2 One of the advantages of being captain is being able to ask for advice without necessarily having to take it.Peace or utter destruction, its up to you.If you’d keep your nose off my bridge, I’d be thankful.
8 What is CRM?Effective use of all resources, to achieve the highest possible level of safety and efficiency.(Transport Canada)
9 Heinrich Safety Triangle 1AccidentSerious AccidentMinor Accident withDamage and InjuryIncidents andNear MissesObservedWork ErrorsLaggingIndicators~ 29IncidentsLeadingIndicators~ 300Hazardous Conditions~ 3,000Unreported “Unsafe“ ActsMr. Heinrich was an Industrial Safety Engineer, who in 1931 developed a model describes how major injuries/industrial accidents occur. For a given population of workers, his model proposes that for every 300 unsafe acts (defined as FAR violations, Hazardous Attitudes, Safety Reports) there are 29 minor injuries and one major injury. Heinrich's theory accounts for the first three levels of the model. For more than 75 years, industrial safety managers have tried to reduce such accidents and injuries by attacking the problem from different ends of a three level pyramid. If investigative efforts are focused only on those rare occurrences where there is serious injury, or significant damage, its a wasted opportunity. The latent factors contributing to such accidents may be present in hundreds of other incidents, and could be identified – before serious injury or damage ensues.We all understand close calls. We've all had them. Some more than others. And that's the point. Some folks simply have more close calls, take more shortcuts & unnecessary risks. Sometimes they are lucky. Sometimes luck runs out. If you keep playing darts, eventually you'll get a bulls eye. Out of 3,000 unreported “unsafe” acts, one is going to be the winner that awards the pilot a check in the fatal column. Those are defined as taking shortcuts, unnecessary risks, and close calls.Even more insidious is the "Pilot Qualifications" layer. Imagine an employer reviewing all your flights, all the decisions you made on those flights, and all the little things that surprised you on all those flights. Would the employer select you to be a pilot for them? This layer includes (but not limited to):Pilot qualificationsDecision making skillsLegally qualified & current?Proficient & skilled?Hazardous Attitudes?Flying habitsCurrent Life Stress EventsPsychological make-upSubstance use?Medically qualified? Healthy?Mature thinking style?Conservative?Risk adverse?Personal Lifestyle Choices (Credit-Criminal-Educational)(Source: cfidarren.com)Just remember the cost to learn the lesson grows as you get to the top of the triangle. Intervening at the lowest level saves more lives, pain and suffering.~ 30,000Pilot Qualification – Selection Issues
10 Strategies Continental Airlines RESIST RESOLVE ERRORS CONSEQUENCE THREATSStrategiesERRORSRESISTHARDWARE & SOFTWARE THATEXISTS BEFORE THE HUMAN ENTERSRESOLVEWHAT THE HUMAN BRINGS TO THE SYSTEMResistResolveCONSEQUENCE
11 Anything that increases operational complexity What’s a Threat?Anything that increases operational complexityDefinition of a threat: A threat is anything that makes a flight more complicated. Threats are not always a danger to a flight, but can cause distractions if not managed properly. Distractions increase the chance that a crew will commit an error.Facts of life about threats:Inevitable - part of the territoryExternal conditions or events that must be managed during normal, everyday flights, in order to maintain safety margins.Events which increase operational complexity, posing a safety risk to the flight at some level
12 Example Threats Passenger Events Distractions ATC Cabin Crew Terrain WeatherSimilar Call SignMaintenanceTime PressuresGround CrewFlight DiversionYou’ve all seen this chart…Let’s dig into error more indepth. I want to show you a video on medical errors because it similar to what we do. It has similar:ComplexityTraining intensityTime constraintsScrutinyTeamwork dependency[Show CBS HealthWatch clip, Medical Error]Heavy TrafficSystem MalfunctionUnfamiliar AirportMissed ApproachAutomation Event
13 Real Threats Child Support Spouse(s) Work Rules Chief Pilot Pay ManagementFlight AttendantsSleepParent AirlineGround CrewScheduleYou’ve all seen this chart…Let’s dig into error more indepth. I want to show you a video on medical errors because it similar to what we do. It has similar:ComplexityTraining intensityTime constraintsScrutinyTeamwork dependency[Show CBS HealthWatch clip, Medical Error]14 Hour DayFriendsInexperienced CrewmembersMerger?My career isn’t going the way I thought it would
16 Northwest Airlines Undesired Aircraft State Trap: Managing Error Here’s a simplified model of Threat & Error Management. You spend your time managing threats, and if you don’t manage the threat, it becomes an error, and a mismanaged error becomes an undesired aircraft state (incident/accident).Just remember the cost to learn the lesson grows as you get to the top of the triangle. Intervening at the lowest level saves more lives, pain and suffering.Let’s define a few of these things properly…Avoid Error:Managing Threats
17 Layered System of Defenses Undesired Aircraft StateElements of layered system (e.g., Preflight)Read and sign paperwork (weather, clearance)Conduct exterior inspectionConduct cockpit inspectionBrief cabin crewPreflight checklistThreats
20 Error Types Intentional Noncompliance – violations ex) Performing a checklist from memoryProcedural – Followed procedures but wrong executionex) Wrong altitude setting dialed into the MCPCommunication – Missing information or misinterpretationex) Miscommunication with ATCProficiency – Error due to a lack of knowledge or skillex) Lack of knowledge with automationDecision – Discretionary decision that unnecessarily increased riskex) Unnecessary navigation through adverse weatherSource Flight Safety Foundation
21 When Do Errors Occur?49.4%10.7%16.3%Source: Helmreich, 199823.6%
26 What we did at NWA7-hole cards to all5500 pilotsMailboxBriefing RoomsJumpseat HandoutLounges7-hole cards
27 Video Training & Scenario What we did at NWAVideo Training & Scenario
28 Integrating Threat & Error Management Flight StandardsLine checks to reinforce threat recognition, error avoidance and managementFlight OperationsReview/revise SOPs and policiesSafetyError reporting system (ASAP) for dataSafety Programs (HF, FOQA)Ongoing QA AuditsTrainingThreat recognition & error avoidance and managementCaptain LeadershipFocus on technical and procedural excellence
29 Because Flying IS our Business: Threats must be identified and reduced or eliminated.Crew Errors must be avoided and managed.-- Therefore --Threat & Error Management must be integrated into Flt Ops culture.