work
Preoccupation of the PNF duties
prevents them from adequately
monitoring the PF.
Be cautions when programming
the FMS, making performance
calculations or other head down
work while flying.
• Unexpected change in instrument
approach procedure.
Situational Awareness
4 areas that may lead to loss of SA
Searching for VMC traffic
Climbing on a DP, the crew receives a traffic advisory
that upgrades to an RA. While trying to identify the
VMC traffic, the crew fails to comply with a required
turn on the DP.
Responding to Abnormal situations
Navigating thunderstorms while approaching KLAS,
the crew experiences several equipment malfunctions
and the cabin altitudes begins climbing.
While descending through FL180 neither pilot resets
their altimeters placing them 300ft low at FL130.
Situational Awareness
Cockpit management skills
Treat interruptions as red flags
Explicitly assign PF and PNF duties, especially during
abnormal situations.
When two tasks must be performed concurrently,
avoid letting your attention linger too long on either
task.
Recognize heads down activities greatly reduce
your ability to monitor the PF and aircraft status.
Realize conversation is a powerful distracter
Situational Awareness
As a pilot, only 2 bad things can happen to you
and one of them will.
1.
One day you will walk out to the aircraft
knowing that it is your last flight.
2.
One day you will walk out to the aircraft not
knowing that it is your last flight
Learning Outcomes
The student shall…
Define situational awareness
Define and describe the 3 levels of situational
awareness
Identify equipment designed to improve
situational awareness
Describe common situational awareness
failures
Describe methods of improving situational
awareness
Analyze Eastern Airlines Flight 401 and
distinguish CRM failures
Questions?
Crew
Resource
Management
RISK MANAGEMENT
Learning Outcomes
The student shall…
Define and describe the concept of
risk management
Identify and describe all components
of the PAVE model
Analyze a risk assessment matrix
Identify and describe all components
of the CARE model
Identify and describe all components
of the TEAM model
Risk Management
Risk management and intervention
Processes designed to identify hazards, assess the
degree of risk, and determine the best course of
action.
The part of the decision making process which relies
on situational awareness, problem recognition, and
good judgment to reduce risks associated with
each flight.
Risk Management
What is a hazard or risk in aviation?
A present condition, event, or object that could
lead to or contribute to an unplanned or undesired
event.
Risk Management
Recognizing the Hazard
Critical step in the risk management process
Pilot must be able to look past the immediate
condition and project into the future which
depends upon;
Experience
Training
Observation
PAVE model
The pilot must continually
make decisions about each
of the following:
Physical, Mental, and Emotional State (IMSAFE)
Proficiency
Currency
Risk Management
Aircraft
Airworthiness
Equipment
Performance Capabilities
Risk Management
EnVironment
Weather Hazards
Terrain
Airport Environment
Runway Conditions
Risk Management
External pressures
Meetings, People waiting at destinations, Deadlines
Commercial Operators must balance safety with
economics.
Risk Management
Once hazards are identified the pilot must assess
the degree of risk.
How do you assess risk prior to each flight?
Is this process subjective or objective?
Assess the Degree of Risk
Process risk level
CARE Model
Consequences posed by each hazard
Alternatives that eliminate hazards
Reality (avoid wishful thinking!)
External pressures
Perform Risk Management
TEAM model
Transfer
Eliminate
Accept
Mitigate
Risk Management
Since all risks cannot be successfully removed, the
pilot should consider each of the following
carefully:
1.
Accepted risk-risk that will be allowed to persist.
2.
Unacceptable risk-risk that cannot be tolerated
by the flight crew. This risk must be eliminated.
3.
Residual Risk-the amount of risk remaining after all
safety efforts have been employed. The sum of
accepted risk and unidentified Risk.
Risk Management
What is acceptable risk?
Unique to each individual
When a situation’s residual risk
exceeds the pilot’s capability, the
pilot relies on luck to succeed.
Learning Outcomes
The student shall…
Define and describe the concept of
risk management
Identify and describe all components
of the PAVE model
Analyze a risk assessment matrix
Identify and describe all components
of the CARE model
Identify and describe all components
of the TEAM model
Questions?
