COVER

uman error has been a concern since the dawn of aviation, and Hvarious forms of training to reduce its impact have long been a focus in military aviation. But it was not until the early 1980s that research on the causes of aviation acci- dents led to the introduction of structured training in the civil aviation sector. !e “red alert” on human error in civil operations was "rst sounded in 1979 when NASA convened a conference, “Resource management on the #ight deck”, to discuss work at NASA Ames Research Centre on RED commercial crashes. !is research found that more than 60 US jet transport accidents between 1968 and 1976 involved failures in decision making, , pilot judgment, communication and crew ALERT coordination. Among those accidents singled out at the 1979 safety summit was the 1972 crash of a Lockheed L-1011 in the , which occurred a$er the crew became so preoc- cupied with changing a burned-out nose landing gear indicator lamp that they failed to notice that the altitude hold function of the had disengaged, causing the aircra$ to gradually descend and crash. In the same year a crashed at Chicago Midway Airport while attempting a go-around from a non-precision approach. !e crew had focused on a light indicating “#ight data recorder inoperative” and lost . A$er crossing the "nal approach "x high, fast and not con"gured for landing, the crew attempted to land using speed brakes. When they realised they could not make the landing, they tried to go around with the speed brakes fully deployed and crashed o% the end of the runway. World-renowned expert on human !e focus on human error was given added impetus by the results of a classic study con- ducted under NASA sponsorship by Patrick factors, Bob Helmreich, reviews the Ru%ell Smith and reported at the 1979 con- ference. In this simulator study, experienced development of CRM since it was B-747 crews #ew a demanding full #ight from takeo% to landing. !ose who made first introduced 25 years ago. e%ective use of all resources performed well while those with poor communications and coordination skills made a large number of errors, including a 100,000 pound error in calculating gross weight for landing. KLM in Europe, United in North America and Ansett in Australia were early adopters of the "rst generation of CRM, known then as cockpit resource manage-

