1. Lecture 9: Generation of Crew Resources Management

2. Introduction Term generation is used in describing the changes in CRM over the last 3 decades. Generation refers to the process of growth & development. Till now, CRM have arrive the 6 th generation. 1 st Generation  2 nd Generation  3 rd Generation  4 th Generation  5 th Generation  6 th Generation

3. Three final image in the deadly accidents that started (initiated) CRM

4. 1972: Eastern L-1011 crashed during approach in Miami Airport Flight crew's failure to monitor the flight instruments during a malfunction of the landing gear position indicator system. The crew realised their error too late and were too low to recover. Of the 163 persons on board 112 were killed in the crash. 1 st major air disaster that initiated CRM (Loss of Situational Awareness)

5. 1977: Pan-Am Boeing 747 and KLM Boeing 747 runway collision, Tenerife Airport The KLM B747 Captain initiated a takeoff without permission while the Pan Am B747 aircraft was using the runway to taxi out for landing. 337 peoples on the Pan Am B747 and 248 on the KLM B747 were killed. 2 nd major air disaster that initiated CRM (Poor Communication)

6. 1978: UAL 173 DC-8 crashed during approach near Portland First Officer Rodrick Beebe: Portland Tower United 173, Mayday! We're…the engines are flaming out…we're going down. We're not going to be able to make the airport. Captain fixation on landing gear problem. His crews (F/O & F/E) informed about low fuel condition. Captain ignored them or misunderstood them & continue to solve landing gear problem. The DC-8 ran out of fuel and finally crashed. 189 Peoples, 10 killed, 23 seriously injured 3 rd major air disaster that initiated CRM (Loss of SA & Poor Communication)

7. Why need CRM? Many accidents result not from a technical malfunction but most accidents are caused by the inability of crews to respond appropriately to the situation in which they find themselves. For example, inadequate communications between crew members and other parties could lead to a loss of situational awareness, a breakdown in teamwork in the aircraft, and ultimately to a wrong decision or series of decisions which result in a serious incident.

8. First CRM generation concepts

9. 1 st CRM generation Develop from a workshop conducted by NASA in 1979. 1 st training was initiated by United Airlines in 1981. Initially the term was Cockpit Resource Management (CRM). 1 st CRM generation concerns are –Need to use the right people –Need to use right materials. –Need to use right equipments. –Need to use right technology.

10. 1 st CRM generation OBJECTIVES: To reduce pilot error by improving human resources on the flight deck. To fix the “Wrong Stuff” leaders and make junior crew members assertive. * “Wrong Stuff” term refers to the captain’s failure to accept input from junior crewmembers. To focus on individual management style & interpersonal style.

11. 1 st CRM generation 1 st generation training was conducted in the classroom and also in simulator settings called Line Orientated Flight Training (LOFT). Skills taught in the classroom setting were adapted to training scenarios in simulators where techniques could be practiced without danger.

12. Second CRM generation concepts

13. 2 nd CRM generation In 1986, NASA developed another CRM workshop. Change in name from “Cockpit” to ‘Crew Resource Management’. Realized that better outcomes could be produced if the entire crew was involved. Name change in order to acknowledge the roll of cabin crews along with ground handling, maintenance, and dispatching crews.

14. 2 nd CRM generation OBJECTIVES: To improve team building (use of team-building exercises) To focus on Situational Awareness (SA) and stress management. To break the chain of errors that could cause an accident. Much of the training that originated in this era continues to be used, either in stand-alone modules, or combined within newer programs.

15. Third CRM generation concepts

16. 3 rd CRM generation The so-called, CRM 3 rd generation evolved during the early 1990s. Efforts began to integrate CRM with TECHINICAL TRAINING. Also to focus on specific skills and behaviors that pilots could use to function more effectively. Almost courses focus on the need to improve flight crew. Several airlines began to include modules addressing CRM issues in the use of ‘FLIGHT DECK AUTOMATION’

17. 3 rd CRM generation Flight deck automation means machines on the commercial transport aircraft flight deck that perform functions (not pilot). Current flight deck automation includes autopilots, flight management systems, electronic flight instrument systems, and warning and alerting systems.

18. Airbus A320 Glass Cockpit

19. “The magic roundabout in the UK” 7

20. This slide shows one of the teaching slides “The magic roundabout in the UK” - Five roundabouts centred around another. It is an example of an excessively complicated system lead to error.

21. Fourth CRM generation concepts

22. 4 th CRM generation 4 th generation saw the change of CRM training to organisations themselves. The first move to recognise that CRM training has to be tailored to the organisation. Aim is to solve the problems of human error by making CRM an integral part of all flight training.

23. Fifth CRM generation concepts

24. 5 th CRM generation Begin in 1996, 5 th generation CRM showed great maturity in the concept. Assume human error is pervasive and cannot be totally eliminated. Focus on error management with the development of error countermeasures. (an action taken to counteract a danger) There are three lines of defence in these counter measures. –1: Firstly we can attempt to minimise error –2: Secondly we can try to trap the errors, and –3: Thirdly we can mitigate errors.

25. 3 lines of defence to counter act the dangers The point of the exercise is to achieve safety – which is a major determinant of morale.

26. 5 th CRM generation For example, consider an advanced aircraft experiences Controlled Flight Into Terrain (CFIT) because wrong data is entered to Flight Management System (FMS). But this error actually can be managed through these 3 actions: –1 st :A careful briefing on procedures combined with communication & verification of FMS entries can avoid the error. – 2 nd : Cross-checking entries should trap the error. –3 rd : Inquiry & monitoring of the position should result in mitigating the error consequences before CFIT.

