epub lecture outline june 2013

8/10/2019 EPUB Lecture Outline JUNE 2013

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Crew Resource Management

Lecture Outline

NAVAVSCOLSCOM

CRM Director

181 Chambers Ave, Suite C

Pensacola, FL 32508-5221

850-452-2088 DSN 459

2013


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COURSE OVERVIEW


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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 daysuspension / 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 wh ile operating a Cell Phone w /o Hands-Free device / IllegalHandicap Parking / Failure to use s eatbelt:

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 fo r 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


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Maps

BOQ

GalleyO Club

Portside

Naval Aviation

Museum

Starbucks

Aviation Plaza

Privileged

FOR OFFICIAL USE ONLYTHIS IS A PRIVILEGED, LIMITED-USE, LIMITED-

DISTRIBUTION, SAFETY INVESTIGATIONREPORT. UNAUTHORIZED DISCLOSURE OF THEINFORMATION IN THIS REPORT OR ITSSUPPORTING ENCLOSURES BY MILITARYPERSONNEL IS A CRIMINAL OFFENSEPUNISHABLE UNDER ARTICLE 92, UNIFORMCODE OF MILITARY JUSTICE. UNAUTHORIZEDDISCLOSURE OF THE INFORMATION IN THISREPORT OR ITS SUPPORTING ENCLOSURES BYCIVILIAN PERSONNEL WILL SUBJECT THEM TODISCIPLINARY ACTION UNDER CIVILIANPERSONNEL INSTRUCTION 752. THIS REPORTMAY NOT BE RELEASED, IN WHOLE OR IN PART,EXCEPT BY THE COMMANDER, NAVAL SAFETYCENTER.

Questions on admin?

LCDR Brendan T. OBrien

CRM Director

CRM Instructional Model Manager

CRM

for

Instructors

CRM

To EDUCATE aviation officers at all levels to:Identify hazards

Manage risks

Investigate and report mishaps

Develop and administer command safety programs

ASC - ASO - CRM

To foster and conduct safety-related research, and

provide assistance in support of the Naval Aviation

Safety ProgramThereby,

Enhancing Combat Readiness

through the Preservation of Human and Material Assets

School of Aviation Safety

Mission


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CRM-I course

4 days

Twice a monthMobile Training Team

4 times per year

Fleet concentration area

Assist Visits 30-40 per year)

FRS/Wing Program Manager

All T/M/S platforms (over 45)

Program Manager Conference

Conference Attendances

Fleet Support

CRM

Instructional Model ManagerWhat is CRM?

YOU(7 skills)

Ability to use allavailable

resources

in order toaccomplish 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 miss ion is WARFIGHTING.

Knowledge

Tools Guidance

And enable you to take this to the fleet

Purpose Of The

CRM Instructors Course


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YOURPARTICIPATION

IS THE KEY

Why?...

CP

R

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.

CE S

Class Introductions

Administration

Syllabus Overview

Course Format

Classroom Participation Responsibilities

Course Evaluation

STUDENT/STAFF INTROS

(name, a/c, command)


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HISTORY


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HISTORY OF CRM

C-050-1503A5001 01

Terminal Objectives

Identify what drove the development of

CRM

Define and Understand some of the

errors 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 in

Commercial Aviation

Discuss the growth and evolution ofCRM research in private and military

sectors 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 andMarine Corps

Challenges

Future

Purpose of CRM

Summary


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Tenerife Background

A runway collision involving two 747s

583 fatal injuries, the most ever in any

single 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: HollandInternational

- Captain: Jacob vanZanten (Chief Pilot)

Faceof KLM

- 11,700 hrs

A Tale of Two 747s

PAA Flight 1736

- 378 Passengers

- 16 Crew- From Los Angeles via

NY

- Captain: VictorGrubbs

- 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 follow3rdtaxiway?

