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CRM- Crew Resource CRM- Crew Resource ManagementManagement
Rules of EngagementRules of Engagement
Participation is KeyParticipation is Key
Non-AttributionNon-Attribution
No Names – What Not WhoNo Names – What Not Who
CRM – What is the Goal?CRM – What is the Goal?
To achieveTo achieveOptimal Optimal
Performance Performance from a team from a team executing executing multiple, multiple,
complex tasks.complex tasks.
CRM – What is the Goal?CRM – What is the Goal?
Does Optimal Does Optimal Performance Performance
Equate to Equate to Perfection?Perfection?
CRM…..CRM…..
To Error is HumanTo Error is Human
You Can Not Engage In Human You Can Not Engage In Human Activity Without Introducing Activity Without Introducing
Human ErrorHuman Error
So, Can We Reach The Goal of CRM So, Can We Reach The Goal of CRM Without Eliminating Error? Without Eliminating Error?
AbsolutelyAbsolutely
We Manage Our We Manage Our ErrorsErrors
We Incorporate We Incorporate
Error ManagementError Management into into
Every Aspect of Every Aspect of CRMCRM
Error Management is the “What” Error Management is the “What” Intervention/PreventionIntervention/Prevention
CRM is the “How”CRM is the “How”Trap, Mitigate, AvoidTrap, Mitigate, Avoid
GOAL: OPTIMAL PERFORMANCEGOAL: OPTIMAL PERFORMANCE
Error ManagementError Management
Overview:Overview:– What it is… and, isn’tWhat it is… and, isn’t– What Error Management Seeks to AchieveWhat Error Management Seeks to Achieve– Where Error LivesWhere Error Lives– Where it Fits in Our Skills as Pilots/AircrewWhere it Fits in Our Skills as Pilots/Aircrew
Error ManagementError Management
Systematic Approach to Determining Systematic Approach to Determining Common Errors & Contributing FactorsCommon Errors & Contributing Factors
Drives Cultural Change to Accept:Drives Cultural Change to Accept:Error is Universal. Error is Inevitable.Error is Universal. Error is Inevitable.Shifts Focus from Shifts Focus from WhoWho to to WhatWhat
Teach aircrews toTeach aircrews to TRAP, MITIGATE & AVOID Error.TRAP, MITIGATE & AVOID Error.
Error ManagementError Management
ErrorError does not, has not, and will not does not, has not, and will not
cause an incident, an accident, or a fatalitycause an incident, an accident, or a fatality
So, what does?So, what does?
ConsequenceConsequence
Error ManagementError Management
ConsequenceConsequence
Consequences are not universal or inevitable.Consequences are not universal or inevitable.Errors Errors happen all of the time. happen all of the time.
Incidents, accidents, and fatalities do not. Incidents, accidents, and fatalities do not.
EM targets the GAP between EM targets the GAP between Error and ConsequenceError and Consequence!!
Where Error LivesWhere Error Lives
LATENT – LATENT – present but not visible…present but not visible…hidden in hidden in the things we do routinelythe things we do routinely
ACTIVE – ACTIVE – present, in use…present, in use…individual errorindividual error
The Swiss Cheese Model The Swiss Cheese Model (REASONS)(REASONS)
Latent Errorsin System
1
2
3
4
Latent Errorsat MgtLevel
Individual Error(Active Error) Result/error
Organizational Filters: Training/Stan/CRM/ORM
Trajectory ofAccident/Error
Unchecked
5
Error Management… The CruxError Management… The Crux
Mitigating the Consequence of ErrorMitigating the Consequence of Error
Employ Employ Error TrappingError Trapping in Every Aspect of: in Every Aspect of:
TrainingTrainingStandardizationStandardization
CRM & ORMCRM & ORM
Error Trapping = Prevention & InterventionError Trapping = Prevention & Intervention
What was EM Outcome What was EM Outcome
6555 Aug ‘946555 Aug ‘94Practice Auto Practice Auto
Latent & Active ErrorsLatent & Active Errors
EM & CRMEM & CRM
Error Management must be Error Management must be imbedded in all four imbedded in all four
principles of CRM (SCAR)principles of CRM (SCAR)
CRM Principle - S.A.CRM Principle - S.A.
