Upload
lythuy
View
235
Download
3
Embed Size (px)
Citation preview
Crew Resource Management Lecture Outline
NAVAVSCOLSCOM
CRM Director 181 Chambers Ave, Suite C Pensacola, FL 32508-5221
850-452-2088 DSN 459
June 2013
COURSE OVERVIEW
Welcome Aboard
• Please fill out blue name tags with the supplied black marker.
• Please fill in CRM class information sheet with your full social.
CRMI
School of Aviation SafetyNAS Pensacola
WELCOME ABOARD
!!!
• TIMES / UNIFORM• FILL OUT NAME PLATES,
CLASS ROSTER, BOOKS, ETC• Off Limits:
“Psychedelic Shack” and “Groovy Gifts”
• PHONES• SUPPORT• COFFEE
CRM Course Administration
• Speeding 15-20 over posted limit = 7 day suspension• Speeding 21+ over posted limit = 30 day suspension• Speeding in high student concentration areas 10 over = 7 day
suspension / 10+ = 14 day suspension• Fleeing / Attempting to elude = 1 year suspension• Racing on roadway = 1 year suspension• Failure to use child restraint system = 30 day suspension• Littering (including cigarette butts) = 7 day suspension
• Driving while operating a Cell Phone w/o Hands-Free device / Illegal Handicap Parking / Failure to use seatbelt:• 1st Violation = 7 day suspension• 2nd Violation = 30 day suspension• 3rd Violation = 6 month suspension
• Operating a Motorcycle w/o all required PPE, on or off base: • Same as Above (re-attend motorcycle safety course for 3rd
Violation)
Zero Tolerance Guidelines
•Food•Heads•Smoking
NASC Lunch • O Club
• Lunch 1100-1400 – Tues-Fri• Bar 1500 to close – Wed-Fri• Take out available – 452-2026
• Subway, Asian, Italian – NEX• Taco Bell & Pizza Hut, A&W – Portside Club• The Oaks at the Golf Club • Naval Aviation Museum - Cubi Point Bar• Navy Yard Eatery – Daily Specials• Off Base via front gate
Maps
BOQ
GalleyO Club
Portside
Naval AviationMuseum
Starbucks
Aviation Plaza
Privileged
FOR OFFICIAL USE ONLYTHIS IS A PRIVILEGED, LIMITED-USE, LIMITED-DISTRIBUTION, SAFETY INVESTIGATION REPORT. UNAUTHORIZED DISCLOSURE OF THE INFORMATION IN THIS REPORT OR ITS SUPPORTING ENCLOSURES BY MILITARY PERSONNEL IS A CRIMINAL OFFENSE PUNISHABLE UNDER ARTICLE 92, UNIFORM CODE OF MILITARY JUSTICE. UNAUTHORIZED DISCLOSURE OF THE INFORMATION IN THIS REPORT OR ITS SUPPORTING ENCLOSURES BY CIVILIAN PERSONNEL WILL SUBJECT THEM TO DISCIPLINARY ACTION UNDER CIVILIAN PERSONNEL INSTRUCTION 752. THIS REPORT MAY NOT BE RELEASED, IN WHOLE OR IN PART, EXCEPT BY THE COMMANDER, NAVAL SAFETY CENTER.
Questions on admin?
LCDR Brendan T. O’BrienCRM Director
CRM Instructional Model Manager
CRMfor
Instructors
CRMTo EDUCATE aviation officers at all levels to:
Identify hazardsManage risksInvestigate and report mishapsDevelop and administer command safety programs
ASC - ASO - CRMTo foster and conduct safety-related research, and
provide assistance in support of the Naval Aviation Safety Program
Thereby,Enhancing Combat Readiness
through the Preservation of Human and Material Assets
School of Aviation SafetyMission
CRM-I course 4 daysTwice a month
Mobile Training Team4 times per yearFleet concentration area
Assist Visits (30-40 per year)FRS/Wing Program ManagerAll T/M/S platforms (over 45)
Program Manager ConferenceConference AttendancesFleet Support
CRMInstructional Model Manager
What is CRM?
YOU(7 skills)
Ability to use all availableresources…
…in order to accomplish your mission.
• Use all available resources to Increase Operational Mission Effectiveness
• The goal is to increase mission effectiveness by :• Minimizing crew preventable errors• Maximizing crew coordination• System of behavior modifications• Optimizing risk management
CRM Is: CRM and ORM
CRM is the foundational skill set that enables proper use of ORM
In depth ORM Deliberate ORM Time Critical ORM
WARFIGHTING
CRM Is:
CRM is about optimizing our ability to fly our aircraft to best perform our mission,
and our mission is WARFIGHTING.
• Knowledge • Tools• Guidance
And enable you to take this to the fleet
Purpose Of TheCRM Instructor’s Course
YOUR PARTICIPATION
IS THE KEY
Why?...
Classroom Participation Responsibilities
• Your squadron is going to expect a:• Human factors expert• Stan / Eval expert for check rides• Curriculum development expert• Possibly a contractor interface expert• Scenario development expert and POC for
check ride and curriculum integration matters• All around CRM Guru
Because in one week….
1. a. b.
Course Evaluation Summary
• Class Introductions• Administration• Syllabus Overview• Course Format• Classroom Participation Responsibilities• Course Evaluation
STUDENT/STAFF INTROS (name, a/c, command)
HISTORY
HISTORY OF CRM
C-050-1503A 5001 01
Terminal Objectives
• Identify what drove the development ofCRM
• Define and Understand some of theerrors made along the way
• Understand the future of CRM
Enabling Objectives
• Instruct CRM history per CNAF 1542.7(series), and the Evolution of CrewResources Management Training inCommercial Aviation
• Discuss the growth and evolution ofCRM research in private and militarysectors per aforementioned applicableinstructions
There will always be something or somebody out there trying to kill you...
Aviation Is Inherently Dangerous Outline
• Events that led to CRM development –Tenerife Case Study
• Human error• CRM development in the civil sector• CRM development in the Navy and
Marine Corps• Challenges• Future• Purpose of CRM• Summary
Tenerife Background
• A runway collision involving two 747s
• 583 fatal injuries, the most ever in anysingle aviation related mishap
• A major accident that led to CRMdevelopment
A Tale of Two 747s
KLM Flight 4805
- 234 Passengers 14 Crew - From Amsterdam,
chartered: Holland International
- Captain: Jacob van Zanten (Chief Pilot)
“Face” of KLM - 11,700 hrs
A Tale of Two 747s
PAA Flight 1736
- 378 Passengers - 16 Crew - From Los Angeles via
NY - Captain: Victor
Grubbs - 21,000 hrs - “Clipper Victor”
Tenerife
Africa
Tenerife
Las Palmas
Tenerife Summary
12 30
• Disembark passengers
• 55 tons of fuel
• Crew day
Tenerife Summary
12 30
• Pan Am instructed to follow…3rd taxiway?
• RVR 500m with 700 required
Tenerife Summary
12 30
• KLM immediately to full power
• Copilot challenges
• Departure vs takeoff clearance
Tenerife
Tenerife Summary
• What caused the mishap?• Holes in the cheese
Holes in the Cheese
• Divert• Unfamiliar airfield• Language barrier• Weather• Stress vs Time• Stepped on communications• Takeoff without clearance
• 70 crash investigators (Spain, Netherlands, US)
• Mishap Findings / Probable cause:
• KLM initiated take-off without clearance • Wx conditions caused poor visibility • PAA exited at incorrect taxi-way • Simultaneous radio transmissions blocked key instructions • Nonstandard instructions and phraseology • Disruption of normal procedures due to airport crowding • Human Error
International Investigation
• Greater emphasis on English as international language of aviation
• Establishment of standard phraseology • FAA/ICAO: “line up and wait.”
• Requirement for precise read-back instructions (no “OK” or “roger”)
• Phrase "take-off" is only spoken when the actual take-off clearance is given (e.g. “departure”)
• Development of Crew Resource Management theory
Safety Response Commercial CRM 1977 - Current
• 1977 – Interviews with commercial airline pilots reveal dissatisfaction with training in non-technical skills
• 1979 – NASA workshop: “Resource Management on the Flight Deck”
- H/E major cause of accidents • 1981 – United Airlines DC-8 CRM /
Simulator (1st generation of CRM) • 1993 – Delta “Chain of Events” /
modular training (2nd generation) • 1995 – 3rd and 4th Generations of CRM• 1997 – Continental Threat and Error
Management (5th generation)
Tenets of Commercial CRM • 4 Critical Skills
• Decision Making • Command • Leadership • Communication
• Standardized Crew Training • Team Building • Briefing Strategies • Leadership • Communications • Situational Awareness • Stress Management
• Begins to grow…….everybody wants one, and everyone has their own method
• Difficult to duplicate – Corporate Culture • Criticism of “psychobabble”
CRM And The Military • 1986 - NASA and USAF MAC CRM workshop:
“Cockpit Resource Management training, focusing on Communication, Leadership, Situational Awareness, and Crew Coordination is just as appropriate, with some modification, to pilots manning a flight of single seat tactical aircraft as it is to the pilots, Flight Engineers, and Loadmasters operating a C‑5 transport aircraft".
• Differences between civilian and military aircrews:
CIV MIL • Age OLDER YOUNGER • Experience MORE LESS • Rank TENURE UCMJ • Mission Objectives TRANSPORT NUMEROUS • Mission Requirements BENIGN HOSTILE • Crew Duties SERVICE TACTICAL • Centralized training FAA PLATFORM
CRM 1987 - 1989
• 1987 – Contract to modify civilian CRM courses for Navy (Allen Corp.)
• 1989 – CRM introduced to Naval Aviation • Slow to accept due to “one size fits all” approach
• 1989 – Naval Air Warfare Center begins R&D program to develop Navy CRM Program:
• Theoretically driven, researched based • By aviators, for aviators • Instructional Strategies • Focus on entire aircrew • Skills relevant to tactical environment • Measurement and Feedback • Validated and Evaluated
Navy Research and Development Naval Air Warfare Center
1992 NAWC published their findings: CRM must be systematically incorporated into all phases of crew training (i.e., initial qualification, transition, upgrade, recurrent). Must train the specific coordination skills
and behaviors required by aircraft type, aircraft model, phase of flight, and overall mission (e.g., transport, cargo) utilizing the
Seven Skill areas. The Navy’s CRM program would be called Aircrew
Coordination Training (ACT).
CRM 1990 - 1995
• 1993 – Navy implements Fam/Interim ACTprogram, OPNAVINSTS 3710 & 1542.7A
• 1993 – Tiger Team formed• “sell it to the Fleet”• begin T/M/S specific CRM program
• 1994 – ACT School House created (7) daycourse
• 1995 – OPNAV 1542.7A signed• First Integrated ACT: S-3B Viking• Funding for Integrated and Recurrency for
all Navy and Marine Corps platforms
CRM 1997 – 2012
• 1998 – 1542.7B signed• CRM flight evaluation• Required topics for yearly qualifications.
• History, seven skills, T/M case studies
• 2001 – U.S. Navy changed ACT toCRM (1542.7C)
• 2002 – Integration complete for allU.S. Navy and Marine Corpsplatforms
• 2012 – CNAF 1542.7 signed
Current CRM Principles
• Research Based – Not theory
• Incorporates Existing Knowledge Base– Not reinventing the wheel
• For Aircrew by Aircrew – who better?
• Emphasizes Evaluation and Validation– Realistic opportunity to learn
• Mission Specific – H-46 ≠ F/A-18
• Skill Based – specific training objectives
• Integrated – taught from the beginning throughout career, not an afterthought
D.A.M.C.L.A.S
• Decision Making (DM) • Assertiveness (AS) • Mission Analysis (MA) • Communication (CM) • Leadership (LD) • Adaptability / Flexibility (AF) • Situational Awareness (SA)
Human Error Background
• For the past four decades commercialaviation, the federal government, andmore recently the military have expendedsubstantial resources in determining thecause of mishaps
• Information recovered from cockpit voicerecorders, SIRs, HAZREPS, and civilianmishap reports indicate the number onecause is
Human Error
NAVAL SAFETY CENTER
• 1991 Naval Safety Center Report• “Human error is a contributing factor in
50% of all Class A mishaps”• Human error is defined as “any incident
involving crew pilot error which relates topoor employment of aircrew coordination,S/A, judgment, sub-optimal physiologicalstate, or a violation of NATOPS”
NHA Symposium. April 14-17 2008 31
Non-HE
15%HE 85%
No. of Class A Mishaps Human Error
USN Aviation 71 of 84
Non-HE
17%HE 83% USMC Aviation 40 of 48
USN/USMC, FY97-01 Human Error Past
Leading Causal Factors • Human Error (84%)
• Aircrew (breakdown in Crew Resource Management, poor decision making, failure to properly perform emergency procedures) • Supervisory (failure to provide adequate guidance and training)
• Material/Systems Malfunction (16%) • Material/component catastrophic failure (no human error involved) NHA Symposium. April 14-17 2008 32
Non-HE6%
HE 94%
No. of Class A Mishaps Human Error
USN Aviation 81 of 86
Non-HE9%
HE 91% USMC Aviation 52 of 57
USN/USMC, FY03-07
NSC Data: 22 Feb 08
Human Error Past
Leading Causal Factors • Human Error (90%)
• Aircrew (breakdown in Crew Resource Management, poor decision making, failure to properly perform emergency procedures) • Supervisory (failure to provide adequate guidance and training)
• Material/Systems Malfunction (10%) • Material/component catastrophic failure (no human error involved)
NHA Symposium. April 14-17 2008 33
HE 85%
No. of Class A Mishaps Human Error
USN Aviation 52 of 61
HE 97% USMC Aviation 32 of 33
USN/USMC, FY05-09
NSC Data: 05 Oct 2010
Human Error Past
Leading Causal Factors • Human Error (89%)
• Aircrew (breakdown in Crew Resource Management, poor decision making, failure to properly perform emergency procedures) • Supervisory (failure to provide adequate guidance and training)
• Material/Systems Malfunction (11%) • Material/component catastrophic failure (no human error involved) NHA Symposium. April 14-17 2008 34
Non-HE
27%HE 73%
No. of Class A Mishaps Human Error
USN Aviation 19 of 26 Non-HE
41%
HE 59% USMC Aviation 10 of 17
USN/USMC, FY10-12
NSC Data: 13 Nov 2012
Human Error Today
Leading Causal Factors • Human Error (67%)
• Aircrew (breakdown in Crew Resource Management, poor decision making, failure to properly perform emergency procedures) • Supervisory (failure to provide adequate guidance and training)
• Material/Systems Malfunction (33%) • Material/component catastrophic failure (no human error involved)
Future: Where is CRM headed?
• CRM/ORM integrated into NATOPS
• More focus on individual error prevention/mitigation
• Better data collection tools to spot trends
• Integration of CRM concepts in other facets of Navy • Surface • Subsurface • Special Operations • Medical Practices
IT IS NOT:
A SAFETY PROGRAM.
IT IS:
A program to effect a positive behavioral change in individuals (as opposed to
attitude changes or management theory) in order to prevent and/or
minimize human factor and crew errors.
YOU own the program.
Summary
• History• Commercial• Navy/MC
• Challenges• Future
• Your input and ownership
Questions?
CRM
PROGRAM MANAGEMENT
CRM Program Management
C-050-1503A
Terminal Objective
• Maintain a CRM Program in anoperational setting
Enabling Objectives
• Review CRM instruction changes• State the requirements for documenting
annual CRM qualifications• Review CRM Programs• Manage a CRM Program• Explain the importance of integration of
CRM throughout flight operations
References
• CNAF 1542.7• OPNAVINST 3710.7 series• T/M/S NATOPS• Wing and Squadron SOP
Instruction changes
CRM Qualification and Life Cycle Training Model
References:
• OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it does not need to be redone prior to first flight.
• CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight training shall be conducted in all Chief of Naval Air Training (CNATRA) squadrons and at the Fleet Replacement Squadrons (FRS) prior to first flight and is required for all students, instructors under training and any NATOPS qualified aircrew members without documented T/M specific ground training as defined by reference (a): (OPNAVINST 3710.7 series).
Instruction changes (cont.)
Initial T/M Specific Training
OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be conducted by a designated CRM instructor or facilitator…
CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted by a designated CRM Instructor (CRMI)…
• Some squadrons may initially be short CRM instructors to ensure this new requirement is met.