RVR 500m with 700 required


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Greater emphasis on English as international language ofaviation

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

Requirement for precise read-back instructions (no OKor roger)

Phrase "take-off" is only spoken when the actual take-offclearance is given (e.g. departure)

Development of Crew Resource Management theory

Safety ResponseCommercial

CRM 1977 - Current

1977 Interviews with commercial

airline pilots reveal dissatisfaction withtraining in non-technical skills

1979 NASA workshop: ResourceManagement on the Flight Deck

- H/E major cause of accidents

1981 United Airlines DC-8 CRM /Simulator (1stgeneration of CRM)

1993 Delta Chain of Events/modular training (2ndgeneration)

1995 3rdand 4thGenerations of CRM

1997 Continental Threat and ErrorManagement (5thgeneration)

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 onCommunication, Leadership, Situational Awareness, and CrewCoordination is just as appropriate, with some modification, topilots manning a flight of single seat tactical aircraft as it is tothe pilots, Flight Engineers, and Loadmasters operating a C 5transport aircraft".

Differences between civilian and militaryaircrews:

CIV MIL Age OLDER YOUNGER Experience MORE LESS

Rank TENURE UCMJ

Mission Objec ti ves TRANSPORT NUMEROUS

Mission Requirements BENIGN HOSTILE

Crew Duties SERVICE TACTICAL Centralized training FAA PLATFORM

CRM 1987 - 1989

1987 Contract to modify civilian CRM courses forNavy (Allen Corp.)

1989 CRM introduced to Naval Aviation Slow to accept due to one size fits allapproach

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 findi ngs:CRM must be systematically incorporated

into all phases of cr ew training(i.e., initialqualification, transition, upgrade, recurrent).

Must train the specific coordi nation skillsand behaviors required by aircraft type,

aircraft model, phase of flight, and overall

mission (e.g., transport, cargo) utilizing theSeven Skill areas. The Navys CRM

program would be c alled Aircrew

Coordination Training (ACT).


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CRM 1990 - 1995

1993 Navy implements Fam/InterimACTprogram, 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 forall 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 changedACT 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 BaseNot reinventing the wheel

For Aircrew by Aircrew who better?

Emphasizes Evaluation and ValidationRealistic opportunity to learn

Mission Specific H-46 F/A-18

Skill Based specific training objectives

Integrated taught from the beginningthroughout 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 expended

substantial resources in determining the

cause of mishaps

Information recovered from cockpit voice

recorders, 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 asany incidentinvolving crew pilot error which relates to

poor employment of aircrew coordination,

S/A, judgment, sub-optimal physiological

state, or a violation of NATOPS


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NHA Symposium. April 14-17 2008 31

Non-

HE

15%HE 85%

No. of Class A MishapsHuman 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%)

Aircr ew (breakdown in Crew Resou rceManagement, poor decision making, failure toproperly perform emergency procedures)

Supervisory (failure to provide adequateguidance and training)

Material/Systems Malfunction (16%)Material/component catastrophic failure (no

human error involved) NHA Symposium. April 14-17 2008 32

Non-

HE

6%

HE 94%



Non-

HE

9%

HE 91%USMC Aviation 52 of 57

USN/USMC, FY03-07

NSCData: 22 Feb 08

Human Error Past





human error involved)

NHA Symposium. April 14-17 2008 33

HE 85%




USN/USMC, FY05-09

NSC Data: 05 Oct 2010

Human Error Past





human error involved) NHA Symposium. April 14-17 2008 34

Non-

HE

27%HE 73%



Non-

HE

41%


USN/USMC, FY10-12

NSC Data: 13 Nov 2012

Human Error Today





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.


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IT IS:

A program to effect a positivebehavioralchange in individuals (as opposed to

attitude changes or management

theory) in order to prevent and/orminimize human factor and crew errors.

YOU own the program.

Summary

History

Commercial

Navy/MC

Challenges

Future

Your input and ownership

Questions?


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CRM

PROGRAM MANAGEMENT


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CRM Program Management

C-050-1503A

Terminal Objective

Maintain a CRM Program in an

operational 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 shallbe conducted in all Chief of Naval Air Training (CNATRA)

squadrons and at the Fleet Replacement Squadrons (FRS) prior tofirst flight andis 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.: Initialand recurrencyCRM training shallbe

conducted by a designated CRM instructor or facilitator

CNAFINST 1542.7; 6.c.: InitialT/M Specific Training. Shallbe conducted

by a designated CRM Instructor (CRMI)

Some squadrons may initially be short C RM instructors to ensure thisnew 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.