Situational AwarenessSituational Awareness……
……is the realistic understanding of all is the realistic understanding of all factors which affect the safety and factors which affect the safety and effectiveness of your crew and aircraft.effectiveness of your crew and aircraft.
CRM Principle - S.A.CRM Principle - S.A.
Elements of Situational Awareness?Elements of Situational Awareness?
Spatial Orientation/attitudeSpatial Orientation/attitudeOrientation to traffic, geography & timeOrientation to traffic, geography & timeAircraft status & capabilitiesAircraft status & capabilitiesAircrew status & Crew-life cycleAircrew status & Crew-life cycleMission concept & Mission-life cycleMission concept & Mission-life cycle
CRM Principle - S.A.CRM Principle - S.A.
Loss of Situational Awareness Loss of Situational Awareness
Still the Leading Cause of Aircraft MishapsStill the Leading Cause of Aircraft Mishaps(NASA/FAA: causal factor in 65-80% accidents)(NASA/FAA: causal factor in 65-80% accidents)
Rarely is it Instantaneous!Rarely is it Instantaneous!
CRM Principle - S.A.CRM Principle - S.A.
Why do we lose Situational AwarenessWhy do we lose Situational Awareness??
Mode confusion/Automation ComplacencyMode confusion/Automation ComplacencyStress/FatigueStress/FatigueStimulus Fixation Stimulus Fixation Decision Making/Task Management Decision Making/Task Management Inadequate Error Management/TrappingInadequate Error Management/Trapping
““Roadblocks”Roadblocks”
CG 6541 - Humboldt Bay, 12 Jul ‘94CG 6541 - Humboldt Bay, 12 Jul ‘94
CRM Principle - S.A.CRM Principle - S.A.
What are the “Loss of S.A.” flags?What are the “Loss of S.A.” flags?
Not CommunicatingNot Communicating Ambiguity Ambiguity
No one flying the aircraftNo one flying the aircraft Failure to meet targets Failure to meet targets
Deviating from StandardsDeviating from Standards Not addressing discrep’s Not addressing discrep’s
Violating MinimumsViolating Minimums Preoccupation Preoccupation
ConfusionConfusion
CRM Principle - S.A.CRM Principle - S.A.
What do you do when you suspect you What do you do when you suspect you have have lostlost S.A.?S.A.?
ReactReact RegainRegain ReconstructReconstruct
ROADBLOCKSROADBLOCKS
The common obstructions to good CRM!The common obstructions to good CRM!A combination of negative human A combination of negative human
factors, ingrained habits, and our own factors, ingrained habits, and our own personal attitudes and those of the crew-personal attitudes and those of the crew-members we are working with.members we are working with.
ROADBLOCKSROADBLOCKSNORMS: unwritten rules that become NORMS: unwritten rules that become
pressures that act upon a group, be alert pressures that act upon a group, be alert for “Killer Norms.”for “Killer Norms.”
ODD MAN OUT: Ignore input from a ODD MAN OUT: Ignore input from a particular member of the crew. Results particular member of the crew. Results in a loss of total crew effectiveness.in a loss of total crew effectiveness.
HIDDEN AGENDA: Intentionally HIDDEN AGENDA: Intentionally withholding information about intentions withholding information about intentions or plans from the rest of the crew.or plans from the rest of the crew.
ROADBLOCKS (cont):ROADBLOCKS (cont):
CHAIN OF ERRORS: Often the key is to CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a recognize the chain developing-then a crewmember can act to change the crewmember can act to change the situation. situation.