Recommendations: Look through all NATOPS jackets and find personnel that have attended CRMI and utilize them to help with the initial shortfall.
• Send current CRMF personnel to attend CRMI.
Instruction changes (cont.)
Annual T/M Specific Recurring Training
OPNAVINST 1542.7C: Not specified.
CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet their own annual requirements.
Instruction changes (cont.)
CRM Instructor Training
OPNAVINST 1542.7C; e: Not specified.
CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor course is a prerequisite to designation as a CRM Community Program Manager (PM) or CRMI. T/M CRM Facilitator training must also be completed in order to be designated a CRMI in a specific T/M.
New requirement in the CNAFINST. This was seen as a best practice and not specifically required in OPNAVINST 1542.7 (series). However, it was a requirement in the Assist Visit Checklist.
Recommendation: Send current CRMF personnel to attend CRMI.
Instruction changes (cont.)
CRM Facilitator Training
OPNAVINST 1542.7C; 7.f.: Not specified.
CNAFINST 1542.7; 6.g.(1)/(2):
(1) If the CRMF training is being administered with the intent of qualifying a CRMF,…
(2) If the CRMF training is being administered with the intent of qualifying a CRMI,…
Provides specific guidance for CRM training topics for CRMI and CRMF qualification that were not covered in OPNAVINST 1542.7 (series). This section clarifies that CRMF training does not need to occur first to become a CRMI.
Instruction changes (cont.)
Civilian Aircrew Members/Instructors
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall maintain the same qualifications as a uniformed aviator. Non-flying civilians that provide flight instruction to USN/USMC aviators are required to maintain the same ground CRM currencies as uniformed aviators. If they are providing CRM initial ground training they are required to be a CRMI. If they are only providing CRM recurrent ground training they are required to be a CRMI or CRMF.
This section provides specific guidance for Civilians mirroring the requirements of uniformed aviators.
Instruction changes (cont.)
Unmanned Aircraft Systems
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in accordance with this instruction, to include training for UAS crewmembers (UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO), and Ground Maintenance Vehicle Operators (GMVO).
This section provides guidance for UAS mirroring the requirements of uniformed aviators.
CRM Organization
Controlling Custodians
CRM IMM
Curriculum Model Manager (CO)
Program Manager CRM Instructors CRM Facilitators
CRM Director
Naval Safety Center
CRM Fleet Organization
CRM Instructional Model Manager
NSC
CRM Director SAS Divo
USN TacAir Inst. Model Mgr. CRM-I Instructor
T/M/S Curriculum Model Manager
FRS CO
T/M/S Curriculum Model Manager
FRS CO
T/M/S Curriculum Program Manager
FRS Instructor
CRM Instructor CRM Instructor
CRM Facilitator Squadron Level
CRM Facilitator Squadron Level
USMC TacAir Inst. Model Mgr. CRM-I Instructor
Same Organization
USN Prop/Heavy Inst. Model Mgr. CRM-I Instructor
Same Organization
USMC Prop/Heavy Inst. Model Mgr. CRM-I Instructor
Same Organization
USN Helo Inst. Model Mgr. CRM-I Instructor
Same Organization
USMC Helo Inst. Model Mgr. CRM-I Instructor
Same Organization
Enlisted Inst. Model Mgr. CRM-I Instructor
Controlling Custodian
Controlling Custodian
Designations
• CRMFs are designated by their respectiveCommanding Officers or Officers in Chargeas applicable they require endorsementfrom the PM or CRMI
• The PM and CRMIs are designated inwriting by the CRM T/M/S CMM per CNAF
Documentation
• NATOPS Jacket• Designation Letter • Section 2, Tab C
(miscellaneous)• Enclosure 3
• CRM IMM • Designation
(CRMI, ULM, and CRMF)
• Ground Training (T/M/S)
• Flight Evaluation (T/M/S)
Documentation
• NATOPS Jacket • Slash 7 • Instrument Check • Paragraph on Command
Letterhead signed by the Commanding Officer • Annual Flight CRM
Check/Training ““Conducted CRM flight evaluation per CNAFINST 1542.7.””
• Note any CRM observations
• Proper flight code in the logbook 2L3/2L4/2L5
• Ensure the date matches all 3 documents (Encl 3, slash 7, and logbook)
Conducted CRM flight evaluation per CNAFINST 1542.7.
Training
• All CRM ground training contains thefollowing common elements:• CRM history• 7 critical skills• CNAFINST 1542.7• T/M specific case study
Types of Training
• Initial ground training: Covers whatsomeone new to the platform should knowregarding CRM issues within thecommunity
• Annual recurrency training: Similar toinitial, but more focus on communityspecific issues and personal experience
• Squadron instructor training: Tailored tosuit the needs of CRM during studenttraining (CNAFINST 1542.7; 6.g.(1)/(2))
Types of Training (Cont.)
• CRMF training: Specific for those whoconducting annual training. CRMF: History,7 skills, CNAF 1542.7, program admin,facilitation and evaluation techniques,workload management, teamwork, reviewof community specific annual groundtraining brief, and conduct grading of theCRM flight evaluation
Types of Training (Cont.)
• CRMI training: CRMI course graduate,program admin, facilitation and evaluationtechniques, review of community specificannual ground training brief, and conductgrading of the CRM flight evaluationAdditional topics may be included by CMM
• Remember this CRMI course is only one ofFIVE requirements to qualify (NATOPSqualified; Designated by your CMM; CRMF;and E5/03 and above)
Training Techniques
• Teach facilitators, and students,platform specific cases thatdemonstrate good and/or bad examplesof the seven skills and threat/errormanagement• Examine HAZREPs and Mishap
Reports as your resource• Personal experiences are valuable!
Training Techniques (Cont.)
• Case studies should be T/M specific• Case studies from other aircraft can be
used provided there are common elementsbetween aircraft:
F-18 ≠ H-60 • Transferability is the issue. Just ask
yourself does the case study haveanything to do with my platform?
H-53 SAR = H-60 SAR
Training Techniques (Cont.)
• Case studies should be crew positionspecific
• Include current equipment, especiallyautomation
• Maintenance, operational, andadministrative impacts on CRM shouldalso be included
Training Techniques (Cont.)
• Personal examples are invaluable• Old case studies and training materials
indicate a stale CRM program• Case studies can be developed by using
SIRs, HAZREPS, ASAP, MFOQA,personal experiences, the FAA, and theIMMs
• You will inherit the program• Know your squadron CRMIs and CRMFs• Maintain a contact list• Standardize training media• Know the state of CRM practices in yourT/M/S
PM turnover binder
Good CRM Programs Good CRM Programs (Cont.)
• Designations in the NATOPS jacket andalso in the PM binder
• Documentation of check-flight evaluationson enclosure (3) in NATOPS jacket, onNATOPS/Instrument/Stan checkpaperwork, and identified in the flightlogbook with the correct codes
Good CRM Programs (Cont.)
• Developed CRM SOP• Tracking, scheduling, and monitoring of
qualifications• Have an effective number of
experienced CRMI and CRMF• CRM incorporated into procedures
including NATOPS, briefs/debriefs,checklists, and FTI
• Incorporates human error concepts andThreat and Error Management
CRM Programs should NOT be • Ground training focuses exclusively on 7
skills (DAMCLAS check in the block) • Ground training as part of Safety Stand
down • Evaluation documented as an afterthought• Not knowing or tracking the facilitators for
your model
Good CRM Programs (Cont.)
Good CRM Programs (Cont.)
• CRM ground training conducted prior tothe first flight and/or check-flightevaluation:T/M/S specific
Scenario intensive • CRM dedicated flight events, in a high
fidelity simulator if available, and evaluate crew performance
Check-flight Grade Sheet
EVALUEE: _________________________________ OUTSTANDING _________ 3.5-4.0EXCELLENT _________ 2.8-3.4
INSTRUCTOR: __________________________________ SATISFACTORY _________ 2.0-2.7UNSATISFACTORY _________ 0.0-1.9
1. Situational Aw areness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
2. Assertivness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
3. Decision Making OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
4. Communication OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
5. Leadership OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
6. Adaptability/Flexibility OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
7. Mission Analysis OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1
COMMENTS:
RESULT IN AN OVERALL GRADE OF UNSATISFACTORY.
AIRCREW CRM CHECK FLIGHT EVAL WORKSHEET
OVERALL GRADE
INSTRUCTOR SIGNATURE _______________________ DATE ______________
1. A GRADE OF UNSATISFACTORY IN ANY CRM SKILL WILL FLIGHT EVALUATION DETERMINATION
Example
• The following is an example of how toincorporate CRM into T/M/Sinstructions/SOP’s.
NATOPS
Poor Practices
• Ground training focuses on 7 skills only• CRM ground training conducted in
conjunction with a Safety Stand-down• Evaluation documented as an
afterthought• Improper tracking of CRMI and CRMF• Improper designations or tracking• CRM not integrated into procedures• Chain of Command or culture does not
support CRM
Poor Practices
• CRM training not standardized or out ofdate
• No CRM turnover binder• Contractors teaching CRM differently
because they failed to attended CRMItraining
Summary
• CRM organizational structure• Designations• Documentation• Training• Good program practices• Poor program practices
Ques%ons?
CRM Program Instruction Changes
Reference
CNAFINST 1542.7
Instruction changes
CRM Qualification and Life Cycle Training Model
References:
• OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it does not need to be redone prior to first flight.
• CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight training shall be conducted in all Chief of Naval Air Training (CNATRA) squadrons and at the Fleet Replacement Squadrons (FRS) prior to first flight and is required for all students, instructors under training and any NATOPS qualified aircrew members without documented T/M specific ground training as defined by reference (a): (OPNAVINST 3710.7 series).
Instruction changes (cont.)
Initial T/M Specific Training
OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be conducted by a designated CRM instructor or facilitator…
CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted by a designated CRM Instructor (CRMI)…
• Some squadrons may initially be short CRM instructors to ensure this new requirement is met.
Recommendations: Look through all NATOPS jackets and find personnel that have attended CRMI and utilize them to help with the initial shortfall.
• Send current CRMF personnel to attend CRMI.
Instruction changes (cont.)
Annual T/M Specific Recurring Training
OPNAVINST 1542.7C: Not specified.
CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet their own annual requirements.
Instruction changes (cont.)
CRM Instructor Training
OPNAVINST 1542.7C; e: Not specified.
CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor course is a prerequisite to designation as a CRM Community Program Manager (PM) or CRMI. T/M CRM Facilitator training must also be completed in order to be designated a CRMI in a specific T/M.
New requirement in the CNAFINST. This was seen as a best practice and not specifically required in OPNAVINST 1542.7 (series). However, it was a requirement in the Assist Visit Checklist.
Recommendation: Send current CRMF personnel to attend CRMI.
Instruction changes (cont.)
CRM Facilitator Training
OPNAVINST 1542.7C; 7.f.: Not specified.
CNAFINST 1542.7; 6.g.(1)/(2):
(1) If the CRMF training is being administered with the intent of qualifying a CRMF,…
(2) If the CRMF training is being administered with the intent of qualifying a CRMI,…
Provides specific guidance for CRM training topics for CRMI and CRMF qualification that were not covered in OPNAVINST 1542.7 (series). This section clarifies that CRMF training does not need to occur first to become a CRMI.
Instruction changes (cont.)
Flight Instructor CRM Training
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.h.: FRS and TRACOM units shall incorporate formal CRM training into instructor indoctrination. This requirement can be combined with initial ground training.
This section provides specific IUT guidance in FRS and TRACOM units.
Instruction changes (cont.)
Civilian Aircrew Members/Instructors
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall maintain the same qualifications as a uniformed aviator. Non-flying civilians that provide flight instruction to USN/USMC aviators are required to maintain the same ground CRM currencies as uniformed aviators. If they are providing CRM initial ground training they are required to be a CRMI. If they are only providing CRM recurrent ground training they are required to be a CRMI or CRMF.
This section provides specific guidance for Civilians mirroring the requirements of uniformed aviators.
Instruction changes (cont.)
Unmanned Aircraft Systems
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in accordance with this instruction, to include training for UAS crewmembers (UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO), and Ground Maintenance Vehicle Operators (GMVO).
This section provides guidance for UAS mirroring the requirements of uniformed aviators.
Instruction changes (cont.)
Documentation Requirements
OPNAVINST 1542.7C; 7.g.:
CNAFINST 1542.7; 6.m.: The CRM Training/Evaluation Record, enclosure (3), shall be used to document CRM courses, designations, ground training, and extensions in the individual’’s NATOPS Flight Personnel Training/Qualifications Jacket in Section II, part C. All CRM designation letters and flight evaluations shall also be filed in the NATOPS Jacket. CRM flight evaluations shall be documented on an applicable T/M approved form with the following statement included in the write up; ““Conducted CRM flight evaluation per CNAFINST 1542.7A.””*
New requirement specifically for designations to be recorded and designation letters to be filed in the NATOPS Jackets. Also provides a standard statement for recording the CRM flight evaluation.
*CNAFINST 1542.7A is a typo and should be CNAFINST 1542.7.
Instruction changes (cont.)
Responsibilities
OPNAVINST 1542.7C; 8.:
CNAFINST 1542.7; 7.:
Removed: a. Chief of Naval Operations (N78) b. CG Marine Corps Combat Development Command (C473) c. Commander, Naval Air Systems Command (PMA-205) e. Controlling Custodians
Replaced with: a. Commander, Naval Air Forces b. Commander, Naval Air Forces NATOPS Officer (N455) c. Deputy Commandant for Aviation (DC AVN)
Instruction changes (cont.)
Responsibilities (cont.)
OPNAVINST 1542.7C; 8.h:
CNAFINST 1542.7; 7.d:
CRM Instructional Model Manager has been incorporated into Naval Aviation Schools Command Program Officer. (This will change once we transition to Naval Aviation Safety Center).
OPNAVINST 1542.7C; 8.d:
CNAFINST 1542.7; 7.e:
Naval Safety Center changed to Naval Safety Center CRM Program Officer.*
*Typo Naval Safety Center CRM Program Officer should be underlined in the instruction.
Instruction changes (cont.)
Responsibilities (cont.)
OPNAVINST 1542.7C; 8.f:
CNAFINST 1542.7; 7.f:
CRM Curriculum Model Manager changed to CRM T/M/S CMM (refer to enclosure (4) ).
(8) Forward detailed copies of contractor-developed CRM materials to the IMM for review and concurrence.
(9) When a TRACOM air wing commander (CTW) is the CMM for multiple T/M/S, the CTW may designate in writing a PM for each T/M/S training aircraft.
Instruction changes (cont.)
Responsibilities (cont.)
OPNAVINST 1542.7C; 8.i:
CNAFINST 1542.7; 7.g:
Unit Level
(1) Designate in writing a CRM Unit Level Manager (ULM). ULMs shall be a qualified CRMF and should normally be the Unit NATOPS Instructor.
(4) Ensure flow of pertinent CRM related issues to the CRM CMM via the PM to include T/M/S lessons learned, documented CRM breakdowns, and specific areas of concern for the T/M/S. Ensure appropriate material is briefed to all aircrew members.
Instruction changes (cont.)
Responsibilities (cont.)
OPNAVINST 1542.7C: Not specified.
CNAFINST 1542.7; 7.h:
Individual Naval Aircrew Members
(1) Ensure CRM is applied to all phases of flight planning, flight execution, and debriefing.
(2) Ensure the ULM is informed of all CRM-related incidents involving the breakdown of CRM, as well as hazard mitigation that resulted from effective CRM practices. The goal is to learn from our mistakes and our positive CRM practices and behaviors that increase mission effectiveness and mitigate preventable aircrew errors.
Provides specific guidance for all aircrew members.
Instruction changes (cont.)
Responsibilities (cont.)
OPNAVINST 1542.7C: Not specified.
CNAFINST 1542.7; 7.h:
Individual Naval Aircrew Members
(1) Ensure CRM is applied to all phases of flight planning, flight execution, and debriefing.
(2) Ensure the ULM is informed of all CRM-related incidents involving the breakdown of CRM, as well as hazard mitigation that resulted from effective CRM practices. The goal is to learn from our mistakes and our positive CRM practices and behaviors that increase mission effectiveness and mitigate preventable aircrew errors.