24 FLIGHT SAFETY AUSTRALIA SEPTEMBER–OCTOBER 2006 COVER ment. !e impetus for KLM was the loss of warnings by the #ight engineer that the Texas, our research group surveyed crews one of the company’s aircra$ in a runway fuel state was becoming critical. in 1991 to "nd out how they assessed the incursion accident at Los Rodeos airport at United Airlines called in consultants usefulness of the training. We collected Teneri%e in the Canary Islands in 1977. who had conducted training in mana- data from more than 15,000 crew mem- A KLM 747 taking o% in fog slammed into gerial e%ectiveness for corporations to bers from 12 airlines and military organi- a Pan Am 747 taxiing on the same runway. help the company address human error. sations in the US. !e majority rated A total of 583 people died, and the accident In 1981 the airline rolled out one of the the training as very or extremely useful. remains the deadliest in aviation history. world’s "rst comprehensive CRM pro- Additionally, the great majority agreed Among the chain of events that led to grams (which they called CLR or com- that CRM training had the potential to the disaster was a series of communica- mand-leadership-resource management). increase safety. tion problems, including confusion about CRM training for crew has since been We also measured changes in attitudes whether a takeo% clearance had been issued introduced and developed by aviation to concepts such as communications and by ATC to the KLM crew. It is likely that organisations worldwide. coordination and the e%ects of stressors the captain mistook a clearance to #y a cer- [In Australia, Ansett Airlines was on human performance. On each of the tain route a$er takeo% for an actual takeo% among the "rst to pioneer the “new tech- scales re#ecting these concepts highly clearance nology” of CRM training. A$er survey- signi"cant improvements in attitudes !e KLM #ight engineer expressed con- ing the available resources, KLM mate- following CRM training were noted cern that the Pan Am 747 was not yet clear rials were chosen in 1982. !e package (these data were reported by Helmreich of the runway just as the captain of the consisted of a slide-tape program, cover- & Wilhelm in the International Jour- KLM #ight began the takeo% run, but he ing all aspects of #ight crew behaviour, nal of Aviation Psychology in 1991 and was overruled. including performance weaknesses and are not limited to "rst generation CRM !e cockpit voice recorder captured what illusions.] courses). happened. No more dramatic endorsement of the tower: Stand by for takeo%, I will ... more than 60 US jet e%ectiveness of CRM can be given than call you. transport accidents between the judgement of Al Haynes, the pilot of Pan Am captain: And we’re still taxiing 1968 and 1976 involved failures in a United Airlines DC-10 that managed down the runway, the clipper one seven decision making, leadership, pilot a successful crash landing at Sioux City, three six. judgment, communication and crew Iowa, in 1989 a$er an uncontrolled engine Tenerife communications caused a shrill failure severed hydraulic lines, resulting coordination. noise in KLM cockpit – messages not heard in the loss of #ight controls. by KLM crew. [In early 1985, the two creators of the !e crew, using all their available Tower: Roger alpha one seven three six KLM program, Captain Frank Hawkins resources, controlled the aeroplane using report when runway clear and Professor Elwyn Edwards, of Aston di%erential thrust on the two remaining Pan Am captain: OK, we’ll report when University, UK, delivered a two-week engines. Captain Al Haynes gave credit we’re clear. course for senior Ansett managers, for the outcome to CRM training the Tower: !ank you. “Human factors for transport aircra$ crew had received. KLM Flight engineer: Is hij er niet af dan? (Is operation”. !is course attracted repre- At a 1991 presentation on the #ight at he not clear then?) sentatives from Qantas, TAA, the RAAF, NASA’s Dryden Flight Research Facility KLM captain: Wat zeg je? (What do you Air New Zealand, the then Bureau of Air in California he said, “As for the crew, say?) Safety Investigation, the Department of there was no training procedure for KLM !ight engineer: Is hij er niet af, die Pan Aviation (now CASA) and many others.] hydraulic failure. We’ve all been through American? (Is he not clear that Pan Ameri- !e United Airlines program was con- one failure or double failures, but never can?) ducted in an intensive seminar setting and a complete hydraulic failure. But the KLM captain: Jawel. (Oh yes [emphatic].) included getting participants to analyse preparation that paid o% for the crew was !e accident sparked changes to com- their own interpersonal styles (based on something that United … called cockpit munication protocols and a new focus on a questionnaire). !e focus of the training resource management, or command lead- group decision making that down played was correcting behavioural de"cits such ership resource training. the cockpit hierarchy. as a lack of assertiveness by juniors and “Up until [then] we kind of worked on In the , structured cockpit/ authoritarian behaviour by captains. Other the concept that the captain was THE crew resource management training was airlines developed similar programs. authority on the aircra$. What he [says], "rst instituted by United Airlines follow- Reactions to the "rst generation of CRM goes. We had 103 years of #ying experi- ing an accident at Portland, Oregon when were generally positive – with some reser- ence there in the cockpit, trying to get a United Airlines Douglas DC-8 ran out vations. Some referred to the program as that [aeroplane] on the ground, not one of fuel and crashed short of the runway in “charm school” and the content as “psy- minute of which we had actually prac- December of 1978. !e crew in this acci- chobabble”. tised, any one of us. If I hadn’t used CLR, dent was preoccupied with a landing gear By the early 1990s, attitudes to CRM if we had not let everybody put their input warning and continued to circle, despite training had shi$ed. At the University of in, it’s a cinch we wouldn’t have made it.”