BREAK THE CHAINBREAK THE CHAIN
ROADBLOCKS (cont):ROADBLOCKS (cont):
HAZARDOUS ATTITUDES: Attitudes HAZARDOUS ATTITUDES: Attitudes that impede effective CRM.that impede effective CRM.– Macho - “I can do it.”Macho - “I can do it.”– Anti-Authority - “Don’t tell me.”Anti-Authority - “Don’t tell me.”– Impulsivity - “Do something -quickly!”Impulsivity - “Do something -quickly!”– Resignation - “What’s the use?”Resignation - “What’s the use?”– Missionitis - “Let’s press on.”Missionitis - “Let’s press on.”
FATIGUEFATIGUE Widely recognized enemy of pilots & crewmembersWidely recognized enemy of pilots & crewmembers ..
– A low frustration thresholdA low frustration threshold– Degraded coordinationDegraded coordination– Slowness in responseSlowness in response– CarelessnessCarelessness– Acceptance of low standards of Acceptance of low standards of
accuracyaccuracy
ROADBLOCKSROADBLOCKS
STRENGTH OF AN IDEA: Tendency to STRENGTH OF AN IDEA: Tendency to unconsciously make the available unconsciously make the available evidence fit a preconceived situation; to evidence fit a preconceived situation; to see or hear what we want to hear, and see or hear what we want to hear, and substitute that for reality. It can take 15 substitute that for reality. It can take 15 seconds to “break” an idea that has been seconds to “break” an idea that has been ingrained, but is incorrect.ingrained, but is incorrect.
TOOLSTOOLS
Will help in assuring Will help in assuring a good balance of;a good balance of;
Effective Effective communicationcommunication
Personal monitoringPersonal monitoring Strong team work Strong team work
skillsskills
ERROR TRAPSERROR TRAPS
STERILE COCKPIT/CABINSTERILE COCKPIT/CABIN
TWO CHALLENGE RULETWO CHALLENGE RULE
TOOLS cont:TOOLS cont:
PERSONAL MONITORINGPERSONAL MONITORING “I’M SAFE”“I’M SAFE”
ILLNESSILLNESS
MEDICATIONMEDICATION
SLEEPSLEEP
ALCOHOLALCOHOL
FATIGUEFATIGUE
EATING/EXERCISEEATING/EXERCISE
CRM Principle - CommunicationCRM Principle - Communication
Elements of Communication SkillsElements of Communication Skills
The most obvious of the CRM principles.The most obvious of the CRM principles.
And, the easiest to affect through training.And, the easiest to affect through training.
“Say what you mean, mean what you say.”“Say what you mean, mean what you say.”
CRM Principle - CommunicationCRM Principle - Communication
Apply the A-B-C’s of communicationApply the A-B-C’s of communication
AccurateAccurateBoldBold
ConciseConcise
CRM Principle - CommunicationCRM Principle - Communication
Understand the communication loopUnderstand the communication loop
Idea-Encode-Xmit-Receive-Decode-IdeaIdea-Encode-Xmit-Receive-Decode-Idea
Say what you mean, mean what you say. Say what you mean, mean what you say.
But, “Have I been understood?”But, “Have I been understood?”
CRM Principle - AssertivenessCRM Principle - Assertiveness
Elements of Assertive Behavior Elements of Assertive Behavior
Authority with ParticipationAuthority with ParticipationAssertiveness with RespectAssertiveness with Respect
The genuine, complete & direct The genuine, complete & direct communication of ideas, wants & needs.communication of ideas, wants & needs.
CRM Principle - AssertivenessCRM Principle - Assertiveness
The genuine, complete & direct The genuine, complete & direct communication of ideas, wants & needs.communication of ideas, wants & needs.
CRM Principle - AssertivenessCRM Principle - Assertiveness
The Assertive StatementThe Assertive Statement
Open-up; get their attentionOpen-up; get their attentionState concern as “owned emotion”State concern as “owned emotion”State the problem - real or perceivedState the problem - real or perceivedOffer a solutionOffer a solutionObtain agreement/closureObtain agreement/closure
““Say what needs to be said”Say what needs to be said”
CRM Principle - Risk CRM Principle - Risk
Risk ManagementRisk Management
RISK is a factor of:RISK is a factor of:ProbabilityProbability
SeveritySeverityExposureExposure
Risk Management - M3710.1DRisk Management - M3710.1D
What is an acceptable level of Risk?What is an acceptable level of Risk?……potential risks to the aircraft and crew potential risks to the aircraft and crew
shall be weighted against risks to the shall be weighted against risks to the personnel and/or property in distress if personnel and/or property in distress if the mission is not taken.the mission is not taken.