Provides specific guidance for all aircrew members.
Instruction changes (cont.)
Records Management
OPNAVINST 1542.7C; 9: The reporting requirements required by this instruction are exempt from reports control per SECNAVINST 5214.2.
CNAFINST 1542.7; 9.*: (*Typo should be 8.): Records created as a result of this instruction, regardless of media format, shall be managed per SECNAV M-5210.1C.
Instruction changes (cont.)
Forms and Reports
OPNAVINST 1542.7C; 7. g: Enclosure (4)
CNAFINST 1542.7; 10.* (*Typo should be 9.): Enclosure (3) of this instruction shall be locally produced to document CRM qualifications and be permanently maintained in the NATOPS Flight Personnel Training/Qualification Jacket Section II, Part C.
Instruction changes (cont.)
Definitions Enclosure (1)
OPNAVINST 1542.7C
CNAFINST 1542.7
Added more to clarify the existing definitions:
• Crew Resource Management (CRM) • Crew Resource Management Critical Skills: AF, AS, CM, DM, LD, MA, SA • Time Critical ORM (TC-ORM) • CRM T/M/S Community Assistant Program Manager • CRM Unit Level Manager (ULM) • Naval Aviation Activity
Instruction changes (cont.)
CRM Training/Evaluation Record
OPNAVINST 1542.7C (Enclosure (4) )
CNAFINST 1542.7 (Enclosure (3) ).
CRM Facilitator Course
replaced with
CRM Designations
(List all CRM Designations Attained to include Instructor, ULM and Facilitator in this section).
Allows for all CRM qualifications, not just the Facilitator course.
Instruction changes (cont.)
CRM Training/Evaluation Record (cont.)
OPNAVINST 1542.7C (Enclosure (4) ): Annotation required T/M
CNAFINST 1542.7 (Enclosure (3) ): Annotation requires T/M/S
This ensures CRM training is created and tailored to identify the specific CRM and Mission differences in multiple series aircraft in the Naval Aviation inventory.
Instruction changes (cont.)
CRM Training/Evaluation Record (cont.)
OPNAVINST 1542.7C (Enclosure (4) ):
CNAFINST 1542.7 (Enclosure (3) ): Has typos. There is no difference between the two instructions and should read as below:
Ground Training Flight Training Annual CRM Ground Training CRM renewal expires last expires the last day of the day of current month plus current month plus one year. one year and may be accomplished 60 days early
Instruction changes (cont.)
TABLE OF T/M/S CRM CURRICULUM MODEL MANAGERS AND INSTRUCTOR REQUIREMENTS
OPNAVINST 1542.7C: (Enclosure (2) ):
CNAFINST 1542.7 (Enclosure (4) ):
Most of aircraft in the inventory were not removed from the inventory/table have a change in one or more of the following: T/M/S, T/M/S CURRICULUM MODEL MANAGER COMMAND, CONTROLLING CUSTODIAN OR MINIMUM NUMBER/TYPE INSTRUCTOR.
7 CRITICAL SKILLS LD AF MA
Leadership Adaptability/Flexibility
Mission Analysis
CRM SKILLS
C-050-1503A PPT 5001 01
Terminal Objective
• Implement CRM academics, in aclassroom setting, in accordancewith Instruction, Crew ResourceManagement Program, CNAF1542.7 (series); and CrewResource ManagementInstructor Course Student Guide.
Terminal Objective
• Upon completion of this unit ofinstruction, the student willdemonstrate knowledge of thepurpose and goals of CRM, aswell as the importance ofleadership, adaptability/flexibility,and mission analysis.
Enabling Objectives
• Discuss and understand theimportance of Leadership.
• Discuss and understand theimportance of Adaptability/Flexibility.
• Discuss and understand theimportance of Mission Analysis.
Why CRM?
• The leading cause of aviation mishaps isdue to human error.
• Technology has developed to reducemechanical failure.
• Human behavior has not developed toreduce human error.
• CRM is the method to modify humanbehavior.
Philosophy
• In the past the best way to learn goodCRM skills was to be fortunate enoughto fly with and learn by experience ofthose who practice CRM well.
• This a process which identifies thesuccessful traits of our best aircrew inan effort to teach it in an academicenvironment.
CRM Defined
• CRM: The effective use of all availableresources by individuals, crews and teams tosafely and efficiently accomplish the missionor task.
• CRM also refers to identifying and managingthe conditions that lead to error.
CRM Program
• Program: A training program to effectbehavioral modification (as opposed toattitude changes or management theory) inorder to prevent human factor and crewpreventable errors.
Purpose
• Purpose: CRM is intended to improvethe mission effectiveness of all aviationcommunities by enhancing crewcoordination through increasedawareness of associated behavioralskills (Seven Critical Skills) and errortheory.
• It is your program.
CRM Goals
• Increase mission effectiveness• Minimize crew preventable errors• Maximize crew coordination• Good → Better
External Factors (Threats)
• WEATHER• ENVIRONMENT• TERRAIN• ENEMY THREATS• AIRCREW COMPOSITION• MISSION DURATION• MISSION CHANGES• MISSION TASKING• MORE?
Seven Critical Skills
• Decision Making DM • Assertiveness AS • Mission Analysis MA • Communication CM • Leadership LD • Adaptability / Flexibility AF • Situational Awareness SA
Leadership
Definition: The ability to direct and coordinate the
activities of crew members and to encourage them to work together as a team
• Designated• Functional
(lē'dəәr-shĭp')
Leadership
DESIGNATED LEADERSHIP • Obtained by rank, crew position or title• Responsible for crew and mission
accomplishment; therefore, makes all finaldecisions
FUNCTIONAL LEADERSHIP • Refers to leadership by knowledge or expertise
and occurs when expertise and need for infobecomes critical
• Allows for most qualified crew member to takecharge / meet situational demands
Leadership
• What makes a good leader?
• What makes a poor leader?
Traits of an Effective Leader • Respected• Decisive• Delegates tasks• Provide feedback• Keeps crew informed• Open to suggestions• Builds team spirit• Leads by example• Directs and coordinates• Maintains professional atmosphere• Knowledgeable
Leader’s Responsibilities
• Directs actions• Also solicits input and asks for help.
• Sets the tone – professionalatmosphere
• Delegates tasks and keeps groupfocused
• Keeps crew or section members aware ofmission information including:• Altered plans• Decisions that are made• Feedback on their performance
• Defines boundaries & expectations
• Ultimately responsible for performance ofcrew
Leader’s Responsibilities
FOLLOWERSHIP
Followership
Followership
SURVIVORS
ALIENATED Air India Express Boeing 737-800
Active
Dependent Uncritical Thinking
YES PEOPLE
EFFECTIVE
SHEEP
Independent Critical Thinking
Passive
R.E. Kelley, 1992
B-52 Crash
ADAPTABILITY/FLEXIBILITY Definition: The ability to alter a course of
action based on new information, maintain constructive behavior under pressure, and adapt to internal and
external environmental changes.
The success of a mission depends upon the crew’s ability to alter behavior and dynamically manage crew
resources to meet situational demands.
ADAPTABILITY / FLEXIBILITY (əә-dāp'təә-bil-əәtē) / (flěk'səә- bil-əәtē)
• Every mission is potentially different• Even canned missions
• React to unexpected• Priorities may change, but tasks still required
• Counters rigidity• Less vs. more experienced crews
Importance of A/F
• Unbriefed situations arise• Routine mission becomes an emergency• Interactions are strained• Aircraft is partial mission capable• WX changes
When is Adaptability / Flexibility required?
ADAPTABILITY / FLEXIBILITY
ADAPTABILITY / FLEXIBILITY
• What makes YOU successful atadapting or flexing?
• Recognize and acknowledge change• Anticipate Problems / Mission Analysis• Determine if an SOP or Habitual
Response is appropriate• Interact constructively with others• Can you go too far?
Joint Ops
• Establish an open, professional atmosphere
• Ensure the crew understands the mission
• Communicate!
Setting the tone for A/F
ADAPTABILITY / FLEXIBILITY
MISSION ANALYSIS
MISSION ANALYSIS
Definition: The ability to develop short term, long term, and contingency plans and to coordinate, allocate, and monitor
crew and aircraft resources.
Effective planning leads to flight conduct that removes uncertainty, increases mission effectiveness, and
enhances safety.
(mĭsh'əәn əә-nāl'ĭ-sĭs)
MISSION ANALYSIS
• PRE FLIGHT
• IN FLIGHT
• POST FLIGHT
THREE PHASES
Pre-Mission Analysis
• Identifying Mission Objectives• Identifying Mission Constraints,
challenges and Options• Preparation• Contingency plans• Briefing
Pre-Mission Analysis
• Planning• Professional• Focused• Assign
Responsibilities• Interactive• Complete
Characteristics of an Effective Brief
IN FLIGHT MISSION ANALYSIS
• Short Term Planning
• Monitoring Mission Progress
• Identifying and Reporting Challengesor Changes
POST-MISSION ANALYSIS
• Selective Review
• Interactive
• Timely
• Lessons Learned
SUMMARY
• Defined and explained the purpose of CRM• Identified the goals of CRM• Defined leadership• Stated the responsibilities of leadership• Stated the behaviors associated with effective
leadership• Stated the traits of effective leaders• Defined adaptability / flexibility• Identified the importance of adaptability /
flexibility
SUMMARY • Identified situations that require adaptability/
flexibility• Explained how to set the tone and maintain
high adaptability/flexibility• Define mission analysis• Identified the importance of mission analysis• Stated the phases of mission analysis• Defined in-flight mission analysis• Discussed the importance of the debrief in
mission analysis
Questions?
7 CRITICAL SKILLS CM AS
SEVEN CRITICAL SKILLS CM, AS
CREW RESOURCE MANAGEMENT
C-050-1503A PPT 5006 01
Terminal Objective
• Implement CRM academics, in a classroomsetting, in accordance with Instruction, CrewResource Management Program,CNAF1542.7; and Crew ResourceManagement Instructor Course StudentGuide
Enabling Objectives
• Instruct CRM critical skills • Define assertiveness • Discuss assertive behaviors • State the barriers to assertiveness • Describe situations requiring assertiveness • Define communication • Explain the importance of communication• Explain the process of communication • State the different types of communication• Explain the characteristics of effective communication • State the barriers to effective communication • Explain the methods to overcome barriers to effective
communication
Seven Critical Skills
• Decision Making DM • Assertiveness AS • Mission Analysis MA • Communication CM • Leadership LD • Adaptability / Flexibility AF • Situational Awareness SA
ASSERTIVENESS
What Is Assertiveness?
Definition: The willingness to actively participate, state and maintain a position,
until convinced by the facts that other options are better.
Requires the COURAGE and INITIATIVE to act.
(əә-sûr'tĭv-nəәs)
Comfort Level
Comfort level is an internal anxiety gauge that alerts us
when something isn’t right and needs to be corrected.
Lack of Assertiveness?
Behavior Types
Passive Assertive Overly Aggressive
Overly Aggressive
• DOMINATION• INTIMIDATION• ABUSIVE /
HOSTILE
Fired up!
• Overly courteous
• “Beats around the bush”
• Avoids conflicts
• “Along for the ride”
Passive
Assertiveness
• Active involvement during flight• Provides relevant information without
being asked• Readiness to take action
• Makes suggestions• No fear of retribution
Barriers To Assertiveness
• Position of authority• Experience• Rank• Qualifications• Personal characteristics• Lack of confidence• Fear of reprisal
3 Times You Have To Speak Up
• Will improve results of group
• Gives others permission to speaktheir truth
• Costs of silence are too high
Nilofer Merchant, 2011
Creating An Assertive Statement
• Typically use active verbs or recommendan action.
• Get the attention of the receiver• State your concern• Offer a solution• Ask for feedback
• “Gobblin’, I show us 300ft below assignedaltitude. Recommend we climb. What areyou showing?”
Rules Of Thumb
• Most Conservative Response• If disagreement in the aircraft exists, take the
most conservative action until moreinformation is available.
• Two Challenge Rule• In extreme situations, if the pilot (flying) does
not respond appropriately to two demands,the copilot (pilot not flying) should take thecontrols.
COMMUNICATION
Communication
Definition: The ability to clearly and accurately send and acknowledge
information, instructions, or commands, and provide useful feedback.
(kəә-myōō'nĭ-kā'shəәn)
Communication
• Vital to mission accomplishment• Maintains Situational Awareness
Important, why?
Verbal Communication
Words
Tone
Non verbal cues (e.g. gesture, posture, facial expression)
7%
38%
55%
Dr. Albert Mehrabian, (1972)
* When communication is ambiguous.
Decode Encode Transmit Receive
Meaning (Interpret)
Meaning (Intent)
Message Meaning
(Interpret)
Meaning (Intent)
Encode Decode Receive Transmit
Feedback
Noise
Basic Communication Model
COMMUNICATION EXERCISE
One-way Communication
• Rapid
• Looks and sounds neater
• Generally requires more planning
• Responsibility lies with sender
• The sender feels in control
• Receiver may switch off
DIAGRAM #1 Two-way Communication
• Potentially more reliable and effective• Permits correction of details• Requires less planning• Receivers have more confidence• Both sender and receiver have responsibility• Non-verbal communication more important• Generally takes longer• Can lead to frustration and anger• Sender can feel threatened
DIAGRAM #2 External Barriers
• Noise• Low voice• Electrical interference• Separation in space, time• Lack of visual cues• (e.g. gesture, posture, facial expression)
Internal Barriers
• Personality• Motivation• Expectations• Past Experience• Prejudice• Rank• Emotions/Moods• Language Difference• Culture
List The Barriers
• Active Listening• Appropriate mode and decibel level• Pre-briefed Terminology• Professional Attitude• Compartmentalization• Resolving conflicts on deck• Avoid bad “cockpit marriages”
Overcoming Barriers Effective Communication
• Explicitness - Clearly stating the desired action and who should do it.
• Directness - Degree of pressure to comply with the desired action.
• Social appropriateness - Sensitivity to the roles and status of speaker/addressees and to the seriousness of the situation
Most Effective
• Explicitly state what to do and maintain positive team climate:
• Obligation Statements: States an obligation or an intention:
“Waveoff, Gobblin’.”
• Suggestions: Suggests an action to be taken, a strategy, or an ability:
“We can ask them to go left of that if you want.”
• Relayed Requests: Restating a third-party request:
“Now [ATC] wants us to go right.”
Least Effective
• Too vague to identify problem or action
• Mild Hints: Queries or observations that donot refer directly to the problem:
“How are things coming along?”
Spatial D Monitoring And Challenging
• Essential elements of aviation safety• Monitor each others’ performance• Communicate observed errors to prevent
problems from escalating
• Communication dilemma• How to communicate unambiguously and
encourage compliance • While maintaining positive team climate
(Fischer & Orasanu, 2000)
Air Florida Flight 90 (1982)
First officer: ‘That don’t seem right does it? Ah, that’s not right’.
Captain: ‘Yes it is, there’s eighty’ (knots).
First officer ‘Naw, I don’t think that’s right’
Captain: (No response)
“The first officer continued to show concern as the aircraft accelerated through a ‘hundred and twenty’ (knots).”
(NTSB, 1982: 64
NASA Simulation Results
• More effective communicationstrategies used when risk was high.
• FOs less likely to challenge when FaceThreat (degree of challenge to the otherpilot’s skill, judgment, or competence)was high.
Implications
• Importance of challenging in teams• Promotes functional conflict• Supports team goals• Can improve performance
• Dangers of not challenging errors• Avoiding relationship conflict may
undermine performance and safety
Effective Communication?
Communication
• Communication is vital!• Be aware barriers will happen and
overcome them.• The greatest enemy of effective
communication is the illusion of it.
REMEMBER
Illusion Of Communication
Assertiveness Summary
• Comfort level
• The range of behavior types
• Barriers to assertiveness
• Situations requiring assertiveness
Communication Summary
• The basic communication model
• The differences between one and two-waycommunication
• Barriers to communication
• Effective communication
• Monitoring and challenging
Questions?
7 CRITICAL SKILLS SA DM
The Cognitive Components of CRM
Situational Awareness & Decision Making
C-050-1503A PPT 5007 01
Lesson Topic 2.5 Terminal Objective Instruct CRM Critical Skills
Enabling Objectives • Instruct CRM critical skills, in a classroom setting, in accordance with
Instruction, Crew Resource Management Instructor Course Student Guide.
