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Crew Resource Management CRM • Done out of a need to avoid pilot or crew error • Done to break the chain of poor decisions – Aeronautical Decision Making (ADM) FAA Document ac60-22.pdf • Four out of five crashes due to pilot error have a root cause that starts well before the aircraft is airborne • Errors of omission, errors of commission

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Page 1: Crew resource

Crew Resource ManagementCRM

• Done out of a need to avoid pilot or crew error

• Done to break the chain of poor decisions– Aeronautical Decision Making (ADM)– FAA Document ac60-22.pdf

• Four out of five crashes due to pilot error have a root cause that starts well before the aircraft is airborne

• Errors of omission, errors of commission

Page 2: Crew resource

CRM Origin

• As Aviation Progressed, Hardware Became More Reliable

• Environment Became More Demanding

• Higher Demands Required Better Decision Making By Pilots

• The Human Factor Became The Weak Link

Page 3: Crew resource

Air Florida Flight 90

• January 13, 1982, Washington DC• Boeing 737-200 crashed immediately

after take-off en route to Florida• Aircraft failed to develop T/O power• Struck 14th street bridge and 7

occupied vehicles on it• Killed 4 people on bridge and 73 in

aircraft• Aircraft submerged in freezing cold

Potomac river• What was the chain of events that

lead to the crash?

Page 4: Crew resource

Air Florida Flight 90• January 13, 1982 was a bitter winter's day at Washington's National Airport

with temperatures reaching only minus five degrees Celsius by the afternoon. • Cloud ceilings were 400ft with visibility limited to just over half a mile in snow

showers. • Among the many aircraft scheduled to depart National that day was Air

Florida's 737 service to Ft. Lauderdale, call sign Palm 90. • Piloting that day's 2:15pm flight was Captain Larry Wheaton and First Officer

Roger Pettit, both fairly young pilots enjoying their new jobs with Air Florida, a fairly new airline which expanded rapidly as the result of deregulation.

• ......Just before 1:40pm, the airport was closed so crews could plow National's one instrument runway, scheduled to re-open at 2:30pm.

• Air Florida elected to begin boarding regardless and by 2:30pm, all of the 74 passengers were on board the aircraft.

• Meanwhile, Wheaton had asked for Palm 90 to be de-iced in preparation for departure.

• The tower told the aircraft that there would be a further delay and that Palm 90 was number eleven in priority when the airport did re-open.

• Wheaton then instructed the de-icing to be discontinued• Half an hour later, Wheaton again called for de-icing as the airport was about

to re-open. • By 3:10pm, de-icing was complete and ground personnel reported to

Wheaton that there was only a "light dusting" or snow on the wings. • Snow was still falling at National at the time. At 3:23pm, Palm 90 was cleared

to push from the gate. • The tug tried to push the 737, but snow that had accumulated on the ground

caused it's tires to spin. • Wheaton then suggested that, contrary to policy, they would use the

aircraft's reverse thrust to assist in the push.

http://pw2.netcom.com/~asapilot/

Page 5: Crew resource

Air Florida Flight 90• The reversers were engaged for about a minute and a half, but

were only successful in throwing up slush and snow. • Another tug was brought in with chains and the aircraft was

successfully pushed back.• ......Palm 90 then taxied into position behind a New York Air DC-9

which was the last of sixteen aircraft in line for takeoff. • Fifteen minutes later the New York Air aircraft was cleared for

takeoff and Palm 90 was instructed to taxi into position and hold, being prepared for immediate takeoff.

• At 3:59pm, Palm 90 was cleared for takeoff as it was still positioning itself on the runway, visibility now down to a quarter mile.

• ......The departure from runway 36 requires aircraft to make a left 40 degree turn shortly after becoming airborne so as to follow the Potomac River and avoid flying over the Washington monument and the White House.

• The tower lost sight of Palm 90 during it's roll due to the reduced visibility, but radar showed it airborne and the tower controller instructed Palm 90 to contact the departure controller.

• Less than a minute after taking off, Palm 90 descended at low airspeed into the Rochambeau bridge and plowed through into the Potomac river, only it's tail not submerged.

