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C R M

C R M. CRM . Cockpit Resource Management  Crew Resource Management What? Objective? Case-study (Tenerife, March 27, 1977)  CRM. CRM ?. CRM ?.

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C R M

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  1. C R M

  2. CRM • Cockpit Resource Management Crew Resource Management • What? • Objective? • Case-study (Tenerife, March 27, 1977)  CRM

  3. CRM ?

  4. CRM ? • The effective utilisation of all availableresources (all crew members, aeroplane systems and supporting facilities) to achieve a safe and efficientoperation. Focus on non (fly)technical skills

  5. CRM : Objective • To make flying safer and more efficient by improving crew performance through better crew co-ordination and communication (CRM-course…) • Resources: • People • Time • Information • Equipment

  6. Elements of CRM • Communication & assertiveness • Human error • Fatigue & stress • Situational awareness • Personality-attitude-behaviour • Teamwork & leadership • Decision-making • SOP’s

  7. CRM  “Case study” Tenerife accident , March 27, 1977 • Which factors contributed to this accident? • citations from air crash investigation reports • How are these factors related to CRM Elm? • Aim of CRM-courses

  8. TENERIFE ACCIDENT, March 27, 1977 Pan Am 1736 KLM 4805

  9. TENERIFE ACCIDENT, March 27, 1977

  10. VIS: 300 m

  11. Total crew: 30 Total PAX: 614 Survivors: 70 (9 died later) Total cas.:583

  12. CRM : Communication • = the process of transmitting and receiving ideas, information, feelings and messages • verbal (7%) – non verbal (55-70%) • 4 barriers to communication • language ( foreign speech, accent, jargon, dialect…) • psychological (status, stress, personality,…) • physical (noise, distance, fatigue, locked door policy,…) • general…(authority, rank, gender, perception, …)

  13. CRM : Communication • Factors contributing to the Tenerife HAP • “However, even after the enroute clearance was given, the tower instructed 4805 to "standby for take-off" which the crew failed to hear as well as the clear indications that 1763 was still on the runway.” • “In addition, Meurs did nothing to further enlighten van Zanten that they were not cleared for take-off after his initial comment. It is possible that Meurs was not comfortable challenging van Zanten due to his experience level.”

  14. CRM : Communication • Factors contributing to the Tenerife HAP • “The fundamental cause of this accident was the fact that the KLM captain: 1. Took off without clearance. 2. Did not obey the "stand by for take-off" from the tower.” • “The fact that two transmissions took place at the same time. The "stand by for take-off ... I will call you" from the tower coincided with Pan Am's "we are still taxiing down the runway", which meant that the transmission was not received with all the clarity that might have been desired.”

  15. CRM : Communication • KLM captain wants to depart • KLM FO asks route clearance and T/O clearance • Tower gives route clearance, but not T/O clearance • KLM captain: “We go” • KLM FO reads ATC clearance again: “We are now at T/O” • Tower: “OK … (2’’)… STBY for T/O” • PanAm: “We are still taxiing down the RWY” • Tower asks PanAm to declare when they leave RWY • KLM FE: “Is hij er niet af dan?” • KLM captain: “Jawel!” simultaneously

  16. CRM : Human error • Attention error • “attentional blindness” (mental resources focused elsewhere) • Perceptual error • light, contrast, visual illusion, spatial disorientation • Response error • incorrect action/response

  17. CRM : Human error • Factors contributing to the Tenerife HAP • “Now, how is it possible that a pilot with the technical capacity and experience of the captain, whose state of mind during the stopover at Tenerife seemed perfectly normal and correct, was able, a few minutes later, to commit a basic error in spite of all the warnings repeatedly addressed to him.”

  18. CRM : Fatigue & stress • Fatigue = a reduced capacity to perform mental and/or physical activities • Stress = a mental and physical reaction to pressure • chronic • acute

  19. CRM : Fatigue & stress • Causes of fatigue: • lack of restful sleep • stress • workload • disrupted circadian rhythms • … • Identifying stress: • rapid breathing • impatient • sweaty hands • negative thoughts • …

  20. CRM : Fatigue & stress • Factors contributing to the Tenerife HAP • Fatigue: • “On approaching the Canaries six hours later, the crew were informed of the temporary closure of the airport and diverted to Tenerife's Los Rodeos airport.This was unwelcome news to the crew, who had already been on duty for eight hours.”