• Define Situational Awareness, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Explain the difference between perception & reality, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Describe the levels of SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
Objectives
• Explain the cognitive mechanisms at work in the brain which enable development of SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• List factors that reduce SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• State techniques for maintaining and recovering SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
* The more discussion the better!
Objectives (cont.) Human Factors Research
• Offshore oil production
• Nuclear power generation
• Medicine
• Civil aviation
• Navy divers, EOD, SEALs
• Navy/ Marine Corps aviation
What do these industries have in common?
Human Information Processing
Limitations of the human information processing system have an enormous effect on the ability of an aviator to gather the information required, and make a good decision on the basis of that information.
Memory Model
Long term Memory
Sensory memory
Short term memory
& Working memory
INPUT
INFORMATION RECALLED
Adapted from Atkinson & Shiffrin (1971)
• Knowledge • Skills • Experience • Diagnostic rules • Procedures etc.
Working Memory
• People cannot remember large amounts of information due to the size of working memory
• Duration is 18 to 20 seconds without rehearsal
• The amount of information retained can be increased by rehearsal and by ‘chunking’
• Susceptible to distraction, stress, and fatigue
• Can be freed up through experience • Eventually becomes long term memory
Information Processing Summary
Working memory is critical to: • Situational Awareness• Decision Making• Workload Management
Situational Awareness Situational Awareness
As much as 88% of human error is due to problems with
Situational Awareness.
Endsley, 1995
Error???
What is the percentage of mishaps due to human error?
Definition
What is your definition of Situational Awareness?
Navy Definition
• The degree of accuracy by whichone’s perception of the currentenvironment mirrors reality
• Only requires that we know:• What is currently happening• Where the aircraft is in three-dimensional space
Academic Definition
“…the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future”
Endsley, 1995
Performance of Actions
Perception of elements in current situation
Comprehension of current situation
Projection of future
status
Decision Making
Situational Awareness
Level 1 Level 2 Level 3
Model of Situational Awareness
Endsley, 1995
Perception of elements in the current situation • Data unavailable• Data difficult to detect• Failure to scan or observe
• Omission • Attention narrowing (tunnel vision) • Distraction • High task-load
• Misperception of data• Memory capability
Level 1: Error
Comprehension of current situation
• Lack of/poor mental model
• Use of incorrect mental model
• Over-reliance on default values in model
• Memory failure
Level 2: Error
Mental models are created by
Experience Briefing Expectations
The Creation of Mental Models
Pilot
NFO
Mental model
Mental model
Common Understanding Event
Need a Shared Mental Model
Pilot
NFO
Mental Model
A Interpretation A
Interpretation B
Event
Everyone’s Mental Model Can be Different
Mental Model
B
Projection of future status • Failure to accurately project the mental
model
Level 3: Error
Leve
l 3 - 5
% Level 2 17%
Level 1 78%
In What Levels are Errors Occurring?
Level 1: Data Perception
Level 2: Data Comprehension
Level 3: Data Projection
Jones & Endsley (1996)
What is the Most Common Cause of Level 1?
• Data unavailable• Hard to discriminate/detect data• Failure to scan• Misperception• Memory capability
0
5
10
15
20
25
30
35
40
A B C D E F G H I J K L
Level 1 Level 2 Level 3
Perc
ent o
f tota
l SA
erro
rs
Situational Awareness Errors A= Data not available B= Hard to discriminate/detect data C= Failure to scan D= Misperception E= Memory loss F= Lack or incomplete mental model G= Use of incorrect mental model H= Over-reliance on default values I= Other J= Lack or incomplete mental model K= Over-projection of current trend L= Other
Factors That Reduce SA
• Insufficient communication• Fatigue/Stress• Task overload/underload• Group mindset• Press on regardless philosophy• Degraded operating conditions
C-5 Case Study
• Location: Dover AFB• MPs arrived at 0340• Took off 0621 from Dover AFB (MP2 flying)• Date and time: 3 April 2006, 0639• Aircrew:
• Pilot: Reservist, evaluator pilot, >4000 hours • Copilot: Reservist, Chief of training, instructor pilot,
>2300 hours• Jump seat: Reservist, CO, >3800 hours (observer) • 3xFE: 2750-8200 hours • 5x Loadmasters
Lead Up to Mishap
• 3 minutes into flight FE1 noticed a flickering‘thrust reverser not locked’ light on #2 engine
• MP2 shutdown #2 engine, advised Doverapproach that they were returning
• MP3 (CO) suggested MP1 land, so MP1assumed control
• Two ICS Nets• New Glass Cockpit• Recent Hot Brakes HAZREP
How do you lose SA in the aircraft?
What are the clues that you, or a member of your team
has lost SA?
Clues to SA Problems
• Ambiguity – information from 2 or more sourcesdo not agree• Fixation – focusing on one thing• Confusion• Lack of required information• Failure to maintain critical tasks (e.g. fly the A/C)• Failure to meet an expected checkpoint• Failure to resolve discrepancies• A bad gut feeling that things are not quite right
Civil Aviation Authority (2003)
• I didn’t realize that…• I didn’t notice that…• I was busy attending to…• I wasn’t aware that…• We were very surprised when…• We were convinced that…
Retrospective Statements of lost SA
How do you maintain Situational Awareness in the
aircraft?
Maintaining SA
• Good brief• Fitness for work• Minimize distractions and interruptions duringcritical tasks• Sterile cockpit• Update – regularly compare mental models• Monitoring – be sensitive to clues of ‘zoningout’• Speak up• Time management
Flin, O’Connor & Crichton, 2008
• What is the immediate goal of your team?• What are you doing to support that goal?• What are you worried about?• What is the current problem, size, and
intention?• What do you think this situation will look like
in __ minutes, and why?
Questions to Calibrate SA
London Fire Brigade
Summary
• Memory Model
• S/A has three levels• L1: Perception
• L2: Comprehension
• L3: Projection
• Failure of scan is the most likely toaffect you
Questions? Break
Decision Making
Napoleon Bonaparte Nothing is more difficult, and therefore
more precious, than to be able to decide.
Terminal Objective Instruct CRM Critical Skills
Enabling Objectives • Define decision making, in a classroom setting, in accordance with
Instruction, Crew Resource Management Instructor Course Student Guide.
• List the steps in classical decision making and why they do not normally apply to aviation, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Describe some alternative models to classical decision making models, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Explain decision making in a time critical/high risk environment, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
Objectives
• Explain decision making where there is little or no experience with the situation, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Discuss rule-based decision making, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
• Discuss some of the tools that enhance decision making skills, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.
Objectives (cont.)
• The ability to choose a course of actionusing logical and sound judgment basedon available information.
Decision Making
FA-18 Case Study
• 26 March 2004, Raleigh Durham• Second leg of a three leg cross-country• MP had recently joined the squadron
from the FRS, and had about 100 hoursin the Hornet
• MP was dash 2, preparing for a 10second separation takeoff
• MP clears informational error code
Decision Point Failures
• Failed to clear error codes• Failed to recognize the paddle switch
disengaged nose steering• Failed to abort on the tarmac• Failed to abort on the grass• Failed to retard throttles, and
disengage afterburner at any time
Stroop (1935)
This test illustrates the difficulty of humans to inhibit one well-learned response and do something else.
Instructions: Start at row one, reading left to right, then row two, and finally, row three.
Task 1 Task 2 Task 3
Red Blue
10 9 8 7 6 5 4 3 2 1 State the Colors
Row 1
Row 2
Row 3
State the Colors
Row 1 Red Blue Green Yellow
Row 2 Yellow Green Blue Red
Row 3 Green Red Yellow Blue
10 9 8 7 6 5 4 3 2 1 State the Colors
Row 1 Red Blue Green Yellow
Row 2 Yellow Green Blue Red
Row 3 Green Red Yellow Blue
10 9 8 7 6 5 4 3 2 1
Stroop Take Away
• Using heuristics is useful to free up ourworking memory in normal situations.
• However, in situations that are not quitenormal, our well learned response canput us in difficulties.
Aviation Decision Environment
• Ill-defined goals• Uncertainty, ambiguity, missing data• Shifting and competing goals• Dynamic and continually changing conditions• Action feedback loops (real-time reactions to
changed conditions)• Time stress• Multiple players• Organizational goals and norms• Experienced decision makers
Klein, 1991
How Do You Make
Decisions?
British Airways – DODAR
D – Diagnosis What is the problem? O – Options What are they? D – Decision What are we going to do? A – Assign tasks Who does what? R – Review What happened?
What are we doing about it?
Lufthansa – FORDEC
F – Facts O – Options R – Risks and benefits D – Decision E – Execution C – Check
Naturalistic Decision Making
• Since the 1980s increased interest indecision making in complex real worldsettings
• Navy / Marine Corps has been at theforefront of this research• USS Vincennes shooting down Iranian
airliner in 1988• Tactical decision games
Naturalistic Decision Making
Flin, O’Connor, & Crichton, 2008
Stage 1. ASSESS THE SITUATION
Time risk pressures
Stage 3. Select a course of action
Stage 4.Implement a course of action
(What’s the problem?)
Risk - high Risk - low Time - low Time - high
Stage 2. MAKE A DECISION(What shall I do?)
FEEDBACKAnalyticalIntuitive CreativeRule-based
Stage 1: Assess the Situation
Time available risk variable
What’s the problem? How much time is available? How risky (present and future)?
Gather More Information
Create Solution
Schedule Tasks
Choose Options
ACT
Problem NOT understood
Problem understood
Problem understood OR NOT
understood
Rule available
No options available
Multiple options
available
Multiple tasks to do
Time Limited Risk High
Apply Rule
Stage 2: Make a Decision
The type of decision making strategy which is most appropriate is dependent on the amount of time, amount of information, and expertise of the decision maker.
Four decision making strategies are: • Intuitive
(Recognition Primed Decision – RPD)• Rule based• Analytical (Choice decisions)• Creative
Time available risk variable
What’s the problem? How much time is available? How risky (present and future)?
Gather More Information
Create Solution
Schedule Tasks
Choose Options
ACT
Problem NOT understood
Problem understood
Problem understood OR NOT
understood
Rule available
No options available
Multiple options
available
Multiple tasks to do
Time Limited Risk High
Apply Rule
Intuitive Decision Making (RPD)
Intuitive Decision Making (RPD)
• Actions and reactions based upon pastexperience.
• The emphasis is on reading the situation,rather than on generating different options forpossible actions.
• Experienced reading of a situation, so that theselection of a course of action is obvious.
• The generation of a solution that, while it maynot be the best, should result in a workablecourse of action.
Intuitive Decision Making (RPD)
Positives: • Useful method where time is limited • Requires little thought • Can lead to a satisfactory and workable action • Useful in routine situations
Negatives: • Can only be applied in certain situations • Need to be an expert • Can lead to confirmation bias
Time available risk variable
What’s the problem? How much time is available? How risky (present and future)?
Gather More Information
Create Solution
Schedule Tasks
Choose Options
ACT
Problem NOT understood
Problem understood
Problem understood OR NOT
understood
Rule available
No options available
Multiple options
available
Multiple tasks to do
Time Limited Risk High
Apply Rule
Rule Based Decisions Poor Procedures
• HAZREP: 27MAR06MARAERIALRFLTRANSRON 352 - ALL HERCULES AIRCRAFT ACTIVITIES • A review of EPs and PCL revealed over 260
items that were different, missing, incomplete,or formatted differently.
• PCL missing specific notes, cautions,warnings or procedures that are in NATOPS.
Rule Based Decisions
Positives: • Only need to follow a series of rules • Do not need to be an expert, or understand the
purpose of every step • Easy to justify action
Negatives: • It is easy to miss a step in the sequence • Poor diagnosis can lead to the wrong set of rules
Bird Strike
Time available risk variable
What’s the problem? How much time is available? How risky (present and future)?
Gather More Information
Create Solution
Schedule Tasks
Choose Options
ACT
Problem NOT understood
Problem understood
Problem understood OR NOT
understood
Rule available
No options available
Multiple options
available
Multiple tasks to do
Time Limited Risk High
Apply Rule
Analytical (Choice) Decisions Analytical (Choice) Decisions
• Focus of classical decision makingresearch
• The decision maker generates anumber of possible courses of action,and then compares them to determinethe best fit.
• Time Critical ORM• A-B-C-D Model
Assess your situation for hazards/risks
Balance your resources to control risks
Communicate your risks & intentions
Do & Debrief (act & monitor controls; provide feedback)
Steps of Time Critical ORM ORM
Analytical Decisions
Positives: • Fully compares alternative courses of action • Easy to justify • More likely to produce an optimal solution
Negatives: • Requires time • Not suited to noisy, distracting environments • Can be affected by stress • May produce cognitive overload
Time available risk variable
What’s the problem? How much time is available? How risky (present and future)?
Gather More Information
Create Solution
Schedule Tasks
Choose Options
ACT
Problem NOT understood
Problem understood
Problem understood OR NOT
understood
Rule available
No options available
Multiple options
available
Multiple tasks to do
Time Limited Risk High
Apply Rule
Creative Decision Making
Creative Decision Making
• Devising a novel course of actionfor an unfamiliar situation
• United 232, Sioux City
• Apollo 13
APOLLO 13
Creative Decision Making
Positives: • Produces solutions for unfamiliar problems
Negatives: • Requires time • Untested solution • Can be affected by stress • May produce cognitive overload • May be difficult to justify
Flin, O’Connor, & Crichton, 2008
Stage 1. ASSESS THE SITUATION
Time risk pressures
3. Select a course of action
4. Implement a course of action
(What’s the problem?)
Risk - high Risk - low Time - low Time - high
Stage 2. MAKE A DECISION(What shall I do?)
FEEDB
AC
K
AnalyticalIntuitive CreativeRule-based
Feedback
Factors Influencing DM
• Anything effecting cognition• Stress• Fatigue• Noise• Distraction• Interruption• The Other Critical Skills:
• SA, CM, AS, MA, LD, AF
Finally…
"When anyone asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worth speaking about....I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort."
Edward J. Smith (Captain of the Titanic)
Decision Making Summary
• Unique decision making environment inaviation
• Adopt the appropriate decision strategy• What’s the problem? • Is the level of risk high or low? • How much time do I have available?
• Decision strategies• Intuitive (Recognition primed) – gut feel • Rule-based – procedures • Analytical decisions (Choice) – ORM & matrixes • Creative – test pilot
Resources
• www.satechnologies.com Endsley’s company • www.raes-hfg.com/xsitass.htm Royal Aeronautical
Society conference on SA
• Flin, R. (1996) Sitting in the Hot Seat.
• Flin, R., O’Connor, P., Crichton, M. (2008). Safety at the Sharp End.
• Gladwell, M. (2005) Blink.
• Klein, G. (1999). Sources of Power: How People Make Decisions.
• Civil Aviation Authority (2006). Crew Resource Management. www.caa.co.uk/docs/33/CAP737.PDF
Questions?
WORKLOAD MANAGEMENT
Workload Management
C-050-1503A PPT 5001 01
A Very Loose Tie In
Enabling Objectives
• Implement workload management into CRM instruction, in a classroom setting, in accordance with CNAF 1542.7 and A Guide to Human Factors for Naval Aviators.
• Define workload management, in a classroom setting, in accordance with A Guide to Human Factors for Naval Aviators.
• Explain some of the factors that affect workload in a classroom setting, in accordance with A Guide to Human Factors for Naval Aviators.
Enabling Objectives
• Explain the goal of automation in reducing workload in accordance with A Guide to Human Factors for Naval Aviators.
• Describe how limitations of human performance affect workload and automation management in a classroom setting in accordance with A Guide to Human Factors for Naval Aviators.
• Explain effective workload and automation management in a classroom setting in accordance with A Guide to Human Factors for Naval Aviators.
Remember?
Our ability to handle multiple tasks is a function of our information processing capacity.
The main limitation is working memory.
Workload Management
• Workload:The amount of work performed or capable of being performed usually in the context of a defined period.
• Management:The act or art of supervising. Judicious use ofmeans to accomplish an end.
