1. Avoiding Never Events
Damian Cottle

2. Team Resource Management
TRM
Team Resource Management

3. TRM Team Resource Management Introduced by NASA in the 1980’s
Originally called Cockpit Resource Management

4. Team Resource Management
TRM
Team Resource Management
Communication
Decision making
Incident Reporting

5. Communication

6. Tenerife March 27th 1977 KLM 4805 -Boeing 747, 248 onboard
Pan Am Boeing 747, 396 onboard

9. All 248 aboard KLM flight died

10. All 248 aboard KLM flight died
335 of 396 aboard Pan Am died

11. All 248 aboard KLM flight died
335 of 396 aboard Pan Am died
Total dead 583

12. The deadliest accident in aviation history
All 248 aboard KLM flight died
335 of 396 aboard Pan Am died
Total dead 583
The deadliest accident in aviation history

13. Communication

14. Communication
To foster a less authoritarian culture whilst retaining a command hierarchy

15. Communication
To foster a less authoritarian culture whilst retaining a command hierarchy
Management
Team Leader
Team members

16. Communication
To foster a less authoritarian culture whilst retaining a command hierarchy
Management
Training
Team Leader
Team members

17. Communication
To foster a less authoritarian culture whilst retaining a command hierarchy
Management
Training
Team Leader
Set an inclusive tone
Team members

19. Communication
To foster a less authoritarian culture whilst retaining a command hierarchy
Management
Training
Team Leader
Set an inclusive tone
Team members
Active participation

20. Team Resource Management
TRM
Team Resource Management
Communication
Decision making
Incident Reporting

21. Decision Making

22. UA173 28th Dec 1978
New York to Portland

25. 189 on board
10 Dead
24 injured

26. Decision Making

27. Decision Making

28. Decision Making
Brief
Aims
Threats
Maintenance
Normal Checklist

29. Decision Making
Early intervention
Communication
Non-normal Checklist

30. Decision Making
Memory Actions
Non- normal Checklist
TDODAR

31. T D O D A R

32. Time D O D A R

33. Time
Diagnose O D A R

34. Time
Diagnose
Options D A R

35. Time
Diagnose
Options
Decide A R

36. Time
Diagnose
Options
Decide
Allocate R

37. Time
Diagnose
Options
Decide
Allocate
Review

38. Team Resource Management
TRM
Team Resource Management
Communication
Decision making
Incident Reporting

39. Incident Reporting

40. BEA th June 1972
London to Brussels

43. Worst loss of life in British aviation history
118 dead
Worst loss of life in British aviation history

44. Incident Reporting

45. Clear channels for reporting
Encouraging Reports
No Blame Culture
Clear channels for reporting

46. Effective Reporting
Team Debrief
Learning Points

47. Learning from Reports
Data analysis
Focused development

48. Team Resource Management
TRM
Team Resource Management
Communication
Decision making
Incident Reporting

49. Avoiding Never Events