• Rescue crews attempted to reach the survivors, but icy conditions prevented the passengers from being reached except by helicopter. In the end, only six people survived.

http://pw2.netcom.com/~asapilot/

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Page 7: Crew resource

Air Florida Flight 90• ......Crews were able to recover both the FDR and CVR from the bottom

of the river and both devices proved critical in solving the puzzle of Palm 90.

• Knowing that it had been nearly 50 minutes between the aircraft's de-icing and takeoff, investigators were curious as to what had gone on in the aircraft in that span.

• Their first clue came when, during the after engine start checklist, the captain replied "off" to the First Officer's call for anti-ice.

• Though it seems hard to believe that the captain would reply "off" to anti-ice, extensive audio enhancement has given validity to the tape.

• While waiting in line for takeoff, Wheaton positioned the aircraft behind the New York Air DC-9, attempting to use the aircraft's exhaust to melt the ice off Palm 90's fuselage and wings.

• Though Wheaton thought this a sound practice, in reality the exhaust will just melt the ice and blow it back over the wing, allowing it to re-freeze farther back in areas which the aircraft's anti-ice system can not clear.

• While this information gave evidence of airframe icing, further analysis showed other problems with Palm 90.

• Shortly before takeoff, the crew have a brief discussion concerning anomalies in the engine instrument readings.

• Pettit suggested that the hot (less dense) exhaust from the DC-9 ahead was causing a lower than normal reading on one of the EPR gauges.

• The indications seemed to return to near normal as Palm 90 got closer to takeoff.

• Just before takeoff, Pettit began the brief, calling out takeoff power as EPR 2.04, V1 as 138kts, Vr as 140kts, and V2 as 144kts.

http://pw2.netcom.com/~asapilot/

Page 8: Crew resource

Air Florida Flight 90• As Palm 90 was cleared for takeoff, Pettit advanced the throttle and

immediately remarked at the abnormal indications from the EPR gauges again. • Pettit remarked several time that it was "real cold", indicating that the engines

indicated the takeoff EPR of 2.04 quickly before the throttles were fully advanced.

• Specturm analysis of the engine sounds from the CVR indicated that the engines were actually running at an approximate EPR of 1.70 throughout the takeoff.

• In studying the engines for signs of the anomaly, investigators found that the engine de-ice system was turned off.

• In re-creating the conditions, investigators confirmed that ice on the compressor inlet pressure probe would cause a higher than actual thrust reading on the EPR gauges.

• First Officer Pettit seemed to be aware of the anomaly during takeoff, but did not appear to have any idea what was causing it.

• Pettit remarked several times that "that doesn't seem right", meaning that the low throttle setting was producing a high EPR reading while the aircraft was not accelerating properly.

• Still, 45 seconds into the takeoff roll, Palm 90 reached it's rotation speed and pitched up abruptly, causing Captain Wheaton to exclaim "Easy!" and then, as the stall warning came on, "Forward! Forward!", indicating to Pettit to lower the nose to prevent the stall.

• Investigators found that ice build up in the wing leading edge and slats could cause an abrupt nose up pitch on takeoff.

• Pettit apparently believed that the engines were producing max thrust because at no time during the 30 second flight were the throttles advanced to provide more power to prevent stall.

• The recording ended with the crew's final acknowledgement of the severity of their situation. "Larry-we're going down Larry!". "I know it!".

http://pw2.netcom.com/~asapilot/

Page 9: Crew resource

Air Florida Flight 90• CAM-1 Captain's Cockpit Area Microphone CAM-2 First Officer's Cockpit Area Microphone

