Crew Resource Management Lecture Outline Resource Management . Lecture Outline . NAVAVSCOLSCOM . ... Zero Tolerance Guidelines •Food •Heads ... • KLM initiated take-off without

Crew Resource Management Lecture Outline

NAVAVSCOLSCOM

CRM Director 181 Chambers Ave, Suite C Pensacola, FL 32508-5221

850-452-2088 DSN 459

June 2013

COURSE OVERVIEW

Welcome Aboard

• Please fill out blue name tags with the supplied black marker.

• Please fill in CRM class information sheet with your full social.

CRMI

School of Aviation SafetyNAS Pensacola

WELCOME ABOARD

!!!

• TIMES / UNIFORM• FILL OUT NAME PLATES,

CLASS ROSTER, BOOKS, ETC• Off Limits:

“Psychedelic Shack” and “Groovy Gifts”

• PHONES• SUPPORT• COFFEE

CRM Course Administration

• Speeding 15-20 over posted limit = 7 day suspension• Speeding 21+ over posted limit = 30 day suspension• Speeding in high student concentration areas 10 over = 7 day

suspension / 10+ = 14 day suspension• Fleeing / Attempting to elude = 1 year suspension• Racing on roadway = 1 year suspension• Failure to use child restraint system = 30 day suspension• Littering (including cigarette butts) = 7 day suspension

• Driving while operating a Cell Phone w/o Hands-Free device / Illegal Handicap Parking / Failure to use seatbelt:• 1st Violation = 7 day suspension• 2nd Violation = 30 day suspension• 3rd Violation = 6 month suspension

• Operating a Motorcycle w/o all required PPE, on or off base: • Same as Above (re-attend motorcycle safety course for 3rd

Violation)

Zero Tolerance Guidelines

•Food•Heads•Smoking

NASC Lunch • O Club

• Lunch 1100-1400 – Tues-Fri• Bar 1500 to close – Wed-Fri• Take out available – 452-2026

• Subway, Asian, Italian – NEX• Taco Bell & Pizza Hut, A&W – Portside Club• The Oaks at the Golf Club • Naval Aviation Museum - Cubi Point Bar• Navy Yard Eatery – Daily Specials• Off Base via front gate

Maps

BOQ

GalleyO Club

Portside

Naval AviationMuseum

Starbucks

Aviation Plaza

Privileged

FOR OFFICIAL USE ONLYTHIS IS A PRIVILEGED, LIMITED-USE, LIMITED-DISTRIBUTION, SAFETY INVESTIGATION REPORT. UNAUTHORIZED DISCLOSURE OF THE INFORMATION IN THIS REPORT OR ITS SUPPORTING ENCLOSURES BY MILITARY PERSONNEL IS A CRIMINAL OFFENSE PUNISHABLE UNDER ARTICLE 92, UNIFORM CODE OF MILITARY JUSTICE. UNAUTHORIZED DISCLOSURE OF THE INFORMATION IN THIS REPORT OR ITS SUPPORTING ENCLOSURES BY CIVILIAN PERSONNEL WILL SUBJECT THEM TO DISCIPLINARY ACTION UNDER CIVILIAN PERSONNEL INSTRUCTION 752. THIS REPORT MAY NOT BE RELEASED, IN WHOLE OR IN PART, EXCEPT BY THE COMMANDER, NAVAL SAFETY CENTER.

Questions on admin?

LCDR Brendan T. O’BrienCRM Director

CRM Instructional Model Manager

CRMfor

Instructors

CRMTo EDUCATE aviation officers at all levels to:

Identify hazardsManage risksInvestigate and report mishapsDevelop and administer command safety programs

ASC - ASO - CRMTo foster and conduct safety-related research, and

provide assistance in support of the Naval Aviation Safety Program

Thereby,Enhancing Combat Readiness

through the Preservation of Human and Material Assets

School of Aviation SafetyMission

CRM-I course 4 daysTwice a month

Mobile Training Team4 times per yearFleet concentration area

Assist Visits (30-40 per year)FRS/Wing Program ManagerAll T/M/S platforms (over 45)

Program Manager ConferenceConference AttendancesFleet Support

CRMInstructional Model Manager

What is CRM?

YOU(7 skills)

Ability to use all availableresources…

…in order to accomplish your mission.

• Use all available resources to Increase Operational Mission Effectiveness

• The goal is to increase mission effectiveness by :• Minimizing crew preventable errors• Maximizing crew coordination• System of behavior modifications• Optimizing risk management

CRM Is: CRM and ORM

CRM is the foundational skill set that enables proper use of ORM

In depth ORM Deliberate ORM Time Critical ORM

WARFIGHTING

CRM Is:

CRM is about optimizing our ability to fly our aircraft to best perform our mission,

and our mission is WARFIGHTING.

• Knowledge • Tools• Guidance

And enable you to take this to the fleet

Purpose Of TheCRM Instructor’s Course

YOUR PARTICIPATION

IS THE KEY

Why?...

Classroom Participation Responsibilities

•  Your squadron is going to expect a:•  Human factors expert•  Stan / Eval expert for check rides•  Curriculum development expert•  Possibly a contractor interface expert•  Scenario development expert and POC for

check ride and curriculum integration matters•  All around CRM Guru

Because in one week….

1. a. b.

Course Evaluation Summary

•  Class Introductions•  Administration•  Syllabus Overview•  Course Format•  Classroom Participation Responsibilities•  Course Evaluation

STUDENT/STAFF INTROS (name, a/c, command)

chad.paulus

Typewritten Text

HISTORY

HISTORY OF CRM

C-050-1503A 5001 01

Terminal Objectives

•  Identify what drove the development ofCRM

•  Define and Understand some of theerrors made along the way

•  Understand the future of CRM

Enabling Objectives

•  Instruct CRM history per CNAF 1542.7(series), and the Evolution of CrewResources Management Training inCommercial Aviation

•  Discuss the growth and evolution ofCRM research in private and militarysectors per aforementioned applicableinstructions

There will always be something or somebody out there trying to kill you...

Aviation Is Inherently Dangerous Outline

•  Events that led to CRM development –Tenerife Case Study

•  Human error•  CRM development in the civil sector•  CRM development in the Navy and

Marine Corps•  Challenges•  Future•  Purpose of CRM•  Summary

Tenerife Background

•  A runway collision involving two 747s

•  583 fatal injuries, the most ever in anysingle aviation related mishap

•  A major accident that led to CRMdevelopment

A Tale of Two 747s

KLM Flight 4805

- 234 Passengers 14 Crew - From Amsterdam,

chartered: Holland International

- Captain: Jacob van Zanten (Chief Pilot)

“Face” of KLM - 11,700 hrs

A Tale of Two 747s

PAA Flight 1736

- 378 Passengers - 16 Crew - From Los Angeles via

NY - Captain: Victor

Grubbs - 21,000 hrs - “Clipper Victor”

Tenerife

Africa

Tenerife

Las Palmas

Tenerife Summary

12 30

• Disembark passengers

• 55 tons of fuel

• Crew day

Tenerife Summary

12 30

• Pan Am instructed to follow…3rd taxiway?

• RVR 500m with 700 required

Tenerife Summary

12 30

• KLM immediately to full power

• Copilot challenges

• Departure vs takeoff clearance

Tenerife

Tenerife Summary

•  What caused the mishap?•  Holes in the cheese

Holes in the Cheese

•  Divert•  Unfamiliar airfield•  Language barrier•  Weather•  Stress vs Time•  Stepped on communications•  Takeoff without clearance

•  70 crash investigators (Spain, Netherlands, US)

•  Mishap Findings / Probable cause:

•  KLM initiated take-off without clearance •  Wx conditions caused poor visibility •  PAA exited at incorrect taxi-way •  Simultaneous radio transmissions blocked key instructions •  Nonstandard instructions and phraseology •  Disruption of normal procedures due to airport crowding •  Human Error

International Investigation

•  Greater emphasis on English as international language of aviation

•  Establishment of standard phraseology •  FAA/ICAO: “line up and wait.”

•  Requirement for precise read-back instructions (no “OK” or “roger”)

•  Phrase "take-off" is only spoken when the actual take-off clearance is given (e.g. “departure”)

•  Development of Crew Resource Management theory

Safety Response Commercial CRM 1977 - Current

•  1977 – Interviews with commercial airline pilots reveal dissatisfaction with training in non-technical skills

•  1979 – NASA workshop: “Resource Management on the Flight Deck”

- H/E major cause of accidents • 1981 – United Airlines DC-8 CRM /

Simulator (1st generation of CRM) •  1993 – Delta “Chain of Events” /

modular training (2nd generation) •  1995 – 3rd and 4th Generations of CRM•  1997 – Continental Threat and Error

Management (5th generation)

Tenets of Commercial CRM •  4 Critical Skills

•  Decision Making •  Command •  Leadership •  Communication

•  Standardized Crew Training •  Team Building •  Briefing Strategies •  Leadership •  Communications •  Situational Awareness •  Stress Management

•  Begins to grow…….everybody wants one, and everyone has their own method

•  Difficult to duplicate – Corporate Culture •  Criticism of “psychobabble”

CRM And The Military •  1986 - NASA and USAF MAC CRM workshop:

“Cockpit Resource Management training, focusing on Communication, Leadership, Situational Awareness, and Crew Coordination is just as appropriate, with some modification, to pilots manning a flight of single seat tactical aircraft as it is to the pilots, Flight Engineers, and Loadmasters operating a C‑5 transport aircraft".

•  Differences between civilian and military aircrews:

CIV MIL •  Age OLDER YOUNGER • Experience MORE LESS • Rank TENURE UCMJ • Mission Objectives TRANSPORT NUMEROUS • Mission Requirements BENIGN HOSTILE • Crew Duties SERVICE TACTICAL • Centralized training FAA PLATFORM

CRM 1987 - 1989

•  1987 – Contract to modify civilian CRM courses for Navy (Allen Corp.)

•  1989 – CRM introduced to Naval Aviation •  Slow to accept due to “one size fits all” approach

•  1989 – Naval Air Warfare Center begins R&D program to develop Navy CRM Program:

•  Theoretically driven, researched based •  By aviators, for aviators •  Instructional Strategies •  Focus on entire aircrew •  Skills relevant to tactical environment •  Measurement and Feedback •  Validated and Evaluated

Navy Research and Development Naval Air Warfare Center

1992 NAWC published their findings: CRM must be systematically incorporated into all phases of crew training (i.e., initial qualification, transition, upgrade, recurrent). Must train the specific coordination skills

and behaviors required by aircraft type, aircraft model, phase of flight, and overall mission (e.g., transport, cargo) utilizing the

Seven Skill areas. The Navy’s CRM program would be called Aircrew

Coordination Training (ACT).

CRM 1990 - 1995

•  1993 – Navy implements Fam/Interim ACTprogram, OPNAVINSTS 3710 & 1542.7A

•  1993 – Tiger Team formed•  “sell it to the Fleet”•  begin T/M/S specific CRM program

•  1994 – ACT School House created (7) daycourse

•  1995 – OPNAV 1542.7A signed•  First Integrated ACT: S-3B Viking•  Funding for Integrated and Recurrency for

all Navy and Marine Corps platforms

CRM 1997 – 2012

•  1998 – 1542.7B signed•  CRM flight evaluation•  Required topics for yearly qualifications.

•  History, seven skills, T/M case studies

•  2001 – U.S. Navy changed ACT toCRM (1542.7C)

•  2002 – Integration complete for allU.S. Navy and Marine Corpsplatforms

•  2012 – CNAF 1542.7 signed

Current CRM Principles

•  Research Based – Not theory

•  Incorporates Existing Knowledge Base– Not reinventing the wheel

•  For Aircrew by Aircrew – who better?

•  Emphasizes Evaluation and Validation– Realistic opportunity to learn

•  Mission Specific – H-46 ≠ F/A-18

•  Skill Based – specific training objectives

•  Integrated – taught from the beginning throughout career, not an afterthought

D.A.M.C.L.A.S

•  Decision Making (DM) •  Assertiveness (AS) •  Mission Analysis (MA) •  Communication (CM) •  Leadership (LD) •  Adaptability / Flexibility (AF) •  Situational Awareness (SA)

Human Error Background

•  For the past four decades commercialaviation, the federal government, andmore recently the military have expendedsubstantial resources in determining thecause of mishaps

•  Information recovered from cockpit voicerecorders, SIRs, HAZREPS, and civilianmishap reports indicate the number onecause is

Human Error

NAVAL SAFETY CENTER

•  1991 Naval Safety Center Report•  “Human error is a contributing factor in

50% of all Class A mishaps”•  Human error is defined as “any incident

involving crew pilot error which relates topoor employment of aircrew coordination,S/A, judgment, sub-optimal physiologicalstate, or a violation of NATOPS”

NHA Symposium. April 14-17 2008 31

Non-HE

15%HE 85%

No. of Class A Mishaps Human Error

USN Aviation 71 of 84

Non-HE

17%HE 83% USMC Aviation 40 of 48

USN/USMC, FY97-01 Human Error Past

Leading Causal Factors •  Human Error (84%)

•  Aircrew (breakdown in Crew Resource Management, poor decision making, failure to properly perform emergency procedures) •  Supervisory (failure to provide adequate guidance and training)

•  Material/Systems Malfunction (16%) • Material/component catastrophic failure (no human error involved) NHA Symposium. April 14-17 2008 32

Non-HE6%

HE 94%



Non-HE9%

HE 91% USMC Aviation 52 of 57

USN/USMC, FY03-07

NSC Data: 22 Feb 08

Human Error Past



•  Material/Systems Malfunction (10%) • Material/component catastrophic failure (no human error involved)

NHA Symposium. April 14-17 2008 33

HE 85%




USN/USMC, FY05-09

NSC Data: 05 Oct 2010

Human Error Past



•  Material/Systems Malfunction (11%) • Material/component catastrophic failure (no human error involved) NHA Symposium. April 14-17 2008 34

Non-HE

27%HE 73%


USN Aviation 19 of 26 Non-HE

41%


USN/USMC, FY10-12

NSC Data: 13 Nov 2012

Human Error Today



•  Material/Systems Malfunction (33%) • Material/component catastrophic failure (no human error involved)

Future: Where is CRM headed?

•  CRM/ORM integrated into NATOPS

•  More focus on individual error prevention/mitigation

•  Better data collection tools to spot trends

•  Integration of CRM concepts in other facets of Navy •  Surface •  Subsurface •  Special Operations •  Medical Practices

IT IS NOT:

A SAFETY PROGRAM.

IT IS:

A program to effect a positive behavioral change in individuals (as opposed to

attitude changes or management theory) in order to prevent and/or

minimize human factor and crew errors.

YOU own the program.

Summary

•  History• Commercial• Navy/MC

•  Challenges•  Future

•  Your input and ownership

Questions?

CRM

PROGRAM MANAGEMENT

CRM Program Management

C-050-1503A

Terminal Objective

•  Maintain a CRM Program in anoperational setting

Enabling Objectives

•  Review CRM instruction changes•  State the requirements for documenting

annual CRM qualifications•  Review CRM Programs•  Manage a CRM Program•  Explain the importance of integration of

CRM throughout flight operations

References

•  CNAF 1542.7•  OPNAVINST 3710.7 series•  T/M/S NATOPS•  Wing and Squadron SOP

Instruction changes

CRM Qualification and Life Cycle Training Model

References:

•  OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it does not need to be redone prior to first flight.

•  CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight training shall be conducted in all Chief of Naval Air Training (CNATRA) squadrons and at the Fleet Replacement Squadrons (FRS) prior to first flight and is required for all students, instructors under training and any NATOPS qualified aircrew members without documented T/M specific ground training as defined by reference (a): (OPNAVINST 3710.7 series).

Instruction changes (cont.)

Initial T/M Specific Training

OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be conducted by a designated CRM instructor or facilitator…

CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted by a designated CRM Instructor (CRMI)…

•  Some squadrons may initially be short CRM instructors to ensure this new requirement is met.

Recommendations: Look through all NATOPS jackets and find personnel that have attended CRMI and utilize them to help with the initial shortfall.

•  Send current CRMF personnel to attend CRMI.


