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Crew Resource Management

Crew Resource Management. Introduction. Name Position History/Career Experience of CRM A/C Type & Routes Interests & Activities. Domestic Arrangements. Timings Food & Refreshments Toilets Smoking Policy Fire or Emergency – Exits & Assembly Point Mobile Phones Language

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Crew Resource Management

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  1. CrewResourceManagement

  2. Introduction • Name • Position • History/Career • Experience of CRM • A/C Type & Routes • Interests & Activities

  3. Domestic Arrangements • Timings • Food & Refreshments • Toilets • Smoking Policy • Fire or Emergency – Exits & Assembly Point • Mobile Phones • Language • Course pack

  4. CRM ??? • What does CRM stand for? • Define CRM – What does the term mean to you? • The origin of CRM

  5. To enhance the communication and management skills of the flight crew members by the effective utilisation of all available resources to achieve a safe and efficient operation CRM Objective TGL 44

  6. In the days of early technology, human error was the cause of many safety related incidents

  7. Human errors continued to repeat even with advanced technology

  8. Lessons Learnt • Research carried out by: • NASA • Leading Airline Corporations • International Civil Aviation Authorities and Accident Investigation Units • Universities Worldwide • Human performance cited as the causal factor in 3 out of 4 accidents • Study & Application of an error avoidance programme called CRM has now become mandatory for both civil and military aircraft operations

  9. Error Management Strategies • Understanding the nature and extent of error or risk • Changing the conditions that induce the error • Determining the behaviours that prevent or mitigate error Who is at risk?

  10. Requirements &Blocks to CRM Success • Requirements for CRM Success • Support from Top & Middle Management • CRM Instructors who have the core competencies of good CRM & role model CRM in their words & actions • Dedicated Team • Blocks to CRM Success • Resistance to Change • Fear of Failure • CRM delivery methodology

  11. H S L E L

  12. Liveware Physical size & shape Physical needs (sustenance, sleep etc) Input/Output Characteristics Information processing Environmental tolerances (temp, pressure, humidity, enclosed space, stress &boredom) L Variations inPerformance& limitations

  13. H L Liveware – Hardware • Ergonomics • Displays • Instrument interpretation • Scanning & detection • Work space • Controls with proper movement, codingand location

  14. S L Liveware – Software • Non-physical aspects of systems • Symbology and computer programmes • Procedures (SOP’s, normal, abnormal or emergency drills) • Rules and regulations i.e. company and authority • Training manuals & document design i.e. content and layout

  15. L E Liveware – Environment • Disturbed biological rhythms - Sleep disturbance and deprivation / transmeridian travel • Pressurised cabin • Noise & vibration • Weather conditions

  16. L L Liveware – Liveware • Leadership, co-operation, teamwork, personality interactions • Staff/management relationships, corporate culture & climate, company operating pressures

  17. H S L E L

  18. Causal Factors Breakdown of all fatal accidents by causal group (for primary causal factors only) for the ten-year period 1997 to 2006. (From UK CAA CAP776)

  19. Southwest 1455 Typical approach track 18:03 “left to a heading of 190° and to descend to and maintain 6,000 ft” 18:04 “Southwest 1455 maintain 230 or greater until advised please” 18:05 “descend to 5000 ft, following company traffic at 12 miles” 18:08 “cross Van Nuys at or above three thousand, cleared visual approach runway eight” 8 miles 3,800 ft (msl)

  20. 1000ft 2,275 ft 200 Kt 2,200 ft/min “whoop, whoop, pull up” 3 Miles 900 ft 182 Kt 130 Kt 150 Kt 2000 ft 700 ft/min

  21. 1000ft 2,275 ft 200 Kt 2,200 ft/min “whoop, whoop, pull up” 3 Miles 900 ft 182 Kt 130 Kt 150 Kt 2000 ft 700 ft/min

  22. “2000 gallons unleaded please..”

  23. Crew • Captain • 11,000 Hours • 9,870 on 737 for SouthWest • congenial, mild-mannered, and someone who got along well with everyone. • First Officer • 5,000 hours • 2,500 hours 737 for SouthWest • 12 years USAF F-15 • above-average, good skills, good judgment

  24. What went wrong • The Captain failed to “Go-around” • The First Officer failed to perform his duties regarding: • calling deviations from approach normal criteria • check lists

  25. Why? • They were two hours behind schedule • pressure to avoid further delay caused by going around. • Peer pressure – All other crews on the radio frequency would be aware of their ‘failing’ to make the approach. • this was home base • the aircraft ahead was also Southwest • FO pressure not to challenge his superior • Risk shift • FO failed under stress to complete simple tasks • Both failed under stress to respond to the continuous GPWS warnings

  26. Lessons • The crew were • Skilled • Experienced • Current • They succumbed to • Peer Pressure • Operational Pressures • Under stress • Inability to perform simple tasks • Judgement was compromised

  27. Primary Causes of Fatal Accidents • Inadequate Communication • Deviation from SOP’s • Maintenance Error • Poor Response to, or no GPWS

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