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CRM Refresher 2002

CRM Refresher 2002. 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?.

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CRM Refresher 2002

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  1. CRM Refresher 2002

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

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

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

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

  6. AbsolutelyWe Manage Our Errors We Incorporate Error Managementinto Every Aspect of CRM

  7. Error Management is the “What” Intervention/PreventionCRM is the “How”Trap, Mitigate, Avoid GOAL: OPTIMAL PERFORMANCE

  8. Error Mgt Optimal Peformance CRM

  9. 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

  10. 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 toTRAP, MITIGATE & AVOID Error.

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

  12. Error Management ConsequenceConsequences 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!

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

  14. Latent Errors in System Organizational Filters: Training/Stan/CRM/ORM Latent Errors at Mgt Level Trajectory of Accident/Error Unchecked 1 2 3 Individual Error (Active Error) 4 Result/error 5 The Swiss Cheese Model (REASONS)

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

  16. 6555 Aug ‘94Practice Auto Latent & Active Errors What was EM Outcome

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

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

  19. CRM Principle - S.A. • Elements of Situational Awareness? Spatial Orientation/attitudeOrientation to traffic, geography & timeAircraft status & capabilitiesAircrew status & Crew-life cycleMission concept & Mission-life cycle

  20. 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!

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

  22. CG 6541 - Humboldt Bay, 12 Jul ‘94

  23. 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

  24. CRM Principle - S.A. What do you do when you suspect you have lostS.A.? • React • Regain • Reconstruct

  25. ROADBLOCKS • 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.

  26. ROADBLOCKS • 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. • HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.

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

  28. ROADBLOCKS (cont): • 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.”

  29. FATIGUEWidely recognized enemy of pilots & crewmembers. • A low frustration threshold • Degraded coordination • Slowness in response • Carelessness • Acceptance of low standards of accuracy

  30. 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.

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

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

  33. PERSONAL MONITORING “I’M SAFE” ILLNESS MEDICATION SLEEP ALCOHOL FATIGUE EATING/EXERCISE

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

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

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

  37. CRM Principle - Assertiveness Elements of Assertive Behavior Authority with ParticipationAssertiveness with RespectThe genuine, complete & direct communication of ideas, wants & needs.

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

  39. CRM Principle - Assertiveness The Assertive Statement Open-up; get their attentionState concern as “owned emotion”State the problem - real or perceivedOffer a solutionObtain agreement/closure “Say what needs to be said”

  40. CRM Principle - Risk Risk Management RISK is a factor of: Probability Severity Exposure

  41. Risk Management - M3710.1D • 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. • “probable loss of an aircrew is not an acceptable risk.”

  42. Operational Risk Management (ORM) History: 1996 - multi-dimensional workshop Developed common risk mgmt process Specifically tailored to our size and multi-mission nature.

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

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

  45. Step #3: Assess the Risks SPE RISK ASSESSMENT MODEL • 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: • Injury or death, equip damage, mission degradation, reduced morale, adverse publicity, admin/disciplinary actions

  46. Step #4: Identify the Options • STAAR • Spread Out • Transfer • Avoid • Accept • Reduce

  47. Step #5: Evaluate Risk vs.. Gain • 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 • Consider cumulative risks • This is the “REALITY CHECK!”

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

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

  50. Catastrophic Events Rarely Result From A Single Error

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