Annual T/M Specific Recurring Training

OPNAVINST 1542.7C: Not specified.

CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet their own annual requirements.


CRM Instructor Training

OPNAVINST 1542.7C; e: Not specified.

CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor course is a prerequisite to designation as a CRM Community Program Manager (PM) or CRMI. T/M CRM Facilitator training must also be completed in order to be designated a CRMI in a specific T/M.

New requirement in the CNAFINST. This was seen as a best practice and not specifically required in OPNAVINST 1542.7 (series). However, it was a requirement in the Assist Visit Checklist.

Recommendation: Send current CRMF personnel to attend CRMI.


CRM Facilitator Training

OPNAVINST 1542.7C; 7.f.: Not specified.

CNAFINST 1542.7; 6.g.(1)/(2):

(1) If the CRMF training is being administered with the intent of qualifying a CRMF,…

(2) If the CRMF training is being administered with the intent of qualifying a CRMI,…

Provides specific guidance for CRM training topics for CRMI and CRMF qualification that were not covered in OPNAVINST 1542.7 (series). This section clarifies that CRMF training does not need to occur first to become a CRMI.


Civilian Aircrew Members/Instructors

OPNAVINST 1542.7 (series): Not specified.

CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall maintain the same qualifications as a uniformed aviator. Non-flying civilians that provide flight instruction to USN/USMC aviators are required to maintain the same ground CRM currencies as uniformed aviators. If they are providing CRM initial ground training they are required to be a CRMI. If they are only providing CRM recurrent ground training they are required to be a CRMI or CRMF.

This section provides specific guidance for Civilians mirroring the requirements of uniformed aviators.


Unmanned Aircraft Systems


CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in accordance with this instruction, to include training for UAS crewmembers (UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO), and Ground Maintenance Vehicle Operators (GMVO).

This section provides guidance for UAS mirroring the requirements of uniformed aviators.

CRM Organization

Controlling Custodians

CRM IMM

Curriculum Model Manager (CO)

Program Manager CRM Instructors CRM Facilitators

CRM Director

Naval Safety Center

CRM Fleet Organization

CRM Instructional Model Manager

NSC

CRM Director SAS Divo

USN TacAir Inst. Model Mgr. CRM-I Instructor

T/M/S Curriculum Model Manager

FRS CO

T/M/S Curriculum Model Manager

FRS CO

T/M/S Curriculum Program Manager

FRS Instructor

CRM Instructor CRM Instructor

CRM Facilitator Squadron Level

CRM Facilitator Squadron Level

USMC TacAir Inst. Model Mgr. CRM-I Instructor

Same Organization

USN Prop/Heavy Inst. Model Mgr. CRM-I Instructor

Same Organization

USMC Prop/Heavy Inst. Model Mgr. CRM-I Instructor

Same Organization

USN Helo Inst. Model Mgr. CRM-I Instructor

Same Organization

USMC Helo Inst. Model Mgr. CRM-I Instructor

Same Organization

Enlisted Inst. Model Mgr. CRM-I Instructor

Controlling Custodian

Controlling Custodian

Designations

•  CRMFs are designated by their respectiveCommanding Officers or Officers in Chargeas applicable they require endorsementfrom the PM or CRMI

•  The PM and CRMIs are designated inwriting by the CRM T/M/S CMM per CNAF

Documentation

•  NATOPS Jacket•  Designation Letter •  Section 2, Tab C

(miscellaneous)•  Enclosure 3

•  CRM IMM •  Designation

(CRMI, ULM, and CRMF)

•  Ground Training (T/M/S)

•  Flight Evaluation (T/M/S)

Documentation

•  NATOPS Jacket •  Slash 7 •  Instrument Check •  Paragraph on Command

Letterhead signed by the Commanding Officer •  Annual Flight CRM

Check/Training ““Conducted CRM flight evaluation per CNAFINST 1542.7.””

•  Note any CRM observations

•  Proper flight code in the logbook 2L3/2L4/2L5

•  Ensure the date matches all 3 documents (Encl 3, slash 7, and logbook)

Conducted CRM flight evaluation per CNAFINST 1542.7.

Training

•  All CRM ground training contains thefollowing common elements:•  CRM history•  7 critical skills•  CNAFINST 1542.7•  T/M specific case study

Types of Training

•  Initial ground training: Covers whatsomeone new to the platform should knowregarding CRM issues within thecommunity

•  Annual recurrency training: Similar toinitial, but more focus on communityspecific issues and personal experience

•  Squadron instructor training: Tailored tosuit the needs of CRM during studenttraining (CNAFINST 1542.7; 6.g.(1)/(2))

Types of Training (Cont.)

•  CRMF training: Specific for those whoconducting annual training. CRMF: History,7 skills, CNAF 1542.7, program admin,facilitation and evaluation techniques,workload management, teamwork, reviewof community specific annual groundtraining brief, and conduct grading of theCRM flight evaluation

Types of Training (Cont.)

•  CRMI training: CRMI course graduate,program admin, facilitation and evaluationtechniques, review of community specificannual ground training brief, and conductgrading of the CRM flight evaluationAdditional topics may be included by CMM

•  Remember this CRMI course is only one ofFIVE requirements to qualify (NATOPSqualified; Designated by your CMM; CRMF;and E5/03 and above)

Training Techniques

•  Teach facilitators, and students,platform specific cases thatdemonstrate good and/or bad examplesof the seven skills and threat/errormanagement•  Examine HAZREPs and Mishap

Reports as your resource•  Personal experiences are valuable!

Training Techniques (Cont.)

•  Case studies should be T/M specific•  Case studies from other aircraft can be

used provided there are common elementsbetween aircraft:

F-18 ≠ H-60 •  Transferability is the issue. Just ask

yourself does the case study haveanything to do with my platform?

H-53 SAR = H-60 SAR


•  Case studies should be crew positionspecific

•  Include current equipment, especiallyautomation

•  Maintenance, operational, andadministrative impacts on CRM shouldalso be included


•  Personal examples are invaluable•  Old case studies and training materials

indicate a stale CRM program•  Case studies can be developed by using

SIRs, HAZREPS, ASAP, MFOQA,personal experiences, the FAA, and theIMMs

• You will inherit the program• Know your squadron CRMIs and CRMFs• Maintain a contact list• Standardize training media• Know the state of CRM practices in yourT/M/S

PM turnover binder

Good CRM Programs Good CRM Programs (Cont.)

•  Designations in the NATOPS jacket andalso in the PM binder

•  Documentation of check-flight evaluationson enclosure (3) in NATOPS jacket, onNATOPS/Instrument/Stan checkpaperwork, and identified in the flightlogbook with the correct codes

Good CRM Programs (Cont.)

•  Developed CRM SOP•  Tracking, scheduling, and monitoring of

qualifications•  Have an effective number of

experienced CRMI and CRMF•  CRM incorporated into procedures

including NATOPS, briefs/debriefs,checklists, and FTI

•  Incorporates human error concepts andThreat and Error Management

CRM Programs should NOT be •  Ground training focuses exclusively on 7

skills (DAMCLAS check in the block) •  Ground training as part of Safety Stand

down •  Evaluation documented as an afterthought•  Not knowing or tracking the facilitators for

your model



•  CRM ground training conducted prior tothe first flight and/or check-flightevaluation:T/M/S specific

Scenario intensive •  CRM dedicated flight events, in a high

fidelity simulator if available, and evaluate crew performance

Check-flight Grade Sheet

EVALUEE: _________________________________ OUTSTANDING _________ 3.5-4.0EXCELLENT _________ 2.8-3.4

INSTRUCTOR: __________________________________ SATISFACTORY _________ 2.0-2.7UNSATISFACTORY _________ 0.0-1.9

1. Situational Aw areness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

2. Assertivness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

3. Decision Making OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

4. Communication OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

5. Leadership OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

6. Adaptability/Flexibility OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

7. Mission Analysis OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY4 3 2 1

COMMENTS:

RESULT IN AN OVERALL GRADE OF UNSATISFACTORY.

AIRCREW CRM CHECK FLIGHT EVAL WORKSHEET

OVERALL GRADE

INSTRUCTOR SIGNATURE _______________________ DATE ______________

1. A GRADE OF UNSATISFACTORY IN ANY CRM SKILL WILL FLIGHT EVALUATION DETERMINATION

Example

•  The following is an example of how toincorporate CRM into T/M/Sinstructions/SOP’s.

NATOPS

Poor Practices

•  Ground training focuses on 7 skills only•  CRM ground training conducted in

conjunction with a Safety Stand-down•  Evaluation documented as an

afterthought•  Improper tracking of CRMI and CRMF•  Improper designations or tracking•  CRM not integrated into procedures•  Chain of Command or culture does not

support CRM

Poor Practices

•  CRM training not standardized or out ofdate

•  No CRM turnover binder•  Contractors teaching CRM differently

because they failed to attended CRMItraining

Summary

•  CRM organizational structure•  Designations•  Documentation•  Training•  Good program practices•  Poor program practices

Ques%ons?

CRM Program Instruction Changes

Reference

CNAFINST 1542.7

Instruction changes

CRM Qualification and Life Cycle Training Model

References:

•  OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it does not need to be redone prior to first flight.

•  CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight training shall be conducted in all Chief of Naval Air Training (CNATRA) squadrons and at the Fleet Replacement Squadrons (FRS) prior to first flight and is required for all students, instructors under training and any NATOPS qualified aircrew members without documented T/M specific ground training as defined by reference (a): (OPNAVINST 3710.7 series).


Initial T/M Specific Training

OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be conducted by a designated CRM instructor or facilitator…

CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted by a designated CRM Instructor (CRMI)…

•  Some squadrons may initially be short CRM instructors to ensure this new requirement is met.

Recommendations: Look through all NATOPS jackets and find personnel that have attended CRMI and utilize them to help with the initial shortfall.

•  Send current CRMF personnel to attend CRMI.


Annual T/M Specific Recurring Training


CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet their own annual requirements.


CRM Instructor Training

OPNAVINST 1542.7C; e: Not specified.

CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor course is a prerequisite to designation as a CRM Community Program Manager (PM) or CRMI. T/M CRM Facilitator training must also be completed in order to be designated a CRMI in a specific T/M.

New requirement in the CNAFINST. This was seen as a best practice and not specifically required in OPNAVINST 1542.7 (series). However, it was a requirement in the Assist Visit Checklist.

Recommendation: Send current CRMF personnel to attend CRMI.


CRM Facilitator Training

OPNAVINST 1542.7C; 7.f.: Not specified.

CNAFINST 1542.7; 6.g.(1)/(2):

(1) If the CRMF training is being administered with the intent of qualifying a CRMF,…

(2) If the CRMF training is being administered with the intent of qualifying a CRMI,…

Provides specific guidance for CRM training topics for CRMI and CRMF qualification that were not covered in OPNAVINST 1542.7 (series). This section clarifies that CRMF training does not need to occur first to become a CRMI.


Flight Instructor CRM Training


CNAFINST 1542.7; 6.h.: FRS and TRACOM units shall incorporate formal CRM training into instructor indoctrination. This requirement can be combined with initial ground training.

This section provides specific IUT guidance in FRS and TRACOM units.


Civilian Aircrew Members/Instructors


CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall maintain the same qualifications as a uniformed aviator. Non-flying civilians that provide flight instruction to USN/USMC aviators are required to maintain the same ground CRM currencies as uniformed aviators. If they are providing CRM initial ground training they are required to be a CRMI. If they are only providing CRM recurrent ground training they are required to be a CRMI or CRMF.

This section provides specific guidance for Civilians mirroring the requirements of uniformed aviators.


Unmanned Aircraft Systems


CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in accordance with this instruction, to include training for UAS crewmembers (UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO), and Ground Maintenance Vehicle Operators (GMVO).

This section provides guidance for UAS mirroring the requirements of uniformed aviators.


Documentation Requirements

OPNAVINST 1542.7C; 7.g.:

CNAFINST 1542.7; 6.m.: The CRM Training/Evaluation Record, enclosure (3), shall be used to document CRM courses, designations, ground training, and extensions in the individual’’s NATOPS Flight Personnel Training/Qualifications Jacket in Section II, part C. All CRM designation letters and flight evaluations shall also be filed in the NATOPS Jacket. CRM flight evaluations shall be documented on an applicable T/M approved form with the following statement included in the write up; ““Conducted CRM flight evaluation per CNAFINST 1542.7A.””*

New requirement specifically for designations to be recorded and designation letters to be filed in the NATOPS Jackets. Also provides a standard statement for recording the CRM flight evaluation.

*CNAFINST 1542.7A is a typo and should be CNAFINST 1542.7.


Responsibilities

OPNAVINST 1542.7C; 8.:

CNAFINST 1542.7; 7.:

Removed: a. Chief of Naval Operations (N78) b. CG Marine Corps Combat Development Command (C473) c. Commander, Naval Air Systems Command (PMA-205) e. Controlling Custodians

Replaced with: a. Commander, Naval Air Forces b. Commander, Naval Air Forces NATOPS Officer (N455) c. Deputy Commandant for Aviation (DC AVN)


Responsibilities (cont.)

OPNAVINST 1542.7C; 8.h:

CNAFINST 1542.7; 7.d:

CRM Instructional Model Manager has been incorporated into Naval Aviation Schools Command Program Officer. (This will change once we transition to Naval Aviation Safety Center).

OPNAVINST 1542.7C; 8.d:

CNAFINST 1542.7; 7.e:

Naval Safety Center changed to Naval Safety Center CRM Program Officer.*

*Typo Naval Safety Center CRM Program Officer should be underlined in the instruction.



OPNAVINST 1542.7C; 8.f:

CNAFINST 1542.7; 7.f:

CRM Curriculum Model Manager changed to CRM T/M/S CMM (refer to enclosure (4) ).

(8) Forward detailed copies of contractor-developed CRM materials to the IMM for review and concurrence.

(9) When a TRACOM air wing commander (CTW) is the CMM for multiple T/M/S, the CTW may designate in writing a PM for each T/M/S training aircraft.



OPNAVINST 1542.7C; 8.i:

CNAFINST 1542.7; 7.g:

Unit Level

(1) Designate in writing a CRM Unit Level Manager (ULM). ULMs shall be a qualified CRMF and should normally be the Unit NATOPS Instructor.

(4) Ensure flow of pertinent CRM related issues to the CRM CMM via the PM to include T/M/S lessons learned, documented CRM breakdowns, and specific areas of concern for the T/M/S. Ensure appropriate material is briefed to all aircrew members.




CNAFINST 1542.7; 7.h:

Individual Naval Aircrew Members

(1) Ensure CRM is applied to all phases of flight planning, flight execution, and debriefing.

(2) Ensure the ULM is informed of all CRM-related incidents involving the breakdown of CRM, as well as hazard mitigation that resulted from effective CRM practices. The goal is to learn from our mistakes and our positive CRM practices and behaviors that increase mission effectiveness and mitigate preventable aircrew errors.

Provides specific guidance for all aircrew members.




CNAFINST 1542.7; 7.h:

Individual Naval Aircrew Members

(1) Ensure CRM is applied to all phases of flight planning, flight execution, and debriefing.

(2) Ensure the ULM is informed of all CRM-related incidents involving the breakdown of CRM, as well as hazard mitigation that resulted from effective CRM practices. The goal is to learn from our mistakes and our positive CRM practices and behaviors that increase mission effectiveness and mitigate preventable aircrew errors.

Provides specific guidance for all aircrew members.


Records Management

OPNAVINST 1542.7C; 9: The reporting requirements required by this instruction are exempt from reports control per SECNAVINST 5214.2.

CNAFINST 1542.7; 9.*: (*Typo should be 8.): Records created as a result of this instruction, regardless of media format, shall be managed per SECNAV M-5210.1C.


Forms and Reports

OPNAVINST 1542.7C; 7. g: Enclosure (4)

CNAFINST 1542.7; 10.* (*Typo should be 9.): Enclosure (3) of this instruction shall be locally produced to document CRM qualifications and be permanently maintained in the NATOPS Flight Personnel Training/Qualification Jacket Section II, Part C.