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From cockpit to crew: Research and expe- leadership and e%ective communication. diluted the initial focus on error reduction. rience during the 1980s led to a key shi$ Second generation CRM was typi"ed by a Fourth generation CRM training in CRM from a focus on cockpit resource name change from cockpit to crew resource re#ected the introduction of the US Fed- management to one on crew resource man- management, re#ecting growing awareness eral Aviation Administration’s advanced agement. !is change was highlighted at a of the involvement of more than the cock- quali"cation program (AQP). !e AQP second NASA workshop, held in 1986, that pit crew in safe #ight. Second generation program gave airlines the ability to develop recognised that CRM needed to involve all courses dealt with more speci"c aviation innovative training re#ecting the needs crew members as well as other resources concepts and became more modular as well and cultures of their organisations. Two existing in the aviation system (mainte- as more team oriented. Concepts included of the requirements of AQP have been the nance, air tra&c control, and so on). While team building, brie"ngs, situation aware- integration of CRM into technical training many of the early CRM courses that were ness and (in some cases) stress manage- and the provision of full mission, non-jeop- derived from general management devel- ment. Criticisms regarding too much pop ardy simulation (line oriented #ight train- opment programs focussed on the immedi- psychology still continued – for example, ing, or LOFT). As part of this integration of ate operational environment, experts saw the concept of synergy was o$en derided as CRM with technical training some airlines a need to re"ne the CRM concept to take silly jargon. began to “proceduralise” CRM by adding account of the broader complexity of air- !ird generation CRM courses emerged speci"c behaviours to their checklists and cra$ operations. in the early 1990s and addressed a broader to require formal evaluation of crews in full Our research at the University of Texas segment of the aviation environment mission simulation (line operational evalu- has followed the evolution of CRM training including #ight attendants, dispatchers and ation or LOE). that has occurred over the past 25 years. We maintenance personnel. Some organisa- have identi"ed six “generations” of CRM, as tions began to conduct joint cockpit/cabin One of the most positive a way of trying to make sense of the changes CRM training. Attention was given to fac- developments I have observed we have observed. tors such as how organisational culture can among airlines has been the !ese descriptive labels try to capture in#uence safety. E%orts were made to pres- willingness of organisations that are signi"cant changes in the nature of the ent speci"c skills and behaviours that pilots fierce competitors in the marketplace training – although I suspect one could can use to work more e%ectively. Some to share information. "nd early generation training programs carriers also developed specialised CRM still being delivered by some companies. training for new captains to address lead- Fi$h generation CRM represents a return !e " rst generation of CRM, as imple- ership issues related to command. While to the original of CRM as an error reduction mented by pioneering organisations in the these courses were very useful in extend- and management strategy. Underlying "$h US, Europe and Australia, focused mainly ing the concept of crew to those outside the generation CRM is awareness that error is on resources in the cockpit, teamwork, cockpit, they may also have inadvertently ubiquitous and inevitable. Behaviours that are taught and reinforced can be under- HIGH RISK ENVIRONMENTS stood as countermeasures against error and strategies to mitigate the consequences of error. !e success of this generation of CRM is contingent on organisational rec- ognition that errors happen and that a non- punitive attitude towards error is needed (except, of course, for intentional violations of procedures or rules). Sixth generation CRM is a logical exten- sion of the "$h generation. It re#ects the fact that #ight crews must not only cope with human error within the cockpit but also with threats to safety that come from the operating environment. In this frame- work an ATC error (for example an erro- neous communication that could cause a mid-air) is a threat that must be managed. !e di%erence between "$h and sixth gen- eration training is signi"cant in the fact that it reveals a much greater awareness of Istockphoto/Scott Fichter US Navy the contextual risks that must be handled. Under pressure: Systematic observation techniques developed to study group interaction in aviation Pilots exposed to the sixth generation of have been applied in other high-risk environments, including undersea habitats, and increasingly to study interpersonal dynamics during surgery. CRM training have been enthusiastic about

