Threat and Error Managementin Aviation

Center of Excellence

October 28th 2002

Captain Mark Auerman

Topics

• Brief history of Crew Resource Management

• Threat and Error Management

• Error management tools in aviation

• Questions are encouraged!!

What is Crew Resource Management (CRM) ?

• Crew Resource Management – effective use of all resources, to achieve the effective use of all resources, to achieve the

highest possible level of safety and efficiency. highest possible level of safety and efficiency. (Transport Canada)(Transport Canada)

Historical Development of CRM

Aircraft accident rates were extremely high post WWII to the 1970’s

These high accident rates were largely attributable to unreliable

aircraft equipment

Caused accident rates to decline significantly until the mid 1970’s

Since then the accident rate has leveled off

Now we must address deficiencies in Crew Performance with

Crew Resource Management Training

Goal of CRM

• Provide resources and strategies to allow airline crews to effectively manage threats and errors.

Latent and Active Errors

Active errors are caused by the crew mismanaging the resources

POLICIES PROCEDURES

Latent errors are errors we inherit

What is CRM training all about ?

CRM Training develops skills and strategies in the following

areas…

• Communication

• Crew Performance

• Leadership

• Situational Awareness

• Decision Making

Proactive Error Management Tools

• CRM training mandated by Transport Canada– Initial 3 day courseInitial 3 day course– Periodic refresher training focused on Periodic refresher training focused on

topical issuestopical issues– Practical based training Practical based training

Evolution of trainingAdvanced Qualification Program

– Script a simulator event looking for specific Script a simulator event looking for specific observable CRM behaviorsobservable CRM behaviors

– 50% of the grade is based on CRM practices50% of the grade is based on CRM practices

– Collect crew performance data that feeds back Collect crew performance data that feeds back into the training system and modifies future into the training system and modifies future training curriculumtraining curriculum

Simulator Training• Procedures Trainers – must demonstrate competency every 6 – 8 months • Decision making Trainers

– Real life scenarios played out in Real life scenarios played out in real timereal time

– Allows crews to gain experience Allows crews to gain experience and practice decision makingand practice decision making

Line Checks

• Assess and evaluate crew performance during line operations

Technical + CRM = Crew Performance*

Challenges

• Cost issue

• Changing Attitudes and Culture

• Very difficult to gradeVery difficult to grade

• Are we making a difference?Are we making a difference?

Conclusions

• many “soft skills” combined with practical strategies are required to manage error

• CRM is the most flexible error management tool

• CRM has effectively increased crew performance to make flight operations safer