Definitions Enclosure (1)

OPNAVINST 1542.7C

CNAFINST 1542.7

Added more to clarify the existing definitions:

• Crew Resource Management (CRM) • Crew Resource Management Critical Skills: AF, AS, CM, DM, LD, MA, SA • Time Critical ORM (TC-ORM) • CRM T/M/S Community Assistant Program Manager • CRM Unit Level Manager (ULM) • Naval Aviation Activity


CRM Training/Evaluation Record

OPNAVINST 1542.7C (Enclosure (4) )

CNAFINST 1542.7 (Enclosure (3) ).

CRM Facilitator Course

replaced with

CRM Designations

(List all CRM Designations Attained to include Instructor, ULM and Facilitator in this section).

Allows for all CRM qualifications, not just the Facilitator course.


CRM Training/Evaluation Record (cont.)

OPNAVINST 1542.7C (Enclosure (4) ): Annotation required T/M

CNAFINST 1542.7 (Enclosure (3) ): Annotation requires T/M/S

This ensures CRM training is created and tailored to identify the specific CRM and Mission differences in multiple series aircraft in the Naval Aviation inventory.


CRM Training/Evaluation Record (cont.)

OPNAVINST 1542.7C (Enclosure (4) ):

CNAFINST 1542.7 (Enclosure (3) ): Has typos. There is no difference between the two instructions and should read as below:

Ground Training Flight Training Annual CRM Ground Training CRM renewal expires last expires the last day of the day of current month plus current month plus one year. one year and may be accomplished 60 days early


TABLE OF T/M/S CRM CURRICULUM MODEL MANAGERS AND INSTRUCTOR REQUIREMENTS

OPNAVINST 1542.7C: (Enclosure (2) ):

CNAFINST 1542.7 (Enclosure (4) ):

Most of aircraft in the inventory were not removed from the inventory/table have a change in one or more of the following: T/M/S, T/M/S CURRICULUM MODEL MANAGER COMMAND, CONTROLLING CUSTODIAN OR MINIMUM NUMBER/TYPE INSTRUCTOR.

7 CRITICAL SKILLS LD AF MA

Leadership Adaptability/Flexibility

Mission Analysis

CRM SKILLS

C-050-1503A PPT 5001 01

Terminal Objective

•  Implement CRM academics, in aclassroom setting, in accordancewith Instruction, Crew ResourceManagement Program, CNAF1542.7 (series); and CrewResource ManagementInstructor Course Student Guide.

Terminal Objective

•  Upon completion of this unit ofinstruction, the student willdemonstrate knowledge of thepurpose and goals of CRM, aswell as the importance ofleadership, adaptability/flexibility,and mission analysis.

Enabling Objectives

•  Discuss and understand theimportance of Leadership.

•  Discuss and understand theimportance of Adaptability/Flexibility.

•  Discuss and understand theimportance of Mission Analysis.

Why CRM?

•  The leading cause of aviation mishaps isdue to human error.

•  Technology has developed to reducemechanical failure.

•  Human behavior has not developed toreduce human error.

•  CRM is the method to modify humanbehavior.

Philosophy

•  In the past the best way to learn goodCRM skills was to be fortunate enoughto fly with and learn by experience ofthose who practice CRM well.

•  This a process which identifies thesuccessful traits of our best aircrew inan effort to teach it in an academicenvironment.

CRM Defined

•  CRM: The effective use of all availableresources by individuals, crews and teams tosafely and efficiently accomplish the missionor task.

•  CRM also refers to identifying and managingthe conditions that lead to error.

CRM Program

•  Program: A training program to effectbehavioral modification (as opposed toattitude changes or management theory) inorder to prevent human factor and crewpreventable errors.

Purpose

•  Purpose: CRM is intended to improvethe mission effectiveness of all aviationcommunities by enhancing crewcoordination through increasedawareness of associated behavioralskills (Seven Critical Skills) and errortheory.

•  It is your program.

CRM Goals

•  Increase mission effectiveness•  Minimize crew preventable errors•  Maximize crew coordination•  Good → Better

External Factors (Threats)

•  WEATHER•  ENVIRONMENT•  TERRAIN•  ENEMY THREATS•  AIRCREW COMPOSITION•  MISSION DURATION•  MISSION CHANGES•  MISSION TASKING•  MORE?

Seven Critical Skills

•  Decision Making DM •  Assertiveness AS •  Mission Analysis MA •  Communication CM •  Leadership LD •  Adaptability / Flexibility AF •  Situational Awareness SA

Leadership

Definition: The ability to direct and coordinate the

activities of crew members and to encourage them to work together as a team

•  Designated•  Functional

(lē'dəәr-shĭp')

Leadership

DESIGNATED LEADERSHIP •  Obtained by rank, crew position or title•  Responsible for crew and mission

accomplishment; therefore, makes all finaldecisions

FUNCTIONAL LEADERSHIP •  Refers to leadership by knowledge or expertise

and occurs when expertise and need for infobecomes critical

•  Allows for most qualified crew member to takecharge / meet situational demands

Leadership

•  What makes a good leader?

•  What makes a poor leader?

Traits of an Effective Leader •  Respected•  Decisive•  Delegates tasks•  Provide feedback•  Keeps crew informed•  Open to suggestions•  Builds team spirit•  Leads by example•  Directs and coordinates•  Maintains professional atmosphere•  Knowledgeable

Leader’s Responsibilities

•  Directs actions•  Also solicits input and asks for help.

•  Sets the tone – professionalatmosphere

•  Delegates tasks and keeps groupfocused

•  Keeps crew or section members aware ofmission information including:•  Altered plans•  Decisions that are made•  Feedback on their performance

•  Defines boundaries & expectations

•  Ultimately responsible for performance ofcrew

Leader’s Responsibilities

FOLLOWERSHIP

Followership

Followership

SURVIVORS

ALIENATED Air India Express Boeing 737-800

Active

Dependent Uncritical Thinking

YES PEOPLE

EFFECTIVE

SHEEP

Independent Critical Thinking

Passive

R.E. Kelley, 1992

B-52 Crash

ADAPTABILITY/FLEXIBILITY Definition: The ability to alter a course of

action based on new information, maintain constructive behavior under pressure, and adapt to internal and

external environmental changes.

The success of a mission depends upon the crew’s ability to alter behavior and dynamically manage crew

resources to meet situational demands.

ADAPTABILITY / FLEXIBILITY (əә-dāp'təә-bil-əәtē) / (flěk'səә- bil-əәtē)

•  Every mission is potentially different•  Even canned missions

•  React to unexpected•  Priorities may change, but tasks still required

•  Counters rigidity•  Less vs. more experienced crews

Importance of A/F

•  Unbriefed situations arise•  Routine mission becomes an emergency•  Interactions are strained•  Aircraft is partial mission capable•  WX changes

When is Adaptability / Flexibility required?

ADAPTABILITY / FLEXIBILITY


•  What makes YOU successful atadapting or flexing?

•  Recognize and acknowledge change•  Anticipate Problems / Mission Analysis•  Determine if an SOP or Habitual

Response is appropriate•  Interact constructively with others•  Can you go too far?

Joint Ops

•  Establish an open, professional atmosphere

•  Ensure the crew understands the mission

•  Communicate!

Setting the tone for A/F


MISSION ANALYSIS

MISSION ANALYSIS

Definition: The ability to develop short term, long term, and contingency plans and to coordinate, allocate, and monitor

crew and aircraft resources.

Effective planning leads to flight conduct that removes uncertainty, increases mission effectiveness, and

enhances safety.

(mĭsh'əәn əә-nāl'ĭ-sĭs)

MISSION ANALYSIS

•  PRE FLIGHT

•  IN FLIGHT

•  POST FLIGHT

THREE PHASES

Pre-Mission Analysis

•  Identifying Mission Objectives•  Identifying Mission Constraints,

challenges and Options•  Preparation•  Contingency plans•  Briefing

Pre-Mission Analysis

•  Planning•  Professional•  Focused•  Assign

Responsibilities•  Interactive•  Complete

Characteristics of an Effective Brief

IN FLIGHT MISSION ANALYSIS

•  Short Term Planning

•  Monitoring Mission Progress

•  Identifying and Reporting Challengesor Changes

POST-MISSION ANALYSIS

•  Selective Review

•  Interactive

•  Timely

•  Lessons Learned

SUMMARY

•  Defined and explained the purpose of CRM•  Identified the goals of CRM•  Defined leadership•  Stated the responsibilities of leadership•  Stated the behaviors associated with effective

leadership•  Stated the traits of effective leaders•  Defined adaptability / flexibility•  Identified the importance of adaptability /

flexibility

SUMMARY •  Identified situations that require adaptability/

flexibility•  Explained how to set the tone and maintain

high adaptability/flexibility•  Define mission analysis•  Identified the importance of mission analysis•  Stated the phases of mission analysis•  Defined in-flight mission analysis•  Discussed the importance of the debrief in

mission analysis

Questions?

7 CRITICAL SKILLS CM AS

SEVEN CRITICAL SKILLS CM, AS

CREW RESOURCE MANAGEMENT

C-050-1503A PPT 5006 01

Terminal Objective

•  Implement CRM academics, in a classroomsetting, in accordance with Instruction, CrewResource Management Program,CNAF1542.7; and Crew ResourceManagement Instructor Course StudentGuide

Enabling Objectives

•  Instruct CRM critical skills •  Define assertiveness •  Discuss assertive behaviors •  State the barriers to assertiveness •  Describe situations requiring assertiveness •  Define communication •  Explain the importance of communication•  Explain the process of communication •  State the different types of communication•  Explain the characteristics of effective communication •  State the barriers to effective communication •  Explain the methods to overcome barriers to effective

communication

Seven Critical Skills

•  Decision Making DM •  Assertiveness AS •  Mission Analysis MA •  Communication CM •  Leadership LD •  Adaptability / Flexibility AF •  Situational Awareness SA

ASSERTIVENESS

What Is Assertiveness?

Definition: The willingness to actively participate, state and maintain a position,

until convinced by the facts that other options are better.

Requires the COURAGE and INITIATIVE to act.

(əә-sûr'tĭv-nəәs)

Comfort Level

Comfort level is an internal anxiety gauge that alerts us

when something isn’t right and needs to be corrected.

Lack of Assertiveness?

Behavior Types

Passive Assertive Overly Aggressive

Overly Aggressive

•  DOMINATION•  INTIMIDATION•  ABUSIVE /

HOSTILE

Fired up!

•  Overly courteous

•  “Beats around the bush”

•  Avoids conflicts

•  “Along for the ride”

Passive

Assertiveness

•  Active involvement during flight•  Provides relevant information without

being asked•  Readiness to take action

•  Makes suggestions•  No fear of retribution

Barriers To Assertiveness

•  Position of authority•  Experience•  Rank•  Qualifications•  Personal characteristics•  Lack of confidence•  Fear of reprisal

3 Times You Have To Speak Up

•  Will improve results of group

•  Gives others permission to speaktheir truth

•  Costs of silence are too high

Nilofer Merchant, 2011

Creating An Assertive Statement

•  Typically use active verbs or recommendan action.

•  Get the attention of the receiver•  State your concern•  Offer a solution•  Ask for feedback

•  “Gobblin’, I show us 300ft below assignedaltitude. Recommend we climb. What areyou showing?”

Rules Of Thumb

•  Most Conservative Response•  If disagreement in the aircraft exists, take the

most conservative action until moreinformation is available.

•  Two Challenge Rule•  In extreme situations, if the pilot (flying) does

not respond appropriately to two demands,the copilot (pilot not flying) should take thecontrols.

COMMUNICATION

Communication

Definition: The ability to clearly and accurately send and acknowledge

information, instructions, or commands, and provide useful feedback.

(kəә-myōō'nĭ-kā'shəәn)

Communication

•  Vital to mission accomplishment•  Maintains Situational Awareness

Important, why?

Verbal Communication

Words

Tone

Non verbal cues (e.g. gesture, posture, facial expression)

7%

38%

55%

Dr. Albert Mehrabian, (1972)

* When communication is ambiguous.

Decode Encode Transmit Receive

Meaning (Interpret)

Meaning (Intent)

Message Meaning

(Interpret)

Meaning (Intent)

Encode Decode Receive Transmit

Feedback

Noise

Basic Communication Model

COMMUNICATION EXERCISE

One-way Communication

•  Rapid

•  Looks and sounds neater

•  Generally requires more planning

•  Responsibility lies with sender

•  The sender feels in control

•  Receiver may switch off

DIAGRAM #1 Two-way Communication

•  Potentially more reliable and effective•  Permits correction of details•  Requires less planning•  Receivers have more confidence•  Both sender and receiver have responsibility•  Non-verbal communication more important•  Generally takes longer•  Can lead to frustration and anger•  Sender can feel threatened

DIAGRAM #2 External Barriers

•  Noise•  Low voice•  Electrical interference•  Separation in space, time•  Lack of visual cues•  (e.g. gesture, posture, facial expression)

Internal Barriers

•  Personality•  Motivation•  Expectations•  Past Experience•  Prejudice•  Rank•  Emotions/Moods•  Language Difference•  Culture

List The Barriers

•  Active Listening•  Appropriate mode and decibel level•  Pre-briefed Terminology•  Professional Attitude•  Compartmentalization•  Resolving conflicts on deck•  Avoid bad “cockpit marriages”

Overcoming Barriers Effective Communication

•  Explicitness - Clearly stating the desired action and who should do it.

•  Directness - Degree of pressure to comply with the desired action.

•  Social appropriateness - Sensitivity to the roles and status of speaker/addressees and to the seriousness of the situation

Most Effective

•  Explicitly state what to do and maintain positive team climate:

•  Obligation Statements: States an obligation or an intention:

“Waveoff, Gobblin’.”

•  Suggestions: Suggests an action to be taken, a strategy, or an ability:

“We can ask them to go left of that if you want.”

•  Relayed Requests: Restating a third-party request:

“Now [ATC] wants us to go right.”

Least Effective

•  Too vague to identify problem or action

•  Mild Hints: Queries or observations that donot refer directly to the problem:

“How are things coming along?”

Spatial D Monitoring And Challenging

•  Essential elements of aviation safety•  Monitor each others’ performance•  Communicate observed errors to prevent

problems from escalating

•  Communication dilemma•  How to communicate unambiguously and

encourage compliance •  While maintaining positive team climate

(Fischer & Orasanu, 2000)

Air Florida Flight 90 (1982)

First officer: ‘That don’t seem right does it? Ah, that’s not right’.

Captain: ‘Yes it is, there’s eighty’ (knots).

First officer ‘Naw, I don’t think that’s right’

Captain: (No response)

“The first officer continued to show concern as the aircraft accelerated through a ‘hundred and twenty’ (knots).”

(NTSB, 1982: 64

NASA Simulation Results

•  More effective communicationstrategies used when risk was high.

•  FOs less likely to challenge when FaceThreat (degree of challenge to the otherpilot’s skill, judgment, or competence)was high.

Implications

•  Importance of challenging in teams•  Promotes functional conflict•  Supports team goals•  Can improve performance

•  Dangers of not challenging errors•  Avoiding relationship conflict may

undermine performance and safety

Effective Communication?

Communication

•  Communication is vital!•  Be aware barriers will happen and

overcome them.•  The greatest enemy of effective

communication is the illusion of it.

REMEMBER

Illusion Of Communication

Assertiveness Summary

•  Comfort level

•  The range of behavior types

•  Barriers to assertiveness

•  Situations requiring assertiveness

Communication Summary

•  The basic communication model

•  The differences between one and two-waycommunication

•  Barriers to communication

•  Effective communication

•  Monitoring and challenging

Questions?

7 CRITICAL SKILLS SA DM

The Cognitive Components of CRM

Situational Awareness & Decision Making

C-050-1503A PPT 5007 01

Lesson Topic 2.5 Terminal Objective Instruct CRM Critical Skills

Enabling Objectives •  Instruct CRM critical skills, in a classroom setting, in accordance with

Instruction, Crew Resource Management Instructor Course Student Guide.

•  Define Situational Awareness, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  Explain the difference between perception & reality, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  Describe the levels of SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

Objectives

•  Explain the cognitive mechanisms at work in the brain which enable development of SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  List factors that reduce SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  State techniques for maintaining and recovering SA, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

* The more discussion the better!

