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

2. Crew Resource Management
In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers.
There were 224 fatalities!
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3. 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.
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4. 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.
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5. 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.
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6. Western Electricity Coordinating Council
1979 NASA Workshop
Focused on causes and recommended solutions to commercial aviation accidents
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7. 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
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8. 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
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9. Evolution beyond the “Cockpit”
All available resources
Non-flying crew members
Airline dispatchers
Maintenance personnel
Air traffic control
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10. Evolution beyond the “Cockpit”
Other industries
Military (primarily aviation)
Medicine
First responders (firefighters)
Maritime industry
Bulk electric system operations?
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11. Western Electricity Coordinating Council
Obstacles to Success
Professional Culture
Organizational Culture
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12. 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.
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13. 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
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14. 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
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15. Components for Training
Communications
Situational awareness
Decision making
Teamwork
Barriers
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16. Communications Competencies
Efficient
Clear
Professional
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17. Situational Awareness
System monitoring
Part of technical competency
Forecasting and anticipation
Goal of no surprises
Cross-training
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18. Planning and Decision Making
Operations and outage planning
Are conditions as expected
Go/No Go
Pre evolution brief
And…
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19. 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
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20. Western Electricity Coordinating Council
Barriers
Stress
Task saturation
Time pressure
Confusion (Automation and MMI)
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21. 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
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22. Case Study - Air France Flight 447
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23. 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
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24. Western Electricity Coordinating Council
Air France Flight 447
Airbus A 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
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25. 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.
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26. 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
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27. 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
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28. 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.
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29. 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.
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30. Western Electricity Coordinating Council
Weather
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31. Western Electricity Coordinating Council
Control Rooms
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32. Western Electricity Coordinating Council
Operating Limits
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33. Western Electricity Coordinating Council
Alarm Displays
EMS Alarm Display Screen
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34. Western Electricity Coordinating Council

35. Western Electricity Coordinating Council
Controls
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36. 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
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37. 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.
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38. 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
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39. Phil O’Donnell Manager Operations and Planning Audits
Thank You
Phil O’Donnell
Manager Operations and Planning Audits
Western Electricity Coordinating Council