Crew Resource Management Phil O’Donnell Manager Operations and Planning Audits Western Electricity Coordinating Council

Crew Resource Management In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers. There were 224 fatalities! Western Electricity Coordinating Council

What is Crew Resource Management? Definition(s) Beginnings Evolution Elements of CRM Why you should add it to your training program Case study for comparison to the power industry. Western Electricity Coordinating Council

Western Electricity Coordinating Council Definitions Crew Resource Management (CRM) is a management system which makes optimal use of all available resources—equipment, procedures and people—to promote safety and enhance the efficiency of flight operations. CRM is a tool created to optimize human performance by reducing the effect of human error through the use of all resources. Western Electricity Coordinating Council

Western Electricity Coordinating Council Definition Slightly modified for consideration by the power industry… Crew Resource Management A management system which makes optimal use of all available resources—equipment, procedures and people—to promote safety and reliability and enhance the efficiency of system operations. Western Electricity Coordinating Council

Western Electricity Coordinating Council 1979 NASA Workshop Focused on causes and recommended solutions to commercial aviation accidents Western Electricity Coordinating Council

Common Elements of Accidents Preoccupation with minor mechanical problems Inadequate leadership Failure to delegate tasks and assign responsibilities Failure to set priorities Inadequate monitoring Failure to utilize available data Failure to communicate intent and plans Western Electricity Coordinating Council

Western Electricity Coordinating Council Environments for CRM High-impact, adverse (or life threatening) outcomes when mistakes are made Technical complexity Multiple path/task options Team/individual interactions Communications Western Electricity Coordinating Council

Evolution beyond the “Cockpit” All available resources Non-flying crew members Airline dispatchers Maintenance personnel Air traffic control Western Electricity Coordinating Council

Evolution beyond the “Cockpit” Other industries Military (primarily aviation) Medicine First responders (firefighters) Maritime industry Bulk electric system operations? Western Electricity Coordinating Council

Western Electricity Coordinating Council Obstacles to Success Professional Culture Organizational Culture Western Electricity Coordinating Council

Western Electricity Coordinating Council Cultural Challenges In 2013, a study published in the Journal of Patient Safety put the number of premature deaths associated with preventable harm at more than 40,000 per year. Western Electricity Coordinating Council

Western Electricity Coordinating Council Culture Medical doctors at pinnacle of their industry (and society) Need to look good Striving for perfection Reluctance of anyone to speak up Pilots were no different Requires a significant cultural shift Western Electricity Coordinating Council

What does your “Crew” Look Like? How many have a formal shift supervisor? System Operations “Crew” Transmission Operator (how many) Balancing Desk or Generator Dispatch Transmission Schedulers Engineering Support IT/Data Support Your Reliability Coordinator Western Electricity Coordinating Council

Components for Training Communications Situational awareness Decision making Teamwork Barriers Western Electricity Coordinating Council

Communications Competencies Efficient Clear Professional Western Electricity Coordinating Council

Situational Awareness System monitoring Part of technical competency Forecasting and anticipation Goal of no surprises Cross-training Western Electricity Coordinating Council

Planning and Decision Making Operations and outage planning Are conditions as expected Go/No Go Pre evolution brief And… Western Electricity Coordinating Council

Teamwork Competencies Leadership Inspiring leadership is good Authoritarian leadership—not so good Team workload management Pace tasks when possible Use available resources Adaptability Cross-training Western Electricity Coordinating Council

Western Electricity Coordinating Council Barriers Stress Task saturation Time pressure Confusion (Automation and MMI) Western Electricity Coordinating Council

Western Electricity Coordinating Council Barriers Lack of Assertiveness Can be related to teamwork, communications, leadership or culture Get attention State concern Identify the problem Offer a solution Obtain agreement Western Electricity Coordinating Council

Case Study - Air France Flight 447 Western Electricity Coordinating Council

Case Study - Air France Flight 447 Rio de Janeiro – Paris: June 1, 2009 Weather Complex, automatic flight systems Alarm displays and task saturation Time of day and crew rest Leadership and teamwork Western Electricity Coordinating Council

Western Electricity Coordinating Council Air France Flight 447 Airbus A330-203 Aircraft 3 experienced flight crew, Collectively 61 years experience, 20,471 hours behind the controls 9 cabin crew and 216 passengers also on board Departed 10:29 p.m. local time The flight data recorder was found and brought to the surface on May 1, 2011, and the cockpit voice recorder on the next day Almost 2 years after the accident Western Electricity Coordinating Council

Western Electricity Coordinating Council 447 Cause of Accident Sensor inputs for airspeed indication failed. The crew did not make the connection between the loss of indicated airspeeds and the appropriate procedure. Inappropriate control inputs that destabilized the flight path. One pilot’s late identification that other pilot was not making proper corrections. The crew’s failure to diagnose the situation and, consequently, the lack of any actions that would have made recovery possible. Western Electricity Coordinating Council

Western Electricity Coordinating Council Time Element First problem at 2 hours 10 minutes and 5 seconds into the flight Impact with the sea at 2 hours 14 minutes and 28 seconds 4 minutes and 23 seconds Western Electricity Coordinating Council

Western Electricity Coordinating Council Time Element During the September 8, 2011 Southwest Blackout Initial trip of the Hassayampa-North Gila 500-kV line at 15:27:38 Collapse of the San Diego, Yuma, CFE island at 15:38:39 10 minutes and 59 seconds Western Electricity Coordinating Council

Western Electricity Coordinating Council Air France Flight 447 41 Safety Recommendations related to: Flight recorders; Certification, training, and recurrent training of pilots; Relief of the captain; Search and rescue; Air traffic control; Flight simulators; Cockpit ergonomics; and Operational feedback and oversight of operators by the national oversight authority. Western Electricity Coordinating Council

Western Electricity Coordinating Council 2011 Southwest Blackout 27 Recommendations related to: Next-day planning; Seasonal planning; Modeling deficiencies; Situational awareness tools; External visibility; Staffing and training of the Reliability Coordinator; Communications; System analysis; IROLs; and Protection systems. Western Electricity Coordinating Council

Western Electricity Coordinating Council Weather Western Electricity Coordinating Council

Western Electricity Coordinating Council Control Rooms Western Electricity Coordinating Council

Western Electricity Coordinating Council Operating Limits Western Electricity Coordinating Council

Western Electricity Coordinating Council Alarm Displays EMS Alarm Display Screen Western Electricity Coordinating Council

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Western Electricity Coordinating Council Controls Western Electricity Coordinating Council

Air France CRM Training Flight crew attend an initial two-day course First day when rated to fly an aircraft Second day after 6 months experience Each year ½ day Twice per year during simulator training Western Electricity Coordinating Council

Improving CRM can Enhance Reliability It’s NOT a silver bullet. Takes more than one effort. Challenge to make it realistic. Like any training, focus on weak areas or barriers. Western Electricity Coordinating Council

Western Electricity Coordinating Council Defense in Depth It is rarely one failure that results in an incident or accident Every resource, when used correctly, can help stop the progression Western Electricity Coordinating Council

Phil O’Donnell Manager Operations and Planning Audits Thank You Phil O’Donnell Manager Operations and Planning Audits Western Electricity Coordinating Council