Crew
Resource
Management
DECISION MAKING
Learning Outcomes
The student shall…
Define and describe the concept
of decision making
Define and describe judgment
Identify and describe the five
hazardous attitudes
Decision Making
“A systematic approach to the mental process used
by pilots to consistently determine the best course of
action to a given set of circumstances.” –FAA
Decision Making and
Judgment
What is judgment?
The mental process of recognizing and analyzing all
pertinent information in a particular situation, a
rational evaluation of alternative actions in
response to it, and a timely decision on which
action to take.
Decision making and
judgment
Forms of judgment
Perceptual
Decisions are based upon familiar situations and responses.
Experience, practice and repetition increase the speed of perceptual
judgment.
Decision making and
judgment
Forms of judgment
Cognitive
Almost all skills start using cognitive judgment
Requires a high level of attention and concentration
Risk assessment is more difficult
Multiple factors to consider
MORE TIME IS NEEDED
Try to divide perceptual and cognitive tasks during
emergencies…(e.g. one person flies while another person completes
checklists and procedures.)
Decision Making
Making good and bad decisions
Develop perceptual skills and learn what information is necessary
to evaluate a situation
Consider personal and operational biases which may influence
decision quality
Practice making decisions and assessing the result of your
decisions
Be aware of vicarious learning
Avoid disregarding anomalies
When things don’t fit the story we tend to disregard it.
Pilot tend to believe their own stories and don’t want to change it.
Decision Making
Risk detection and evaluation
Consider the Best and Worst likely outcomes of
decisions and plans
Consider the trade off between safety and
efficiency
Decision Making
Establish and Communicate “bottom lines” with
backup plans
Establish limits and communicate them to ensure
understanding
Maintain “bottom lines” and conduct predetermined
action which must be performed if the bottom line is
attained.
Backup plans are briefed as alternatives when certain
conditions of performance or standards are not met.
Example: Visual approach
Crew briefs the “bottom line” weather minimums for a
visual approach and also briefs the instrument
approach as an alternative plan.
Decision Making
Hazardous attitudes that effect our decision
making process:
Anti-Authority
Impulsivity
Invulnerability
Macho
Resignation
Decision Making
Anti-Authority
Resistant to established rules, policies, regulations
and procedures.
Some are motivated because it is not allowed
Speed limitations
Under age drinking
Some are motivated because we don’t like being
told what to do.
Address the attitude NOT the individual. How will
you solve this once it is fully developed?
Decision Making
Impulsive
Crewmembers are often compelled to act quickly.
Signs of impulsive behavior
A strong desire to act before options are considered
An abrupt move to take control of a situation
Impulsive behavior is more common in high
workload situations.
Misperceived time pressure
Can be fatal in aviation
Decision Making
Invulnerability
The belief that negative consequences are unlikely
to occur.
“Accidents happen to other people”
How do you exhibit invulnerability in everyday life?
How do previous experiences affect our attitudes?
Anyone flown through icing conditions?
What did you learn?
Decision Making
Macho
The need to prove your ability to another beyond
the practice of good sense.
Have you ever heard, “hey watch this?”
Have you ever said, “hey watch this?”
What did you learn?
Decision Making
Resignation
The belief that your input will have no effect on the
outcome of the flight.
A feeling of helplessness
What is the point in even trying?
Have you ever exhibited resignation?
Have you ever resigned to silence because of
intimidation during a stage check?
Decision
Making #1
Decision Making Scenario
A passenger becomes very sick,
including vomiting, on a flight that
is completely full. The flight
attendant says the passenger just
completed heart surgery the day
before but felt stable enough to
travel.
The flight attendant also says that
the immediate environment
surrounding the passenger is filthy.
Decision Making Scenario
What additional information can you gather?
Flight attendant’s assessment of the passenger?
Physicians on board?
Access to medical advice through dispatch?
Who should make the final decision as to the
severity of the problem?
Physician
Flight Attendant
First officer
Captain
Decision Making Scenario
Which of the following issues should be
considered in determining how to handle the
situation?