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Ann ual T/M Sp ecifi c Recu rri ng Trai nin g

OPNAVINST 1542.7C: Not specified.

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


CRM Instructor Training

OPNAVINST 1542.7C; e: Not specified.

CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructorcourse 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 C NAFINST. This was seen as a best practice and

not specifically required in OPNAVINST 1542.7 (series). However, it was arequirement 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,


CRMI,

Provides specific guidance for CRM training topics for CRMI and CRMFqualification 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 shallmaintain 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 CR M currencies as uniformed aviators. Ifthey are providing CRM initial ground training they are required to be

a CRMI. If they are only providing CRM recurrent groundtraining they

are required to be a CRMI or CRMF.

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


Unmanned Aircraft Systems


CNAFINST 1542.7; 6.j.: All UAS platforms shallconduct CRM training inaccordance 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

CurriculumModel Manager (CO)

Program ManagerCRM Instructors CRM Facilitators

CRM Director

Naval Safety Center


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CRM Fleet Organization

CRMInstructionalModel Manager

NSC

CRMDirectorSAS Divo

USNTacAirInst. Model Mgr.

CRM-I Instructor

T/M/S CurriculumModel Manager

FRS CO

T/M/S CurriculumModel Manager

FRS CO

T/M/S CurriculumProgram Manager

FRS Instructor

CRMInstructor CRMInstructor

CRMFacilitatorSquadron Level

CRMFacilitatorSquadron Level

USMCTacAirInst. Model Mgr.

CRM-I Instructor

Same Organization

USNProp /HeavyInst. Model Mgr.

CRM-I Instructor

Same Organization

USMCProp/HeavyInst. Model Mgr.

CRM-I Instructor

SameOrganization

USNHeloInst. Model Mgr.

CRM-I Instructor

SameOrganization

USMCHeloInst. Model Mgr.

CRM-I Instructor

SameOrganization

EnlistedInst. Model Mgr.

CRM-I Instructor

ControllingCustodian

ControllingCustodian

Designations

CRMFs are designated by their respective

Commanding Officers or Officers in Charge

as applicable they require endorsement

from the PM or CRMI

The PM and CRMIs are designated in

writing 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, andCRMF)

Ground Training (T/M/S)

Flight Evaluation (T/M/S)

Documentation

NATOPS Jacket

Slash 7

Instrument Check Paragraph on Command

Letterhead signed by theCommanding Officer

Annu al Fli ght CRMCheck/TrainingConducted CRM flightevaluation perCNAFINST 1542.7.

Note any CRMobservations

Proper flight code in thelogbook 2L3/2L4/2L5

Ensure the date matchesall 3 documents (Encl 3,slash 7, and logbook)

Conducted CRMfl ight evaluation per CNAFINST 1542.7.

Training

All CRM ground training contains the

following common elements:

CRM history

7 critical skills

CNAFINST 1542.7

T/M specific case study

Types of Training

Initial ground training: Covers what

someone new to the platform should know

regarding CRM issues within the

community

Annual recurrency t raining : Similar to

initial, but more focus on community

specific issues and personal experience

Squadron instructor training: Tailored to

suit the needs of CRM during student

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


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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, review

of community specific annual ground

training brief, and conduct grading of the

CRM flight evaluation

Types of Training (Cont.)

CRMI training: CRMI course graduate,program admin, facilitation and evaluation

techniques, review of community specificannual ground training brief, and conduct

grading of the CRM flight evaluation

Additional topics may be included by CMM

Remember this CRMI course is only one ofFIVErequirements to qualify (NATOPS

qualified; Designated by your CMM; CRMF;

and E5/03 and above)

Training Techniques

Teach facilitators, and students,platform specificcases that

demonstrate good and/or bad examples

of the seven skills and threat/error

management

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 have

anything to do with my platform?

H-53 SAR = H-60 SAR


Case studies should be crew position

specific

Include current equipment, especially

automation

Maintenance, operational, and

administrative impacts on CRM should

also be included


Personal examples are invaluable

Old case studies and training materials

indicate a stale CRM program

Case studies can be developed by usingSIRs, HAZREPS, ASAP, MFOQA,

personal experiences, the FAA, and the

IMMs


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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 your

T/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 evaluations

on enclosure (3) in NATOPS jacket, on

NATOPS/Instrument/Stan check

paperwork, and identified in the flight

logbook with the correct codes

Good CRM Programs (Cont.)