RDO-1 Captain's Radio TWR Washington National Tower • 15:59:16 CAM-1 Given. • 15:59:16 CAM-2 Bleeds? • 15:59:17 CAM-1 They're off. • 15:59:18 CAM-2 Strobes, external lights. • 15:59:18 CAM-1 On. • 15:59:19 CAM-2 Anti-skid? • 15:59:19 CAM-1 On. • 15:59:21 CAM-2 Transponder? • 15:59:21 CAM-1 On. • 15:59:24 TWR Palm 90 cleared for takeoff. • 15:59:28 TWR No delay on departure if you will, traffic's two and a half out for the runway. • 15:59:32 CAM-1 Okay, your throttles. • 15:59:35 [SOUND OF ENGINE SPOOLUP] • 15:59:49 CAM-1 Holler if you need the wipers. • 15:59:51 CAM-1 It's spooled. Real cold, real cold. • 15:59:58 CAM-2 God, look at that thing. That don't seem right, does it? Uh, that's not right. • 16:00:09 CAM-1 Yes it is, there's eighty. • 16:00:10 CAM-2 Naw, I don't think that's right. Ah, maybe it is. • 16:00:21 CAM-1 Hundred and twenty. • 16:00:23 CAM-2 I don't know • 16:00:31 CAM-1 Vee-one. Easy, vee-two. • 16:00:39 [SOUND OF STICKSHAKER STARTS AND CONTINUES UNTIL IMPACT] • 16:00:41 TWR Palm 90 contact departure control. • 16:00:45 CAM-1 Forward, forward, easy. We only want five hundred. • 16:00:48 CAM-1 Come on forward....forward, just barely climb. • 16:00:59 CAM-1 Stalling, we're falling! • 16:01:00 CAM-2 Larry, we're going down, Larry.... • 16:01:01 CAM-1 I know it. • 16:01:01 [SOUND OF IMPACT]

http://pw2.netcom.com/~asapilot/

Page 10: Crew resource

Crew Resource ManagementIssues on Flight 90

• Decision on de-icing

• Pressure to get mission accomplished

• Non SOP use of TR

• Using DC-9 for De-Icing

• Incorrect EPR reading– No cross check with fuel flow– OK to overboost engines for one minute

• Captain not heeding signals from FO

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What is CRM?

• Situational Awareness

• Judgment• Expect Unexpected• Attitude (Professional)• Knowledge

• Lack of Situational Awareness

• Complacency• Poor Mindset• Lack of Knowledge• Bad Attitude• Fatigue

CRM is a Tool for Error & Risk Management

YES NO

Source: CAP CRM

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CRM Skills

• Manage (use) resources

• Ask the right questions - Inquiry

• State your opinion - Advocacy

• Resolve differences - Conflict Resolution

• Make Decisions

• Evaluate Constructively - Critique

Source: CAP CRM

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Defining CRM

• Effective use of all available resources

• Broad resource categories– People– Machinery– Fuel/time– Information

• CRM is not limited to multi-pilot crews

Source: CAP CRM

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Situation Awareness• Knowledge of all pertinent aspects of your surroundings as it applies to the safe accomplishment

of a task.• Elements of Situational Awareness

– Weather, Aircraft Condition and Capabilities– Mission Goals or Objectives– Airspace, Terrain, Traffic– Crew Tasking

• Perception Versus Reality– View of Situation – Incoming information – Expectations & Biases – Incoming Information versus Expectations

• Factors That Reduce Situational Awareness– Insufficient Communication – Fatigue / Stress – Task Overload – Task Underload – Group Mindset – "Press on Regardless" Philosophy – Degraded Operating Conditions

• Levels of SA– Level 1: The ability to Perceive and recall from memory– Level 2: The ability to comprehend– The ability to project future outcomes

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Workload Affects SA

• Humans are essentially single channel information processors

• Searchlight metaphor– focus of attention

• Resource metaphor– divisibility of attention– supply and demand of attentional resources

• single resource theory vs. multiple resource theory

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Attentional Resources

Page 17: Crew resource

SART (10D)

0 1 2 3 4 5 6 7

DEMAND ON Low High

ATTENTIONAL 0 1 2 3 4 5 6 7

RESOURCES Low High

(D) 0 1 2 3 4 5 6 7

Low High

0 1 2 3 4 5 6 7

Low High

SUPPLY OF 0 1 2 3 4 5 6 7

ATTENTIONAL Low High

RESOURCES 0 1 2 3 4 5 6 7

(S) Low High

0 1 2 3 4 5 6 7

Low High

0 1 2 3 4 5 6 7

Low High

UNDERSTANDING 0 1 2 3 4 5 6 7

(U) Low High

0 1 2 3 4 5 6 7

Low High

Instability of SituationHow changeable were the situations and environmental factors encountered in this run?