Objectives (cont.) Human Factors Research

•  Offshore oil production

•  Nuclear power generation

•  Medicine

•  Civil aviation

•  Navy divers, EOD, SEALs

•  Navy/ Marine Corps aviation

What do these industries have in common?

Human Information Processing

Limitations of the human information processing system have an enormous effect on the ability of an aviator to gather the information required, and make a good decision on the basis of that information.

Memory Model

Long term Memory

Sensory memory

Short term memory

& Working memory

INPUT

INFORMATION RECALLED

Adapted from Atkinson & Shiffrin (1971)

•  Knowledge •  Skills •  Experience •  Diagnostic rules •  Procedures etc.

Working Memory

•  People cannot remember large amounts of information due to the size of working memory

•  Duration is 18 to 20 seconds without rehearsal

•  The amount of information retained can be increased by rehearsal and by ‘chunking’

•  Susceptible to distraction, stress, and fatigue

•  Can be freed up through experience •  Eventually becomes long term memory

Information Processing Summary

Working memory is critical to: • Situational Awareness• Decision Making• Workload Management

Situational Awareness Situational Awareness

As much as 88% of human error is due to problems with

Situational Awareness.

Endsley, 1995

Error???

What is the percentage of mishaps due to human error?

Definition

What is your definition of Situational Awareness?

Navy Definition

•  The degree of accuracy by whichone’s perception of the currentenvironment mirrors reality

• Only requires that we know:• What is currently happening• Where the aircraft is in three-dimensional space

Academic Definition

“…the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future”

Endsley, 1995

Performance of Actions

Perception of elements in current situation

Comprehension of current situation

Projection of future

status

Decision Making

Situational Awareness

Level 1 Level 2 Level 3

Model of Situational Awareness

Endsley, 1995

Perception of elements in the current situation •  Data unavailable•  Data difficult to detect•  Failure to scan or observe

•  Omission •  Attention narrowing (tunnel vision) •  Distraction •  High task-load

•  Misperception of data•  Memory capability

Level 1: Error

Comprehension of current situation

•  Lack of/poor mental model

•  Use of incorrect mental model

•  Over-reliance on default values in model

•  Memory failure

Level 2: Error

Mental models are created by

Experience Briefing Expectations

The Creation of Mental Models

Pilot

NFO

Mental model

Mental model

Common Understanding Event

Need a Shared Mental Model

Pilot

NFO

Mental Model

A Interpretation A

Interpretation B

Event

Everyone’s Mental Model Can be Different

Mental Model

B

Projection of future status •  Failure to accurately project the mental

model

Level 3: Error

Leve

l 3 - 5

% Level 2 17%

Level 1 78%

In What Levels are Errors Occurring?

Level 1: Data Perception

Level 2: Data Comprehension

Level 3: Data Projection

Jones & Endsley (1996)

What is the Most Common Cause of Level 1?

•  Data unavailable•  Hard to discriminate/detect data•  Failure to scan•  Misperception•  Memory capability

0

5

10

15

20

25

30

35

40

A B C D E F G H I J K L

Level 1 Level 2 Level 3

Perc

ent o

f tota

l SA

erro

rs

Situational Awareness Errors A= Data not available B= Hard to discriminate/detect data C= Failure to scan D= Misperception E= Memory loss F= Lack or incomplete mental model G= Use of incorrect mental model H= Over-reliance on default values I= Other J= Lack or incomplete mental model K= Over-projection of current trend L= Other

Factors That Reduce SA

•  Insufficient communication•  Fatigue/Stress•  Task overload/underload•  Group mindset•  Press on regardless philosophy•  Degraded operating conditions

C-5 Case Study

•  Location: Dover AFB•  MPs arrived at 0340•  Took off 0621 from Dover AFB (MP2 flying)•  Date and time: 3 April 2006, 0639•  Aircrew:

•  Pilot: Reservist, evaluator pilot, >4000 hours •  Copilot: Reservist, Chief of training, instructor pilot,

>2300 hours•  Jump seat: Reservist, CO, >3800 hours (observer) •  3xFE: 2750-8200 hours •  5x Loadmasters

Lead Up to Mishap

•  3 minutes into flight FE1 noticed a flickering‘thrust reverser not locked’ light on #2 engine

•  MP2 shutdown #2 engine, advised Doverapproach that they were returning

•  MP3 (CO) suggested MP1 land, so MP1assumed control

•  Two ICS Nets•  New Glass Cockpit•  Recent Hot Brakes HAZREP

How do you lose SA in the aircraft?

What are the clues that you, or a member of your team

has lost SA?

Clues to SA Problems

• Ambiguity – information from 2 or more sourcesdo not agree• Fixation – focusing on one thing• Confusion• Lack of required information• Failure to maintain critical tasks (e.g. fly the A/C)• Failure to meet an expected checkpoint• Failure to resolve discrepancies• A bad gut feeling that things are not quite right

Civil Aviation Authority (2003)

•  I didn’t realize that…•  I didn’t notice that…•  I was busy attending to…•  I wasn’t aware that…•  We were very surprised when…•  We were convinced that…

Retrospective Statements of lost SA

How do you maintain Situational Awareness in the

aircraft?

Maintaining SA

• Good brief• Fitness for work• Minimize distractions and interruptions duringcritical tasks• Sterile cockpit• Update – regularly compare mental models• Monitoring – be sensitive to clues of ‘zoningout’• Speak up• Time management

Flin, O’Connor & Crichton, 2008

• What is the immediate goal of your team?• What are you doing to support that goal?• What are you worried about?• What is the current problem, size, and

intention?• What do you think this situation will look like

in __ minutes, and why?

Questions to Calibrate SA

London Fire Brigade

Summary

•  Memory Model

•  S/A has three levels•  L1: Perception

•  L2: Comprehension

•  L3: Projection

•  Failure of scan is the most likely toaffect you

Questions? Break

Decision Making

Napoleon Bonaparte Nothing is more difficult, and therefore

more precious, than to be able to decide.

Terminal Objective Instruct CRM Critical Skills

Enabling Objectives •  Define decision making, in a classroom setting, in accordance with

Instruction, Crew Resource Management Instructor Course Student Guide.

•  List the steps in classical decision making and why they do not normally apply to aviation, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  Describe some alternative models to classical decision making models, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

• Explain decision making in a time critical/high risk environment, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

Objectives

•  Explain decision making where there is little or no experience with the situation, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  Discuss rule-based decision making, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

•  Discuss some of the tools that enhance decision making skills, in a classroom setting, in accordance with Instruction, Crew Resource Management Instructor Course Student Guide.

Objectives (cont.)

•  The ability to choose a course of actionusing logical and sound judgment basedon available information.

Decision Making

FA-18 Case Study

•  26 March 2004, Raleigh Durham•  Second leg of a three leg cross-country•  MP had recently joined the squadron

from the FRS, and had about 100 hoursin the Hornet

•  MP was dash 2, preparing for a 10second separation takeoff

•  MP clears informational error code

Decision Point Failures

•  Failed to clear error codes•  Failed to recognize the paddle switch

disengaged nose steering•  Failed to abort on the tarmac•  Failed to abort on the grass•  Failed to retard throttles, and

disengage afterburner at any time

Stroop (1935)

This test illustrates the difficulty of humans to inhibit one well-learned response and do something else.

Instructions: Start at row one, reading left to right, then row two, and finally, row three.

Task 1 Task 2 Task 3

Red Blue

10 9 8 7 6 5 4 3 2 1 State the Colors

Row 1

Row 2

Row 3

State the Colors

Row 1 Red Blue Green Yellow

Row 2 Yellow Green Blue Red

Row 3 Green Red Yellow Blue

10 9 8 7 6 5 4 3 2 1 State the Colors

Row 1 Red Blue Green Yellow

Row 2 Yellow Green Blue Red

Row 3 Green Red Yellow Blue

10 9 8 7 6 5 4 3 2 1

Stroop Take Away

•  Using heuristics is useful to free up ourworking memory in normal situations.

•  However, in situations that are not quitenormal, our well learned response canput us in difficulties.

Aviation Decision Environment

•  Ill-defined goals•  Uncertainty, ambiguity, missing data•  Shifting and competing goals•  Dynamic and continually changing conditions•  Action feedback loops (real-time reactions to

changed conditions)•  Time stress•  Multiple players•  Organizational goals and norms•  Experienced decision makers

Klein, 1991

How Do You Make

Decisions?

British Airways – DODAR

D – Diagnosis What is the problem? O – Options What are they? D – Decision What are we going to do? A – Assign tasks Who does what? R – Review What happened?

What are we doing about it?

Lufthansa – FORDEC

F – Facts O – Options R – Risks and benefits D – Decision E – Execution C – Check

Naturalistic Decision Making

•  Since the 1980s increased interest indecision making in complex real worldsettings

•  Navy / Marine Corps has been at theforefront of this research•  USS Vincennes shooting down Iranian

airliner in 1988•  Tactical decision games

Naturalistic Decision Making

Flin, O’Connor, & Crichton, 2008

Stage 1. ASSESS THE SITUATION

Time risk pressures

Stage 3. Select a course of action

Stage 4.Implement a course of action

(What’s the problem?)

Risk - high Risk - low Time - low Time - high

Stage 2. MAKE A DECISION(What shall I do?)

FEEDBACKAnalyticalIntuitive CreativeRule-based

Stage 1: Assess the Situation

Time available risk variable

What’s the problem? How much time is available? How risky (present and future)?

Gather More Information

Create Solution

Schedule Tasks

Choose Options

ACT

Problem NOT understood

Problem understood

Problem understood OR NOT

understood

Rule available

No options available

Multiple options

available

Multiple tasks to do

Time Limited Risk High

Apply Rule

Stage 2: Make a Decision

The type of decision making strategy which is most appropriate is dependent on the amount of time, amount of information, and expertise of the decision maker.

Four decision making strategies are: •  Intuitive

(Recognition Primed Decision – RPD)•  Rule based•  Analytical (Choice decisions)•  Creative




Create Solution

Schedule Tasks

Choose Options

ACT


Problem understood


understood

Rule available


Multiple options

available



Apply Rule

Intuitive Decision Making (RPD)


•  Actions and reactions based upon pastexperience.

•  The emphasis is on reading the situation,rather than on generating different options forpossible actions.

•  Experienced reading of a situation, so that theselection of a course of action is obvious.

•  The generation of a solution that, while it maynot be the best, should result in a workablecourse of action.


Positives: •  Useful method where time is limited •  Requires little thought •  Can lead to a satisfactory and workable action •  Useful in routine situations

Negatives: •  Can only be applied in certain situations •  Need to be an expert •  Can lead to confirmation bias




Create Solution

Schedule Tasks

Choose Options

ACT


Problem understood


understood

Rule available


Multiple options

available



Apply Rule

Rule Based Decisions Poor Procedures

• HAZREP: 27MAR06MARAERIALRFLTRANSRON 352 - ALL HERCULES AIRCRAFT ACTIVITIES •  A review of EPs and PCL revealed over 260

items that were different, missing, incomplete,or formatted differently.

•  PCL missing specific notes, cautions,warnings or procedures that are in NATOPS.

Rule Based Decisions

Positives: •  Only need to follow a series of rules •  Do not need to be an expert, or understand the

purpose of every step •  Easy to justify action

Negatives: •  It is easy to miss a step in the sequence •  Poor diagnosis can lead to the wrong set of rules

Bird Strike




Create Solution

Schedule Tasks

Choose Options

ACT


Problem understood


understood

Rule available


Multiple options

available



Apply Rule

Analytical (Choice) Decisions Analytical (Choice) Decisions

•  Focus of classical decision makingresearch

•  The decision maker generates anumber of possible courses of action,and then compares them to determinethe best fit.

•  Time Critical ORM•  A-B-C-D Model

Assess your situation for hazards/risks

Balance your resources to control risks

Communicate your risks & intentions

Do & Debrief (act & monitor controls; provide feedback)

Steps of Time Critical ORM ORM

Analytical Decisions

Positives: •  Fully compares alternative courses of action •  Easy to justify •  More likely to produce an optimal solution

Negatives: •  Requires time •  Not suited to noisy, distracting environments •  Can be affected by stress •  May produce cognitive overload




Create Solution

Schedule Tasks

Choose Options

ACT


Problem understood


understood

Rule available


Multiple options

available



Apply Rule

Creative Decision Making


• Devising a novel course of actionfor an unfamiliar situation

• United 232, Sioux City

• Apollo 13

APOLLO 13


Positives: •  Produces solutions for unfamiliar problems

Negatives: •  Requires time •  Untested solution •  Can be affected by stress •  May produce cognitive overload •  May be difficult to justify

Flin, O’Connor, & Crichton, 2008

Stage 1. ASSESS THE SITUATION

Time risk pressures

3. Select a course of action

4. Implement a course of action

(What’s the problem?)

Risk - high Risk - low Time - low Time - high

Stage 2. MAKE A DECISION(What shall I do?)

FEEDB

AC

K

AnalyticalIntuitive CreativeRule-based

Feedback

Factors Influencing DM

•  Anything effecting cognition•  Stress•  Fatigue•  Noise•  Distraction•  Interruption•  The Other Critical Skills:

•  SA, CM, AS, MA, LD, AF

Finally…

"When anyone asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worth speaking about....I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort."

Edward J. Smith (Captain of the Titanic)

Decision Making Summary

•  Unique decision making environment inaviation

•  Adopt the appropriate decision strategy•  What’s the problem? •  Is the level of risk high or low? •  How much time do I have available?

•  Decision strategies•  Intuitive (Recognition primed) – gut feel •  Rule-based – procedures •  Analytical decisions (Choice) – ORM & matrixes •  Creative – test pilot

Resources

•  www.satechnologies.com Endsley’s company •  www.raes-hfg.com/xsitass.htm Royal Aeronautical

Society conference on SA

•  Flin, R. (1996) Sitting in the Hot Seat.

•  Flin, R., O’Connor, P., Crichton, M. (2008). Safety at the Sharp End.

•  Gladwell, M. (2005) Blink.

•  Klein, G. (1999). Sources of Power: How People Make Decisions.

•  Civil Aviation Authority (2006). Crew Resource Management. www.caa.co.uk/docs/33/CAP737.PDF

Questions?

WORKLOAD MANAGEMENT

Workload Management

C-050-1503A PPT 5001 01

A Very Loose Tie In

Enabling Objectives

•  Implement workload management into CRM instruction, in a classroom setting, in accordance with CNAF 1542.7 and A Guide to Human Factors for Naval Aviators.

•  Define workload management, in a classroom setting, in accordance with A Guide to Human Factors for Naval Aviators.

•  Explain some of the factors that affect workload in a classroom setting, in accordance with A Guide to Human Factors for Naval Aviators.

Enabling Objectives

•  Explain the goal of automation in reducing workload in accordance with A Guide to Human Factors for Naval Aviators.

•  Describe how limitations of human performance affect workload and automation management in a classroom setting in accordance with A Guide to Human Factors for Naval Aviators.

• Explain effective workload and automation management in a classroom setting in accordance with A Guide to Human Factors for Naval Aviators.

Remember?

Our ability to handle multiple tasks is a function of our information processing capacity.

The main limitation is working memory.

Workload Management

•  Workload:The amount of work performed or capable of being performed usually in the context of a defined period.

•  Management:The act or art of supervising. Judicious use ofmeans to accomplish an end.

A WORKING DEFINITION

Factors Affecting Workload

•  The nature of the task•  Physical demands it requires •  Mental demands it requires

•  The circumstances under which the task isperformed•  Standards of performance •  Time available •  Requirements to perform more than one task •  Environmental conditions •  Crew composition


Factors Affecting Workload

•  The aviator and his/her state

•  Skills

•  Experience

•  Current health and fitness

•  Emotional state


•  Difficulty adhering to performance standards

•  Errors and erratic performance

•  Poor fundamental aircraft control

•  Uncertainty, indecision, or discomfort

•  Degraded scan, tunnel vision, fixation

•  Hesitant, confused speech

Signs of Overload

•  Boredom

•  Fatigue

•  Frustration

•  Dissatisfaction

•  Failure to Scan

Signs of Underload

Arousal and Workload

•  To achieve an optimum level of task

performance should you be overloaded or

underloaded?