A WORKING DEFINITION
Factors Affecting Workload
• The nature of the task• Physical demands it requires • Mental demands it requires
• The circumstances under which the task isperformed• Standards of performance • Time available • Requirements to perform more than one task • Environmental conditions • Crew composition
Civil Aviation Authority (2006)
Factors Affecting Workload
• The aviator and his/her state
• Skills
• Experience
• Current health and fitness
• Emotional state
Civil Aviation Authority (2006)
• Difficulty adhering to performance standards
• Errors and erratic performance
• Poor fundamental aircraft control
• Uncertainty, indecision, or discomfort
• Degraded scan, tunnel vision, fixation
• Hesitant, confused speech
Signs of Overload
• Boredom
• Fatigue
• Frustration
• Dissatisfaction
• Failure to Scan
Signs of Underload
Arousal and Workload
• To achieve an optimum level of task
performance should you be overloaded or
underloaded?
• It is necessary to have certain levels of stimulation
or arousal.
Workload Vs. Performance
HIGH
HIGH LOW
LOW
UNDERLOAD OVERLOAD OPTIMUM
PERFORMANCE
WORKLOAD
KC-130 Case Study
Work Overload. Bristol MOA/29 Palms
KC-130 Case Study
Synopsis • FWAR / Crew Training / T3P initial Night Fam • T3P (400 hr) Left seat, TPC (2100 hr) Right seat,
FE (3100 hr) Jump seat • FWAR CANX. VFR Round-Robin, 2 Inst App off
airfield • Touch and go pattern during pinky time at NXP
expeditionary airfield
CREW T3P TPC
KC-130 Route of Flight KC-130 Case Study
• Flight engineer mismanages FUEL panel (gravity feeding engines #1 & #4)
• No. 1 and 4 engines lose power after rotation • No. 1 is shut down and 4 fails • TPC believes only #1 has failed• FE confused by #4 indications • TPC turns left (into dead engine/terrain)
CREW T3P TPC
KC-130 Case Study
• FE Calls for more power • TPC discusses #1 air-start
• TPC Doesn’t order it, T3P holds condition lever to start (6-8 sec) • #1 lights off but stalls
• TPC calls for flaps 20%• T3P complies without comment, takes hand off #1 condition lever
• Aircraft impacts ground 106 sec after last takeoff
CREW T3P TPC
KC-130 Case Study
• TPC workload rapidly went from low to extreme• Where? How? How did crew coordination break
down? • Counterproductive activities on the part of the
TPC, T3P and the Flight Engineer
KC-130 Case Study
• Overload Caused:
• Flight engineer unable to properly diagnose No. 4 engine
• TPC to fixate on No. 1 engine (working mem?)
• T3P to become a voice-activated copilot
• All to not determine cause of dual flameout
How Was Their Workload Managed?
• What were the signs of overload?
Working Memory & Attention
• Can we attend to more than one thing
simultaneously?
• No, although attention can move very quickly from one
item to another, it can only deal with one item at a time
• Our attention is limited by working memory
capacity
Divided Attention Example
• Task: Follow a pace car through heavy traffic in
a high-fidelity driving simulation.
• Performance was compared between driving
without conversing, and driving while conversing
on a hands-free cell phone.
Strayer et al, 2003
Results: Driving and Cell-Phone Use
Driving only Driving and talking
Brakes on (msec) 933 1,112
Brakes off (msec) 580 653
Following distance (m) 26 29
Distracted Driving With Hands-Free Device
National Safety Council, March 2010
• Drove simulator and listened to spoken sentences for true / false
• Listening decreased brain activity by 37% • Not actual conversation – may underestimate impact
Attention Exercise BREAK
Get some refreshment…
Goals of Automation
• Definition: The execution by a machine of afunction previously carried out by a human
• Reduce workload• Help pilots focus on the most important
aspects of the job• Decrease errors, increase accuracy• Has automation achieved these goals?
Air France 447
Current Automation
• HUD/HMD• TAWS• EFB/iPad• Synthetic Vision• FMS with coupling and auto-land• ADS-B/ASDE-X Transponders• GPWS• TCAS
TH-57C / D Cockpit DC10 / 11 Cockpit
MD11 DC10
AH-64A / D Cockpit
Traditional (alpha) Glass (delta)
Chelton Synthetic Vision EFIS
Synthetic Vision
EFIS MOVING MAP EICAS
EICAS Excedance Boeing 757 Crash
Cali Columbia
• Prime example of the limitations ofautomation
• Poor workload management once crisisensued
Boeing 757 CFIT Mode Awareness Errors
• Common causes of mode failure• Pilots fail to verify the mode selections • Notice automatic mode failures • Process mode annunciations to understand
aircraft behavior
Nadine Starter, Human Factors, June 2008
Automation Bias
• Automation encourages pilots to adopt a naturaltendency to follow the choice requiring the leastbrain power.
• 55% of the time pilots committed errors whenthe automation presented incorrect informationin the presence of correct information. Theyfailed to detect the anomaly.
Mosier et al, 1998, 2001
China Air Flight 140
Civilian Hull Loss Rate (per million departures)
Conventional Advanced
Conventional Advanced
A300-1/2/3/4 A300-600 1.18 1.33
B737-100/200 B737- 300/400/500 1.20 0.43
B747-100/200/300 B747-400 1.79 0.77
DC9 MD80 1.28 0.40
DC10 MD11 2.67 0.00
Boeing, 1997
Army Rotary Wing (per 100,000 flight hours)
Traditional Glass
OH-58 Kiowa 4.37 20.30
UH-60 Blackhawk 8.81 17.06
AH-64 Apache 18.36 23.00
CH-47 Chinook 6.97 3.94
Rash et al, 2001
Reasons for an Increased Mishap Rate?
• AH-64 pilots acknowledge there is anincreased workload in the glass aircraft
• AH-64 pilots acknowledge that it is harder toremain proficient in the glass aircraft
• Small margin of error if both pilots suckedinside the cockpit
• Transition pilots• New missions
Nevertheless, the majority of AH-64 pilots preferred the glass cockpit
Rash & Francis, 2003
Automation and Workload
Wor
kloa
d
Hand-fly Autopilot FMS control
Abnormal
Normal
Chidester, 1999
Possible Impacts of Cockpit Automation
• Increased monitoring, less flying
• Requires more “heads - down” time
• Induces complacency and dependency
• Loss/erosion of situation awareness
• May cause erosion of flying proficiency
• May introduce new forms of “human error”
• Minor input error - serious consequences
Automation Dependency- Complacency
• Pilots may become complacent in highlyreliable automated aircraft
• In high reliability systems, detection ofautomation failures was low
• In variable reliability, automation monitoringwas very efficient
Singh et al, 1993, 1997
Northwest 255 The Future?
Automation Take-Aways
• Potential for both decreasing and increasingcrew workload
• Can cause mode awareness error
• Can cause incidents of “perceived control”
• SOPs are an effective means of avoiding manyautomation pitfalls
• Flight time is crucial to remain proficient
• Crew Resource Management skills are moreimportant in automated cockpits
• Anticipate high workload periods
• Recognize onset of high workload
• Carry out ‘what if’ scenarios during periods of low
workload
• Be aware of signs that other crew members have
become overloaded
• Be aware of distractions
Countermeasures
Summary
• Our ability to manage workload isdependent upon the limitations of attentionand working memory
• Automation must be carefully managed andCRM skills are of increased importance inhighly automated aircraft
• Avoid distractions
Questions?
• Civil Aviation Authority (2006). CrewResource Management. www.caa.co.uk/
• Civil Aviation Authority (2004). Flight CrewReliance on Automation. www.caa.co.uk/
• www.satechnologies.com Endsley’s company
• www.flightdeckautomation.com/about.aspxFlight deck automation issues
THREAT & ERROR MANAGEMENT
Threat & Error Management
Lesson Topic 2.5
C-050-1503A PPT 5001 01
Terminal Objective
The student will demonstrate knowledge of Threat and Error Management, and be able to apply those techniques to their specific platform as the Program Manager
Enabling Objectives
• Implement error management into CRM instruction • Explain importance of Threat & Error Management • Explain information collection programs • Define threat • Describe categories of threats • Explain human limitations that lead to error • Define error • Describe categories of error • Explain T & E Management model and how to use it
inside and outside of the aircraft
Why Threat & Error Management?
The idea behind all CRM Courses is to define the “best practices” in applying threat and error management counter-measures to reduce or
eliminate the consequences of threats and errors, which are precursors of accidents and incidents.
Safer operations can be had by imbedding the best practices of our pilots into our training and
everyday operations. Pilots learn many of their positive traits from the sharing of ideas and
experiences with their peers and then applying them to their own operational philosophy.
Why Threat & Error Management?
• Tenants of the original University TexasContinental Human Factors Study (1996/2000):
• To analyze adverse affects of errors within aviation
• To define training needs to reduce crew related errors
• To define organizational strategies to recognize and manage threat and error
Why Threat & Error Management?
“To Err is Human” -Marcus Tullius Cicero 106-43 BC
• Defines human fallibility• As long as humans remain a functional
component in any aviation system therewill always be errors
Why Threat and Error Management?
HUMAN ERROR has posed threats to mission accomplishment since
humans began to deal with technology…
…Errors REPEAT evenwith new technology…
Even for the Military…
Errors exist…
..and some errors are MORE COSTLY than
others…
• In the past: We focused on eliminatinghuman error in aviation.
• Contemporary acknowledgement: Errorsare inevitable, so…• We must instead focus on ways to effectively
MANAGE and REDUCE errors
Why Threat & Error Management?
Why are we still doing CRM training?
Threat & Error = Mission Effectiveness
CRM = Mission Effectiveness
Threat & Error = CRM
Safety is a by-product!
CRM Mission: Supporting Mission Accomplishment Through Enhanced Aircrew Performance.
Continental’s T&E Mission: Error management enhances mission accomplishment and effectiveness.
Sound familiar?
• Have you ever said “nice save”?• Have you ever scared yourself on a flight?• Have you ever thought “Don’t question me, I know
what I’m doing”?• You've done it a thousand times.• It comes naturally to you.• Its what you've been trained to do your whole
career.• Nothing could possibly go wrong.
Why are we still doing CRM training?
OR?
Because Errors Exist
THE PROGRAM
Because Errors Exist
Because Errors Exist Because Errors Exist
Because Errors Exist
Accidents/Incidents • Reactive
What is happening here?
• Proactive• Data Collection
Error Reporting
Data Collection
• Why is it important?• Still making the same mistakes
• Where do we start?• Information Collection
• What kind of data are we looking for?• Find the common errors that are being
made by aircrew routinely!• Not just on check flights !
• Need to acknowledge errors occur in order to fix them…
• LOSA – Line Operations Safety Audit
• FOQA – Flight Operations Quality Assurance
• ASAP – Aviation Safety Action Program
Data Collection Programs
Less
ons
Lear
ned
Collect Data
(Measure)
ASAP
FOQA
There
We
Were
Data Collection Programs
LOSA ““Do the concepts taught in training transfer to normal, everyday flight operations?
Observations of flight crew performance during everyday flights
• Observers unobtrusive – collecting data not participating in flight
• Team of observers from different backgrounds• Line pilots / Union representatives • Check airmen • Safety and Training pilots
• All data is DE-IDENTIFIED, CONFIDENTIAL, and NON-PUNITIVE
Line Operations Safety Audit
UT and Continental, 1996
• 31% of flights had an Automation error • 21% of flights had a checklist error • 72% of flights w/at least one external threat
(adverse wx, ATC error, aircraft malfunction)
Average = 2, Most = 17
Of all errors committed:
• 85% were inconsequential • 15% were consequential
• 3% caused additional errors • 12% resulted in an undesired aircraft state
First LOSA Collaborative Results
FLIGHT OPERATIONS QUALITY ASSURANCE
Used to collect, store, and analyze recorded flight data.
• Post Mission Aircrew Debrief (PMAD): flight visualization and aircrew debrief
• Aircraft Maintenance & Troubleshooting System (AMATS): analysis and material fault isolation
• Flight Data Analysis (FDA): monitoring the safe and efficient operation of aircraft
FLIGHT OPERATIONS QUALITY ASSURANCE MFOQA Objective
MFOQA – An Enterprise Wide Solution • One common tool used across the entire Naval Aviation Enterprise
• Squadron: Enhancement/efficiencies in maintenance, safety, operations and training • Wing: Track maintenance, safety, operations and training • NAE: Enterprise wide analysis and decision making
• No additional hardware required • Software resides on NMCI / Marine Internet / IT21 / ONE-NET workstations and NFSA enterprise servers
• Complements currently deployed systems (AME, IVHM, etc)
Naval Aviation Enterprise FA-18C-F, EA-18G (Wing)
FA-18 C-F, EA-18G (Squadron)
MV-22B (Wing)
MV-22B (Squadron)
MH-60R/S (Wing)
MH-60R/S (Squadron)
CH-53E (Wing)
CH-53E (Squadron)
T-45C (Wing)
T-45C (Squadron) Fixed Wing *
Rotary Wing *
UAVs * * CDD states “All future DOD aircraft and all existing DOD aircraft unless a cost benefit analysis (CBA) demonstrates need for exclusion.”
AH-1Z / UH-1Y (Wing)
AH-1Z / UH-1Y(Squadron)
Voluntary reporting of mistakes and incidents by promising no reprisals
Aviation Safety Action Program (ASAP)
ASAP Sample Size: 212,856
Airfield 1454
Airmanship 1116
Airspace 5703
CommunicaAon 5988
Compliance 2801
Maintenance 5612
Mission Flow 3118
Physiology 757
Recovery 1942
Runway Events 474
Unsafe PracAces 1014
Weather 1339
Other 412
No Event Occurred (With Comments)
15,218
No Event Occurred (No Comments)
165,908
All Navy ASAP Reports as of 2/2/2011 (CNAF)
Navy ASAP Users Report that on 78% of their flights
"No Event Occurred" and no comments are required.
On 7% of their flights "No Event Occurred", but they have ORM, CRM, or
Command Safety Climate inputs.
All "Actionable" Navy ASAP Reports as of 2/2/2011
ASAP Sample Size: 212,856
Airfield 1454
Airmanship 1116
Airspace 5703
CommunicaAon 5988
Compliance 2801
Maintenance 5612
Mission Flow 3118
Physiology 757
Recovery 1942
Runway Events 474
Unsafe PracAces 1014
Weather 1339
Other 412
No Event Occurred (With Comments)
15,218
No Event Occurred (No Comments)
165,908
ASAP Human Factors 2009-2010
0
1000
2000
3000
4000
5000
6000
Judgment or Decision Skill Based Misperception
Judgment or Decision 5670
Skill Based 3237
MispercepAon 2558
Total ASAP Reports 11465
Key Performance Indicators (KPIs) or Outcomes (What Happened)
ASAP Human Factors Judgment or Decision Sub-Category
0 200 400 600 800
1000 1200 1400 1600 1800
Inade
quate
Rea
l Tim
e ORM
Impro
per T
ask P
rioriti
zatio
n
Rushe
d a N
eces
sary
Action
Delaye
d a N
eces
sary
Action
Ignore
d a C
autio
n/Warn
ing
Failure
to E
xecu
te Prop
er Proc
edure
Inade
quate
Rea
l Tim
e CRM
Contin
ue B
eyon
d Proc
edure
Limits
Other
Key Performance Indicators (KPIs) or Outcomes (What Happened)
Inadequate Real Time ORM 1151 Improper Task PrioriAzaAon 500 Rushed a Necessary AcAon 411 Delayed a Necessary AcAon 345 Ignored a CauAon/Warning 120 Failure to Execute Proper Procedure 1128 Inadequate Real Time CRM 246 ConAnue Beyond Procedure Limits 93 Other 1676
Sample ASAP Report
Date 20 Oct 2008
Report Type Information
Category Airspace
Subject Near Mid Air Collision
Report Status Submitted
Workgroup of Entry VT-10IP
Ops Type Flight
Stage VNAV
Safety Related Yes
Risk Factor 110
Phase of Operation Low Level
Action Taken Evasive Action Taken
Time of Day Day
Weather VMC
Comments Had near mid-air on first leg of VR-1022. TCAS was showing the A/C coming from the east at 1000 ft above the T-1. The other A/C began to descend, down to co-altitude. All crew members were aware of the threat and were actively looking for the other A/C. Pilot was taking evasive action based on TCAS suggestions. Aft observer spotted the A/C first, then the jumpseat called talley keeping eyes on as it passed slightly above and barely behind the T-1. It was a civilian single engine prop, red and white in color, headed west. As far as the crew could tell the civilian took no evasive action to avoid the T-1, maintaining course, speed, and altitude. All proper procedures were followed by the T-1 crew and the entire crew worked together to stay safe.