Variability of SituationWere many elements changing at any one time with large number of dynamic variables?

Complexity of Situation

How complicated were the situations in this run ?

Arousal

What was the level of stimulation in this run?

Spare Mental Capacity

How much mental capacity did you have to spare in this run?

ConcentrationHow much could you concentrate your attention on the important tasks?

How much useful information were you able to obtain from all available sources in this run?

FamiliarityHow familiar were you with the different elements and events in this run?

Division of AttentionWere you able to divide your attention between several relevant sources?

Information Quality

How good was the information you obtained in this run?

1. Situational Awareness Assessment - SART (SA = U - D - S)Rate each workload subscale

Information Quantity

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Mental Workload Measurement

• Criteria for a good workload metric– Sensitive

– Selective• Method should not consider extraneous

load

– Interference free

– Reliable

– Acceptable

Page 19: Crew resource

Mental Workload Measurement

• Workload Metric Categories– Primary task measures

– Secondary task measures

– Physiological measures

– Subjective Measures

Page 20: Crew resource

Mental Workload Measurement

• Primary task measures– Measure performance with which a

task can be performed• W/INDEX program

– Problem• As long as resources are available two

tasks may yield the same performance but be different in their workload

• Task specific

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Mental Workload Measurement

• Subjective Measures–Modified Cooper Harper Scale

–Subjective Workload Assessment Technique (SWAT)

–NASA-TLX (Task Load Index)

Page 22: Crew resource

Original Cooper Harper Scale on Aircraft Controllability

Page 23: Crew resource

NASA Task Loading Index Technique

• Multi-dimensional subjective rating procedure – provides overall workload score based on the sum of the

weighted values of six sub-scales: • Demands imposed by task

– Mental demand– Physical demands– Temporal demands

• Subject-Task Interaction– Own performance– Effort– Frustration.

• Subscale ranges from 0 to 100, scored in steps of 5 points– Marking a line– Workload of a particular task is expressed by the weighting

applied to each subscale• Pair-wise comparisons of the six subscales• The weights can range from 0 (all other subscales are more

important) to 5 (no other subscale is more important).

Page 24: Crew resource

TLX In-Flight Debrief Card

Mental Demand 0 1 2 3 4 5 6 7 8 9 10(mental + perceptual activity)

Physical Demand 0 1 2 3 4 5 6 7 8 9 10(activate levers, knobs, aircraft control) Low High

Temporal Demand 0 1 2 3 4 5 6 7 8 9 10(time pressure, pace of tasks) Low High

Performance 0 1 2 3 4 5 6 7 8 9 10(success of performing task)

Effort 0 1 2 3 4 5 6 7 8 9 10(combined mental and physical workload) Low High

Frustration 0 1 2 3 4 5 6 7 8 9 10(level of stress and annoyance) Low High

ability to judge aircraft clearance 0 1 2 3 4 5 6 7 8 9 10 with respect to terrain

ability to judge path/route clearance 0 1 2 3 4 5 6 7 8 9 10 with respect to terrain

ease of comprehending guidance cues 0 1 2 3 4 5 6 7 8 9 10

level of comfort of flying this (these) 0 1 2 3 4 5 6 7 8 9 10 display(s) in this terrain

desirability of this (these) display(s) 0 1 2 3 4 5 6 7 8 9 10

Describe features you particularly liked and disliked.

If anything, what would you change is this (these) display format(s) ?.

Were you comfortable flying the pathway (or FD in conventional config.)?

Please state any remarks, suggestions, opinions, critiques.