Developed CRM SOP

Tracking, scheduling, and monitoring ofqualifications

Have an effective number ofexperienced CRMI and CRMF

CRM incorporated into procedures

including NATOPS, briefs/debriefs,checklists, and FTI

Incorporates human error concepts and

Threat 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 to

the first flight and/or check-flight

evaluation:

T/M/S specific

Scenario intensive

CRM dedicated flight events, in a high

fidelity simulator if available, and evaluatecrew performance

Check-flight Grade Sheet

EVALUEE: _________________________________ OUTSTANDING _________ 3.5-4.0

EXCELLENT _________ 2.8-3.4

INSTRUCTOR: __________________________________ SATISFACTORY _________ 2.0-2.7

UNSATISFACTORY_________ 0.0-1.9

1. SituationalAwareness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

2.Assert ivness OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

3.DecisionMaking OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

4.Communicat ion OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

5.Leadership OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 16. Adaptability/Flexibility OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

7.MissionAnalysis OUTSTANDING EXCELLENT SATISFACTORY UNSATISFACTORY

4 3 2 1

COMMENTS:

RESULTINANO VERALLGRADE OFUNSATISFACTORY.

AIRCREWCRM CHECKFLIGHT EVAL WORKSHEET

OVERALL GRADE

INSTRUCTORSIGNATURE_______________________ DATE______________

1.A GRADEOF UNSATISFACTORY INANY CRMSKILLWILL

FLIGHT EVALUATIONDETERMINATION


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Example

The following is an example of how toincorporate CRM into T/M/S

instructions/SOPs.

NATOPS

Poor Practices

Ground training focuses on 7 skills only

CRM ground training conducted inconjunction with a Safety Stand-down

Evaluation documented as anafterthought

Improper tracking of CRMI and CRMF

Improper designations or tracking

CRM not integrated into procedures

Chain of Command or culture does notsupport CRM

Poor Practices

CRM training not standardized or out ofdate

No CRM turnover binder

Contractors teaching CRM differently

because they failed to attended CRMI

training

Summary

CRM organizational structure

Designations

Documentation

Training Good program practices

Poor program practices

Ques%ons?


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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 shallbe conducted in all Chief of Naval Air Training (CNATRA)

squadrons and at the Fleet Replacement Squadrons (FRS) prior tofirst flight andis 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.: Initialand recurrencyCRM training shallbe

conducted by a designated CRM instructor or facilitator

CNAFINST 1542.7; 6.c.: InitialT/M Specific Training. Shallbe conducted

by a designated CRM Instructor (CRMI)

Some squadrons may initially be short C RM instructors to ensure thisnew 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.


Ann ual T/M Sp ecifi c Recu rri ng Trai nin g


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


CRM Instructor Training

OPNAVINST 1542.7C; e: Not specified.

CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructorcourse 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 C NAFINST. This was seen as a best practice and

not specifically required in OPNAVINST 1542.7 (series). However, it was arequirement in the Assist Visit Checklist.

Recommendation: Send current CRMF personnel to attend CRMI.


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CRM Facilitator Training

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

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


CRMF,


CRMI,

Provides specific guidance for CRM training topics for CRMI and CRMFqualification 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 incorporateformal 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 flyas active aircrew members shallmaintain 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 C RM currencies as uniformed aviators. Ifthey are providing CRM initial ground training they are required to be

a CRMI. If they are only providing CRM recurrent groundtraining they

are required to be a CRMI or CRMF.

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


Unmanned Aircraft Systems


CNAFINST 1542.7; 6.j.: All UAS platforms shallconduct CRM training inaccordance 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 C RM Training/Evaluation Record, enclosure(3), shallbe used to document CRM courses, designations, ground

training, and extensions in the individuals NATOPS Flight Personnel

Training/Qualifications Jacket in Section II, part C.All CRMdesignation lettersand flight evaluations shallalso be filed in the

NATOPS Jacket. CRM flight evaluations shallbe documented on an

applicable T/M approved form with the following statement included in thewrite up; Conducted CRM flight evaluation per CNAFINST 1542.7A.*

New requirement specifically for designations to be r ecorded 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 typ o and s hould 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)


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Responsibilities (cont.)