Feedback is Essential for Continued Program Success
What are some methods of feedback at your commands?
Safety Grams / Newsletters Blue Brain Additions
MDG Changes SOP Changes
NATOPS Changes
Feedback is Essential for Continued Program Success
THREAT and ERROR MANAGEMENT
MODEL
Strategies
Resist
Resolve
Legacy CAL before 2011 and UAL merger
Planning and Decision Making
Leadership Effectiveness
Situation Awareness Communication
Monitor/Cross-Check Workload Management
Automation Management
CRM/TEM Skills
Safe Operations
Threats Prepare
Errors
Prepare
Repair
Prepare
Repair
Recover
CRM
/TEM
Incident/Accident
New Model in 2011
Undesired Aircraft State
Threats
Errors
Safe Operations
Prepare
Repair
Recover
CRM
/TEM
Incident/Accident
MISSION EFFECTIVENESS
CRM 7 Critical Skills
Decision Making
Assertiveness
Mission Analysis
Communication
Leadership
Adaptability / Flexibility
Situational Awareness
Strategies
Resist / Resolve
Planning and Decision Making
Leadership Effectiveness
Situation Awareness Communication
Monitor/Cross-Check Workload Management
Automation Management
CRM/TEM Skills
Undesired Aircraft State
RISK
46 of 20
What are examples of “acceptable/reasonable” risk?
Why are these risks “acceptable/reasonable?”
RISK
What are examples of “unacceptable/unreasonable” risk?
Why are these risks “unreasonable?”
47 of 20
Incident/Accident
48 of 20
Why ?
“risky” behavior
Do you think humans do things they know are risky?
Why?
Because we do not identify THREATS!
and/or
Because we have done it before without any consequences?
Risk and Threats
What makes aviation “risky?”
Threats
We call these “risks”
How do we assess the “risk?”
50 of 20
How do we assess risk? Threats
We maintain in a “risky”
environment by identifying and effectively managing
THREATS!
MISSION EFFECTIVENESS
• When the THREATS become unmanageablethe risk is unacceptable
• We identify the THREATS and our abilityto effectively manage them
Risk Assessment
51 of 20
What’s the “bottom line?” Threats
• ACTIVE Threat:Factors that increase the likelihood of an errorbeing committed, or of not accomplishing themission.
• These may be: • Environmental (Wx, terrain, enemy) • Internal Cockpit (Fatigue, stress) • External Cockpit (ATC, Other A/C) • Aircraft (EPs, Systems)
A THREAT is anything that increases operational complexity that, if not managed properly, can decrease
the safety margins.
THREATS
• LATENT Threat: aspects of the Squadron or Strike Group organization, or individual that are not always easily identifiable, but that predispose the commission of errors, or the emergence of overt threats
• Organizational / Professional culture (squadron / type wing level)• Regulatory practices and oversight (SOP) • Training philosophy and practices• Qualification standards (qualifications, currency, proficiency) • Aircraft characteristics• Equipment design issues • Flawed procedures (SOP, FTI, MDG, NATOPS, etc)• Scheduling practices • Preparation for duty / tasking / event (personal responsibility) • Personal stress, preoccupation or illness
• Threats• Do not equal errors• Increased potential for error
• Threats = Red Flags
Threats
Examples of Threats
Weather
Maintenance
Ground Crew
Aircrew
Other Aircraft ATC
Terrain
Similar call sign
Time pressures
Heavy traffic
Unfamiliar airport / Landing environment
Automation event Missed approach
Flight diversion
System malfunction
Distractions
Threats
• Think back to a recent flight,describe a threat you may have encountered?
• What types of different threats doyou face in different areas?• CONUS • Training • Overseas • Combat
What Threats have you faced?
57 of 20
Threats
Can we eliminate THREATS from aviation?
No, unless we don’’t fly!
How do we operate in spite of the fact that we cannot eliminate the THREATS from aviation?
We EFFECTIVELY manage (prepare for) them.
Threats
Threats Safe Operations
MISSION EFFECTIVENESS
What is our strategy to manage threats?
Identify and Prepare
Things we can use in our tool bag to counter threats:
• CRM / ORM / TEM • Clearly defined roles of aircrew members • Complete briefing and effective communication • Limit being “heads down” at critical times• NATOPS / System Knowledge
What strategies do you use to counter threats?
Strategies to Prepare for Threats
VVM is a key element of Threat and Error Management process.
The verbalization by both pilots “verifies” a shared understanding of what is expected and then both pilots “monitor” to ensure strict adherence to all instructions.
Verbalize, Verify, Monitor
• Break the chain by recognizing errors and fixing them.• Don’t hope someone else will notice!
VVM
Accident Data
• Factor in 84% of 37 crew-caused aircarrier accidents
• 76% of the monitoring/challengingerrors failed to catch something thatwas causal
• Factor in 50% of the CFIT accidents
Why is Monitoring so Important?
62 of 20
Threats
CRM/TEM Skills
What tools do we have to help us IDENTIFY and MANAGE (PREPARE for)?
Situational Awareness
Communication
Mission Analysis
Decision Making
63 of 20
Errors: Crew action or inaction that leads to deviations from expectations, reduces safety margins, and may occur from either mismanaged threats or mistakes.
Errors
What can happen if we ignore or mismanage a THREAT?
Threats
Errors
Safe Operations
MISSION EFFECTIVENESS
Questions?
Take 5 Human Error
Definitions
• Error:Crew action or inaction that leads to deviationsfrom expectations, reduces safety margins, andmay occur from either mismanaged threats ormistakes.
• Error Management: Process of correcting an error before itbecomes consequential, i.e. Undesired AircraftState and Incident/Accident.
Categories of Error
• Procedural - Following procedures but wrong execution (wrong altitude setting dialed into the FCP)
• Communication - Missing info or misinterpretation (miscommunication with ATC)
• Proficiency - Error due to a lack of knowledge/currency (lack of automation knowledge)
• Decision - Crew decision unbounded by procedures that unnecessarily increased risk (unnecessary navigation through adverse wx)
• Intentional Noncompliance - Violations (checklist from memory)
69 of 20
Operating with Errors
How do we operate in an environment where we cannot eliminate human errors?
Minimize and Manage Them!
How many passes did the “White” team make?
Notice anything other than the players?
A Gorilla…Really?
How many ““Black”” team members were playing at the end of the game?
Exercise
73
Pattern Matching
• You see what you expect to see• It happened like this last week• It happened before, it will happen again
SJU Int’l Airport Lagoon Visual Rwy 8
• Crew planned and set for ILS 10
• Clearance change to Lagoon Visual Rwy 8
• Captain “airport in sight”• 3 Go-around calls from
Tower • Rate of descent at 1000’
AGL is 2170 fpm • SIG Tower uses red
signal light • Airplane successfully
lands on 4150’ runway
Isla Grande Pattern Matching
• Pattern Match • Runway same basic
orientation as SJU• Pitfalls
• Expectancy • Defense
• SOP • Brief two airports in vicinity • Anticipate clearance
changes • Crew cross check • Hangar fly the approach
Minimizing Pattern Matching Pitfalls
• Adequately define the problem.• Use Standard Operating Procedures.• Get confirmation by another crewmember.
77 of 20
What skills do we have to help us Manage Errors?
Errors
CRM/TEM Skills
Communication
Assertiveness
Adaptability/Flexibility
Leadership
78 of 20
Error Management
Does managing an error so that there are no consequences achieve
the same result as no error?
79 of 20
Error Management
There are two categories of Error Management Tools
• RESIST:• The hardware and software built into the
system that trap ERRORS
• RESOLVE:• The human skills that are used to trap and
correct ERRORS
80 of 20
Error Management
What are some examples of
RESIST &
RESOLVE Tools?
Resist
Resolve
TCAS
Windshear
Detection FMC WX Radar
Monitoring
Challenging
Warning Systems
Professionalism
Systems
Knowledge Health
Autopilot
Expe
rienc
e
Map Display GPS
GPWS
Attitud
e
Hardware What Are Your
Systems Doing For
You?
Human-ware What Tools Are You Bringing To
The Fight? 82 of 20
Threats Prepare
Errors
Prepare
Repair
Strategies for Errors
What is our strategy to manage errors?
Identify and Repair
Mission Effectiveness
Resist
Resolve
Your Goal
Prevent / Manage / Correct Errors
Checklists
Good Briefs
Effective Communication
Resolve to follow SOPs / NATOPS
SOPs
Aircraft Warnings
Avoid Unwanted Consequences
NATOPS
Your Goal
Prevent / Manage / Correct Errors
Avoid Unwanted Consequences
“Trap the Error”: It is detected and managed before it becomes consequential
“Exacerbate”: It is detected but the crew’s actions or inaction leads to a negative outcome
“Fail to respond”: The crew fails to react to the error either because it is undetected or ignored
85 of 20
Mission Effectiveness
Threats Prepare
Errors
Prepare
Repair
Undesired Aircraft State: A position, speed, attitude, condition, or configuration of an aircraft that reduces safety margins.
What can Happen if We Don’t “Repair” the Error ?
Undesired Aircraft State
86 of 20
Threats Prepare
Errors
Prepare
Repair Repair
Prepare
Recover
How do we Manage an Undesired Aircraft State?
Identify and Recover
Undesired Aircraft State
Mission Effectiveness
87 of 20
What if we do not Recover?
MISSION EFFECTIVENESS
Threats Prepare
Errors
Incident/Accident
Prepare
Repair Repair
Prepare
Recover
Undesired Aircraft State
88 of 20
Incident/Accident
Undesired Aircraft State
Incidents/Accidents that result from pilot error are always the result of an Undesired Aircraft State.
Undesired Aircraft State
89 of 20
Planning and Decision Making
Incident/Accident
Does an Undesired Aircraft State always result in an
Why ?
Accident Rate Since 1959…
The overall accident rate has improved dramatically from 1959 – 2010! Can the RATE be “0”
91 of 20
Incident/Accident
What do want YOUR
“rate” to be ?
How are the skills related ?
What do they have in common ? Decision Making
Situation Awareness
Assertiveness
Adaptability / Flexibility
Mission Analysis
Communication Leadership
Mission Effectiveness
What is a norm?
• Unwritten practice accepted by mostmembers of a given group• Can be positive or negative• Effective/Ineffective
• What have you seen in your previousflight experience?
What is a norm?
What are your expectations?
Compliant with SOP
At Risk Behavior
Reckless Behavior
Compliant with SOP
Reckless Behavior
Drift is the gradual departure from an intended course due to external factors. At Risk Behavior
Norms
Compliant with SOP
At Risk Behavior
Reckless Behavior
How much drift do they expect?
DRIFT?
Unexpected or Unfamiliar Routing
Verbalize, Verify And Monitor
Waypoint Not Input Correctly
Map Display and SOPs
Crew action
Phone call / Violation
AH-64 / F-16 / H-60
• Identify Threats• Identify Strategies
• Identify Errors• Identify Resist/Resolve
Case Study
F-16 Case Study
H-60 Case Study
http://www.youtube.com/watch?v=qYExH8hpgXI
http://www.youtube.com/watch?v=0fnAkb_jGoc&feature=related
http://www.youtube.com/watch?v=Ql0-xDne42U&feature=related
AH-64 Case Study
Threats
Errors
Safe Operations Prepare
Repair
Recover
CRM
/TEM
Incident/Accident
MISSION EFFECTIVENESS
CRM 7 Critical Skills
Decision Making
Assertiveness
Mission Analysis
Communication
Leadership
Adaptability / Flexibility
Situational Awareness
Strategies
Resist / Resolve
Identify: • Threats • Strategies • Errors • Resist/Resolve
Undesired Aircraft State
Summary
• Why Threat & Error Management (TEM)• Data Collection• Threat Categories• Error Categories• TEM Model
References
“SAFETY ACROSS HIGH-CONSEQUENCE INDUSTRIES CONFERENCE”, St. Louis, MO
09 Mar – 10 Mar, 2004
The University of Texas Threat & Error Management Model: Components & Examples
Robert L. Helmreich Ph.D., David M.Musson, MD.
Models of Threat, Error and CRM in Flight Operations Robert L. Helmreich Ph.D., James R. Klinect, John A. Wilhelm
UNIVERSITY OF TEXAS TEAM RESEARCH PROJECT THE UNIVERSITY OF TEXAS AT AUSTIN
DEPARTMENT OF PSYCHCOLOGY
Questions?
INTRODUCTION TO CASE STUDIES AND DEVELOPEMENT
CASE STUDY DEVELOPMENT
Lesson 3.7
Terminal Objective
Conduct CRM Instruction, in a classroom setting, in accordance with Instruction, Crew Resource Management Program, CNAF 1542.7 (series)
Enabling Objectives
• Build case study scenarios for CRMexplanation and training
• Assemble sources and media into acomplete case study Presentation
TRANET Computers
• Use your CAC Card and log onto theTRANET computers.
• Open student share drive folder on yourdesktop: O:\CRM\Production\StudentAccess\(Assigned class folder e.g. 13-01)
TRANET (Cont.)
• Verify:
• That you can save data in your studentaccess assigned class folder.
• That you have internet access.
• That you have access to the Roxioprogram (CD burner program).
Case Study Template
1. Go to O:\CRM\Production\7 Skills CaseStudy Templates
Case Study Template
• O:\CRM\Production\7 Skills Case StudyTemplates
• Open “A/F Word Doc Template”
A/F Word Doc Template Instructor Guide
Type of A/C Title of your case study
Where you got the info
List your EO’s Brief description
A/F Word Doc Template Instructor Guide
All this is provided for you in the template
A/F Word Doc Template Instructor Guide
Synopsis with skills identified
Items to add to the synopsis during the
class discussion
A/F Word Doc Template Instructor Guide
Provided for you on your template
Your questions with answers
Provided for you on your template
A/F Word Doc Template Student Handout
Type of A/C Title of your case
study Where you got the info
Synopsis without skills identified
A/F Word Doc Template Student Handout
Questions without the answers
Case Study Template
• Open “A/F PP Template”
A/F Case Study PP Template
A/F Case Study PP Template
A/F Case Study PP Template
A/F Case Study PP Template Presentations
• Time limit is 20 minutes!• Burn templates to CDs.• Issued student disks are not RW.• Save files on computer under:
“Production\Student Access\Class 13-XX”(videos need to be saved in same folder by0830 Thursday).
• Be complete by Thursday morning.• Print 1 copy of the Instructor Guide.• First person covers all 7 skills.• Lunch options: Break or in house Pizza
Summary
• Build case study scenarios for CRMexplanation and training
• Assemble sources and media into acomplete case study
Questions?
FATIGUE & STRESS
ASSASS
Aeromedical
CAPT Jack “Bags” Wyland Command Flight Surgeon, School of Aviation Safety
[email protected] (850) 452-5140; DSN 459-
Room 161C
ASSASS Background
• AOCS• SH60-B• Recruiting Duty• Med School• Internship• Flight Surgery• VMMT-204• Residencies in Aerospace and Family Medicine• 3D MAW• NAVHOSP P’cola• SAS
ASSASS
0
10
20
30
40
50
60
50 55 60 65 70 75 80 85 90 95 00
776 aircra( destroyed in
1954
USN/USMC, FY50-‐06
Class A Mishap Rate
USN USMC FY07: 0.98 2.05 FY08: 1.51 2.26 FY09: 1.17 1.41 FY10: 0.78 1.46 FY11: 0.96 2.44
Naval Aviation Mishap History
NSC Data: Oct ’’06
FY 2011 11 Aircra( Destroyed
Bags born Tricycle to bicycle transition
Firecracker Mishap
HS/College AOCS
Wench
Sister Janet born Sister Joyce born
““The June Cleaver effect””
Med School
Jack Sr & Betty say ““I do””
Sister Mary Alice
ASSASS
CRM Aeromedical Topics
Fatigue and Stress
C-050-1503A PPT 5010 01
“The mechanization of modern war has produced a chain of health problems. One of the greatest of these is fatigue. In the complicated meshwork of speed and change, many factors make for fatigue. Scarcely any key man in modern war is more subject to stress and strain, to demands on his body and mind making for fatigue, than the military pilot.”