  21. CRM : Fatigue & stress • Factors contributing to the Tenerife HAP • Stress: • “A growing feeling of tension as the problems for the captain continued to accumulate. He knew that, on account of the strictness in the Netherlands regarding the application of rules on the limitation of duty time, if he did not take off within a relatively short space of time he might have to interrupt the flight - with the consequent upset for his company and inconvenience for the passengers. Moreover, the weather conditions in the airport were getting rapidly worse, which meant that he would either have to take off under his minima or else wait for better conditions and run the risk of exceeding the aforementioned duty time limit.”

  22. CRM : Situational awareness • = an accurate “mental model” of all the factors and conditions which affect an aircraft and its crew… • = knowing what is going on around us! •  GROUP Situation Awareness

  23. CRM : Situational awareness • Loss of S.A.: • poor communications • confusion, concern • exceeding personal limitations • fixation / boredom • high workload • unfamiliarity • …

  24. CRM : Situational awareness • internal - external factors • internal: individual • external: task environment • direct - indirect influence to S.A. • direct: perception + comprehension decision making + actions • Indirect: procedures, rules

  25. CRM : Situational awareness

  26. CRM : Situational awareness • Factors contributing to the Tenerife HAP • “It seems clear that van Zanten was aware that the clearance hadn't been received when Meurs checked him and he replied "No, I know that. Go ahead and ask." It is likely that van Zanten was in a rush to get to Las Palmas because of the delay on the ground and his crew's lack of extra duty hours.” • “A final consideration was the difficulty with English of the tower controller and the 4805 crew. With the weather as bad as it was, relying solely on radio communications was already a dangerous practice, but the non-standard communications of both parties lead to the breakdown of situational awareness.”

  27. CRM : Situational awareness • Factors contributing to the Tenerife HAP • “Although the captain had flown for many years on European and intercontinental routes, he had been an instructor for more than 10 years, which relatively diminished his familiarity with route flying. Moreover, on simulated flights, which are so customary in flying instruction, the training pilot normally assumes the role of controller - that is, he issues take-off clearances. In many cases no communications whatsoever are used in simulated flights, and for this reason take-off takes place without clearance.”

  28. TENERIFE ACCIDENT, March 27, 1977 • Investigation RECOMMENDATIONS (communication related): • Use of standard, concise and unequivocal aeronautical language. • Avoidance of the word "TAKE-OFF" in the ATC clearance and adequate time separation between the ATC clearance and the TAKE-OFF clearance

  29. Conclusion / aim of CRM • Aircraft crews = • highly structured, mechanised groups • perform very well as far as tasks are predictable and routine • crisis situations: trained responses tend to break down • Air transportation industry • accidents attributable to human error: 3/4 = Comm

  30. Conclusion / aim of CRM • CRM is not about being nice to each other, or taking votes in what should be done during emergencies. • Make no mistake: the captain is responsible, meaning he has to take the final decision. His authority is in no way eroded. • The huge difference with the past is that the captain now has to make sure he has the right perception of what is going on and what should be done about it. And this is only possible if adequate open communication exists around him. Crew members also have a responsability to assume in the cockpit, by themselves being assertive, proactive and at all time constructive.

  31. References • Subsecretaria de Aviation Civil • FAA • AirDisaster.com • John McCreary, Michael Pollard, Kenneth Stevenson and, Marc B. Wilson, University of Maryland Eastern Shore, Princess Anne, MD • CRM Instructor Manual, ASD (EBBE)

  32. Useful websites • www.jaa.nl • www.icao.int • www.ntsb.gov • www.flightsafety.org • www.nasa.gov • www.airdisaster.com • www.airlinebiz.com • www.aviation-safety.net • www.airsafe.com • www.planecrashinfo.com

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