26 FLIGHT SAFETY AUSTRALIA SEPTEMBER–OCTOBER 2006 COVER the addition of threat recognition and man- agement. While error management is a reality, in some ways the focus on pilot error has been somewhat limited by being seen to concentrate on those at the “sharp end”. One of the most positive developments I have observed among airlines has been the willingness of organisations that are "erce competitors in the marketplace to share information. For many years those involved in CRM have met regularly to share approaches to training and, in many cases, resource material, and to exchange experiences in the delivery of CRM train- ing. As a result, I think it most appropriate Courtesy Robert Helmriech to say the evolution of CRM that we have seen has re#ected industry’s shared suc- cesses and failures in training. niversity of Texas psychology pro- tion Administration, he has worked with fessor Bob Helmreich is one of the crews from airlines around the world to At a global level, initial attempts to export U modern-day pioneers of aviation human establish an extensive database of infor- CRM to other cultures (or indeed to other factors and CRM. A former US Navy of- mation about crew performance in op- organisations within the same culture) have ficer, his interest in human behaviour led erational settings. sometimes met with resistance. Within a him to doctoral studies in personality and Helmreich is head of the University of culture, crews might apply the NIH (not social psychology at Yale University. Texas Human Factors Research Project invented here) response to denigrate pro- His key interest is the study of high-de- (formerly the Aerospace Crew Research grams acquired from another carrier. !ere mand and high-risk environments where Project), a research group dedicated to are, of course, some organisations that have team performance plays a critical role. investigating individual, team and or- delivered e%ective CRM training to pilots Supported by NASA, the National Sci- ganisational factors that influence per- in a variety of cultures by being sensitive to ence Foundation, the National Institute formance and safety in aviation, space local issues and by using local subject mat- of Mental Health and the Federal Avia- and medicine. ter experts to validate the approach and material employed. “Local solutions for undersea habitats during projects SEALAB nesses that an airline can use to bolster the local issues” appears to be the most e%ective and TEKTITE and in operating theatres “health” of its safety margins and prevent approach. during surgery. their degradation. Airlines that have developed their pro- In aviation, this systematic observation LOSA is distinct from but complementary grams locally or showed sensitivity to cul- technique is known as a line operations to other safety programs such as electronic tural issues (such as deference to hierar- safety audit (LOSA). LOSA is a formal data acquisition systems (for example #ight chy) seem to have been quite successful in process that requires expert and highly operational quality assurance, or FOQA), implementing CRM. !ese companies have trained observers to ride the jumpseat dur- and voluntary reporting systems (such as stressed the responsibility crews have to the ing regularly scheduled #ights in order to the US reporting system, health of their organisation. collect safety-related data on environmen- or ASRS). !ere are two major conceptual !ere is, of course, a lot of variability in tal conditions, operational complexity and di%erences. First, FOQA and ASRS rely the quality of courses, the amount of time #ight crew performance. Con"dential data on outcomes to generate data. For FOQA, devoted to the training, and the degree of collection and non-jeopardy assurance for it is #ight parameter exceedances, and for support demonstrated by senior manage- pilots are fundamental to the process. ASRS, it is adverse events that crews report. ment to CRM. As my colleague and LOSA expert, James By contrast, LOSA samples all activities Systematic observation: Contemporary Klinect, says, you could say that a LOSA is in normal operations. !ere may be some CRM involves looking at how crews utilise similar to a patient’s annual physical exam- reportable events, but there will also be some all available resources to manage threat and ination. People have comprehensive check- near-events, and importantly, a majority of error. But to understand how crews manage ups in the hope of detecting serious health well-managed, successful #ights. threat and error you need to know what is issues before they become consequential. A !e second major di%erence is the per- actually happening during normal #ight. set of diagnostic measures – such as blood spective taken by each program. With its One way of doing this is to use systematic pressure, cholesterol and liver function focus on electronic data acquisition down- observation methods that have been well – #ag potential health concerns, which in loaded directly from the aircra$, FOQA validated through research in social psy- turn suggest changes that might be needed can be said to have the “aeroplane perspec- chology. At the University of Texas we have to the patient’s lifestyle. A LOSA is built tive”. ASRSs provide the “pilot perspective” employed systematic observation in a vari- upon the same notion. It provides a diag- by utilising pilots’ voluntary disclosure ety of settings, including people living in nostic snapshot of strengths and weak- and self-reporting of events. ASRS reports