– Dr. Martyn Kafka, 1942.
Kafka, M. Martyn. Flying Health. Harrisburg, PA: Military Service Publishing Company, 1942.
ASSASS Terminal Objectives
• Become familiar with the leadingaeromedical causes of mishaps andHAZREPs to further understand howCRM can prevent mishaps through theuse of an effective ASO-FS team.
ASSASS Learning Objectives
• DESCRIBE the science and physiology of sleepand stress, and their effects
• DESCRIBE symptoms/signs of fatigue and stress• DESCRIBE performance decrement from fatigue
and stress• DISCUSS the prime causes of fatigue and stress• DESCRIBE effects of circadian cycles in fatigue• RECOGNIZE mishaps where fatigue or stress
may be a factor• IDENTIFY key countermeasures for fatigue and
stress• UNDERSTAND performance-maintenance
pharmaceuticals
ASSASS
“Fatigue and Related Human Factors in the Near Crash of a Large Military
Aircraft.”
Do you feel yourself wanting to doze after lunch?
Do you fall asleep within ten minutes after lights out?
Do you sleep more on weekends than during the week?
Do you sleep more on vacation than when you are working?
52 recognized cases
The Brain • Massively parallel, electro-
chemical digital computer• ~ 100 billion neurons;
trillions of logic gates(synapses)
• “Clock” frequencies of 1/3 to> 100 Hz.
• Runs on oxygen & glucose• 2% of body mass• 25% of resting energy use
Neurons
• Synapses:• the logic
elements• Facilitated
transmissionand structuralchanges atsynapses:• learning &
memory
http://www.pfizer.com/brain/images/neuron_large.gif
The Science of Fatigue
• The brain is a digitalcomputer:• Electro-chemical• It cannot run
continuously awake• It requires scheduled
recharge &maintenance intervals
• Fatigue is aphysiologic state• Not due to rank, rate,
experience, motivation,or attitude
• The brainaccumulates“fatigue” whenoperatingØ It’s computing at less
than 100%
Brain Functions
• Mood, personality• Problem-solving• High-level
reasoning• Body sense and
Movement• Memory• Speech• Vision• Balance &
Coordination• Consciousness• Breathing• Heart rate
Signs and Symptoms of Fatigue
• Irritability, mooddeterioration,reduced patience
• Impairedcommunication
• Reduced vigilance,inattention
• Task fixation• Tolerance for error
and risk
• Complex reasoning& decision making
• Conservation ofeffort, reduced motivation
• Forgetfulness• Increased reaction
times • Lapses and
“microsleeps”
Decision Making
Adaptability; Flexibility
Communication
Assertiveness
Mission Analysis
Leadership
Situational Awareness
Threat & Error
Management
Fatigue’s Effects are Task-Dependent
• Sense of well-being• Judgment & decision
making• Vigilance & attention• • • • Well-learned/simple
intellectual or physicaltasks
More sensitive to Fatigue
More resistant to Fatigue
CRM, ORM
ASSASS
• Truck accidents 30-40% by NTSB• Daylight Savings Time: +8%, -9%• Challenger, Exxon Valdez,
Chernobyl, Three Mile Island,Roosevelt-Leyte Gulf?
The Problem: Performance Degradation
Adapted from Steven R. Hursh, SAIC
Three Days of Sleep Deprivation WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction
50
65
80
95
110
0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day
Mea
n Sp
eed
on P
sych
omot
or V
igila
nce
Task
(as
a %
of B
asel
ine)
9 Hr
7 Hr
5 Hr
3 Hr
SAFTE/FASTR 2 = 0.94
Recovery 7 Day Restricted Sleep Baseline
50
65
80
95
110
0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day
Mea
n Sp
eed
on P
sych
omot
or V
igila
nce
Task
(as
a %
of B
asel
ine)
9 Hr
7 Hr
5 Hr
3 Hr
SAFTE/FASTR 2 = 0.94
Recovery 7 Day Restricted Sleep Baseline
WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction
50
65
80
95
110
0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day
Mea
n Sp
eed
on P
sych
omot
or V
igila
nce
Task
(as
a %
of B
asel
ine)
9 Hr
7 Hr
5 Hr
3 Hr
SAFTE/FASTR 2 = 0.94
Recovery 7 Day Restricted Sleep Baseline
WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction
USN Recruits Test Scores by Year 6 vs. 8 hours sleep
6 hr 6 hr
8 hr
Dr. Nita Miller, Research Asst. Prof., NPS
How Much Sleep Do You Need?
4 5 6 7 8 9 10 11 12
Old-thinking
New-thinking
“Humans are the only animals that willingly deprive themselves of sleep.”
– Eve Van CauterSleep researcherUniversity of Chicago
Lapses / Microsleeps in a Taxi Driver
Microsleeps in Military Security
Velocity: 14 mph
ASSASS Roosevelt - Leyte Gulf
Mishap Board Findings:
HUMAN ERROR: “CVN OOD: • ... in disregard of nautical rules
of the road...”” • ...unable to recognize or
unwilling to act....”” • ...without communicating
intent. ““ • ...did not act with appropriate
dispatch...””• ...did not advise CO that ...”” • ...did not advise CO of
conflicting concurrent events...””
• ...did not advise CG in a timely manner...,
• ... failed to sense the urgency of...””
• ...did not notify the CO...”” • ...became overly involved in
managing...””
HUMAN ERROR: “CG CO: • ... failed to recognize the
seriousness...”” HUMAN ERROR: “CG XO:
• ...failed to properly analyze the movements of...””
• ...failure to consider the possibility of ...””
HUMAN ERROR: “CG OOD: • ...failed to properly analyze the
movements of...””• ...was not proactive ... in
communications, ...was focused on...””
• ...failed to demand proper support from ...””
• ...failed to prioritize bridge duties...””
HUMAN ERROR: “CG TAO: • ...focused on the ... scenario,
failed to supervise, ... did not recognize,...””
Identifying Fatigue • No simple measurement of fatigue
• If we can’t measure it, we miss it…• Self assessment of fatigue unreliable
• The greater the impairment, the poorer the assessment• Can be inferred from performance measurement
• But other things also affect performance -stress, illness, hypoxia, alcohol, drugs, etc.
• Fatigue can be modeled and predicted:• Hours of continuous wakefulness• Circadian rhythm effects• Sleep debt = (Ideal - Actual) x days• Sleep disorders (sleep apnea, RLS, narcolepsy, etc.)
How Long Can You Live Without…
• Oxygen ?• Water ?• Nutrition ?• Sleep ?
è 4-10 minutes è 5-7 days è 1-2 months è 2-3 weeks
Ø Sleep-deprived animals die from insulin resistance, immune system failure and sepsis. Ø Sleep is a physiologic requirement for survival. Ø Sleep is a fundamental drive, powerful enough to interrupt any waking activity.
Sleep • “Sleep” is the set of maintenance
& recharge procedures the brainuses to eliminate fatigue.– Complex activity– Scheduled by circadian rhythms
• Based on evolution and theorbital motion of planet Earth… a 24-hour day
Sleep Facts
• Sleep is the recharge procedure to alleviate fatigue• Based on genetics and Earth’s 24 hour rotation• Normal amount of sleep 8 – 8 1/4 hours
• Min 5 hours/night to “maintain performance?” NO!• ~ 2 hrs of performance for each 1 hr of sleep• 6 > sleep > 10 hours - higher mortality• Sleep cannot be “banked” but deficits accumulate• Rest does not replace sleep
Sleep Research
• NREM deep sleep important in cellularrecharge/health?
• REM sleep important in memory storage?• The brain wakes up out of REM
• Ratio of REM/NREM sleep varies with need• The brain must have both
• Sleep induction and maintenance tied tocircadian rhythms
• Efficiency of sleep deteriorates with age• MSLT – less than 5 minutes is pathologic
Sleep Architecture Ultradian Cycles ~ 90 mins
Sleep Stages vs. Age MSLT Averages
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Latency in Minutes
Mean 11.4
moderate sleepiness (29%)
excessive daytime sleepiness (7.7%)
0 hr TIB x 1 night
Narcolepsy
Sleep apnea
6 hr TIB x 4 nights
8 hr TIB x 5 nights
10 hr TIB x 14 nights (full alertness)
anesthesia residents
Adapted from Dement; Sleep Medicine
Pilot Performance Long Haul vs. Naps
With 40 minute nap Without naps
Rosekind MR, et. al. Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations.
ASSASS Nap Rules
• Naps are good• More naps are better• Long naps are best• Expect sleep inertia
Take a nap!
Circadian Rhythms
The circadian ““alerting”” signal
The brain ““energy”” level
The “Circadian Cycle”
Circadian Rhythms
• Over 300 circadian rhythms (temp,pulse, immune function, hormones, etc.)
• Entrained by light, period ~24 hours• Time zone travel requires clocks to
phase-shift/ speed up or slow down• Week or more to normalize:• 1 1/2 hrs phase shift/day west• 1 hr phase shift/day east
ASSASS Circadian Rhythms AS
SASSBiological Circadian Fluctuations
JA & JL Caldwell. Understanding and Managing Fatigue in Operational Aviation Contexts.
ASSASS Internal Synchronosis Core
temperature
Immune function
Gastric acid secretion
Stress hormones
Glucose level
Metabolic rate
Hydration
Kidney flow
Gut activity
Lipids
Growth hormone
Liver function
ASSASS Desynchronosis
• External desynchronosis• A time shift occurs (transmeridian travel)• The circadian clocks are all off by the same amount of
time, but are together, in phase.• Internal desynchronosis
• Following a time shift (generally 6 hours or greater)• The circadian clocks start to drift in opposite
directions at different rates – they’re out of phasewith each other
• Takes days to weeks to resynchronize to the newtime zone
During this time the brain is fatigued and performance suffers
Fatigue and Visual Illusions
• Spatial Orientation is80-85% visual
• Brain takes 2-D imagesfrom retinas andinterprets 3-D world:requires high-levelcognition andcomputing speed
• Visual illusions resultfrom misperception ofreality – hypnagogichallucinations
• Fatigue impairsvisual interpretation!
Fatigue and Spatial Disorientation
• Vestibular & “seat-of-the-pants” senses conflictwith reality
• Spatial Orientation inaviation depends onhigh-level cognitivepower
• Loss of visual cues, tasksaturation, scanbreakdown all lead to SD
• Fatigue aggravatesall of these!
ASSASS
When you have fully grasped the ““big picture””
Lets take a break
ASSASS
FAST™ Computer Modeling
of Fatigue
Animal Modeling of Fatigue
ASSASS
24-hour period
Sleep
Afternoon circadian
dips Performance
drop
Work
BAC equivalent
scale
Day-night cycles
Night shift
Exxon Valdez – 00:15 Bhopal – 01:00
Chernobyl – 01:23 Kuwait H-46 Mishap – 02:33
Roosevelt Leyte Gulf – 02:52 Three Mile Island – 04:00
HSL SH-60B Mishap – 05:30
The midnight to 0600 window is a very dangerous
place to do business!
Wrist Activity Monitor
• Wristwatch-like device• Identifies awake and
sleep periods• Measures acceleration
(movement) also light(some models) vs.time
• Records up to oneyear
• Download data tocomputer program
Actiwatch
Dr. Nita Miller, Research Asst. Prof., NPS
Reasonably Good Sleep
Dr. Nita Miller, Research Asst. Prof., NPS
FAST Graph: USS Stennis # 03
Dr. Nita Miller, Research Asst. Prof., NPS
Poor Sleep
Dr. Nita Miller, Research Asst. Prof., NPS
FAST Graph: USS Stennis #52
Dr. Nita Miller, Research Asst. Prof., NPS
ASSASS
Mishap Analysis with FASTTM
ASSASS
“Fatigue and Related Human Factors in the Near Crash of a Large Military
Aircraft.”
Thanks to Maj. Jeffrey Armentrout for slides and graphics
Armentrout JJ, et. al. Fatigue and Related Human Factors in the Near Crash of a Large Military Aircraft. Aviat Space Environ Med 2006; 77:963-70.
Recommended Fatigue Countermeasures
• Go into high OPTEMPOevolutions well-rested
• Pre-plan; minimize changes• Schedule with knowledge of
circadian effects• Minimize shifts > 12 hours• Schedule/ encourage naps• Sleep etiquette• Diet/ meals and feeding• Exercise and activity• Shift work – how to handle?• Who knows when to quit?
Adjuncts
Stimulants and
Sedatives
NAVMED P-6410
• ComprehensiveGuide for FatigueManagement inOperational Settings
• Includes medicationuse re: stimulants &sedatives
• http://navymedicine.med.navy.mil/instructions/external/6410.pdf
Pharmacologic Agents: Stimulants
• “Go-pills” • Modafinil (Added Apr 2012) or Dextroamphetamine
• Will forestall fatigue, and maintain performance• Will not alleviate need for sleep, just postpone
it.• Required in increased quantities to overcome
fatigue• Limited by hallucinations, psychosis, etc.
““I said, ‘‘One of us is hallucinating!’’””
• “No-go Pills”
• Ambien or Sonata (changed Apr 2012)• Will enable sleep, but may interfere with
normal sleep efficiency• Rebound sleep difficulty possible for 1-2
days• May produce hangover effects• Require grounding following use• Limited by amnesia, etc.• NEVER carried in aircraft!
Pharmacologic Agents: Sedatives NATOPS, Ch. 8
• 8.3.2.1 – Rest & Sleep:• Must have opportunity for 8 hours sleep
per 24 hours• Should not schedule continuous awake
periods over 18 hours (or else shall give15 hours off afterward)
• 8.3.2.1.1 – Circadian Rhythm:Ø “accommodation period
estimated by allowing 1 day for every hour over three (of time zone shift)”
Ø “… expect to perform at less than optimal level”
NATOPS, Ch. 8 ASSASS Take-home Points:
Fatigue / Circadian Rhythm Disruption
• Fatigue is a physiologic state; not due tomotivation, or attitude
• Normal need for sleep is 8 – 8 ¼ hours/day• High-level problem solving is most susceptible
• Emergency procedures, SD susceptibility, etc.• “Stick & rudder” skills relatively resistant
• Naps help• Beware sleep inertia
• Expect circadian rhythm disruption, difficulty ingetting sleep when time’s available, higherfatigue, and poor performance
ASSASS
What is Stress?
Mechanical “Stress”
• Material placed under a load; measured as force per unit area
STRESS • Material deforms slightly, bulges,
and responds to stress STRAIN
• Once STRESS is removed, if the elastic limits haven’’t been exceeded, the material returns to it’’s normal shape, unchanged.
• If material is ““overstressed”” it undergoes plastic deformation, or may even fail completely.
• Hooke’’s Law - 1658
Stress
Strain
Dr. Hans Selye
• 1907 – 1982• Neuro-endocrinologist
at Montreal• The “Einstein of
Medicine”
• Discovered thecommon reactions toall stressors
• Coined the term“stress” but reallymeant “strain.”
Human “Stress”
• The weight isthe STRESS
• How does thebody react?
Origin of the Stress Response
• Brain sends out alerting/alarmmessages• In response to physical stressors• In response to psychological stressors
• Brain (hypothalamus) sendsmessages to the pituitary• ACTH
• Adrenals start pumping out• Norepinephrine, adrenalin• Adrenocorticoids; mineralocorticoids
• Combination of hormonal andneural signals drastically alters thebody physiology
Stress Reaction
• Heart rate goes up• Blood pressure, breathing rate goes up• Muscle tension increases• Perspiration goes up, saliva decreases• Mental alertness and senses increase• Blood flow to brain, heart, muscles goes up• Blood flow to skin, gut, and kidneys goes down• Blood sugar, cholesterol, clotting factors go up.
The “fight or flight” response
Stress is:
“The non-specific response of the body to any demands made upon it”
Is it really better to be the boss?