Sick passenger’s health
Health hazard to other passengers and crew
Surrounding passenger’s comfort
Inconvenience to passengers if the aircraft is
diverted.
Flight attendant convenience
Decision Making Scenario
Who should contribute to making the decision as
to how to resolve the problem?
Captain
First officer
Flight Attendant
The Physician
The sick passenger
Other passengers
Dispatch
Decision Making Scenario
What other factors could influence your decision?
Weather at possible diversion airports
Passenger connections
Fuel requirements
Airport and performance requirements
Does this situation constitute an emergency?
Will you deviate from SOPs? FARs? Airplane
limitations?
Decision Making Scenario
What would you want to do (captain)?
Proceed to destination
Land sooner
What would you likely do (captain)?
The same as above
Consensus of all the others’ input
Rely on dispatch’s recommendation
Not rely on dispatch’s recommendation if it is
different than what you prefer
Decision Making Scenario
If the captain chooses to continue to your
destination and you would like to divert, how
might you influence the captain towards the
method you prefer?
Decision
Making #2
Decision Making Scenario
Aircraft has #2 FMS MEL’d because the ENTER
button is difficult to read, resulting in CAT I
approaches only (2 operational FMS are required
for CAT III operations).
While approaching your destination, weather
drops just below CAT I minimums. Captain plans
on utilizing the CAT III approach.
Decision Making Scenario
Are you, as a first officer, comfortable with the
captains decision?
Who is responsible for determining whether this
operation is safe? Legal?
Captain
First officer
Pilot Flying
Pilot Not Flying
The crew’s general consensus
Other?
Decision Making Scenario
How would your decision, or input to the decision, be altered if:
This is the last landing on a 4 day trip. Captain has demonstrated
themselves to be professional and safe the entire trip. You have
developed a good report with the captain. Alternate airport is
300nm.
This is the first landing on a 1 leg trip. Captain has skipped several
checklists and is complaining about being at work, as he has
important things at home to take care of.
Decision Making
How would you handle this situation?
Remind the captain weather is below CAT I
weather minimums at the destination.
Remind the captain of the MEL and that CAT III
approaches are not authorized.
Insist on going to an alternate airport.
Take control of the aircraft.
Other????
Decision Making
•
Plan Continuation Bias
–
Unconscious cognitive bias to continue your original
plan in spite of changing conditions.
–
Appears stronger as one nears completion of an
activity (failure to execute GAR after successful
approach )
–
Bias may prevent you from noticing subtle cues
indicating original conditions have changed
–
May combine with other cognitive biases
•
Frequency sampling bias (“it’s always worked before”)
Learning Outcomes
The student shall…
Define and describe the concept
of decision making
Define and describe judgment
Identify and describe the five
hazardous attitudes
Questions?
Crew
Resource
Management
THREAT AND ERROR MANAGEMENT
Learning Outcomes
The student shall…
Define and describe the concept
of threat and error management
Describe the Swiss Cheese model
Describe methods of error
detection and avoidance
Error detection and
management
What is an error?
When a planned series of actions fail to achieve the
desired outcome and when this failure cannot be
attributed to the intervention of some change
occurrence.
Errors can take place in many ways with variable
impacts.
Error detection and
management
Types of errors
Slip errors (errors of omission)
Occurs when a person intends to do one thing, but
then inadvertently does something else.
Slips are error of action and can take on a variety of
different forms.
Example: Have you ever confuse two things that are
similar? (e.g. pilot raises the landing gear instead of
the flaps)
Example: ATC asks you to execute a routine
procedure in a slightly different way…
Error detection and
management
Types of errors
Mistake errors (errors of commission)
Occurs when a person plans to do the wrong thing
and is successful.
Mistakes are errors of thought.
The result of misconceptions or gaps in knowledge or
understanding.
Error detection and
management
Types of Errors
Perceptual Motor Errors
Errors caused by faulty perception, interpretation or
poor motor control.
What causes a hard landing?
Improper perceptions
Poor motor (skills) control
The Error Chain
Defined:
When one error increases the likelihood of
subsequent errors.
Each link is critical to the development of others
that contribute to an accident/incident.