•  It is necessary to have certain levels of stimulation

or arousal.

Workload Vs. Performance

HIGH

HIGH LOW

LOW

UNDERLOAD OVERLOAD OPTIMUM

PERFORMANCE

WORKLOAD

KC-130 Case Study

Work Overload. Bristol MOA/29 Palms

KC-130 Case Study

Synopsis •  FWAR / Crew Training / T3P initial Night Fam •  T3P (400 hr) Left seat, TPC (2100 hr) Right seat,

FE (3100 hr) Jump seat •  FWAR CANX. VFR Round-Robin, 2 Inst App off

airfield •  Touch and go pattern during pinky time at NXP

expeditionary airfield

CREW T3P TPC

KC-130 Route of Flight KC-130 Case Study

•  Flight engineer mismanages FUEL panel (gravity feeding engines #1 & #4)

•  No. 1 and 4 engines lose power after rotation •  No. 1 is shut down and 4 fails •  TPC believes only #1 has failed•  FE confused by #4 indications •  TPC turns left (into dead engine/terrain)

CREW T3P TPC

KC-130 Case Study

•  FE Calls for more power •  TPC discusses #1 air-start

•  TPC Doesn’t order it, T3P holds condition lever to start (6-8 sec) •  #1 lights off but stalls

•  TPC calls for flaps 20%•  T3P complies without comment, takes hand off #1 condition lever

•  Aircraft impacts ground 106 sec after last takeoff

CREW T3P TPC

KC-130 Case Study

•  TPC workload rapidly went from low to extreme•  Where? How? How did crew coordination break

down? •  Counterproductive activities on the part of the

TPC, T3P and the Flight Engineer

KC-130 Case Study

•  Overload Caused:

•  Flight engineer unable to properly diagnose No. 4 engine

•  TPC to fixate on No. 1 engine (working mem?)

•  T3P to become a voice-activated copilot

•  All to not determine cause of dual flameout

How Was Their Workload Managed?

•  What were the signs of overload?

Working Memory & Attention

•  Can we attend to more than one thing

simultaneously?

•  No, although attention can move very quickly from one

item to another, it can only deal with one item at a time

•  Our attention is limited by working memory

capacity

Divided Attention Example

•  Task: Follow a pace car through heavy traffic in

a high-fidelity driving simulation.

•  Performance was compared between driving

without conversing, and driving while conversing

on a hands-free cell phone.

Strayer et al, 2003

Results: Driving and Cell-Phone Use

Driving only Driving and talking

Brakes on (msec) 933 1,112

Brakes off (msec) 580 653

Following distance (m) 26 29

Distracted Driving With Hands-Free Device

National Safety Council, March 2010

•  Drove simulator and listened to spoken sentences for true / false

•  Listening decreased brain activity by 37% •  Not actual conversation – may underestimate impact

Attention Exercise BREAK

Get some refreshment…

Goals of Automation

•  Definition: The execution by a machine of afunction previously carried out by a human

•  Reduce workload•  Help pilots focus on the most important

aspects of the job•  Decrease errors, increase accuracy•  Has automation achieved these goals?

Air France 447

Current Automation

•  HUD/HMD•  TAWS•  EFB/iPad•  Synthetic Vision•  FMS with coupling and auto-land•  ADS-B/ASDE-X Transponders•  GPWS•  TCAS

TH-57C / D Cockpit DC10 / 11 Cockpit

MD11 DC10

AH-64A / D Cockpit

Traditional (alpha) Glass (delta)

Chelton Synthetic Vision EFIS

Synthetic Vision

EFIS MOVING MAP EICAS

EICAS Excedance Boeing 757 Crash

Cali Columbia

•  Prime example of the limitations ofautomation

•  Poor workload management once crisisensued

Boeing 757 CFIT Mode Awareness Errors

•  Common causes of mode failure•  Pilots fail to verify the mode selections •  Notice automatic mode failures •  Process mode annunciations to understand

aircraft behavior

Nadine Starter, Human Factors, June 2008

Automation Bias

•  Automation encourages pilots to adopt a naturaltendency to follow the choice requiring the leastbrain power.

•  55% of the time pilots committed errors whenthe automation presented incorrect informationin the presence of correct information. Theyfailed to detect the anomaly.

Mosier et al, 1998, 2001

China Air Flight 140

Civilian Hull Loss Rate (per million departures)

Conventional Advanced

Conventional Advanced

A300-1/2/3/4 A300-600 1.18 1.33

B737-100/200 B737- 300/400/500 1.20 0.43

B747-100/200/300 B747-400 1.79 0.77

DC9 MD80 1.28 0.40

DC10 MD11 2.67 0.00

Boeing, 1997

Army Rotary Wing (per 100,000 flight hours)

Traditional Glass

OH-58 Kiowa 4.37 20.30

UH-60 Blackhawk 8.81 17.06

AH-64 Apache 18.36 23.00

CH-47 Chinook 6.97 3.94

Rash et al, 2001

Reasons for an Increased Mishap Rate?

•  AH-64 pilots acknowledge there is anincreased workload in the glass aircraft

•  AH-64 pilots acknowledge that it is harder toremain proficient in the glass aircraft

•  Small margin of error if both pilots suckedinside the cockpit

•  Transition pilots•  New missions

Nevertheless, the majority of AH-64 pilots preferred the glass cockpit

Rash & Francis, 2003

Automation and Workload

Wor

kloa

d

Hand-fly Autopilot FMS control

Abnormal

Normal

Chidester, 1999

Possible Impacts of Cockpit Automation

•  Increased monitoring, less flying

•  Requires more “heads - down” time

•  Induces complacency and dependency

•  Loss/erosion of situation awareness

•  May cause erosion of flying proficiency

•  May introduce new forms of “human error”

•  Minor input error - serious consequences

Automation Dependency- Complacency

•  Pilots may become complacent in highlyreliable automated aircraft

•  In high reliability systems, detection ofautomation failures was low

•  In variable reliability, automation monitoringwas very efficient

Singh et al, 1993, 1997

Northwest 255 The Future?

Automation Take-Aways

•  Potential for both decreasing and increasingcrew workload

•  Can cause mode awareness error

•  Can cause incidents of “perceived control”

•  SOPs are an effective means of avoiding manyautomation pitfalls

•  Flight time is crucial to remain proficient

•  Crew Resource Management skills are moreimportant in automated cockpits

•  Anticipate high workload periods

•  Recognize onset of high workload

•  Carry out ‘what if’ scenarios during periods of low

workload

•  Be aware of signs that other crew members have

become overloaded

•  Be aware of distractions

Countermeasures

Summary

•  Our ability to manage workload isdependent upon the limitations of attentionand working memory

•  Automation must be carefully managed andCRM skills are of increased importance inhighly automated aircraft

•  Avoid distractions

Questions?

•  Civil Aviation Authority (2006). CrewResource Management. www.caa.co.uk/

•  Civil Aviation Authority (2004). Flight CrewReliance on Automation. www.caa.co.uk/

•  www.satechnologies.com Endsley’s company

•  www.flightdeckautomation.com/about.aspxFlight deck automation issues

THREAT & ERROR MANAGEMENT

Threat & Error Management

Lesson Topic 2.5

C-050-1503A PPT 5001 01

Terminal Objective

The student will demonstrate knowledge of Threat and Error Management, and be able to apply those techniques to their specific platform as the Program Manager

Enabling Objectives

•  Implement error management into CRM instruction •  Explain importance of Threat & Error Management •  Explain information collection programs •  Define threat •  Describe categories of threats •  Explain human limitations that lead to error •  Define error •  Describe categories of error •  Explain T & E Management model and how to use it

inside and outside of the aircraft

Why Threat & Error Management?

The idea behind all CRM Courses is to define the “best practices” in applying threat and error management counter-measures to reduce or

eliminate the consequences of threats and errors, which are precursors of accidents and incidents.

Safer operations can be had by imbedding the best practices of our pilots into our training and

everyday operations. Pilots learn many of their positive traits from the sharing of ideas and

experiences with their peers and then applying them to their own operational philosophy.


•  Tenants of the original University TexasContinental Human Factors Study (1996/2000):

•  To analyze adverse affects of errors within aviation

•  To define training needs to reduce crew related errors

•  To define organizational strategies to recognize and manage threat and error


“To Err is Human” -Marcus Tullius Cicero 106-43 BC

•  Defines human fallibility•  As long as humans remain a functional

component in any aviation system therewill always be errors

Why Threat and Error Management?

HUMAN ERROR has posed threats to mission accomplishment since

humans began to deal with technology…

…Errors REPEAT evenwith new technology…

Even for the Military…

Errors exist…

..and some errors are MORE COSTLY than

others…

•  In the past: We focused on eliminatinghuman error in aviation.

•  Contemporary acknowledgement: Errorsare inevitable, so…•  We must instead focus on ways to effectively

MANAGE and REDUCE errors


Why are we still doing CRM training?

Threat & Error = Mission Effectiveness

CRM = Mission Effectiveness

Threat & Error = CRM

Safety is a by-product!

CRM Mission: Supporting Mission Accomplishment Through Enhanced Aircrew Performance.

Continental’s T&E Mission: Error management enhances mission accomplishment and effectiveness.

Sound familiar?

•  Have you ever said “nice save”?•  Have you ever scared yourself on a flight?•  Have you ever thought “Don’t question me, I know

what I’m doing”?•  You've done it a thousand times.•  It comes naturally to you.•  Its what you've been trained to do your whole

career.•  Nothing could possibly go wrong.

Why are we still doing CRM training?

OR?

Because Errors Exist

THE PROGRAM


Because Errors Exist Because Errors Exist


Accidents/Incidents •  Reactive

What is happening here?

• Proactive•  Data Collection

Error Reporting

Data Collection

•  Why is it important?•  Still making the same mistakes

•  Where do we start?•  Information Collection

•  What kind of data are we looking for?•  Find the common errors that are being

made by aircrew routinely!•  Not just on check flights !

•  Need to acknowledge errors occur in order to fix them…

•  LOSA – Line Operations Safety Audit

•  FOQA – Flight Operations Quality Assurance

•  ASAP – Aviation Safety Action Program

Data Collection Programs

Less

ons

Lear

ned

Collect Data

(Measure)

ASAP

FOQA

There

We

Were

Data Collection Programs

LOSA ““Do the concepts taught in training transfer to normal, everyday flight operations?

Observations of flight crew performance during everyday flights

•  Observers unobtrusive – collecting data not participating in flight

•  Team of observers from different backgrounds•  Line pilots / Union representatives •  Check airmen •  Safety and Training pilots

•  All data is DE-IDENTIFIED, CONFIDENTIAL, and NON-PUNITIVE

Line Operations Safety Audit

UT and Continental, 1996

•  31% of flights had an Automation error •  21% of flights had a checklist error •  72% of flights w/at least one external threat

(adverse wx, ATC error, aircraft malfunction)

Average = 2, Most = 17

Of all errors committed:

•  85% were inconsequential •  15% were consequential

•  3% caused additional errors •  12% resulted in an undesired aircraft state

First LOSA Collaborative Results

FLIGHT OPERATIONS QUALITY ASSURANCE

Used to collect, store, and analyze recorded flight data.

•  Post Mission Aircrew Debrief (PMAD): flight visualization and aircrew debrief

•  Aircraft Maintenance & Troubleshooting System (AMATS): analysis and material fault isolation

•  Flight Data Analysis (FDA): monitoring the safe and efficient operation of aircraft

FLIGHT OPERATIONS QUALITY ASSURANCE MFOQA Objective

MFOQA – An Enterprise Wide Solution •  One common tool used across the entire Naval Aviation Enterprise

•  Squadron: Enhancement/efficiencies in maintenance, safety, operations and training •  Wing: Track maintenance, safety, operations and training •  NAE: Enterprise wide analysis and decision making

•  No additional hardware required •  Software resides on NMCI / Marine Internet / IT21 / ONE-NET workstations and NFSA enterprise servers

•  Complements currently deployed systems (AME, IVHM, etc)

Naval Aviation Enterprise FA-18C-F, EA-18G (Wing)

FA-18 C-F, EA-18G (Squadron)

MV-22B (Wing)

MV-22B (Squadron)

MH-60R/S (Wing)

MH-60R/S (Squadron)

CH-53E (Wing)

CH-53E (Squadron)

T-45C (Wing)

T-45C (Squadron) Fixed Wing *

Rotary Wing *

UAVs * * CDD states “All future DOD aircraft and all existing DOD aircraft unless a cost benefit analysis (CBA) demonstrates need for exclusion.”

AH-1Z / UH-1Y (Wing)

AH-1Z / UH-1Y(Squadron)

Voluntary reporting of mistakes and incidents by promising no reprisals

Aviation Safety Action Program (ASAP)

ASAP Sample Size: 212,856

Airfield 1454

Airmanship 1116

Airspace 5703

CommunicaAon 5988

Compliance 2801

Maintenance 5612

Mission Flow 3118

Physiology 757

Recovery 1942

Runway Events 474

Unsafe PracAces 1014

Weather 1339

Other 412

No Event Occurred (With Comments)

15,218

No Event Occurred (No Comments)

165,908

All Navy ASAP Reports as of 2/2/2011 (CNAF)

Navy ASAP Users Report that on 78% of their flights

"No Event Occurred" and no comments are required.

On 7% of their flights "No Event Occurred", but they have ORM, CRM, or

Command Safety Climate inputs.

All "Actionable" Navy ASAP Reports as of 2/2/2011

ASAP Sample Size: 212,856

Airfield 1454

Airmanship 1116

Airspace 5703

CommunicaAon 5988

Compliance 2801

Maintenance 5612

Mission Flow 3118

Physiology 757

Recovery 1942

Runway Events 474

Unsafe PracAces 1014

Weather 1339

Other 412

No Event Occurred (With Comments)

15,218

No Event Occurred (No Comments)

165,908

ASAP Human Factors 2009-2010

0

1000

2000

3000

4000

5000

6000

Judgment or Decision Skill Based Misperception

Judgment or Decision 5670

Skill Based 3237

MispercepAon 2558

Total ASAP Reports 11465

Key Performance Indicators (KPIs) or Outcomes (What Happened)

ASAP Human Factors Judgment or Decision Sub-Category

0 200 400 600 800

1000 1200 1400 1600 1800

Inade

quate

Rea

l Tim

e ORM

Impro

per T

ask P

rioriti

zatio

n

Rushe

d a N

eces

sary

Action

Delaye

d a N

eces

sary

Action

Ignore

d a C

autio

n/Warn

ing

Failure

to E

xecu

te Prop

er Proc

edure

Inade

quate

Rea

l Tim

e CRM

Contin

ue B

eyon

d Proc

edure

Limits

Other

Key Performance Indicators (KPIs) or Outcomes (What Happened)

Inadequate Real Time ORM 1151 Improper Task PrioriAzaAon 500 Rushed a Necessary AcAon 411 Delayed a Necessary AcAon 345 Ignored a CauAon/Warning 120 Failure to Execute Proper Procedure 1128 Inadequate Real Time CRM 246 ConAnue Beyond Procedure Limits 93 Other 1676

Sample ASAP Report

Date 20 Oct 2008

Report Type Information

Category Airspace

Subject Near Mid Air Collision

Report Status Submitted

Workgroup of Entry VT-10IP

Ops Type Flight

Stage VNAV

Safety Related Yes

Risk Factor 110

Phase of Operation Low Level

Action Taken Evasive Action Taken

Time of Day Day

Weather VMC

Comments Had near mid-air on first leg of VR-1022. TCAS was showing the A/C coming from the east at 1000 ft above the T-1. The other A/C began to descend, down to co-altitude. All crew members were aware of the threat and were actively looking for the other A/C. Pilot was taking evasive action based on TCAS suggestions. Aft observer spotted the A/C first, then the jumpseat called talley keeping eyes on as it passed slightly above and barely behind the T-1. It was a civilian single engine prop, red and white in color, headed west. As far as the crew could tell the civilian took no evasive action to avoid the T-1, maintaining course, speed, and altitude. All proper procedures were followed by the T-1 crew and the entire crew worked together to stay safe.

