flight operations safety awareness seminar (fosas) fosas 2017... · flight operations safety...
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Flight Operations Safety Awareness Seminar (FOSAS)
Human Factors (HF) and Crew Resource Management (CRM)
Airbus Flight Operations Support and Training Standards Nairobi 19-21 Sep 2017
HF and CRM
2 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
HF and CRM
3 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Tenerife 1977 Two B747 collided on the runway due to Take Off without clearance and poor visibility rsaquo Communication teamwork leadership decision making
One event
This accident had a huge influence on the industry particularly in the area of communication Emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots The word takeoff was removed from general usage and is only spoken by ATC when actually
clearing an aircraft to take off Less experienced flight crew members were encouraged to challenge their captains when they
believed something was not correct Captains were instructed to listen to their crew and evaluate all decisions in light of crew
concerns Finally was implemented what is known today as Crew Resource Management (CRM)
Importance of Human Factors
4 Sept 19-21 2017 ICAOAirbus FOSAS
But every day there are good ones
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 5
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
HF and CRM
2 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
HF and CRM
3 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Tenerife 1977 Two B747 collided on the runway due to Take Off without clearance and poor visibility rsaquo Communication teamwork leadership decision making
One event
This accident had a huge influence on the industry particularly in the area of communication Emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots The word takeoff was removed from general usage and is only spoken by ATC when actually
clearing an aircraft to take off Less experienced flight crew members were encouraged to challenge their captains when they
believed something was not correct Captains were instructed to listen to their crew and evaluate all decisions in light of crew
concerns Finally was implemented what is known today as Crew Resource Management (CRM)
Importance of Human Factors
4 Sept 19-21 2017 ICAOAirbus FOSAS
But every day there are good ones
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 5
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
HF and CRM
3 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Tenerife 1977 Two B747 collided on the runway due to Take Off without clearance and poor visibility rsaquo Communication teamwork leadership decision making
One event
This accident had a huge influence on the industry particularly in the area of communication Emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots The word takeoff was removed from general usage and is only spoken by ATC when actually
clearing an aircraft to take off Less experienced flight crew members were encouraged to challenge their captains when they
believed something was not correct Captains were instructed to listen to their crew and evaluate all decisions in light of crew
concerns Finally was implemented what is known today as Crew Resource Management (CRM)
Importance of Human Factors
4 Sept 19-21 2017 ICAOAirbus FOSAS
But every day there are good ones
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 5
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Tenerife 1977 Two B747 collided on the runway due to Take Off without clearance and poor visibility rsaquo Communication teamwork leadership decision making
One event
This accident had a huge influence on the industry particularly in the area of communication Emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots The word takeoff was removed from general usage and is only spoken by ATC when actually
clearing an aircraft to take off Less experienced flight crew members were encouraged to challenge their captains when they
believed something was not correct Captains were instructed to listen to their crew and evaluate all decisions in light of crew
concerns Finally was implemented what is known today as Crew Resource Management (CRM)
Importance of Human Factors
4 Sept 19-21 2017 ICAOAirbus FOSAS
But every day there are good ones
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 5
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
But every day there are good ones
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 5
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Importance of Human Factors
Jakarta June 1982 B747-200
rsaquo Successive Threats Volcanic ash ndash loss of 4 engines ndash Loss of pressurization ndash ATC misunderstanding ndash FO oxygen mask broken ndash Mountainous area ndash Windscreen pollution ndash Glide slope inoperative
rsaquo Successive positive actions Flying Gliding Navigating Keeping the high terrain in mind Communicating (Distress message + A7700) Managing remaining systems Applying restart drills using oxygen masks etchellip Situation awareness (terrain loss of pressurization oxygen mask failurehellip) Teamwork (3 crew members) Captain leadership Decision making (high VS due to FO oxygen mask failure type of approachhellip)
See also Video Falling from the Sky from the TV series Mayday (Air Emergency Air Crash Investigation) [documentary TV series]
Sept 19-21 2017 ICAOAirbus FOSAS 6
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Sourcehellip
rsaquo Cruising FL 370 4 engines failed due to volcanic ash rsaquo The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37000 feet rsaquo Emergency was declared The crew squawked A7700 However Jakarta Area Control misunderstood the
message interpreting the call as meaning that only engine number four had shut down rsaquo A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood rsaquo As pressure dropped in the cabin FO oxygen mask was broken the delivery tube had detached from the
rest of the mask Captain decided to descend at 1800 m per minute rsaquo Reaching 13500 ft after several engine restart procedures the crew finally re-started 4 engines rsaquo After a while engine number two surged again and was shut down rsaquo As Flight 9 approached Jakarta the crew found it difficult to see anything through the windscreen rsaquo An ILS approach was planned However the glide slope was inoperative so the FO monitored the descent