If a crewmember corrects or removes any link, the
chain of events that will lead to an accident are
broken.
Swiss Cheese Model
•
Aircraft accidents typically have multiple factors
or levels of causality.
•
85% of accident involve human error which may
occur at different levels of responsibility.
•
Generally the responsibility for an accident falls
solely on the pilot, according to the Swiss Cheese
model there should be multiple layers that
prevent conditions that allowed the pilot to make
decisions which may result in an accident.
Swiss Cheese Model
Error detection and
management
Reducing errors
Knowledge and experience
Higher levels of knowledge and skill are associated
with a lower frequency and magnitude of errors.
Time management
Work deliberately at a comfortable pace.
Hurrying does not achieve the same results as faster
performance that is gained by increasing one’s skill.
Error detection and
management
Reducing errors
Check for evidence of errors
Look actively for the evidence of errors.
Proper utilization of checklist
Raising awareness
Be careful when operating under conditions which are
known to cause errors (e.g. changes in routine, time
pressure, complex tasks, fatigue)
Error detection and
management
Do all errors occur in flight?
23% of errors cited in incidents and accidents by
Line-Oriented Safety Audit (LOSA) occurred prior to
the aircraft leaving the ground.
Outcomes of such errors vary widely.
When do errors occur?
Six prototypical error producing situations
Interruptions
ATC gives missed approach instructions just as you
pass the FAF and you forget to conduct a before
landing checklist.
Non-habitual tasks that must be deferred
Report passing 10,000ft
Report 4 DME
When do errors occur?
Six prototypical error producing situations
Concurrent task management
Re-programming the FMS during an IAP
Utilize checklists and flows to ensure task completion
Form good habits and mnemonics that are reliable.
Realize these are NOT sufficient for dealing with all
operational demands.
Habitual tasks with normal trigger cues removed
Contact tower at 4 DME
When do errors occur?
Six prototypical error producing situations
Habitual tasks performed out of the normal
sequence
Setting flaps is delayed because of slush on taxiway.
Anti-ice test is delayed because AC power is not
available (have to wait until engine are running)
When do errors occur?
Six prototypical error producing situations
•
Uncertainties and Intrusions
–
Often occur beyond a pilots control
–
Some must be attended to immediately
–
They generate the need for rescheduling, adding,
shedding, or deferring tasks.
–
Can quickly sidetrack any pilot and lead to disastrous
mistakes.
Pilot Response to Errors
Trap
Error is detected and managed before it becomes
consequential.
Exacerbate
Error is detected but the crew’s action or inaction
allows the error to become consequential.
Failure to respond
Maybe undetected or detected
May be consequential or inconsequential
Last lines of defense
Crew cross-checking and checklists
NTSB finds about 80% of accidents involve a failure
of crew monitoring and challenging.
e.g. FO fails to challenge captain during an
unstabilized approach.
ICAO finds 50% of CFIT accidents inadequate crew
monitoring
Checklists: Good
techniques
“Point and Shoot”:
Pilot responded to each challenge by pointing or
touching the item before verbalizing response
Slows down responding, breaks up automaticity
checking becomes more deliberate
Inherent trade-off between speed and accuracy —
which do we want?
Unacceptable to preach reliability and reward speed
Threat
Management
Scenario
Threat Management
Would you fly through this?
Why or why not?
Imagine being a new FO. The
captain says it is routine to fly
through this type of weather
and doesn’t want to waste
time going around it since the
aircraft is behind schedule.
Will this change your decision?
Threat Management
Threat management
Your ability to asses threats or risk is based upon
knowledge, experience and careful calculations.
This can be easily shifted as a result of influence
from other crewmembers.
How will vicarious learning affect threat
management?
Threat Management
Common errors in threat management
Lack of information to be certain of outcome for
competing choices
Task demands and equipment not well matched to
human information processing characteristics make
information gathering difficult
Competing organizational goals must be balanced
(e.g. production vs. safety)
Learning Outcomes
The student shall…
Define and describe the concept
of threat and error management
Describe the Swiss Cheese model
Describe methods of error
detection and avoidance
Questions?
