1. Join CRM/HFIM for: Pilot; AME; Flight Attendant; FOO; Ground
Personnel Capt. You re resources, Im Management
2. Objectives 1. To demonstrate Human Factors/CRM Concept
(SHELL) 2. To increase safety awareness at any situation and
condition 3. To demonstrate ability to detect and asses hazard
around work place. 4. Able to communicate effectively and
accurately. 5. Able to make decision making. 6. To identify factor
affecting human error. 7. Aware to hazardous attidtude.
3. Technology Developm ent (high Risk) Leadership ;Awarenes s
& Work culture No- Harmonization Response of a frog in a
boiling water (charles Handy) Unsafe Decision & Behavior High
Risk
4. Crew Resources Management 4 A Conceptual Model of Human
Factors Courtesy of Human Factos In Aviation David C. Nagel
5. HUMAN FACTORS SHELL Concept
6. Why Human Factors/CRM? Regulations? Requirements to
revalidate License?
7. Safety is a Need?
8. The definition of Crew Resource Management a flexible,
systemic method for optimizing human performance in general, and
increasing safety in particular, by (1) recognizing the inherent
human factors that cause errors and the reluctance to report them,
(2) recognizing that in complex, high risk endeavors, teams rather
than individuals are the most effective fundamental operating units
and (3) cultivating and instilling customized, sustainable and
team-based tools and practices that effectively use all available
resources to reduce the adverse impacts of those human
factors.
9. A series of aviation disasters in the 1970's triggered the
innovative shift that led to Crew Resource Management. These
included the 1977 Canary Islands disaster in which two Boeing 747's
collided on a runway, killing 582 people. In 1972, a Lockheed
L-1011 (Eastern Air Lines Flight 401) crashed in a Florida swamp,
killing 99 passengers... as the crew worked to repair a burned-out
light bulb. United Airlines Flight 173, making its final approach
to Portland International Airport after a routine flight on
December 28, 1978, ran out fuel and crashed into a residential
area, killing eight passengers and two crew members, and seriously
injuring 23 others. May we can learn from past aircraft accidents,
below:
10. In each case, tragedy traced back to human error: Canary
Islands: in his haste to take off, the captain of the Boeing 747, a
highly seasoned professional, mistakenly assumed a critical
pre-flight step had been performed and barreled down a foggy runway
without first obtaining takeoff clearance.
11. EAL 401: crashed, in essence, because someone forgot to fly
the plane. The National Transportation Safety Board (NTSB), after
investigating, found that the autopilot was inadvertently switched
from "Altitude Hold" to "Control Wheel Steering" mode when the
captain accidentally leaned against a yolk, causing the plane to
enter a gradual descent. No one in the crew noticed or heard the
system's altitude alert warning because the crew was distracted by
the landing gear light and the flight engineer was not in his seat
when the alert sounded and thus could not hear it.
12. UA 173: experienced a similar landing gear light problem.
The experienced captain noticed that the plane's nose gear light
failed to turn green to indicate it was properly deployed. With the
control tower's permission, the pilot circled the plane and ran
through his checklists to troubleshoot the problem, but the nose
gear light stayed red. While circling, the first officer and flight
engineer told the pilot that the plane was running low on fuel. The
pilot apparently ignored the warnings. Post-crash analysis revealed
that the green light bulb for the nose gear had simply burned out;
the landing gear had been deployed the entire time. The NTSB found
that the crash was caused by the captain's failure to accept input
from junior crew members and a lack of assertiveness by the flight
engineer.
13. "We are embarking on an adventure into the flight training
techniques of the future. In recent years a growing consensus has
occurred in industry and government that training should emphasize
crew coordination and the management of crew resources." - Charles
Huettner, FAA
14. Inside or Outside
15. Why Human Factors/CRM?
16. Human Factors CRM Just a Tool to achieve SAFETY
17. Safety is Perception of Human Being how to .
18. Safety is Everyone Perception
19. Bad Situational Awareness
20. Distraction can reduce Situational Awareness
21. Fatigue can reduce Situational Awareness
22. STRESS can reduce Situational Awareness
23. UPS Flt. 1354 Crashed when landing approach due to CFIT.
Contributing factors is Pilot fatigue
24. Why accident still happen? Probable cause in 80% of
accidents (NTSB): Unprofessional attitude 47% Pilot
technique/decision making 26% Visual perception situation
misjudgment 19%
25. A Bird In The The Bush Read the PhotoWhat Does it Say?
26. This illustrates how a mind set can block simple
communications.
27. The Evolution of Crew Resources Management CRM : Emphasize
the human attitude in responding situation TEM : Threat and Error
Management is a major safety process in aviation. It consists of
detecting, responding, avoiding/trapping threats and errors that
challenge safe operations. Where threats and errors are not
contained (resolved), the resulting conditions must be managed and
adverse effects reduced.
28. Threat Management is managing YOUR FutuRe Error Management
is managing YOUR Past
29. 35 What is a Threat? Any condition that increases the
complexity of the operation. Threats, if not managed properly, can
decrease safety margins and can lead to errors. Threats should
serve as a Red Flag. Watch out! Something bad can happen!
30. 36 What is Threat Management? Threat Management There are
two aspects to Threat Management: 1. Recognizing that a threat
exists 2. Coming up with a strategy to deal with the threat, so
that it does not reduce safety margins or contribute to an
error
31. 37 There are two types of threats External Threats Those
outside of your control (e.g., weather, lack of equipment, hard to
understand documentation, system errors, inadequate lighting)
Internal (Human) Threats Those within our control (e.g., fatigue,
loss of situation awareness, stress, disregard for following
procedures) Types of Threats
32. 38 What is an Error? The mistake that is made when threats
are mismanaged. There are 5 types of errors: 1. Intentional
non-compliance errors 2. Procedural errors 3. Communication errors
4. Proficiency errors 5. Operational decision errors
33. 39 What is Error Management? Error Management The
mitigation or reduction in seriousness of the outcome. 1. The
resist and resolve filters or defense mechanisms may be applied to
an existing error before it becomes consequential to safety. 2. By
applying the resist and resolve filters in the analysis of an
error, you may: Improve strategies or counter-measures to identify
and manage both internal and external threats, like fatigue,
condition of ground equipment, etc.
34. 40 Weather New Agent Cabin Crew Passenger events Late Bags
Time pressures Heavy traffic Unfamiliar gate Flight Crew Flight
diversion Distractions Ramp slope Late Cargo Maintenance System
malfunction Late Gate Change Threats That Can Lead to Ramp Agent
Error
35. 41 CommunicationDocumentation Lighting Temperature Access
equipment Tools Noise Hazardous materials Airplane/ parts design
Threats That Can Lead to Mechanic Error Lack of Skill Time pressure
Task distraction/ interruption
36. INVULNERABILITY It cant happen to me Macho Can Do Risk
taking Impulsivity Do something fast! Anti-Authority Dont tell me
Resignation Whats the use? Start thinking the unthinkable Risk
taking is foolish STOP! Think! Select the best course Follow the
rules You can make a difference HAZARDOUS ATTITUDE ANTIDOTE
Pressing Get-thereitis Its better to get there late than never
37. Your Project You as engineer, identify the threat and error
in aircraft maintenance You as pilot, identify the threat and error
in aircraft maintenance
38. WHO FAULT.?
39. The Summary Safety is everybody need Think safe, act safe,
Be assertive in any condition Be Enlightening