OPNAVINST 1542.7C; 8.h:

CNAFINST 1542.7; 7.d:

CRM Instructional Model Managerhas been incorporated into Naval

Avi atio n Sch ool s Comm and Pr ogr am Offi cer. (This will change once wetransition to Naval Aviation Safety Center).

OPNAVINST 1542.7C; 8.d:

CNAFINST 1542.7; 7.e:

Naval Safety Centerchanged to Naval Safety Center CRM Program

Officer.*

*Typo Naval Safety Center CRM Program Officershould be underlinedin the instruction.



OPNAVINST 1542.7C; 8.f:

CNAFINST 1542.7; 7.f:

CRM Curriculum Model Managerchanged 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 win g comm ander (CTW) is the CMM formultiple 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 wri ting 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 thePM to include T/M/S lessons learned, documented CR M 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 fromeffective 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 fromeffective 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 thisinstruction 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, shallbe managed per

SECNAV M-5210.1C.


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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 andFacilitator in this section).

All ows for all CRM qu alif icat ion s, not jus t th e Facili tato r co urs e.


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 specificCRM 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

exp ires the last day of the day o f cur rent month pluscu rren t mon th plus one year. one year and may be

accomplished 60 daysearly


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/tablehave 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.


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7 CRITICAL SKILLS

LD AF MA


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LeadershipAdaptability/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 of

instruction, the student willdemonstrate knowledge of the

purpose and goals of CRM, aswell as the importance of

leadership, adaptability/flexibility,and mission analysis.

Enabling Objectives

Discuss and understand the

importance of Leadership.


importance ofAdaptab il ity/Flexibi li ty .


importance of Mission Analysis.

Why CRM?

The leading cause of aviation mishaps is

due to human error.

Technology has developed to reducemechanical failure.

Human behavior has not developed to

reduce human error.

CRM is the method to modify human

behavior.

Philosophy

In the past the best way to learn goodCRM skills was to be fortunate enough

to fly with and learn by experience of

those who practice CRM well.

This a process which identifies the

successful traits of our best aircrew in

an effort to teach it in an academicenvironment.


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CRM Defined

CRM: The effectiveuse 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 effect

behavioral modification (as opposed toattitude changes or management theory) in

order to prevent human factor and crew

preventable errors.

Purpose

Purpose: CRM is intended to improvethe mission effectiveness of all aviationcommunities by enhancing crew

coordination through increasedawareness of associated behavioral

skills (Seven Critical Skills) and error

theory.

It is your program.

CRM Goals

Increase mission effectiveness

Minimize crew preventable errors

Maximize crew coordination

GoodBetter

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

Adaptabi li ty / Flexibil ity AF

Situational Awareness SA


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FOLLOWERSHIP

Followership

Followership

SURVIVORS

ALIENATEDAir 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/FLEXIBILITYDefinition: The ability to alter a course of

action based on new information,maintain constructive behavior under

pressure, and adapt to internal andexternal environmental changes.

The success of a mission depends upon the crews

ability to alter behavior and dynamically manage crew

resources to meet situational demands.

ADAPTABILITY / FLEXIBILITY

(-dp't-bil-t) / (flk's- bil-t)


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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?



What makes YOU successful atadapting or f lexing?

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


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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?


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7 CRITICAL SKILLS

CM AS


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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

Asser tiveness AS

Mission Analys is MA

Communication CM

Leadership LD

Adaptabi li ty / Flexibil ity 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 otheroptions are better.

Requires the COURAGEand

INITIATIVEto act.

(-sr'tv-ns)


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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 speak

their truth

Costs of silence are too high

Nilofer Merchant, 2011

Creating An AssertiveStatement

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

COMMUNICATION


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Communication

Definition: The ability to clearly and

accurately send and acknowledge

information, instructions, or commands,

and provide useful feedback.

(k-my'n-k'shn)

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.

DecodeEncode Transmit Receive

Meaning

(Interpret)

Meaning

(Intent)

Message

Meaning

(Interpret)

Meaning

(Intent)EncodeDecode 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


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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 desiredaction and who should do it.

