Crew Resource Management

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

2. In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers. There were 224 fatalities! Crew Resource Management Western Electricity Coordinating Council

3. Definition(s) • Beginnings • Evolution • Elements of CRM • Why you should add it to your training program • Case study for comparison to the power industry. What is Crew Resource Management? Western Electricity Coordinating Council

4. 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. Definitions Western Electricity Coordinating Council

5. 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. Definition Western Electricity Coordinating Council

6. Focused on causes and recommended solutions to commercial aviation accidents 1979 NASA Workshop Western Electricity Coordinating Council

7. 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 Common Elements of Accidents Western Electricity Coordinating Council

8. High-impact, adverse (or life threatening) outcomes when mistakes are made Technical complexity Multiple path/task options Team/individual interactions Communications Environments for CRM Western Electricity Coordinating Council

9. All available resources • Non-flying crew members • Airline dispatchers • Maintenance personnel • Air traffic control Evolution beyond the “Cockpit” Western Electricity Coordinating Council

10. Other industries • Military (primarily aviation) • Medicine • First responders (firefighters) • Maritime industry • Bulk electric system operations? Evolution beyond the “Cockpit” Western Electricity Coordinating Council

11. Professional Culture Obstacles to Success • Organizational Culture Western Electricity Coordinating Council

12. 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. Cultural Challenges Western Electricity Coordinating Council

13. 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 Culture Western Electricity Coordinating Council

14. 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 What does your “Crew” Look Like? Western Electricity Coordinating Council

15. Communications Situational awareness Decision making Teamwork Barriers Components for Training Western Electricity Coordinating Council

16. Efficient Clear Professional Communications Competencies Western Electricity Coordinating Council

17. System monitoring • Part of technical competency • Forecasting and anticipation • Goal of no surprises • Cross-training Situational Awareness Western Electricity Coordinating Council

18. Operations and outage planning • Are conditions as expected • Go/No Go • Pre evolution brief • And… Planning and Decision Making Western Electricity Coordinating Council

19. Leadership • Inspiring leadership is good • Authoritarian leadership—not so good • Team workload management • Pace tasks when possible • Use available resources • Adaptability • Cross-training Teamwork Competencies Western Electricity Coordinating Council

20. Stress • Task saturation • Time pressure • Confusion (Automation and MMI) Barriers Western Electricity Coordinating Council

21. Lack of Assertiveness Can be related to teamwork, communications, leadership or culture Barriers • Get attention • State concern • Identify the problem • Offer a solution • Obtain agreement Western Electricity Coordinating Council

22. Case Study - Air France Flight 447 Western Electricity Coordinating Council

23. 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 Case Study - Air France Flight 447 Western Electricity Coordinating Council

24. Airbus A330-203 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 Air France Flight 447 Western Electricity Coordinating Council

25. 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. 447 Cause of Accident Western Electricity Coordinating Council

26. 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 Time Element Western Electricity Coordinating Council

27. 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 Time Element Western Electricity Coordinating Council

28. 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. Air France Flight 447 Western Electricity Coordinating Council

29. 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. 2011 Southwest Blackout Western Electricity Coordinating Council

30. Weather Western Electricity Coordinating Council

31. Control Rooms Western Electricity Coordinating Council

32. Operating Limits Western Electricity Coordinating Council

33. Alarm Displays EMS Alarm Display Screen Western Electricity Coordinating Council

34. Western Electricity Coordinating Council

35. Controls Western Electricity Coordinating Council

36. 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 Air France CRM Training Western Electricity Coordinating Council

37. 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. Improving CRM can Enhance Reliability Western Electricity Coordinating Council

38. 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 Western Electricity Coordinating Council

39. Thank You Phil O’Donnell Manager Operations and Planning Audits Western Electricity Coordinating Council