1. Workload AssessmentIn Flight Debriefing Card

Worse Same Better

Worse Same Better

3. Open Ended Questions and CommentsDescribe in your own words and to the degree of detail you see fit

Worse Same Better

Worse Same Better

Worse Same Better

Rate each workload subscale

2. Comparison with BaselineRate each question with regard to the conventional 757 displays

Compared to the Boeing 757 baseline condition, how do you rate the

Poor Good

Low High

Page 25: Crew resource

• TLX can be used to project workload based on task analysis

• Normal use of TLX is on operational system or prototype• Rater must be familiar with task• Rater must have very detailed knowledge of scale

– Requires a lot of training and calibration time

• Advantages– easy to use– more sensitive than many other subjective methods such as SWAT and

Cooper-Harper– use of six subscales is important to reduce inter rater variability

• Disadvantages – Time intensive– Disruptive

NASA Task Loading Index Technique

Page 26: Crew resource

Evaluating Risk in the Flight Environment

• The Plane- Type, Equipment, Etc.• The Pilot- FAA I’M SAFE Model

– Illness, Medication, Stress, Alcohol, Fatigue, Experience

• The Environment- IFR,VFR, Mountains,• The Situation- Day, Night, AC Maint, Etc..

Source: CAP CRM

Page 27: Crew resource

High Risk Situations

• Taking Off with Known Problem

• Midair Collision- High Density Area

• Inadequate Terrain Separation- CFIT

• Unstabilized Approach

• Deviation From SOP

• Weather

• COMPLACENCY

Source: CAP CRM

Page 28: Crew resource

Communication Factors

• Bias / Prejudice• Relationship• Choice of words• Perceptions• Preoccupation• Intimidation• Body Language• Habits• Motivation

• Attitude• Education• Background• Assumptions• Fear• Mind Sets• Ego• Voice Tone• Inflection• Clarity

Source: CAP CRM

Page 29: Crew resource

Communication

• Modes of communication– Verbal (7%)– Non-Verbal (38%)– Symbolic (55%)

• Communication Process (Four elements)• Sender• Message• Receiver• Feedback

Source: CAP CRM

Page 30: Crew resource

How to Communicate

• Questions to Consider– “What do they know that I need to know?”– “What do I know that they need to know?”– “What do none of us know that we need to know?”

• State Position• Suggest Solution• Be Persistent• Timely• Listen Carefully• Keep an Open Mind• Use a Predetermined “Key Phrase” To Express Non-

Confrontational Discomfort With Any Situation

Source: CAP CRM

Page 31: Crew resource

Pilot Personalities

• The MACHO Pilot

• The Impulsive Pilot

• The Invulnerable Pilot

• The “Antiauthority” Pilot

• The Resigned Pilot

Source: CAP CRM

Page 32: Crew resource

Attitude Vs Antidote

Source: CAP CRM

Page 33: Crew resource

Behavioral Styles

• Aggressive– High task oriented & low relationship oriented– First consideration to the task or goal

• Relationship Oriented– First consideration to the feeling of others– Caring or nurturing style of behavior

• Combinations– Low relationship & low task oriented traits– Considered to be loners or autonomous in behavior

Source: CAP CRM

Page 34: Crew resource

In the Cockpit

• As a crew member, you have the right to assure that your life will not be compromised by any action/inaction, miscommunication, or misunderstanding.

• Assertive behavior in the cockpit does not challenge authority; it clarifies position, understanding or intent, and as a result enhances the safe operation of the flight.

Source: CAP CRM

Page 35: Crew resource

Human Problem Solving

• Humans Solve Problems Three Different Ways– Skills-based actions

• accomplished will little effort• dependant on mastery of basic skills

– Rules-based actions• well prescribed procedures• crew reaction to an emergency situation

– Knowledge-based actions• ambiguous situation• no clearly proscribed procedures• offers a variety of options

Source: CAP CRM

Page 36: Crew resource

Decision Making

• Begins with Good Situational Awareness• Evaluate Situation

– What needs to be corrected?– What resources do you have?– How can the resources be best used?

• Consider consequences of possible actions• Make decision, inform all involved• Evaluate decision, repeat as needed

You make the wrong decision once, you make the right decision forever

Source: CAP CRM

Page 37: Crew resource

Operational Pitfalls to Sound Decision Making