Directness- Degree of pressure tocomply with the desired action.

Social appropriateness- Sensitivity tothe roles and status of speaker/addressees

and to the seriousness of the situation

Most Effective

Explicitly state what to do and maintain positive teamclimate:

Obligation Statements: States an obligation or an

intention:

Waveoff, Gobblin.

Suggestions: Suggests an action to be taken, astrategy, 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 do

not refer directly to the problem:

How are things coming along?

Spatial D Monitoring And Challenging

Essential elements of aviation safety Monitor each othersperformance

Communicate observed errors to preventproblems from escalating

Communication dilemma

How to communicate unambiguously andencourage compliance

While maintaining positive team climate

(Fischer & Orasanu, 2000)


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Air Florida Flight 90 (1982)

First officer: That dont seem right does it? Ah,thats not right.

Captain: Yes it is, theres eighty (knots).

First officer Naw, I dont think thats right

Captain: (No response)

The first officer continued to show concern asthe aircraft accelerated through a hundred

and twenty (knots).

(NTSB, 1982: 64

NASA Simulation Results

More effective communicationstrategies used when riskwas high.

FOs less likely to challenge when Face

Threat(degree of challenge to the other

pilots 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 mayundermine 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


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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-way

communication

Barriers to communication

Effective communication

Monitoring and challenging

Questions?


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7 CRITICAL SKILLS

SA DM


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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 withInstruction, Crew Resource Management Instructor Course StudentGuide.

Define Situational Awareness, in a classroom setting, in accordance withInstruction, Crew Resource Management Instructor Course StudentGuide.

Explain the difference between perception & reality, in a classroomsetting, in accordance with Instruction, Crew Resource ManagementInstructor Course Student Guide.

Describe the levels of SA, in a classroom setting, in accordance withInstruction, Crew Resource Management Instructor Course StudentGuide.

Objectives

Explain the cognitive mechanisms at work in the brain which enabledevelopment of SA, in a classroom setting, in accordance withInstruction, Crew Resource Management Instructor Course StudentGuide.

List factors that reduce SA, in a classroom setting, in accordance withInstruction, Crew Resource Management Instructor Course StudentGuide.

State techniques for maintaining and recovering SA, in a classroomsetting, in accordance with Instruction, Crew Resource ManagementInstructor 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 h avein common?

Human InformationProcessing

Limitations of the humaninformation processing

system have an

enormous effect on theability of an aviator to

gather the information

required, and make a

good decision on thebasis of that information.

Memory Model

Long term

Memory

Sensory

memory

Short term

memory

&

Working

memory

INPUT

INFORMATION

RECALLEDAdapted from Atkinson & Shiffrin (1971)

Knowledge

Skills

Experience

Diagnostic rules

Procedures etc.


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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 increasedby 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:


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 ofSituational Awareness?


55/145

Navy Definition

The degree of accuracy by whichones 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

Perceptionof elements

in current

situation

Comprehension

of current

situation

Projectionof future

status

Decision

Making


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 modelsare created by

Experience Briefing Expectations

The Creation of Mental Models


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Pilot

NFO

Mentalmodel

Mentalmodel

Common

UnderstandingEvent

Need a Shared Mental Model

Pilot

NFO

MentalModel

A

Interpretation A

Interpretation B

Event

Everyones Mental Model Can be

Different

MentalModel

B

Projection of future status

Failure to accurately project the mental

model

Level 3: Error

Level3

-5%

Level 2

17%

Level 178%

In What Levels are Errors

Occurring?

Level 1: DataPerception

Level 2: DataComprehension

Level 3: DataProjection

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

PercentoftotalS

Ae

rrors

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= OtherJ= Lack or incomplete mental model

K= Over-projection of current trend

L= Other


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How do you lose SA inthe 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 sources

do 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 rightCivil Aviation Authority (2003)

I didnt realize that

I didnt notice that

I was busy attending to

I wasnt aware that

We were very surprised when

We were convinced that

RetrospectiveStatements of lost SA

How do you maintain

Situational Awareness in theaircraft?