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THREE KEY DISASTERS THAT TRIGGERED AN INCREASED FOCUS ON HUMAN ERROR provide insight into why events occur, as seen from the crew’s perspective. LOSA provides an observer’s perspective of how threats and errors are handled on every phase of #ight, regardless of the outcome. Most LOSA observers are pilots from the airline, with some 20 per cent of observa- tions conducted by observers outside of the airline. All three perspectives provide useful data to an airline’s safety manage- ment system. !e foundation of LOSA grew out of the need to "nd out how threats and errors are managed and how well CRM training translated into line operations. AAP In the US LOSA was introduced a$er Everglades: Among the accidents singled out at a 1979 NASA safety summit was the 1972 crash of Delta Airlines put in place a very inten- a Lockheed L-1011 in the Everglades, which occurred after the crew became so preoccupied with sive CRM program in the early 1990s. changing a burned out nose landing gear indicator lamp that they failed to notice that the altitude hold Delta management was eager to discover function of the autopilot had disengaged, causing the aircraft to gradually descend and crash. Ninety- nine of the 176 on board perished. whether the training was working, and approached our research group to "nd out. We were asked to observe crews to obtain these data, with guarantees of con"dentiality of individual informa- tion. Later, in 1996 Continental Airlines and !e University of Texas re"ned the concept and observations were conducted that included recording threats and errors as well as ratings of CRM practices. To date some 5,500 LOSA observations have been completed with around 30 air- lines in the US and elsewhere. !e results

AAP show that there is an average of four threats per #ight – most problematic are chal- Chicago: One of the initiating factors in the crash of a Boeing Pull 737 atquote Chicago Midway Airport in 1972 was crew pre-occupation with a light indicating “flight data recorder inoperative”. Crossing the final lenging ATC clearances and late changes. approach fix high, fast and not configured for landing, the flight crew tried to land using speed brakes, but !ere is also an average of 3 errors per couldn’t make it. On go-around with the speed brakes fully deployed, the aircraft crashed off the end of #ight (20 per cent are error free). !e most the runway. Forty-three of the 61 aboard died. frequent errors are procedural. !e LOSA concept is now being applied within airlines to areas outside the cock- pit where important safety issues exist. For example, the methodology has been extended to ramp operations, as well as to air tra&c control. Airservices Austra- lia is the "rst in the world to test LOSA methodology in ATC. Our LOSA observations have revealed the critical role of threat and error man- agement in normal #ight operations. Indeed, the concept of threat and error management seems to provide a com- AAP AAP mon framework for integrating safety Tenerife: A total of 583 people died in a 1977 runway incursion accident in which a Pan Am B-747 and a KLM data from a variety of sources – from B-747 collided at Los Rodeos Airport at Tenerife in the Canary Islands. The accident remains the deadliest in incident reporting (ASRS) to systematic aviation history. Among the chain of events that led to the disaster was a series of communication problems, observations (LOSA) to accident investi- including confusion about whether a takeoff clearance had been issued by ATC to the KLM crew. It is likely that gations and data recorders (FOQA). !e the captain mistook a clearance to fly a certain route after takeoff for an actual takeoff clearance. ability to examine these components in