““probable loss of an aircrew is not an probable loss of an aircrew is not an acceptable riskacceptable risk.”.”
Operational Risk Management Operational Risk Management (ORM)(ORM)
History:History:
1996 - multi-dimensional workshop1996 - multi-dimensional workshop
Developed common risk mgmt processDeveloped common risk mgmt process
Specifically tailored to our size and Specifically tailored to our size and multi-mission nature.multi-mission nature.
Identify Mission Tasks Identify Mission Tasks
Identify HazardsIdentify Hazards
Eval Risk vs.. GainEval Risk vs.. Gain
Assess Risks Assess Risks
Identify OptionsIdentify Options
Execute DecisionExecute Decision
Monitor SituationMonitor Situation
Operational Risk Management Operational Risk Management (ORM)(ORM)
7 Step Process 7 Step Process
Step #2: Identify HazardsStep #2: Identify Hazards
Use the “PEACE” Model to remember Use the “PEACE” Model to remember the 5 risk factors:the 5 risk factors:– PlanningPlanning– Event ComplexityEvent Complexity– Asset SelectionAsset Selection– CommunicationsCommunications– Environmental ConditionsEnvironmental Conditions
Step #3: Assess the RisksStep #3: Assess the Risks
SPE RISK ASSESSMENT MODELSPE RISK ASSESSMENT MODELRisk=Severity x Probability x ExposureRisk=Severity x Probability x Exposure
• Severity - Potential consequences Severity - Potential consequences measured in terms of degree of measured in terms of degree of damage, injury, or impact on a damage, injury, or impact on a mission. Could occur in one of these mission. Could occur in one of these areas: areas: • Injury or death, equip damage, Injury or death, equip damage,
mission degradation, reduced morale, mission degradation, reduced morale, adverse publicity, admin/disciplinary adverse publicity, admin/disciplinary actionsactions
Step #4: Identify the OptionsStep #4: Identify the Options
STAARSTAAR–Spread OutSpread Out– TransferTransfer–AvoidAvoid–AcceptAccept–ReduceReduce
Step #5: Evaluate Risk vs.. GainStep #5: Evaluate Risk vs.. Gain
Analyze the operation’s degree of risk Analyze the operation’s degree of risk with the proposed controls in placewith the proposed controls in place
Determine if operational benefits exceed Determine if operational benefits exceed the degree of risk the operation presentsthe degree of risk the operation presents
Consider cumulative risksConsider cumulative risksThis is the “REALITY CHECK!”This is the “REALITY CHECK!”
Step #6: Execute the DecisionStep #6: Execute the Decision
The risk control decision is madeThe risk control decision is madeClear communication of decision clarifies Clear communication of decision clarifies
rational behind risk management rational behind risk management decision.decision.
(Done it a hundred times, been there, etc.)(Done it a hundred times, been there, etc.)
Step #7: Monitor SituationStep #7: Monitor Situation
Monitor situation to ensure controls are Monitor situation to ensure controls are effective and in placeeffective and in place
Identify any and all changes requiring Identify any and all changes requiring further risk management and act on further risk management and act on themthem
Risk management is a continuous processRisk management is a continuous process
Catastrophic Events Rarely Result Catastrophic Events Rarely Result From A Single ErrorFrom A Single Error
Crew Resource ManagementCrew Resource Management
The The empowermentempowerment of all crewmembers of all crewmembers to promote safety and increase to promote safety and increase overall aircrew performance.overall aircrew performance.
Think Error ManagementThink Error Management
Execute CRM SkillsExecute CRM Skills