using DME rsaquo After landing the aircraft could not taxi by its own due to poor visibility through the wind screen It was towed
to the gate
Near Jakarta 1982hellip
Importance of Human Factors
Sept 19-21 2017 ICAOAirbus FOSAS 7
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
HF and CRM
8 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
We will develop but before letrsquos go for a concentration exercise
What are Human Factors
Human Factors Model
Sept 19-21 2017 ICAOAirbus FOSAS 9
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Anything that affects a personrsquos performance
Human Factors Model
Human Factors are
Sept 19-21 2017 ICAOAirbus FOSAS 10
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Good Standard
Poor
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 11
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Direct Factors The acts or omissions that directly affect performance
Decision
Distraction Dexterity
Awareness
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 12
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Design Environmental Fatigue Illness Visual illusions Memory Time Ergonomic Organizational Commercial Automation Faulty equipment
System failures Psychological
Negative attitudes Physiological
Language Procedures
Alert systems Emergencies
Relationships Documentation
Cultural Stress
Potential Factors Things that have the potential to influence the direct factors
Poor
Performance
Performance Performance
Sept 19-21 2017 ICAOAirbus FOSAS 13
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Potential Factors Interaction Interactivity between Potential Factors will increase
Poor
Performance
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 14
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Managing Factors Things that manage the effect of the Potential Factors and improve Direct Factors
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 15
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Managing Factors - Organizational
Performance
Performance review Training SOPs Checklists System review
Briefings Tools
Culture change Motivation
hellip
Sept 19-21 2017 ICAOAirbus FOSAS 16
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Problem solving Discipline
Decision making Concentration
Stress management
Monitoring
Fitness Knowledge
Technical skills
Threat amp Error Management Communication Teamwork Leadership Positive attitudes Behaviour Planning Problem prevention Workload management Situation awareness
Managing Factors - Individual
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 17
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Potential Factors
Managing Factors
Direct Factors
Human Factors Model
Performance
Sept 19-21 2017 ICAOAirbus FOSAS 18
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
HF and CRM
20 Sept 19-21 2017 ICAOAirbus FOSAS
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
CRM and Threat and Error Management
What is CRM
We will develop but before letrsquos explore what is Airmanship
Sept 19-21 2017 ICAOAirbus FOSAS 21
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
CRM and Threat and Error Management
What is Airmanship
Airmanship is the Technical and Non technical Knowledge Skills and Attitude that pilots need to ensure that aircraft is operated
Safely Efficiently Effectively
Airmanship Airmanship Technical Non-Technical
Knowledge Skills
Attitude
Knowledge Skills
Attitude
What is CRM
CRM is the Non-technical Knowledge only Sept 19-21 2017 ICAOAirbus FOSAS 22
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Undesired A
ircraft State
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 23
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
CRM and Threat and Error Management
outcom
e
Undesired A
ircraft State
Not avoided not managed poor CRMhellip
THREATS Come to the crew
ERRORS Come from the
crew
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 24
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Undesired A
ircraft State
outcom
e
A V O I D
----- T R A P
Good CRM helpshellip
THREATS Come to the crew
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
Sept 19-21 2017 ICAOAirbus FOSAS 25
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Undesired A
ircraft State
A V O I D
----- T R A P
outcom
e
Good CRM helpshellip
M A N A G E
ERRORS Come from the
crew
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 26
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
M A N A G E
outcom
e
Undesired A
ircraft State ERRORS
Come from the crew
A V O I D
----- T R A P
Good CRM helps
CRM and Threat and Error Management
Errors come from Threats or are independent
THREATS Come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS 27
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Mismanaged Errors
Mismanaged Threats
Mismanaged Situation
Mismanaged UAS
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 28
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Mismanaged Speed drop
OAT increase not detected
Mismanaged Buffet
Mismanaged Stall Recovery
Flying high and heavy with Tropo Tdeg Change
Letting speed drop Buffet
Crash Stalling
Life of a Hazard
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS 29
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
rsaquo Effectiveness of the Defence Barriers
CRM and Threat and Error Management ndash Crew Perfomance
Safety Performance SAFETY PERFORMANCE
Sept 19-21 2017 ICAOAirbus FOSAS 30
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Breach of Barrier Nordm1
Breach of Barrier Nordm2
Breach of Barrier Nordm4
Breach of Barrier Nordm4
Crew Performance
CRM and Threat and Error Management ndash Crew Perfomance
Sept 19-21 2017 ICAOAirbus FOSAS 31
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
How to recognize avoid trap and manage Threats and Errors
Communication
Leadership amp Teamwork
Workload Management
Situation Awareness
Problem solving amp Decision Making
Sept 19-21 2017 ICAOAirbus FOSAS 32
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
HF and CRM
The Importance of Human Factors
Human Factors
Threat amp Error Management and
CRM