Feedback is Essential for Continued Program Success

What are some methods of feedback at your commands?

Safety Grams / Newsletters Blue Brain Additions

MDG Changes SOP Changes

NATOPS Changes

Feedback is Essential for Continued Program Success

THREAT and ERROR MANAGEMENT

MODEL

Strategies

Resist

Resolve

Legacy CAL before 2011 and UAL merger

Planning and Decision Making

Leadership Effectiveness

Situation Awareness Communication

Monitor/Cross-Check Workload Management

Automation Management

CRM/TEM Skills

Safe Operations

Threats Prepare

Errors

Prepare

Repair

Prepare

Repair

Recover

CRM

/TEM

Incident/Accident

New Model in 2011

Undesired Aircraft State

Threats

Errors

Safe Operations

Prepare

Repair

Recover

CRM

/TEM

Incident/Accident

MISSION EFFECTIVENESS

CRM 7 Critical Skills

Decision Making

Assertiveness

Mission Analysis

Communication

Leadership

Adaptability / Flexibility


Strategies

Resist / Resolve


Leadership Effectiveness

Situation Awareness Communication

Monitor/Cross-Check Workload Management

Automation Management

CRM/TEM Skills


RISK

46 of 20

What are examples of “acceptable/reasonable” risk?

Why are these risks “acceptable/reasonable?”

RISK

What are examples of “unacceptable/unreasonable” risk?

Why are these risks “unreasonable?”

47 of 20

Incident/Accident

48 of 20

Why ?

“risky” behavior

Do you think humans do things they know are risky?

Why?

Because we do not identify THREATS!

and/or

Because we have done it before without any consequences?

Risk and Threats

What makes aviation “risky?”

Threats

We call these “risks”

How do we assess the “risk?”

50 of 20

How do we assess risk? Threats

We maintain in a “risky”

environment by identifying and effectively managing

THREATS!


•  When the THREATS become unmanageablethe risk is unacceptable

•  We identify the THREATS and our abilityto effectively manage them

Risk Assessment

51 of 20

What’s the “bottom line?” Threats

•  ACTIVE Threat:Factors that increase the likelihood of an errorbeing committed, or of not accomplishing themission.

•  These may be: •  Environmental (Wx, terrain, enemy) •  Internal Cockpit (Fatigue, stress) •  External Cockpit (ATC, Other A/C) •  Aircraft (EPs, Systems)

A THREAT is anything that increases operational complexity that, if not managed properly, can decrease

the safety margins.

THREATS

•  LATENT Threat: aspects of the Squadron or Strike Group organization, or individual that are not always easily identifiable, but that predispose the commission of errors, or the emergence of overt threats

•  Organizational / Professional culture (squadron / type wing level)•  Regulatory practices and oversight (SOP) •  Training philosophy and practices•  Qualification standards (qualifications, currency, proficiency) •  Aircraft characteristics•  Equipment design issues •  Flawed procedures (SOP, FTI, MDG, NATOPS, etc)•  Scheduling practices •  Preparation for duty / tasking / event (personal responsibility) •  Personal stress, preoccupation or illness

•  Threats•  Do not equal errors•  Increased potential for error

•  Threats = Red Flags

Threats

Examples of Threats

Weather

Maintenance

Ground Crew

Aircrew

Other Aircraft ATC

Terrain

Similar call sign

Time pressures

Heavy traffic

Unfamiliar airport / Landing environment

Automation event Missed approach

Flight diversion

System malfunction

Distractions

Threats

•  Think back to a recent flight,describe a threat you may have encountered?

•  What types of different threats doyou face in different areas?•  CONUS •  Training •  Overseas •  Combat

What Threats have you faced?

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Threats

Can we eliminate THREATS from aviation?

No, unless we don’’t fly!

How do we operate in spite of the fact that we cannot eliminate the THREATS from aviation?

We EFFECTIVELY manage (prepare for) them.

Threats

Threats Safe Operations


What is our strategy to manage threats?

Identify and Prepare

Things we can use in our tool bag to counter threats:

•  CRM / ORM / TEM •  Clearly defined roles of aircrew members •  Complete briefing and effective communication •  Limit being “heads down” at critical times•  NATOPS / System Knowledge

What strategies do you use to counter threats?

Strategies to Prepare for Threats

VVM is a key element of Threat and Error Management process.

The verbalization by both pilots “verifies” a shared understanding of what is expected and then both pilots “monitor” to ensure strict adherence to all instructions.

Verbalize, Verify, Monitor

•  Break the chain by recognizing errors and fixing them.•  Don’t hope someone else will notice!

VVM

Accident Data

•  Factor in 84% of 37 crew-caused aircarrier accidents

•  76% of the monitoring/challengingerrors failed to catch something thatwas causal

•  Factor in 50% of the CFIT accidents

Why is Monitoring so Important?

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Threats

CRM/TEM Skills

What tools do we have to help us IDENTIFY and MANAGE (PREPARE for)?


Communication

Mission Analysis

Decision Making

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Errors: Crew action or inaction that leads to deviations from expectations, reduces safety margins, and may occur from either mismanaged threats or mistakes.

Errors

What can happen if we ignore or mismanage a THREAT?

Threats

Errors

Safe Operations


Questions?

Take 5 Human Error

Definitions

• Error:Crew action or inaction that leads to deviationsfrom expectations, reduces safety margins, andmay occur from either mismanaged threats ormistakes.

• Error Management: Process of correcting an error before itbecomes consequential, i.e. Undesired AircraftState and Incident/Accident.

Categories of Error

•  Procedural - Following procedures but wrong execution (wrong altitude setting dialed into the FCP)

•  Communication - Missing info or misinterpretation (miscommunication with ATC)

•  Proficiency - Error due to a lack of knowledge/currency (lack of automation knowledge)

•  Decision - Crew decision unbounded by procedures that unnecessarily increased risk (unnecessary navigation through adverse wx)

•  Intentional Noncompliance - Violations (checklist from memory)

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Operating with Errors

How do we operate in an environment where we cannot eliminate human errors?

Minimize and Manage Them!

How many passes did the “White” team make?

Notice anything other than the players?

A Gorilla…Really?

How many ““Black”” team members were playing at the end of the game?

Exercise

73

Pattern Matching

•  You see what you expect to see•  It happened like this last week•  It happened before, it will happen again

SJU Int’l Airport Lagoon Visual Rwy 8

•  Crew planned and set for ILS 10

•  Clearance change to Lagoon Visual Rwy 8

•  Captain “airport in sight”•  3 Go-around calls from

Tower •  Rate of descent at 1000’

AGL is 2170 fpm •  SIG Tower uses red

signal light • Airplane successfully

lands on 4150’ runway

Isla Grande Pattern Matching

•  Pattern Match •  Runway same basic

orientation as SJU•  Pitfalls

•  Expectancy •  Defense

•  SOP •  Brief two airports in vicinity •  Anticipate clearance

changes •  Crew cross check •  Hangar fly the approach

Minimizing Pattern Matching Pitfalls

•  Adequately define the problem.•  Use Standard Operating Procedures.•  Get confirmation by another crewmember.

77 of 20

What skills do we have to help us Manage Errors?

Errors

CRM/TEM Skills

Communication

Assertiveness

Adaptability/Flexibility

Leadership

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Error Management

Does managing an error so that there are no consequences achieve

the same result as no error?

79 of 20

Error Management

There are two categories of Error Management Tools

•  RESIST:•  The hardware and software built into the

system that trap ERRORS

•  RESOLVE:•  The human skills that are used to trap and

correct ERRORS

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Error Management

What are some examples of

RESIST &

RESOLVE Tools?

Resist

Resolve

TCAS

Windshear

Detection FMC WX Radar

Monitoring

Challenging

Warning Systems

Professionalism

Systems

Knowledge Health

Autopilot

Expe

rienc

e

Map Display GPS

GPWS

Attitud

e

Hardware What Are Your

Systems Doing For

You?

Human-ware What Tools Are You Bringing To

The Fight? 82 of 20

Threats Prepare

Errors

Prepare

Repair

Strategies for Errors

What is our strategy to manage errors?

Identify and Repair

Mission Effectiveness

Resist

Resolve

Your Goal

Prevent / Manage / Correct Errors

Checklists

Good Briefs

Effective Communication

Resolve to follow SOPs / NATOPS

SOPs

Aircraft Warnings

Avoid Unwanted Consequences

NATOPS

Your Goal

Prevent / Manage / Correct Errors

Avoid Unwanted Consequences

“Trap the Error”: It is detected and managed before it becomes consequential

“Exacerbate”: It is detected but the crew’s actions or inaction leads to a negative outcome

“Fail to respond”: The crew fails to react to the error either because it is undetected or ignored

85 of 20


Threats Prepare

Errors

Prepare

Repair

Undesired Aircraft State: A position, speed, attitude, condition, or configuration of an aircraft that reduces safety margins.

What can Happen if We Don’t “Repair” the Error ?


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Threats Prepare

Errors

Prepare

Repair Repair

Prepare

Recover

How do we Manage an Undesired Aircraft State?

Identify and Recover



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What if we do not Recover?


Threats Prepare

Errors

Incident/Accident

Prepare

Repair Repair

Prepare

Recover


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Incident/Accident


Incidents/Accidents that result from pilot error are always the result of an Undesired Aircraft State.


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Incident/Accident

Does an Undesired Aircraft State always result in an

Why ?

Accident Rate Since 1959…

The overall accident rate has improved dramatically from 1959 – 2010! Can the RATE be “0”

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Incident/Accident

What do want YOUR

“rate” to be ?

How are the skills related ?

What do they have in common ? Decision Making

Situation Awareness

Assertiveness


Mission Analysis

Communication Leadership


What is a norm?

•  Unwritten practice accepted by mostmembers of a given group•  Can be positive or negative•  Effective/Ineffective

•  What have you seen in your previousflight experience?

What is a norm?

What are your expectations?

Compliant with SOP

At Risk Behavior

Reckless Behavior

Compliant with SOP

Reckless Behavior

Drift is the gradual departure from an intended course due to external factors. At Risk Behavior

Norms

Compliant with SOP

At Risk Behavior

Reckless Behavior

How much drift do they expect?

DRIFT?

Unexpected or Unfamiliar Routing

Verbalize, Verify And Monitor

Waypoint Not Input Correctly

Map Display and SOPs

Crew action

Phone call / Violation

AH-64 / F-16 / H-60

•  Identify Threats•  Identify Strategies

•  Identify Errors•  Identify Resist/Resolve

Case Study

F-16 Case Study

H-60 Case Study

http://www.youtube.com/watch?v=qYExH8hpgXI

http://www.youtube.com/watch?v=0fnAkb_jGoc&feature=related

http://www.youtube.com/watch?v=Ql0-xDne42U&feature=related

AH-64 Case Study

Threats

Errors

Safe Operations Prepare

Repair

Recover

CRM

/TEM

Incident/Accident


CRM 7 Critical Skills

Decision Making

Assertiveness

Mission Analysis

Communication

Leadership



Strategies

Resist / Resolve

Identify: •  Threats •  Strategies •  Errors •  Resist/Resolve


Summary

•  Why Threat & Error Management (TEM)•  Data Collection•  Threat Categories•  Error Categories•  TEM Model

References

“SAFETY ACROSS HIGH-CONSEQUENCE INDUSTRIES CONFERENCE”, St. Louis, MO

09 Mar – 10 Mar, 2004

The University of Texas Threat & Error Management Model: Components & Examples

Robert L. Helmreich Ph.D., David M.Musson, MD.

Models of Threat, Error and CRM in Flight Operations Robert L. Helmreich Ph.D., James R. Klinect, John A. Wilhelm

UNIVERSITY OF TEXAS TEAM RESEARCH PROJECT THE UNIVERSITY OF TEXAS AT AUSTIN

DEPARTMENT OF PSYCHCOLOGY

Questions?

INTRODUCTION TO CASE STUDIES AND DEVELOPEMENT

CASE STUDY DEVELOPMENT

Lesson 3.7

Terminal Objective

Conduct CRM Instruction, in a classroom setting, in accordance with Instruction, Crew Resource Management Program, CNAF 1542.7 (series)

Enabling Objectives

•  Build case study scenarios for CRMexplanation and training

•  Assemble sources and media into acomplete case study Presentation

TRANET Computers

•  Use your CAC Card and log onto theTRANET computers.

•  Open student share drive folder on yourdesktop: O:\CRM\Production\StudentAccess\(Assigned class folder e.g. 13-01)

TRANET (Cont.)

•  Verify:

•  That you can save data in your studentaccess assigned class folder.

•  That you have internet access.

•  That you have access to the Roxioprogram (CD burner program).

Case Study Template

1. Go to O:\CRM\Production\7 Skills CaseStudy Templates

Case Study Template

•  O:\CRM\Production\7 Skills Case StudyTemplates

•  Open “A/F Word Doc Template”

A/F Word Doc Template Instructor Guide

Type of A/C Title of your case study

Where you got the info

List your EO’s Brief description


All this is provided for you in the template


Synopsis with skills identified

Items to add to the synopsis during the

class discussion


Provided for you on your template

Your questions with answers

Provided for you on your template

A/F Word Doc Template Student Handout

Type of A/C Title of your case

study Where you got the info

Synopsis without skills identified

A/F Word Doc Template Student Handout

Questions without the answers

Case Study Template

•  Open “A/F PP Template”

A/F Case Study PP Template



A/F Case Study PP Template Presentations

•  Time limit is 20 minutes!•  Burn templates to CDs.•  Issued student disks are not RW.•  Save files on computer under:

“Production\Student Access\Class 13-XX”(videos need to be saved in same folder by0830 Thursday).

•  Be complete by Thursday morning.•  Print 1 copy of the Instructor Guide.•  First person covers all 7 skills.•  Lunch options: Break or in house Pizza

Summary

•  Build case study scenarios for CRMexplanation and training

•  Assemble sources and media into acomplete case study

Questions?

FATIGUE & STRESS

ASSASS

Aeromedical

CAPT Jack “Bags” Wyland Command Flight Surgeon, School of Aviation Safety

[email protected] (850) 452-5140; DSN 459-

Room 161C

ASSASS Background

•  AOCS•  SH60-B•  Recruiting Duty•  Med School•  Internship•  Flight Surgery•  VMMT-204•  Residencies in Aerospace and Family Medicine•  3D MAW•  NAVHOSP P’cola•  SAS

ASSASS

0

10

20

30

40

50

60

50 55 60 65 70 75 80 85 90 95 00

776 aircra( destroyed in

1954

USN/USMC, FY50-‐06

Class A Mishap Rate

USN USMC FY07: 0.98 2.05 FY08: 1.51 2.26 FY09: 1.17 1.41 FY10: 0.78 1.46 FY11: 0.96 2.44

Naval Aviation Mishap History

NSC Data: Oct ’’06

FY 2011 11 Aircra( Destroyed

Bags born Tricycle to bicycle transition

Firecracker Mishap

HS/College AOCS

Wench

Sister Janet born Sister Joyce born

““The June Cleaver effect””

Med School

Jack Sr & Betty say ““I do””

Sister Mary Alice

ASSASS

CRM Aeromedical Topics

Fatigue and Stress

C-050-1503A PPT 5010 01

“The mechanization of modern war has produced a chain of health problems. One of the greatest of these is fatigue. In the complicated meshwork of speed and change, many factors make for fatigue. Scarcely any key man in modern war is more subject to stress and strain, to demands on his body and mind making for fatigue, than the military pilot.”

– Dr. Martyn Kafka, 1942.

Kafka, M. Martyn. Flying Health. Harrisburg, PA: Military Service Publishing Company, 1942.

ASSASS Terminal Objectives

•  Become familiar with the leadingaeromedical causes of mishaps andHAZREPs to further understand howCRM can prevent mishaps through theuse of an effective ASO-FS team.

ASSASS Learning Objectives

•  DESCRIBE the science and physiology of sleepand stress, and their effects

•  DESCRIBE symptoms/signs of fatigue and stress•  DESCRIBE performance decrement from fatigue

and stress•  DISCUSS the prime causes of fatigue and stress•  DESCRIBE effects of circadian cycles in fatigue•  RECOGNIZE mishaps where fatigue or stress

may be a factor•  IDENTIFY key countermeasures for fatigue and

stress•  UNDERSTAND performance-maintenance

pharmaceuticals

ASSASS

“Fatigue and Related Human Factors in the Near Crash of a Large Military

Aircraft.”