27. Controlled flight into terrain (CFIT) CFIT describes about aircraft collision, under pilot control, inadvertently flies into terrain, an obstacle, or water. The pilots are generally unaware of the danger until it is too late.

28. Flight Management System (FMS) The flight management system (FMS) is the avionics that holds the flight plan, and allows the pilot to modify as required in flight. Given the position and the flight plan, the FMS guides the aircraft along the flight plan. The FMS is normally controlled through a small screen and a keyboard.

29. Ground proximity warning system (GPWS) Since 1960s, a series of controlled flight into terrain (CFIT) accidents killed hundreds of people. Thus, a device called a ground proximity warning system (GPWS) had been used to overcome CFIT problem. A Ground Proximity Warning System (GPWS) is a system designed to alert pilots if their aircraft is in immediate danger of flying into the ground or an obstacle

30. Sixth CRM generation concepts

31. 6 th CRM generation Initiated in 2001. Finally today we are sitting with 6 th generation CRM. This is the latest generation that every airliner in the world practicing it. 6 th generation CRM looks beyond the aircraft. It looks at controllers, weather forecasters, dispatchers and command structures.

32. 6 th CRM generation This is where A CRM comes into play. Anyone who is involved with the aircraft’s mission, anyone who is part of the crew, has a role to play in CRM. 6 th generation CRM concepts are based on Threat & Error Management (TEM).

33. Threat & Error Management (TEM) concept Threat & Error Management (TEM) concept was developed to understand the interaction between safety and human performance.

34. Definition of Threat & Error Threat: Event or error that occurs outside the influence of the flight crew, but which requires crew attention and management to maintain safety. Error: Crew action that leads to a deviation from crew or organizational intentions or expectations.

35. Sources of Threat Expected threats –Predicted weather (thunderstorms, hurricanes) –Airport conditions & Terrain Unexpected threats –Aircraft malfunctions Engine failure on take off –ATC commands

36. Type of Error Examples: Handling errors: –Examples include omitting required briefings or checklists. Communications errors: –When information is incorrectly transmitted or interpreted within the crew members

37. % of Crew Errors by Phase of Flight Pre-departure/taxi 26% Take-off 20% Cruise or En-route 6% Descent/approach/landing 42% Taxi in 6%

38. Relation between TEM & CRM training Since CRM training provide the knowledge and skills about effective teamwork & leadership, DM, SA, stress, fatigue, workload management and effective communications, thus CRM training actually provides countermeasures (action taken) against threat and error.

39. Summary CRM is not and never will be the mechanism to eliminate error and assure absolute safety in a high risk endeavor such as aviation. Error is an inevitable result of the natural limitations of human performance and the function of complex systems. CRM is one of an array of tools that organizations can use to manage error. When CRM is viewed in the context of the aviation system, its contributions and limitations can be understood.

40. CRM Training

41. Introduction Findings coming from accident investigations have consistently pointed to the fact that human errors contribute to most aviation accidents. Research findings suggest that crew resource management (CRM) training can result in significant improvements in flight crew performance. CRM training is seen as an effective approach to reducing human errors and increasing aviation safety.

42. CRM Training CRM training for aircrews has been introduced and developed by aviation organizations including major airlines and military aviation worldwide Many airlines have introduced CRM training as part of their total training syllabus. For example: the U.S. Air Force requires all air crew members to receive annual CRM training, in an effort to reduce to human-error caused mishaps

43. CRM Training In CRM training aviation crews will learn specific techniques they need to operate more effectively including, being assertive, how to manage conflict & stress and improving situational awareness CRM training also provide aircrews with the skills as part of a team, improve their communication skills and prepare them to make better decisions. Moreover, it concentrates on crewmembers’ attitudes and behaviors and their impact on safety. Topics covered in CRM training are important to ensure the safety and efficiency of flight operations.

44. How CRM training can improve the aviation personnel?

45. CRM training can improve aircrew productivity by: Promoting better understanding among aircrews. Enhance aircrew awareness of human factors that could affect flight operations. Develop CRM knowledge, skills & attitude which when applied appropriately could prevent aircraft mishaps. Improve the working environments for crews. Promoting a more friendly workplace. Increased motivation to do the job correctly.

46. What are the factors that can lead to Poor Management of Crew Resources?

47. Factors that can lead to poor management of crew resources… 1.Lack of proper CRM training. 2.Poor technical knowledge. 3.Emotional status 4.Fatigue. 5.Prejudices against people.

48. Factors that can lead to poor management of crew resources… 1.Lack of proper CRM training. In the absence of good training, crews may exhibit poor resource management and have an inadequate understanding of the value of CRM. 2.Poor technical knowledge. Not having sound technical knowledge can affect one's performance adversely and also result in confusion and lack of confidence. 3.Emotional status. A very negative experience can reduce resource management skills. If someone experienced a bad result from speaking up,that person may be less inclined to speak out again, even if he or she feels that the situation needs it.

49. Factors that can lead to poor management of crew resources… Fatigue. Being tired can affect a person enough to turn a normally cooperative person into someone who is very difficult to deal with. Fatigued individuals are also can be fixations, low situational awareness and poor decision making. Prejudices against people. If someone has a negative attitude toward another person because of factors such as his or her background, culture or gender, the interactions with that person will be negative.

50. Key Points Aviation is a complex, evolving, safety- critical industry where it is necessary to work as a team in order to reduce the potential for unsafe situations. Poor resource management skills have contributed to many aviation accidents. Because aviation is an international industry, it is particularly important that everyone involved has a good set of resource management skills.