Maintaining SA

Good brief

Fitness for work

Minimize distractions and interruptions during

critical tasks

Sterile cockpit

Update regularly compare mental models

Monitoring be sensitive to clues of zoning

out

Speak up

Time management

Flin, OConnor & Crichton, 2008


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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, andintention?

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 to

affect you

Questions? Break

Decision Making

Napoleon BonaparteNothing is more difficult, and therefore

more precious, than to be able to decide.

Terminal ObjectiveInstruct CRM Critical Skills

Enabling Objectives

Define decision making, in a classroom setting, in accordance withInstruction, Crew Resource Management Instructor Course StudentGuide.

List the steps in classical decision making and why they do not normallyapply 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, ina classroom setting, in accordance with Instruction, Crew ResourceManagement Instructor Course Student Guide.

Explain decision making in a time critical/high risk environment, in aclassroom setting, in accordance with Instruction, Crew ResourceManagement Instructor Course Student Guide.

Objectives


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Explain decision making where there is little or no experience with thesituation, in a classroom setting, in accordance with Instruction, CrewResource Management Instructor Course Student Guide.

Discuss rule-based decision making, in a classroom setting, inaccordance with Instruction, Crew Resource Management InstructorCourse Student Guide.

Discuss some of the tools that enhance decision making skills, in aclassroom setting, in accordance with Instruction, Crew ResourceManagement Instructor Course Student Guide.

Objectives (cont.)

The ability to choose a course of action

using logical and sound judgment based

on 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 10

second 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


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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 in

decision making in complex real worldsettings

Navy / Marine Corps has been at the

forefront of this research

USS Vincennes shooting down Iranian

airliner in 1988

Tactical decision games

Naturalistic Decision Making

Flin, OConnor, & Crichton, 2008

Stage 1. ASSESS THE SITUATION

Time risk pressures

Stage 3. Select a course of action

Stage 4.Implement a course of action

(Whats the problem?)

Risk - high Risk - lowTime - low Time - high

Stage 2. MAKE A DECISION

(What shall I do?)

FE

EDB

ACKAnalyticalIntuitive CreativeRule-based

Stage 1: Assess the Situation

Time availablerisk variable

Whats the problem?

How much time is available?

How risky (present and future)?

Gather More

InformationCreate

Solution

Schedule

TasksChooseOptions

ACT

Problem NOTunderstoodProblemunderstood

Problem

understoodOR NOT

understood

Rule

available

No options

available

Multipleoptions

available

Multipletasks

to do

Time LimitedRisk High

Appl yRule


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Stage 2: Make a Decision

The type of decision making strategy which is

most appropriate is dependent on the amount oftime, 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

Time available

risk variable

Whats the problem?



Gather More

InformationCreate

Solution

Schedule

TasksChoose

OptionsACT

Problem NOT

understood

Problem

understood

Problem

understoodOR NOT

understood

Rule

available

No options

available

Multipleoptions

available

Multiple

tasks

to do

Time Limited

Risk High

Appl yRule

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


Whats the problem?



Gather More

InformationCreate

Solution

Schedule

TasksChooseOptions

ACT

Problem NOTunderstoodProblemunderstood

Problem

understoodOR NOT

understood

Rule

available

No options

available

Multipleoptions

available

Multipletasks

to do


Appl yRule

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.


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Rule Based Decisions

Positives: Only need to follow a series of rules

Do not need to be an expert, or understand thepurpose 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


Whats the problem?How much time is available?


Gather More

InformationCreate

Solution

ScheduleTasks

ChooseOptions

ACT

Problem NOTunderstood

Problemunderstood

Problem

understood

OR NOTunderstood

Rule

available

No options

available

Multiple

optionsavailable

Multipletasks

to do


Appl y

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 ORMA-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


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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

Time available

risk variable

Whats the problem?



Gather More

InformationCreate

Solution

Schedule

TasksChoose

OptionsACT

Problem NOT

understood

Problem

understood

Problem

understoodOR NOT

understood

Rule

available

No options

available

Multipleoptions

available

Multiple

tasks

to do

Time Limited

Risk High

Appl yRule

Creative Decision Making


Devising a novel course of action

for 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, OConnor, & Crichton, 2008

Stage 1. ASSESS THE SITUATION

Time risk pressures

3. Select a course of action

4. Implement a course of action

(Whats the problem?)