Do you feel yourself wanting to doze after lunch?

Do you fall asleep within ten minutes after lights out?

Do you sleep more on weekends than during the week?

Do you sleep more on vacation than when you are working?

52 recognized cases

The Brain •  Massively parallel, electro-

chemical digital computer•  ~ 100 billion neurons;

trillions of logic gates(synapses)

•  “Clock” frequencies of 1/3 to> 100 Hz.

•  Runs on oxygen & glucose•  2% of body mass•  25% of resting energy use

Neurons

•  Synapses:•  the logic

elements•  Facilitated

transmissionand structuralchanges atsynapses:•  learning &

memory

http://www.pfizer.com/brain/images/neuron_large.gif

The Science of Fatigue

•  The brain is a digitalcomputer:•  Electro-chemical•  It cannot run

continuously awake•  It requires scheduled

recharge &maintenance intervals

•  Fatigue is aphysiologic state•  Not due to rank, rate,

experience, motivation,or attitude

•  The brainaccumulates“fatigue” whenoperatingØ  It’s computing at less

than 100%

Brain Functions

•  Mood, personality•  Problem-solving•  High-level

reasoning•  Body sense and

Movement•  Memory•  Speech•  Vision•  Balance &

Coordination•  Consciousness•  Breathing•  Heart rate

Signs and Symptoms of Fatigue

•  Irritability, mooddeterioration,reduced patience

•  Impairedcommunication

•  Reduced vigilance,inattention

•  Task fixation•  Tolerance for error

and risk

•  Complex reasoning& decision making

•  Conservation ofeffort, reduced motivation

•  Forgetfulness•  Increased reaction

times •  Lapses and

“microsleeps”

Decision Making

Adaptability; Flexibility

Communication

Assertiveness

Mission Analysis

Leadership


Threat & Error

Management

Fatigue’s Effects are Task-Dependent

•  Sense of well-being•  Judgment & decision

making•  Vigilance & attention• • • •  Well-learned/simple

intellectual or physicaltasks

More sensitive to Fatigue

More resistant to Fatigue

CRM, ORM

ASSASS

•  Truck accidents 30-40% by NTSB•  Daylight Savings Time: +8%, -9%•  Challenger, Exxon Valdez,

Chernobyl, Three Mile Island,Roosevelt-Leyte Gulf?

The Problem: Performance Degradation

Adapted from Steven R. Hursh, SAIC

Three Days of Sleep Deprivation WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction

50

65

80

95

110

0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day

Mea

n Sp

eed

on P

sych

omot

or V

igila

nce

Task

(as

a %

of B

asel

ine)

9 Hr

7 Hr

5 Hr

3 Hr

SAFTE/FASTR 2 = 0.94

Recovery 7 Day Restricted Sleep Baseline

50

65

80

95

110

0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day

Mea

n Sp

eed

on P

sych

omot

or V

igila

nce

Task

(as

a %

of B

asel

ine)

9 Hr

7 Hr

5 Hr

3 Hr



WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction

50

65

80

95

110

0 T1 T2 B 1 2 3 4 5 6 7 R1 R2 R3Day

Mea

n Sp

eed

on P

sych

omot

or V

igila

nce

Task

(as

a %

of B

asel

ine)

9 Hr

7 Hr

5 Hr

3 Hr



WRAIR Restricted Sleep Study: Adaptation to Chronic Sleep Restriction

USN Recruits Test Scores by Year 6 vs. 8 hours sleep

6 hr 6 hr

8 hr

Dr. Nita Miller, Research Asst. Prof., NPS

How Much Sleep Do You Need?

4 5 6 7 8 9 10 11 12

Old-thinking

New-thinking

“Humans are the only animals that willingly deprive themselves of sleep.”

– Eve Van CauterSleep researcherUniversity of Chicago

Lapses / Microsleeps in a Taxi Driver

Microsleeps in Military Security

Velocity: 14 mph

ASSASS Roosevelt - Leyte Gulf

Mishap Board Findings:

HUMAN ERROR: “CVN OOD: •  ... in disregard of nautical rules

of the road...”” •  ...unable to recognize or

unwilling to act....”” •  ...without communicating

intent. ““ •  ...did not act with appropriate

dispatch...””•  ...did not advise CO that ...”” •  ...did not advise CO of

conflicting concurrent events...””

• ...did not advise CG in a timely manner...,

• ... failed to sense the urgency of...””

• ...did not notify the CO...”” •  ...became overly involved in

managing...””

HUMAN ERROR: “CG CO: •  ... failed to recognize the

seriousness...”” HUMAN ERROR: “CG XO:

•  ...failed to properly analyze the movements of...””

• ...failure to consider the possibility of ...””

HUMAN ERROR: “CG OOD: •  ...failed to properly analyze the

movements of...””• ...was not proactive ... in

communications, ...was focused on...””

•  ...failed to demand proper support from ...””

•  ...failed to prioritize bridge duties...””

HUMAN ERROR: “CG TAO: •  ...focused on the ... scenario,

failed to supervise, ... did not recognize,...””

Identifying Fatigue •  No simple measurement of fatigue

•  If we can’t measure it, we miss it…•  Self assessment of fatigue unreliable

•  The greater the impairment, the poorer the assessment•  Can be inferred from performance measurement

•  But other things also affect performance -stress, illness, hypoxia, alcohol, drugs, etc.

•  Fatigue can be modeled and predicted:•  Hours of continuous wakefulness•  Circadian rhythm effects•  Sleep debt = (Ideal - Actual) x days•  Sleep disorders (sleep apnea, RLS, narcolepsy, etc.)

How Long Can You Live Without…

•  Oxygen ?•  Water ?•  Nutrition ?•  Sleep ?

è  4-10 minutes è  5-7 days è  1-2 months è  2-3 weeks

Ø  Sleep-deprived animals die from insulin resistance, immune system failure and sepsis. Ø  Sleep is a physiologic requirement for survival. Ø  Sleep is a fundamental drive, powerful enough to interrupt any waking activity.

Sleep •  “Sleep” is the set of maintenance

& recharge procedures the brainuses to eliminate fatigue.– Complex activity– Scheduled by circadian rhythms

•  Based on evolution and theorbital motion of planet Earth… a 24-hour day

Sleep Facts

•  Sleep is the recharge procedure to alleviate fatigue•  Based on genetics and Earth’s 24 hour rotation•  Normal amount of sleep 8 – 8 1/4 hours

•  Min 5 hours/night to “maintain performance?” NO!•  ~ 2 hrs of performance for each 1 hr of sleep•  6 > sleep > 10 hours - higher mortality•  Sleep cannot be “banked” but deficits accumulate•  Rest does not replace sleep

Sleep Research

•  NREM deep sleep important in cellularrecharge/health?

•  REM sleep important in memory storage?•  The brain wakes up out of REM

•  Ratio of REM/NREM sleep varies with need•  The brain must have both

•  Sleep induction and maintenance tied tocircadian rhythms

•  Efficiency of sleep deteriorates with age•  MSLT – less than 5 minutes is pathologic

Sleep Architecture Ultradian Cycles ~ 90 mins

Sleep Stages vs. Age MSLT Averages

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Latency in Minutes

Mean 11.4

moderate sleepiness (29%)

excessive daytime sleepiness (7.7%)

0 hr TIB x 1 night

Narcolepsy

Sleep apnea

6 hr TIB x 4 nights

8 hr TIB x 5 nights

10 hr TIB x 14 nights (full alertness)

anesthesia residents

Adapted from Dement; Sleep Medicine

Pilot Performance Long Haul vs. Naps

With 40 minute nap Without naps

Rosekind MR, et. al. Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations.

ASSASS Nap Rules

•  Naps are good•  More naps are better•  Long naps are best•  Expect sleep inertia

Take a nap!

Circadian Rhythms

The circadian ““alerting”” signal

The brain ““energy”” level

The “Circadian Cycle”

Circadian Rhythms

•  Over 300 circadian rhythms (temp,pulse, immune function, hormones, etc.)

•  Entrained by light, period ~24 hours•  Time zone travel requires clocks to

phase-shift/ speed up or slow down•  Week or more to normalize:•  1 1/2 hrs phase shift/day west•  1 hr phase shift/day east

ASSASS Circadian Rhythms AS

SASSBiological Circadian Fluctuations

JA & JL Caldwell. Understanding and Managing Fatigue in Operational Aviation Contexts.

ASSASS Internal Synchronosis Core

temperature

Immune function

Gastric acid secretion

Stress hormones

Glucose level

Metabolic rate

Hydration

Kidney flow

Gut activity

Lipids

Growth hormone

Liver function

ASSASS Desynchronosis

•  External desynchronosis•  A time shift occurs (transmeridian travel)•  The circadian clocks are all off by the same amount of

time, but are together, in phase.•  Internal desynchronosis

•  Following a time shift (generally 6 hours or greater)•  The circadian clocks start to drift in opposite

directions at different rates – they’re out of phasewith each other

•  Takes days to weeks to resynchronize to the newtime zone

During this time the brain is fatigued and performance suffers

Fatigue and Visual Illusions

•  Spatial Orientation is80-85% visual

•  Brain takes 2-D imagesfrom retinas andinterprets 3-D world:requires high-levelcognition andcomputing speed

•  Visual illusions resultfrom misperception ofreality – hypnagogichallucinations

•  Fatigue impairsvisual interpretation!

Fatigue and Spatial Disorientation

•  Vestibular & “seat-of-the-pants” senses conflictwith reality

•  Spatial Orientation inaviation depends onhigh-level cognitivepower

•  Loss of visual cues, tasksaturation, scanbreakdown all lead to SD

•  Fatigue aggravatesall of these!

ASSASS

When you have fully grasped the ““big picture””

Lets take a break

ASSASS

FAST™ Computer Modeling

of Fatigue

Animal Modeling of Fatigue

ASSASS

24-hour period

Sleep

Afternoon circadian

dips Performance

drop

Work

BAC equivalent

scale

Day-night cycles

Night shift

Exxon Valdez – 00:15 Bhopal – 01:00

Chernobyl – 01:23 Kuwait H-46 Mishap – 02:33

Roosevelt Leyte Gulf – 02:52 Three Mile Island – 04:00

HSL SH-60B Mishap – 05:30

The midnight to 0600 window is a very dangerous

place to do business!

Wrist Activity Monitor

•  Wristwatch-like device•  Identifies awake and

sleep periods•  Measures acceleration

(movement) also light(some models) vs.time

•  Records up to oneyear

•  Download data tocomputer program

Actiwatch


Reasonably Good Sleep


FAST Graph: USS Stennis # 03


Poor Sleep


FAST Graph: USS Stennis #52


ASSASS

Mishap Analysis with FASTTM

ASSASS

“Fatigue and Related Human Factors in the Near Crash of a Large Military

Aircraft.”

Thanks to Maj. Jeffrey Armentrout for slides and graphics

Armentrout JJ, et. al. Fatigue and Related Human Factors in the Near Crash of a Large Military Aircraft. Aviat Space Environ Med 2006; 77:963-70.

Recommended Fatigue Countermeasures

•  Go into high OPTEMPOevolutions well-rested

• Pre-plan; minimize changes• Schedule with knowledge of

circadian effects• Minimize shifts > 12 hours• Schedule/ encourage naps• Sleep etiquette• Diet/ meals and feeding• Exercise and activity• Shift work – how to handle?• Who knows when to quit?

Adjuncts

Stimulants and

Sedatives

NAVMED P-6410

•  ComprehensiveGuide for FatigueManagement inOperational Settings

•  Includes medicationuse re: stimulants &sedatives

•  http://navymedicine.med.navy.mil/instructions/external/6410.pdf

Pharmacologic Agents: Stimulants

•  “Go-pills” •  Modafinil (Added Apr 2012) or Dextroamphetamine

•  Will forestall fatigue, and maintain performance•  Will not alleviate need for sleep, just postpone

it.•  Required in increased quantities to overcome

fatigue•  Limited by hallucinations, psychosis, etc.

““I said, ‘‘One of us is hallucinating!’’””

•  “No-go Pills”

•  Ambien or Sonata (changed Apr 2012)•  Will enable sleep, but may interfere with

normal sleep efficiency•  Rebound sleep difficulty possible for 1-2

days•  May produce hangover effects•  Require grounding following use•  Limited by amnesia, etc.•  NEVER carried in aircraft!

Pharmacologic Agents: Sedatives NATOPS, Ch. 8

•  8.3.2.1 – Rest & Sleep:•  Must have opportunity for 8 hours sleep

per 24 hours• Should not schedule continuous awake

periods over 18 hours (or else shall give15 hours off afterward)

•  8.3.2.1.1 – Circadian Rhythm:Ø “accommodation period

estimated by allowing 1 day for every hour over three (of time zone shift)”

Ø “… expect to perform at less than optimal level”

NATOPS, Ch. 8 ASSASS Take-home Points:

Fatigue / Circadian Rhythm Disruption

•  Fatigue is a physiologic state; not due tomotivation, or attitude

•  Normal need for sleep is 8 – 8 ¼ hours/day•  High-level problem solving is most susceptible

•  Emergency procedures, SD susceptibility, etc.•  “Stick & rudder” skills relatively resistant

•  Naps help•  Beware sleep inertia

•  Expect circadian rhythm disruption, difficulty ingetting sleep when time’s available, higherfatigue, and poor performance

ASSASS

What is Stress?

Mechanical “Stress”

•  Material placed under a load; measured as force per unit area

STRESS •  Material deforms slightly, bulges,

and responds to stress STRAIN

•  Once STRESS is removed, if the elastic limits haven’’t been exceeded, the material returns to it’’s normal shape, unchanged.

•  If material is ““overstressed”” it undergoes plastic deformation, or may even fail completely.

•  Hooke’’s Law - 1658

Stress

Strain

Dr. Hans Selye

•  1907 – 1982•  Neuro-endocrinologist

at Montreal•  The “Einstein of

Medicine”

•  Discovered thecommon reactions toall stressors

•  Coined the term“stress” but reallymeant “strain.”

Human “Stress”

•  The weight isthe STRESS

•  How does thebody react?

Origin of the Stress Response

•  Brain sends out alerting/alarmmessages•  In response to physical stressors•  In response to psychological stressors

•  Brain (hypothalamus) sendsmessages to the pituitary•  ACTH

•  Adrenals start pumping out•  Norepinephrine, adrenalin•  Adrenocorticoids; mineralocorticoids

•  Combination of hormonal andneural signals drastically alters thebody physiology

Stress Reaction

•  Heart rate goes up•  Blood pressure, breathing rate goes up•  Muscle tension increases•  Perspiration goes up, saliva decreases•  Mental alertness and senses increase•  Blood flow to brain, heart, muscles goes up•  Blood flow to skin, gut, and kidneys goes down•  Blood sugar, cholesterol, clotting factors go up.

The “fight or flight” response

Stress is:

“The non-specific response of the body to any demands made upon it”

Is it really better to be the boss?

The “Non-specific Response”

The General Adaptation Syndrome

Resistance

Glycogen

Lactic acid

Ketoacids

BMR

Glucose

Temperature

Fat loss

Blood lipids

Liver fats

Cholesterol

Urea

Amino acids

Blood enzymes

Proteins

Serum protein

Creatine

Uric Acid

Sodium

Potassium

Minerals

Tissue minerals Sulfates

Acid-base level

Diuresis

Cell water

Optimal

Per

form

ance

STRESS Level

Stress & Performance Relationship

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Tolerable Demand

Excessive Demand

Underload

Overload

When flight mechanisms become flooded…

Physical “Stressors”

•  Illness, infection, fever•  Trauma, hemorrhage•  Burns•  Surgery•  Dehydration•  Physical exertion•  Etc.

Other Stressors

•  Environment•  Noise, crowding, clutter•  Cold, heat, humidity, vibration•  Bright or low light levels•  Heights or confined spaces

•  Social•  Relationship problems•  Work relationships•  Crowds, parties, strangers•  Rude, aggressive, critical, or competitive people

•  Major life events•  Death of spouse, parent, or child•  Marriage, divorce•  Moving, PCS, deployments•  Crime victim•  Winning the lottery•  Promotion or job loss•  Aircraft mishap•  Etc.

