CRM- Crew Resource Management

Rules of Engagement Participation is Key Non-Attribution No Names – What Not Who

CRM – What is the Goal? To achieve Optimal Performance from a team executing multiple, complex tasks.

CRM – What is the Goal? Does Optimal Performance Equate to Perfection?

CRM….. CRM….. To Error is Human You Can Not Engage In Human Activity Without Introducing Human Error So, Can We Reach The Goal of CRM Without Eliminating Error?

Absolutely We Manage Our Errors We Incorporate Error Management into Every Aspect of CRM

Error Management is the “What” Intervention/Prevention CRM is the “How” Trap, Mitigate, Avoid GOAL: OPTIMAL PERFORMANCE

Error Management Overview: –What it is… and, isn’t –What Error Management Seeks to Achieve –Where Error Lives –Where it Fits in Our Skills as Pilots/Aircrew

Error Management Systematic Approach to Determining Common Errors & Contributing Factors Drives Cultural Change to Accept: Error is Universal. Error is Inevitable. Shifts Focus from Who to What Teach aircrews to TRAP, MITIGATE & AVOID Error.

Error Management Error does not, has not, and will not cause an incident, an accident, or a fatality So, what does? Consequence

Error Management Consequence Consequences are not universal or inevitable. Errors happen all of the time. Incidents, accidents, and fatalities do not. Consequence Consequences are not universal or inevitable. Errors happen all of the time. Incidents, accidents, and fatalities do not. EM targets the GAP between Error and Consequence!

Where Error Lives LATENT – present but not visible…hidden in the things we do routinely LATENT – present but not visible…hidden in the things we do routinely ACTIVE – present, in use…individual error ACTIVE – present, in use…individual error

The Swiss Cheese Model (REASONS) Latent Errors in System Latent Errors at Mgt Level Individual Error (Active Error) Result/error Organizational Filters: Training/Stan/CRM/ORM Trajectory of Accident/Error Unchecked 5

Error Management… The Crux Mitigating the Consequence of Error Employ Error Trapping in Every Aspect of: Training Standardization CRM & ORM Error Trapping = Prevention & Intervention

What was EM Outcome 6555 Aug ‘94 Practice Auto Latent & Active Errors

EM & CRM Error Management must be imbedded in all four principles of CRM (SCAR) Error Management must be imbedded in all four principles of CRM (SCAR)

CRM Principle - S.A. Situational Awareness… …is the realistic understanding of all factors which affect the safety and effectiveness of your crew and aircraft.

CRM Principle - S.A. Elements of Situational Awareness? Elements of Situational Awareness? Spatial Orientation/attitude Orientation to traffic, geography & time Aircraft status & capabilities Aircrew status & Crew-life cycle Mission concept & Mission-life cycle

CRM Principle - S.A. Loss of Situational Awareness Still the Leading Cause of Aircraft Mishaps (NASA/FAA: causal factor in 65-80% accidents) Rarely is it Instantaneous!

CRM Principle - S.A. Why do we lose Situational Awareness? Mode confusion/Automation Complacency Stress/Fatigue Stimulus Fixation Decision Making/Task Management Inadequate Error Management/Trapping “Roadblocks”

CG Humboldt Bay, 12 Jul ‘94

CRM Principle - S.A. What are the “Loss of S.A.” flags? Not Communicating Ambiguity No one flying the aircraft Failure to meet targets Deviating from Standards Not addressing discrep’s Violating Minimums Preoccupation Confusion

CRM Principle - S.A. What do you do when you suspect you have lost S.A.?  React  Regain  Reconstruct

ROADBLOCKS ROADBLOCKS The common obstructions to good CRM! The common obstructions to good CRM! A combination of negative human factors, ingrained habits, and our own personal attitudes and those of the crew- members we are working with. A combination of negative human factors, ingrained habits, and our own personal attitudes and those of the crew- members we are working with.

ROADBLOCKS NORMS: unwritten rules that become pressures that act upon a group, be alert for “Killer Norms.” NORMS: unwritten rules that become pressures that act upon a group, be alert for “Killer Norms.” ODD MAN OUT: Ignore input from a particular member of the crew. Results in a loss of total crew effectiveness. ODD MAN OUT: Ignore input from a particular member of the crew. Results in a loss of total crew effectiveness. HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew. HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.

ROADBLOCKS (cont): CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation. CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation. BREAK THE CHAIN BREAK THE CHAIN

ROADBLOCKS (cont): HAZARDOUS ATTITUDES: Attitudes that impede effective CRM. HAZARDOUS ATTITUDES: Attitudes that impede effective CRM. –Macho - “I can do it.” –Anti-Authority - “Don’t tell me.” –Impulsivity - “Do something -quickly!” –Resignation - “What’s the use?” –Missionitis - “Let’s press on.”

