1. Threat and Error Management in Aviation
Center of Excellence
October 28th 2002
Captain Mark Auerman

2. Topics Brief history of Crew Resource Management
Threat and Error Management
Error management tools in aviation
Questions are encouraged!!

3. What is Crew Resource Management (CRM) ?
effective use of all resources, to achieve the highest possible level of safety and efficiency (Transport Canada)

4. Historical Development of CRM

5. Aircraft accident rates were extremely high post WWII to the 1970’s

6. These high accident rates were largely attributable to unreliable aircraft equipment

7. Caused accident rates to decline significantly until the mid 1970’s

8. Since then the accident rate has leveled off

9. Now we must address deficiencies in Crew Performance with Crew Resource Management Training

10. Goal of CRM
Provide resources and strategies to allow airline crews to effectively manage threats and errors.

11. Latent and Active Errors
Active errors are caused by the crew mismanaging the resources
Latent errors are errors we inherit
POLICIES PROCEDURES

12. What is CRM training all about ?

13. CRM Training develops skills and strategies in the following areas…
Communication
Crew Performance
Leadership
Situational Awareness
Decision Making

14. Proactive Error Management Tools
CRM training mandated by Transport Canada
Initial 3 day course
Periodic refresher training focused on topical issues
Practical based training

15. Evolution of training Advanced Qualification Program
Script a simulator event looking for specific observable CRM behaviors
50% of the grade is based on CRM practices
Collect crew performance data that feeds back into the training system and modifies future training curriculum

16. Simulator Training Procedures Trainers
– must demonstrate competency every
6 – 8 months
Decision making Trainers
Real life scenarios played out in real time
Allows crews to gain experience and practice decision making

17. Line Checks
Assess and evaluate crew performance during line operations
Technical + CRM = Crew Performance*

18. Challenges Very difficult to grade Are we making a difference?
Cost issue
Changing Attitudes and Culture

19. Conclusions
many “soft skills” combined with practical strategies are required to manage error
CRM is the most flexible error management tool
CRM has effectively increased crew performance to make flight operations safer