Risk - high Risk - low

Time - low Time - high

Stage 2. MAKE A DECISION

(What shall I do?)

FE

EDBACK

AnalyticalIntuitive CreativeRule-based

Feedback


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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 sayuneventful. 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

Whats 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.comEndsleys company

www.raes-hfg.com/xsitass.htmRoyal AeronauticalSociety conference on SA

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

Flin, R., OConnor, P., Crichton, M. (2008).Safety atthe Sharp End.

Gladwell, M. (2005) Blink.

Klein, G. (1999). Sources of Power: How PeopleMake Decisions.

Civil Aviation Authority (2006).Crew Resource

Management. www.caa.co.uk/docs/33/CAP737.PDF

Questions?


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WORKLOAD MANAGEMENT


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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

Civil Aviation Authority (2006)

Factors Affecting Workload

The aviator and his/her state

Skills

Experience

Current health and fitness

Emotional state

Civil Aviation Authority (2006)

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 OVERLOADOPTIMUM

PE

R

F

ORM

A

N

C

E

WORKLOAD


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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 offairfield

Touch and go pattern during pinky time at NXPexpeditionary airfield

CREW T3P TPC

KC-130 Route of Flight KC-130 Case Study

Flight engineer mismanages FUEL panel (gravityfeeding 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 Doesnt 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


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KC-130 Case Study

Overload Caused:

Flight engineer unableto properly diagnose No.4 engine

TPC to fixate on No. 1engine (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 onlyDriving andtalking

Brakes on

(msec) 933 1,112

Brakes off

(msec)580 653

Followingdistance (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 underestimateimpact


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Attention Exercise BREAK

Get some refreshment

Goals of Automation

Definition: The execution by a machine of a

function 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

MD11DC10


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AH-64A / D Cockpit

Traditional (alpha) Glass (delta)

Chelton Synthetic Vision EFIS

Synthetic Vision

EFIS MOVING MAP EICAS

EICAS ExcedanceBoeing 757 Crash

Cali Columbia

Prime example of the limitations ofautomation

Poor workload management once crisisensued


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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 natural

tendency to follow the choice requiring the least

brain power.

55% of the time pilots committed errors when

the automation presented incorrect information

in 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

A300-6001.18 1.33

B737-100/200

B737- 300/400/5001.20 0.43

B747-100/200/300

B747-4001.79 0.77

DC9

MD801.28 0.40

DC10

MD112.67 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


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Reasons for an IncreasedMishap Rate?

AH-64 pilots acknowledge there is an

increased workload in the glass aircraft AH-64 pilots acknowledge that it is harder to

remain 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 pilotspreferred the glass cockpit

Rash & Francis, 2003

Automation and Workload

Workload

Hand-fly Autopilot FMS control

Abnormal

Normal

Chidester, 1999

Possible Impacts ofCockpit 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?


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Automation Take-Aways

Potential for both decreasing and increasing

crew 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 attention

and working memory

Automation must be carefully managed and

CRM skills are of increased importance in

highly automated aircraft

Avoid distractions

Questions?

Civil Aviation Authority (2006). Crew

Resource Management. www.caa.co.uk/

Civil Aviation Authority (2004). Flight Crew

Reliance on Automation. www.caa.co.uk/

www.satechnologies.comEndsleys company

www.flightdeckautomation.com/about.aspx

Flight deck automation issues


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THREAT & ERROR

MANAGEMENT


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Threat & Error

ManagementLesson 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 practicesin 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

experienceswith their peers and then applying

them to their own operational philosophy.

Why Threat & Error

Management?

Tenants of the original University Texas

Continental 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

Why Threat & Error

Management?


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..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 effectivelyMANAGE and REDUCE errors

Why Threat & Error

Management?

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.

Continentals 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 Dont question me, I know

what Im 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?


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Because Errors Exist

THE PROGRAM


Because Errors Exist Because Errors Exist


Accidents/Incidents

Reactive

What is happeninghere?

Proactive

Data Collection

Error Reporting


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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 tofix them

LOSA Line Operations Safety Audit

FOQA Flight Operations Quality Assurance

ASAP

epub lecture outline june 2013

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