FATIGUE Widely recognized enemy of pilots & crewmembers. –A low frustration threshold –Degraded coordination –Slowness in response –Carelessness –Acceptance of low standards of accuracy

ROADBLOCKS STRENGTH OF AN IDEA: Tendency to unconsciously make the available evidence fit a preconceived situation; to see or hear what we want to hear, and substitute that for reality. It can take 15 seconds to “break” an idea that has been ingrained, but is incorrect. STRENGTH OF AN IDEA: Tendency to unconsciously make the available evidence fit a preconceived situation; to see or hear what we want to hear, and substitute that for reality. It can take 15 seconds to “break” an idea that has been ingrained, but is incorrect.

TOOLS Will help in assuring a good balance of; Will help in assuring a good balance of; Effective communication Effective communication Personal monitoring Personal monitoring Strong team work skills Strong team work skills

ERROR TRAPS STERILE COCKPIT/CABIN TWO CHALLENGE RULE TOOLS cont:

PERSONAL MONITORING “I’M SAFE” ILLNESSMEDICATIONSLEEPALCOHOLFATIGUEEATING/EXERCISE

CRM Principle - Communication Elements of Communication Skills The most obvious of the CRM principles. And, the easiest to affect through training. “Say what you mean, mean what you say.”

CRM Principle - Communication Apply the A-B-C’s of communication Accurate Bold Concise

CRM Principle - Communication Understand the communication loop Understand the communication loopIdea-Encode-Xmit-Receive-Decode-Idea Say what you mean, mean what you say. But, “Have I been understood?”

CRM Principle - Assertiveness Elements of Assertive Behavior Authority with Participation Assertiveness with Respect The genuine, complete & direct communication of ideas, wants & needs.

CRM Principle - Assertiveness The genuine, complete & direct communication of ideas, wants & needs.

CRM Principle - Assertiveness The Assertive Statement Open-up; get their attention State concern as “owned emotion” State the problem - real or perceived Offer a solution Obtain agreement/closure “Say what needs to be said”

CRM Principle - Risk Risk Management RISK is a factor of: ProbabilitySeverityExposure

Risk Management - M3710.1D What is an acceptable level of Risk? What is an acceptable level of Risk? …potential risks to the aircraft and crew shall be weighted against risks to the personnel and/or property in distress if the mission is not taken. …potential risks to the aircraft and crew shall be weighted against risks to the personnel and/or property in distress if the mission is not taken. “probable loss of an aircrew is not an acceptable risk.” “probable loss of an aircrew is not an acceptable risk.”

Operational Risk Management (ORM) History: multi-dimensional workshop Developed common risk mgmt process Specifically tailored to our size and multi-mission nature.

Identify Mission Tasks Identify Hazards Eval Risk vs.. Gain Assess Risks Identify Options Execute Decision Monitor Situation Operational Risk Management (ORM) 7 Step Process

Step #2: Identify Hazards Use the “PEACE” Model to remember the 5 risk factors: Use the “PEACE” Model to remember the 5 risk factors: –Planning –Event Complexity –Asset Selection –Communications –Environmental Conditions

Step #3: Assess the Risks SPE RISK ASSESSMENT MODEL Risk=Severity x Probability x Exposure Risk=Severity x Probability x Exposure Severity - Potential consequences measured in terms of degree of damage, injury, or impact on a mission. Could occur in one of these areas:Severity - Potential consequences measured in terms of degree of damage, injury, or impact on a mission. Could occur in one of these areas: Injury or death, equip damage, mission degradation, reduced morale, adverse publicity, admin/disciplinary actionsInjury or death, equip damage, mission degradation, reduced morale, adverse publicity, admin/disciplinary actions

Step #4: Identify the Options STAAR STAAR –Spread Out –Transfer –Avoid –Accept –Reduce

Step #5: Evaluate Risk vs.. Gain Analyze the operation’s degree of risk with the proposed controls in place Analyze the operation’s degree of risk with the proposed controls in place Determine if operational benefits exceed the degree of risk the operation presents Determine if operational benefits exceed the degree of risk the operation presents Consider cumulative risks Consider cumulative risks This is the “REALITY CHECK!” This is the “REALITY CHECK!”

Step #6: Execute the Decision The risk control decision is made The risk control decision is made Clear communication of decision clarifies rational behind risk management decision. Clear communication of decision clarifies rational behind risk management decision. (Done it a hundred times, been there, etc.) (Done it a hundred times, been there, etc.)

Step #7: Monitor Situation Monitor situation to ensure controls are effective and in place Monitor situation to ensure controls are effective and in place Identify any and all changes requiring further risk management and act on them Identify any and all changes requiring further risk management and act on them Risk management is a continuous process Risk management is a continuous process

Catastrophic Events Rarely Result From A Single Error

Crew Resource Management The empowerment of all crewmembers to promote safety and increase overall aircrew performance. Think Error Management Execute CRM Skills