Other Stressors (cont’d)

Other Stressors (cont’d)

•  Institutional•  Rules, red tape, regulations•  Deadlines, schedules, meetings, office

politics•  Training!

ASSASS Selye Quotes

“Every stress leaves an indelible scar, and the organism pays for its survival after a stressful situation by becoming a little older.”

“Man should not try to avoid stress any more than he would shun food, love or exercise.”

“Adopting the right attitude can convert a negative stress into a positive one.”

– Hans Selye

Chronic Stress

OPTEMPO

Fatigue

Deploy

Family stress

Financial diffs

Passed over

Stress Overload

•  Breakdown in compartmen-talization

•  Performance deterioration

•  Behavioral problems

•  Emotional instability/ deterioration

•  Chronic health problems

“Well,it’s a delicate situation, sir. … Sophisticatedfiring system, hair-trigger mechanisms, and Bob’s wife just left him last night, so you know his head’s not into this.”

Symptoms of Stress

•  Physical•  Palpitations, pounding heart•  Tense muscles, tension headaches, soreness•  Dry mouth, grinding teeth•  Chest pains•  Indigestion, acid reflux, constipation, diarrhea,

appetite changes, nausea•  Weight change•  Back pain•  Hands and feet sweating (dishydrosis)•  Fatigue, sleep difficulties•  Decreased libido

Symptoms of Stress (cont’d)

•  Mental•  Forgetfulness, memory problems•  Indecision, poor prioritization•  Lack of concentration•  Difficulties in “switching off”

•  Emotional•  Loss of sense of humor•  Nervous, jittery, on edge•  Irritable, easily frustrated, short-tempered•  Apathetic, depressed, sad, tearful

Symptoms of Stress (cont’d)

•  Behavioral•  Fidgety, nail biting, knee jiggling•  Acting-out behaviors, aggressive•  Smoking, compulsive eating•  Talking loudly, swearing•  Alcohol abuse, drug usage•  Eating disorders•  Inappropriate concern over health•  Fear of flying

Some Diseases of the Stress Response

•  Hypertension•  Diabetes•  Peptic Ulcer, Irritable Bowel Syndrome•  Asthma•  Headaches•  Sleep Disorders•  Depressed immune function•  Coronary Artery Disease•  Death, etc.

1. Below-average Nugget or NewTransition Aviator

2. Overconfident Senior Aviator3. “Best Pilot/ Aviator/

Aircrewman”

4. Consistent Poor Performer5. Overstressed Aviator

“At Risk” Aviators

Failed or Absent Defenses

Organizational Factors

Inputs

Unsafe Supervision

Preconditions for

Unsafe Acts

Unsafe Acts

Adapted from Reason (1990)

Accident & Injury

Reason’s “Swiss-cheese” Model of Human Error

Overstressed Aviator •  Key Characteristics

•  Major stressors, such as death of family member, divorce, failed relationship, financial setback, poor job performance

•  Noticeable change in mood or personality

•  Frequent, out-of-proportion anger, resentment, hostility

•  Distracted, mentally preoccupied, loss of focus.

•  Uncharacteristic breakdown of flight discipline or high risk-seeking behavior

•  Possible Interventions•  Command counseling •  Flight surgeon review •  Selective scheduling •  Close supervision and

monitoring •  Temporary grounding or

flight restrictions •  Reduce workload or stress •  Send to Family Services or

Stress Management clinics •  Refer to HFB

Stress Management

Coping With Stress

•  Recognize the problem•  As usual, self assessment is poor•  The sufferer is the last to recognize the problem

•  Eliminate as many stressors as possible:•  Eliminate alcohol, tobacco, caffeine•  Adequate sleep

•  “Let it out”?•  Meditation•  Get exercise•  Take time out, snivel•  Counseling, professional help

ASSASS Take Home Points: Stress

•  Stress is a psychological and physiological condition.•  Sources of stress can be external or internal.•  Stress has long-term detrimental effects on health•  Stress manifests itself as changes in emotional state

and/or overt behavior (performance).•  The nature and scope of psychological aspects of stress

are in-part culturally defined.•  Stress impacts personal relationships and work

environment.•  Stress can be managed.....to a point!

ASSASS Learning Objectives

•  DESCRIBE the science and physiology of sleepand stress, and their effects

•  DESCRIBE symptoms/signs of fatigue and stress•  DESCRIBE performance decrement from fatigue

and stress•  DISCUSS the prime causes of fatigue and stress•  DESCRIBE effects of circadian cycles in fatigue•  RECOGNIZE mishaps where fatigue or stress

may be a factor•  IDENTIFY key countermeasures for fatigue and

stress•  UNDERSTAND performance-maintenance

pharmaceuticals

•  8.3.2.9 – Emotional Upset:Ø “COs must remain alert to the

emotional & physical status of personnel and take corrective action…”

NATOPS, Ch. 8

•Questions???

QUESTIONS???

ASSASS Aeromedical

•  Feedback or questions, please!•  Take critiques seriously!•  Email, call any time

CAPT Jack “Bags” Wyland Command Flight Surgeon, School of Aviation Safety

[email protected] (850) 452-5140; DSN 459-

Room 161C

TEAMWORK

TEAMWORK

C-050-1503

1

Terminal Objective

•  Upon completion of this unit ofinstruction, the student willdemonstrate knowledge of teams,team developmental stages, teamleadership, and associated teamperformance and maintenancetechniques

2

Enabling Objectives

•  Conduct teamwork instruction, in a classroomsetting, in accordance with Crew ResourceManagement Instructor Course LectureOutline.

•  Define team, in a classroom setting, inaccordance with Crew ResourceManagement Instructor Course LectureOutline.

•  Identify team developmental stages, in aclassroom setting, in accordance with CrewResource Management Instructor CourseLecture Outline.

3

Enabling Objectives

•  Describe the relationship between teamworkand leadership, in a classroom setting, inaccordance with Crew ResourceManagement Instructor Course LectureOutline.

•  Describe team performance strategies andmaintenance strategies, in a classroomsetting, in accordance with Crew ResourceManagement Instructor Course LectureOutline.

4

Teamwork Exercise

•  Put all the facts together to solve themystery.

•  Find the MURDERER, WEAPON,TIME, and PLACE.

•  Organize yourselves as you want(Group Leader etc.).

•  You cannot write anything down,pass clues around or show them toanyone else, or walk around theroom.

5

How do “Teams” differ from “Groups?”

•  Attitudes•  Shared mental models•  Interdependence•  Level of performance

Teamwork

6

Level of Performance

HIGHER

7

Interdependence

•  The crew’s success depends oneach member knowing andexecuting his/her job in anaccurate and timely manner.

8

•  Great minds thinking alike

Shared Mental Models

9

What is a “TEAM” ?

A group of people working together to a common purpose

Group of people (2 or more) working together: Teams need to consider the handling of people within the team, of communicating, of keeping people together, of motivating them, so... ALL teams have people (teamwork) aspects.

To a common purpose (goal): Suggests clarity of goals, responsibilities, and objectives, with everyone involved committed to successful completion of task. ALL teams have task aspects.

10

Groups go through Phases...

•  Groups which form around “tasks”go through definite stages duringtheir life.

•  These stages help define the role of thegroup, determine if the group will formfurther into a ““Team.””

•  Sets standards, expectations,roles, leaders, etc., for the group.

11

Team Formation Stages

1. Forming

2. Storming

3. Norming

4. Performing

5. Adjourning

12

(FSNPA) Forming:

The first stage includes all of the discomfort found in any new situation in which one’s ego is involved in new relationships. This initial stage is one of caution.

13

(FSNPA) Storming:

As individuals react to the demands of what has to de done, they become more comfortable with other members and become more themselves.

(Prior to this point persons may “present” themselves differently than they normally act.)

14

(FSNPA) Norming:

Now, the rules of behavior appropriate and necessary for the team to accomplish tasks are spelled out both implicitly and explicitly, and a greater degree of order begins to prevail.

15

(FSNPA) Performing:

Energies focus on the task(s), having worked through issues of membership, orientation, leadership, and roles. The team is now free to develop working alternatives to the problems confronting it.

16

(FSNPA) Adjourning:

Finally, with the task nearing completion, the team moves to what is called the adjourning period, in which closure to the task and a changing of relationships is anticipated.

17

Advantages/Disadvantages

Advantages:

•  Sharing of Information and ideas

•  Mutual Performancemonitoring

•  Improved learning anddecision making

•  Synergy

•  Overcome individualbiases

Disadvantages:

•  Stifling of Individuality

• Cost in time and effort to build a team

• Decision making difficulties

• Group pressure

• Involves more complexcommunications

18

Effective Teamwork Includes

•  Behaviors such as mutualperformance monitoring

•  Intra-team communication and feedback

•  A willingness to both criticize and acceptcriticism constructively

19

What Impact will Leadership Style have on a Team?

Rank Gradient

Tailoring

Leadership

20

Team Performance Strategies

•  Set the tone•  Define and brief objectives•  Communicate•  Implement•  Monitor/Review

21

Set the Tone

•  Use good briefing techniques to set thetone for the crew.

•  Stress the crew’s importance to themission of the Detachment/ Squadron/Wing/Organization.

•  Examine individual values and differentviewpoints, skills, abilities.

•  Ensure that everyone knows why they, inparticular, are part of the crew.

22

Define and Brief Objectives

•  Clearly define objectives•  Prioritize goals:

Must have Nice to have

•  Map out course of action•  Be innovative•  Keep the big picture

23

Communicate

•  Strive for structure and schedule, butmaintain flexibility

•  Keep all team members informed•  Solicit inputs / keep lines of

communication open

24

Implement

•  Execution

•  Meet agreed targets

•  Communicate results of actions

25

Monitor/Review

•  Conduct performance reviews

•  Search for possible improvements

26

Team Maintenance Strategies

•  Involvement

•  Attitudes

•  Conflict Management

27

Involvement

•  Stay involved at the appropriatelevel

•  Clear obstacles for the team•  Anticipate and prevent problems

whenever possible•  Neither over-react nor under-react•  When in doubt as to what the team

needs or wants…ask

28

Attitudes

•  Keep your team members freshbut focused

•  Reward performance

•  Respect individuality

29

Conflict Management

•  2 Types of Conflict:

Operational

Personal

30

Operational Conflict

•  Safety

•  Reliability

•  Legality

31

Personal Conflict

•  Interpersonal

•  Coordination

32

Conflict Management

•  Stress a “Crew/Mission first” attitude•  Recognize the difference between

healthy disagreement and disruptivefeuding

•  When well-managed, conflict can behighly constructive – especially inproblem solving situations

33

Conflict Management

•  It is each crew member’sresponsibility to manage conflict.

•  Disagreements focus on issues,not personalities.

34

Summary

35

Summary

•  Teamwork, why it’s importantand vital for effective CRM

•  Higher level of performance•  FSNPA (stages of teamwork)•  Leadership and it’s role•  Conflict management

36

Questions?

37

INSTRUCTIONAL TECHNIQUES & FACILITATION

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1

INSTRUCTIONAL TECHNIQUES & FACILITATION

Lesson 3.2

C-050-1503A PPT 5001 01 2

Terminal Objective

CONDUCT CRM Instruction, in a classroom setting, in accordance with Instruction, Crew Resource Management Program, CNAF 1542.7 (series)

3

Enabling Objective

•  Implement CRM ground traininginstructional techniques.

•  Explain the basic process of lecturepreparation.

•  State the aspects of classroominteraction.

•  Explain techniques of effectiveinformation presentation.

•  State techniques for dealing withadverse conditions.

4

Instructional Techniques

5

ADULTS #1

FEARPublic Speaking

6

1960 Presidential Debate

7

Principles of Communication

•  Desire to communicate•  Believe in what you say•  Know your subject•  Know your audience•  Deliver with enthusiasm•  Rehearse, Rehearse, Rehearse

8

Communicating the Message

•  7% Verbal Content

•  55% Visual Stimulation

•  38% Tone of Voice

9

Developing Presentations

10

"It takes 3 weeks for me to prepare an impromptu speech."

--Mark Twain

11

Presentation Development

3 basic questions for presentation development

•  Audience - Who am I teaching?•  Material - What do they need to know?•  Instructor - How am I going to present it?

12

Audience Analysis

•  Motivation

•  Interest

•  Familiarity

•  Capability

13

Material

•  Read references

•  Talk to the experts – SME’s

•  Of course, just Google it!

14

Intro. 20%

Body 70%

Summary 10%

Building the Presentation

15

Introduction

Facts Quotes

Joke Video

True Story Current Events

Why should your audience listen?

16

Familiarity

•  Spaces

•  Equipment

17

"Being able to start is more than half the whole."

--Aristotle

Have Your Opening Nailed

18

Visualize Your Success

19

Reduced to it's most Basic form...

You’re only talking... You do that everyday!!!

20

BODY

•  The “MEAT”

•  Built on main points or a premise

•  Supporting Analogies, Images, References

•  5WH – who, what, where, when, why, how

21

"You can't just end it"

Summary

RECAP REVIEW REINFORCE

DO

DON’T NEW INFORMATION

22

Presentation Techniques

•  Complete Memorization

•  Partial Memorization

•  ApproximateMemorization

23

A P P R O X I

M A T E

M E M O R I Z A T I O N

Stealth fighter

24

Notes

•  Use printed PowerPoint note slides ifneeded to refresh your memory

•  There is no substitute forrehearsal!

25

Visuals

•  Simple

•  Readable

•  Accurate

““A picture is worth 1000 words, but 1000 items in one

picture is worth nothing.”” 26

27

Video

•  Great to illustrate a point•  Great attention-getter•  Great at getting people stimulated

•  A GREAT DOUBLE-EDGEDSWORD!!

28

Delivering Presentations

ENTERTAINING IS EFFECTIVE

but….

IT IS NOT REQUIRED

29

NEVER APOLOGIZE !

Your audience will be very distracted and

few people can rejuvenate an atmosphere littered with

self-proclaimed weakness

30

Body Language

•  The Hands

•  Props

•  Movement /Eye Contact

All amount to the audience’s initial

assessment of you, and their continued re-assessment of what you're saying

31

Hands Humor

32

Use of the Voice

•  Quality

•  Intelligently

•  Variety

33

Instructional Challenges

• Classroom distractions

• Questioning technique

• Terminal nervousness

34

Dealing With Distractions

Dealing with Special People

Audience Analysis

•  Continuous

•  Eye-Contact

•  Movement

35

Dealing With Distractions

# 1 - Ignore or Dismiss

# 2 - Subtle Confrontation Get Physically Close Make Eye Contact

SAY "STOP!"

Redirect your attention towards the audience

36

Definition of Facilitation

Facilitation is the design and management of structures and processes that help a group do its work and minimize the common problems people have working together.

37

Facilitation Objectives

•  A process management•  How you do something •  Minimizing problems of people working in groups

•  It’s asking a question•  It’s about guiding a group from a problem to a

solution•  Not entirely about content•  Remain neutral

•  Detach oneself from and relinquish control of the group’s work

38

Facilitation Fundamentals

•  Be engaged•  Maintain good eye contact•  Stay focused on the process•  Be a facilitator, not a performer•  Encourage everyone to participate•  Interpret verbal and nonverbal

behavior•  Manage differences

39

Be Yourself

•  Be comfortable

•  Show your personality

•  Model the behavior you wantyour students to exemplify

40

Evaluator Vs. Facilitator

Evaluator •  Evaluates performance“You were ten knots fast, 50’ high, 5 degrees off”

•  Lectures (passive / one way)

“You need to improve your landings”

•  One size fits all

Facilitator • Promotes self-evaluation “How do you think it went? Tell me what you were thinking at this point?”

• Encourages reflection and self improvement (active/interactive) “How can we improve your landings?”

• Adapt for individual student needs

41

Review

•  Good Vs. Bad instructional technique•  Public speaking•  Communication•  Presentation development techniques•  Instructional challenges•  Facilitation as a method of teaching

42

Questions?

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