The “Non-specific Response”
The General Adaptation Syndrome
Resistance
Glycogen
Lactic acid
Ketoacids
BMR
Glucose
Temperature
Fat loss
Blood lipids
Liver fats
Cholesterol
Urea
Amino acids
Blood enzymes
Proteins
Serum protein
Creatine
Uric Acid
Sodium
Potassium
Minerals
Tissue minerals Sulfates
Acid-base level
Diuresis
Cell water
Optimal
Per
form
ance
STRESS Level
Stress & Performance Relationship
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
Tolerable Demand
Excessive Demand
Underload
Overload
When flight mechanisms become flooded…
Physical “Stressors”
• Illness, infection, fever• Trauma, hemorrhage• Burns• Surgery• Dehydration• Physical exertion• Etc.
Other Stressors
• Environment• Noise, crowding, clutter• Cold, heat, humidity, vibration• Bright or low light levels• Heights or confined spaces
• Social• Relationship problems• Work relationships• Crowds, parties, strangers• Rude, aggressive, critical, or competitive people
• Major life events• Death of spouse, parent, or child• Marriage, divorce• Moving, PCS, deployments• Crime victim• Winning the lottery• Promotion or job loss• Aircraft mishap• Etc.
Other Stressors (cont’d)
Other Stressors (cont’d)
• Institutional• Rules, red tape, regulations• Deadlines, schedules, meetings, office
politics• Training!
ASSASS Selye Quotes
“Every stress leaves an indelible scar, and the organism pays for its survival after a stressful situation by becoming a little older.”
“Man should not try to avoid stress any more than he would shun food, love or exercise.”
“Adopting the right attitude can convert a negative stress into a positive one.”
– Hans Selye
Chronic Stress
OPTEMPO
Fatigue
Deploy
Family stress
Financial diffs
Passed over
Stress Overload
• Breakdown in compartmen-talization
• Performance deterioration
• Behavioral problems
• Emotional instability/ deterioration
• Chronic health problems
“Well,it’s a delicate situation, sir. … Sophisticatedfiring system, hair-trigger mechanisms, and Bob’s wife just left him last night, so you know his head’s not into this.”
Symptoms of Stress
• Physical• Palpitations, pounding heart• Tense muscles, tension headaches, soreness• Dry mouth, grinding teeth• Chest pains• Indigestion, acid reflux, constipation, diarrhea,
appetite changes, nausea• Weight change• Back pain• Hands and feet sweating (dishydrosis)• Fatigue, sleep difficulties• Decreased libido
Symptoms of Stress (cont’d)
• Mental• Forgetfulness, memory problems• Indecision, poor prioritization• Lack of concentration• Difficulties in “switching off”
• Emotional• Loss of sense of humor• Nervous, jittery, on edge• Irritable, easily frustrated, short-tempered• Apathetic, depressed, sad, tearful
Symptoms of Stress (cont’d)
• Behavioral• Fidgety, nail biting, knee jiggling• Acting-out behaviors, aggressive• Smoking, compulsive eating• Talking loudly, swearing• Alcohol abuse, drug usage• Eating disorders• Inappropriate concern over health• Fear of flying
Some Diseases of the Stress Response
• Hypertension• Diabetes• Peptic Ulcer, Irritable Bowel Syndrome• Asthma• Headaches• Sleep Disorders• Depressed immune function• Coronary Artery Disease• Death, etc.
1. Below-average Nugget or NewTransition Aviator
2. Overconfident Senior Aviator3. “Best Pilot/ Aviator/
Aircrewman”
4. Consistent Poor Performer5. Overstressed Aviator
“At Risk” Aviators
Failed or Absent Defenses
Organizational Factors
Inputs
Unsafe Supervision
Preconditions for
Unsafe Acts
Unsafe Acts
Adapted from Reason (1990)
Accident & Injury
Reason’s “Swiss-cheese” Model of Human Error
Overstressed Aviator • Key Characteristics
• Major stressors, such as death of family member, divorce, failed relationship, financial setback, poor job performance
• Noticeable change in mood or personality
• Frequent, out-of-proportion anger, resentment, hostility
• Distracted, mentally preoccupied, loss of focus.
• Uncharacteristic breakdown of flight discipline or high risk-seeking behavior
• Possible Interventions• Command counseling • Flight surgeon review • Selective scheduling • Close supervision and
monitoring • Temporary grounding or
flight restrictions • Reduce workload or stress • Send to Family Services or
Stress Management clinics • Refer to HFB
Stress Management
Coping With Stress
• Recognize the problem• As usual, self assessment is poor• The sufferer is the last to recognize the problem
• Eliminate as many stressors as possible:• Eliminate alcohol, tobacco, caffeine• Adequate sleep
• “Let it out”?• Meditation• Get exercise• Take time out, snivel• Counseling, professional help
ASSASS Take Home Points: Stress
• Stress is a psychological and physiological condition.• Sources of stress can be external or internal.• Stress has long-term detrimental effects on health• Stress manifests itself as changes in emotional state
and/or overt behavior (performance).• The nature and scope of psychological aspects of stress
are in-part culturally defined.• Stress impacts personal relationships and work
environment.• Stress can be managed.....to a point!
ASSASS Learning Objectives
• DESCRIBE the science and physiology of sleepand stress, and their effects
• DESCRIBE symptoms/signs of fatigue and stress• DESCRIBE performance decrement from fatigue
and stress• DISCUSS the prime causes of fatigue and stress• DESCRIBE effects of circadian cycles in fatigue• RECOGNIZE mishaps where fatigue or stress
may be a factor• IDENTIFY key countermeasures for fatigue and
stress• UNDERSTAND performance-maintenance
pharmaceuticals
• 8.3.2.9 – Emotional Upset:Ø “COs must remain alert to the
emotional & physical status of personnel and take corrective action…”
NATOPS, Ch. 8
•Questions???
QUESTIONS???
ASSASS Aeromedical
• Feedback or questions, please!• Take critiques seriously!• Email, call any time
CAPT Jack “Bags” Wyland Command Flight Surgeon, School of Aviation Safety
[email protected] (850) 452-5140; DSN 459-
Room 161C
TEAMWORK
TEAMWORK
C-050-1503
1
Terminal Objective
• Upon completion of this unit ofinstruction, the student willdemonstrate knowledge of teams,team developmental stages, teamleadership, and associated teamperformance and maintenancetechniques
2
Enabling Objectives
• Conduct teamwork instruction, in a classroomsetting, in accordance with Crew ResourceManagement Instructor Course LectureOutline.
• Define team, in a classroom setting, inaccordance with Crew ResourceManagement Instructor Course LectureOutline.
• Identify team developmental stages, in aclassroom setting, in accordance with CrewResource Management Instructor CourseLecture Outline.
3
Enabling Objectives
• Describe the relationship between teamworkand leadership, in a classroom setting, inaccordance with Crew ResourceManagement Instructor Course LectureOutline.
• Describe team performance strategies andmaintenance strategies, in a classroomsetting, in accordance with Crew ResourceManagement Instructor Course LectureOutline.
4
Teamwork Exercise
• Put all the facts together to solve themystery.
• Find the MURDERER, WEAPON,TIME, and PLACE.
• Organize yourselves as you want(Group Leader etc.).
• You cannot write anything down,pass clues around or show them toanyone else, or walk around theroom.
5
How do “Teams” differ from “Groups?”
• Attitudes• Shared mental models• Interdependence• Level of performance
Teamwork
6
Level of Performance
HIGHER
7
Interdependence
• The crew’s success depends oneach member knowing andexecuting his/her job in anaccurate and timely manner.
8
• Great minds thinking alike
Shared Mental Models
9
What is a “TEAM” ?
A group of people working together to a common purpose
Group of people (2 or more) working together: Teams need to consider the handling of people within the team, of communicating, of keeping people together, of motivating them, so... ALL teams have people (teamwork) aspects.
To a common purpose (goal): Suggests clarity of goals, responsibilities, and objectives, with everyone involved committed to successful completion of task. ALL teams have task aspects.
10
Groups go through Phases...
• Groups which form around “tasks”go through definite stages duringtheir life.
• These stages help define the role of thegroup, determine if the group will formfurther into a ““Team.””
• Sets standards, expectations,roles, leaders, etc., for the group.
11
Team Formation Stages
1. Forming
2. Storming
3. Norming
4. Performing
5. Adjourning
12
(FSNPA) Forming:
The first stage includes all of the discomfort found in any new situation in which one’s ego is involved in new relationships. This initial stage is one of caution.
13
(FSNPA) Storming:
As individuals react to the demands of what has to de done, they become more comfortable with other members and become more themselves.
(Prior to this point persons may “present” themselves differently than they normally act.)
14
(FSNPA) Norming:
Now, the rules of behavior appropriate and necessary for the team to accomplish tasks are spelled out both implicitly and explicitly, and a greater degree of order begins to prevail.
15
(FSNPA) Performing:
Energies focus on the task(s), having worked through issues of membership, orientation, leadership, and roles. The team is now free to develop working alternatives to the problems confronting it.
16
(FSNPA) Adjourning:
Finally, with the task nearing completion, the team moves to what is called the adjourning period, in which closure to the task and a changing of relationships is anticipated.
17
Advantages/Disadvantages
Advantages:
• Sharing of Information and ideas
• Mutual Performancemonitoring
• Improved learning anddecision making
• Synergy
• Overcome individualbiases
Disadvantages:
• Stifling of Individuality
• Cost in time and effort to build a team
• Decision making difficulties
• Group pressure
• Involves more complexcommunications
18
Effective Teamwork Includes
• Behaviors such as mutualperformance monitoring
• Intra-team communication and feedback
• A willingness to both criticize and acceptcriticism constructively
19
What Impact will Leadership Style have on a Team?
Rank Gradient
Tailoring
Leadership
20
Team Performance Strategies
• Set the tone• Define and brief objectives• Communicate• Implement• Monitor/Review
21
Set the Tone
• Use good briefing techniques to set thetone for the crew.
• Stress the crew’s importance to themission of the Detachment/ Squadron/Wing/Organization.
• Examine individual values and differentviewpoints, skills, abilities.
• Ensure that everyone knows why they, inparticular, are part of the crew.
22
Define and Brief Objectives
• Clearly define objectives• Prioritize goals:
Must have Nice to have
• Map out course of action• Be innovative• Keep the big picture
23
Communicate
• Strive for structure and schedule, butmaintain flexibility
• Keep all team members informed• Solicit inputs / keep lines of
communication open
24
Implement
• Execution
• Meet agreed targets
• Communicate results of actions
25
Monitor/Review
• Conduct performance reviews
• Search for possible improvements
26
Team Maintenance Strategies
• Involvement
• Attitudes
• Conflict Management
27
Involvement
• Stay involved at the appropriatelevel
• Clear obstacles for the team• Anticipate and prevent problems
whenever possible• Neither over-react nor under-react• When in doubt as to what the team
needs or wants…ask
28
Attitudes
• Keep your team members freshbut focused
• Reward performance
• Respect individuality
29
Conflict Management
• 2 Types of Conflict:
Operational
Personal
30
Operational Conflict
• Safety
• Reliability
• Legality
31
Personal Conflict
• Interpersonal
• Coordination
32
Conflict Management
• Stress a “Crew/Mission first” attitude• Recognize the difference between
healthy disagreement and disruptivefeuding
• When well-managed, conflict can behighly constructive – especially inproblem solving situations
33
Conflict Management
• It is each crew member’sresponsibility to manage conflict.
• Disagreements focus on issues,not personalities.
34
Summary
35
Summary
• Teamwork, why it’s importantand vital for effective CRM
• Higher level of performance• FSNPA (stages of teamwork)• Leadership and it’s role• Conflict management
36
Questions?
37
INSTRUCTIONAL TECHNIQUES & FACILITATION
1
INSTRUCTIONAL TECHNIQUES & FACILITATION
Lesson 3.2
C-050-1503A PPT 5001 01 2
Terminal Objective
CONDUCT CRM Instruction, in a classroom setting, in accordance with Instruction, Crew Resource Management Program, CNAF 1542.7 (series)
3
Enabling Objective
• Implement CRM ground traininginstructional techniques.
• Explain the basic process of lecturepreparation.
• State the aspects of classroominteraction.
• Explain techniques of effectiveinformation presentation.
• State techniques for dealing withadverse conditions.
4
Instructional Techniques
5
ADULTS #1
FEARPublic Speaking
6
1960 Presidential Debate
7
Principles of Communication
• Desire to communicate• Believe in what you say• Know your subject• Know your audience• Deliver with enthusiasm• Rehearse, Rehearse, Rehearse
8
Communicating the Message
• 7% Verbal Content
• 55% Visual Stimulation
• 38% Tone of Voice
9
Developing Presentations
10
"It takes 3 weeks for me to prepare an impromptu speech."
--Mark Twain
11
Presentation Development
3 basic questions for presentation development
• Audience - Who am I teaching?• Material - What do they need to know?• Instructor - How am I going to present it?
12
Audience Analysis
• Motivation
• Interest
• Familiarity
• Capability
13
Material
• Read references
• Talk to the experts – SME’s
• Of course, just Google it!
14
Intro. 20%
Body 70%
Summary 10%
Building the Presentation
15
Introduction
Facts Quotes
Joke Video
True Story Current Events
Why should your audience listen?
16
Familiarity
• Spaces
• Equipment
17
"Being able to start is more than half the whole."
--Aristotle
Have Your Opening Nailed
18
Visualize Your Success
19
Reduced to it's most Basic form...
You’re only talking... You do that everyday!!!
20
BODY
• The “MEAT”
• Built on main points or a premise
• Supporting Analogies, Images, References
• 5WH – who, what, where, when, why, how
21
"You can't just end it"
Summary
RECAP REVIEW REINFORCE
DO
DON’T NEW INFORMATION
22
Presentation Techniques
• Complete Memorization
• Partial Memorization
• ApproximateMemorization
23
A P P R O X I
M A T E
M E M O R I Z A T I O N
Stealth fighter
24
Notes
• Use printed PowerPoint note slides ifneeded to refresh your memory
• There is no substitute forrehearsal!
25
Visuals
• Simple
• Readable
• Accurate
““A picture is worth 1000 words, but 1000 items in one
picture is worth nothing.”” 26
27
Video
• Great to illustrate a point• Great attention-getter• Great at getting people stimulated
• A GREAT DOUBLE-EDGEDSWORD!!
28
Delivering Presentations
ENTERTAINING IS EFFECTIVE
but….
IT IS NOT REQUIRED
29
NEVER APOLOGIZE !
Your audience will be very distracted and
few people can rejuvenate an atmosphere littered with
self-proclaimed weakness
30
Body Language
• The Hands
• Props
• Movement /Eye Contact
All amount to the audience’s initial
assessment of you, and their continued re-assessment of what you're saying
31
Hands Humor
32
Use of the Voice
• Quality
• Intelligently
• Variety
33
Instructional Challenges
• Classroom distractions
• Questioning technique
• Terminal nervousness
34
Dealing With Distractions
Dealing with Special People
Audience Analysis
• Continuous
• Eye-Contact
• Movement
35
Dealing With Distractions
# 1 - Ignore or Dismiss
# 2 - Subtle Confrontation Get Physically Close Make Eye Contact
SAY "STOP!"
Redirect your attention towards the audience
36
Definition of Facilitation
Facilitation is the design and management of structures and processes that help a group do its work and minimize the common problems people have working together.
37
Facilitation Objectives
• A process management• How you do something • Minimizing problems of people working in groups
• It’s asking a question• It’s about guiding a group from a problem to a
solution• Not entirely about content• Remain neutral
• Detach oneself from and relinquish control of the group’s work
38
Facilitation Fundamentals
• Be engaged• Maintain good eye contact• Stay focused on the process• Be a facilitator, not a performer• Encourage everyone to participate• Interpret verbal and nonverbal
behavior• Manage differences
39
Be Yourself
• Be comfortable
• Show your personality
• Model the behavior you wantyour students to exemplify
40
Evaluator Vs. Facilitator
Evaluator • Evaluates performance“You were ten knots fast, 50’ high, 5 degrees off”
• Lectures (passive / one way)
“You need to improve your landings”
• One size fits all
Facilitator • Promotes self-evaluation “How do you think it went? Tell me what you were thinking at this point?”
• Encourages reflection and self improvement (active/interactive) “How can we improve your landings?”
• Adapt for individual student needs
41
Review
• Good Vs. Bad instructional technique• Public speaking• Communication• Presentation development techniques• Instructional challenges• Facilitation as a method of teaching
42
Questions?