CRM Best Practices PM role
Sept 19-21 2017 ICAOAirbus FOSAS 33
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Ensure clear delegation of tasks
Manage competing activities ( ie prioritize )
Use all appropriate system resources
Use on-board documentation
Assess time-critical situations
Verbalize with other crewmember
Manage risk of tunnel vision ( narrow-focus )
CRM Best Practices amp PM role
CRM Best Practices
Sept 19-21 2017 ICAOAirbus FOSAS 34
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Leadership role of Captain Manage priorities Distribute tasks
( if non-standard task sharing ) Consult Share situation analysis Decide Assure final authority and decision making Ensure that everyone contributes to communication information and backup
crosscheck
CRM Best Practices amp PM role
Tasksharing - Captain
Sept 19-21 2017 ICAOAirbus FOSAS 35
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Skill Knowledge
Experience
Good Monitoring
CRM Best Practices amp PM role Attitude
Communication
Requires Knowledge Through Training Experience Application of Knowledge
Skill Both knowledge amp Experience
Attitude Conscientiousnessndash Vigilancendash Assertiveness
Communication Intra-cockpit ATC cabin ndash Sharing Goals amp Intents
Knowledge Skill
Experience
36
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Support and monitoring roles of PM Relay critical information for PF awareness Provide timely inquiry statements before deviations develop Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s) Propose precise solutions if PF does not respond Provide emergency statement if required Take over control if conditions warrant such action
CRM Best Practices amp PM role
Tasksharing - PM
rsaquo A Key Safety Element in the J Reason lsquoSwiss Cheese Modelrsquo of Error Detection
amp Management
Sept 19-21 2017 ICAOAirbus FOSAS 37
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Tasksharing - PM
Taking over ldquoGo-around flapsrdquo
ldquo500 ft not stabilized Go-around rdquo
ldquoV DEV airspeed and GS high Sirrdquo
ldquoShall we extend gear to reduce speed rdquo
ldquoDonrsquot you think we are high and fast rdquo
CRM Best Practices amp PM role rsaquo Unexpected tailwind rsaquo Runway condition rsaquo Visibility change
Sept 19-21 2017 ICAOAirbus FOSAS 38
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
Reinforce the responsibility of PM Explain WHY inefficient monitoring reduces TEM performance
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
Develop clearly defined PM tasks Training Objectives and proficiency standards Ensure Instructors amp Evaluators proficiency Explain HOW clearly defined PM standards training objectives
and instructor proficiency are necessary to enhance pilotrsquos monitoring performance
Incorporate Monitoring training into training exercises Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT) Sept 19-21 2017 ICAOAirbus FOSAS 39
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
CRM Best Practices amp PM role
Training amp Evaluating Monitoring Skills
ICAO DOC 9995 EBT
CAA Paper 2013 Monitoring Matters
Guidance on the Development of Pilot Monitoring Skills
Flight Safety Foundation Flight Path Monitoring
Airbus Operations Training Transmission
(OTT) Ref 999002715 Recommended training for the PM Role
Sept 19-21 2017 ICAOAirbus FOSAS 40
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
copy Airbus SAS All rights reserved Confidential and proprietary document This document and all information contained herein is the sole property of AIRBUS No intellectual property rights are granted by the delivery of this document or the disclosure of its content This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS SAS This document and its content shall not be used for any purpose other than that for which it is supplied The statements made herein do not constitute an offer They are based on the mentioned assumptions and are expressed in good faith Where the supporting grounds for these statements are not shown AIRBUS SAS will be pleased to explain the basis thereof AIRBUS its logo A300 A310 A318 A319 A320 A321 A330 A340 A350 A380 A400M are registered trademarks
copy AIRBUS SAS All rights reserved Confidential and proprietary document
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
ldquoEvents or errors that occur beyond the influence of the crew increase operational complexity and workload and which must be managed to maintain safety marginrdquo
CRM and Threat and Error Management
What is a Threat
rsaquo Threats come to the crew
Sept 19-21 2017 ICAOAirbus FOSAS Page 42
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
ldquoActions or inactions by the Flight Crew that lead to deviations from organizational or Flight Crew intentions or expectationsrdquo Errors are spontaneous linked to threats or
can be part of error chainsrdquo
What is an Error
rsaquo Errors come from the crew
CRM and Threat and Error Management
Sept 19-21 2017 ICAOAirbus FOSAS Page 43
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
rsaquo In TEM Concept Threats amp Errors are considered as Hazards
CRM and Threat and Error Management
What is a Hazard
ldquoA condition or an object with the potential of causing Injuries to personnel Damage to equipment or structures Loss of material or Reduction of ability to perform a prescribed functionrdquo
ICAO (SMM 3rd version)
Sept 19-21 2017 ICAOAirbus FOSAS Page 44
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-
UNDESIRED AIRCRAFT STATE
ldquoFlight Crew-induced aircraft position or speed deviations misapplication of flight controls or incorrect systems configuration associated with a reduction of safety marginsrdquo
CRM and Threat and Error Management
What is an Undesired Aircraft State
Undesired aircraft State is not an outcome
It is a transitional situation between normal situation and outcome Restoring margins of safety is still possible
Sept 19-21 2017 ICAOAirbus FOSAS Page 45
- Flight Operations Safety Awareness Seminar (FOSAS)
- HF and CRM
- HF and CRM
- Slide Number 4
- But every day there are good ones
- Slide Number 6
- Slide Number 7
- HF and CRM
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- HF and CRM
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- HF and CRM
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
-