28 FLIGHT SAFETY AUSTRALIA SEPTEMBER–OCTOBER 2006 COVER a consistent manner should foster the errors (#ight controls, automation), pro- A$er 10 years of examining how #ight development of safety cultures and allow cedural errors (checklists, brie"ngs, call- crews manage error it is clear that there the exchange of data across domains. outs) and communication errors (with is one thing that all successful crews do. Threat and error defined: A threat can ATC, ground, or pilot-to-pilot). !ey all co-operate to rigorously monitor be de"ned as an event or error that is not Understanding how errors are managed and cross-check to make sure they pick caused by the crew, and increases opera- is as important, if not more important, up threats and errors early. !ese crews tional complexity of a #ight, requiring than understanding the prevalence of dif- are actively engaged in checking and ver- crew attention and management if safety ferent types of error. It is of interest then ifying every setting and action that can margins are to be preserved. if and when the error was detected and a%ect safety. Some threats come from the environ- by whom, as well as the response(s) upon !is requires excellent co-ordination ment – adverse weather, airport condi- detecting the error, and the outcome of and a good cross #ow of communication. tions, terrain, tra&c and ATC. Other the error. As with threats, some errors are Rather than any particular personality threats arise from within the airline, quickly detected and resolved, leading to trait, the key marker for a good pilot is such as aircra$ malfunctions and mini- an inconsequential outcome, while others a sense of professionalism, and an appre- mum equipment list (MEL) items, prob- go undetected or are mismanaged. A mis- ciation of backup. lems, interruptions, or errors from dis- managed error is de"ned as an error that is Good leadership is essential, in which a patch, cabin, ground, maintenance and linked to or induces additional error or an tone of professionalism sets the standard. the ramp. !reats may be anticipated undesired aircra$ state. Leadership must be decisive, yet allow for by the crew, for example, by brie"ng a Our error archive provides some inter- input. thunderstorm in advance, or they may esting insights into #ight crew errors and CRM performance is not the magic be unexpected, occurring suddenly and their management. !e most common bullet, but one of many things #ight crew without warning, such as in-#ight air- errors were: have to do to manage threats and errors. cra$ malfunctions. A mismanaged threat • Automation (25 per cent of #ights). In the future we will see sixth generation is de"ned as a threat that is linked to or • Systems/instruments/radio (24 per CRM more fully integrated into training, induces #ight crew error. cent). and an increased emphasis on under- Results from our “10-airline” archive show • Checklists (23 per cent). standing and reacting to how all elements the most prevalent threats by type were: • Manual handling (22 per cent). of the aviation system respond to threat • Adverse weather (61 per cent of • Crew to external communication (22 and error. #ights). per cent). Additional material from James Klinect, • ATC (56 per cent). !e most o$en mismanaged errors researcher at the University of Texas Human • Environmental operational pressures were: Factors Research Program, and head of the LOSA Collaborative, which o"ers LOSA implementa- (36 per cent). • Manual handling (79 per cent misman- tion services to airlines world-wide. • Aircra$ malfunctions (33 per cent). aged). Assistance is acknowledged from University • Airline operational pressures (18 per • Ground navigation (61 per cent). of Texas human factors researchers, Ashleigh cent). • Automation (37 per cent). Merritt, project data specialist, and Chris Henry, !e threats that were most o$en mis- • Checklists (15 per cent). principal investigator, University of Texas nor- mal operations safety survey (NOSS). managed, by type, were: • ATC (12 per cent of threats misman- aged). • Aircra$ malfunctions (12 per cent). • Adverse weather (9 per cent). • Dispatch/paperwork (9 per cent). • Airline operational pressure (7 per cent). !ere was little variability in threat mismanagement, shown by the small range (6-12 per cent). !ese results show that #ight crews are good threat man- agers, in an environment full of threats – with over 81 per cent of #ights observed encountering at least one threat. Crew error is de"ned as action or inac- tion that leads to a deviation from crew or organisational intentions or expectations. Errors in the operational context tend to reduce the margin of safety and increase the probability of adverse events. Broadly speaking, there are handling

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SINGLE-PILOT OPERATIONS MULTI-CREW OPERATIONS before the aircraft enters an undesired aircraft state.

RECOGNISES AND MANAGES UNDESIRED AIRCRAFT STATES

1 Recognises undesired aircraft state. 2 Manipulates aircraft controls or systems, or modifies actions or proce- dures to maintain control of the aircraft or situation, in the time available.

SETS PRIORITIES AND MANAGES TASKS

1 Organise flight, navigation, com- munication and passenger manage-

Istockphoto ment tasks and sets priorities to ensure that the workload at any phase of flight SINGLE-PILOT OPERATIONS allows, in the time available, the pilot to 6 Decides on a course of action. safely manage the flight. MAINTAINS EFFECTIVE LOOKOUT 7 Communicates plans of action and directs crewmembers to clearly speci- 2 Prioritises and organises workload 1 Maintains lookout and traffic sepa- fied tasks. to ensure completion of all tasks rele- ration using a systematic scan tech- 8 Takes actions to achieve optimum vant to the safety of the flight in the time nique at a rate determined by traffic outcomes for the operation. available. density, visibility and terrain. 9 Monitors progress against agreed 3 Puts the safe and effective comple- 2 Maintains radio listening watch plan. tion of every task or operation of an air- and interprets transmissions to deter- 10 Re-evaluates plan in line with craft ahead of competing priorities and mine traffic location and intentions of changing circumstances and is im- demands. traffic. provement focused to achieve optimum 4 Plans events and tasks to occur se- 3 Performs airspace cleared proce- outcomes. quentially. dure before commencing any manoeu- 5 Critical events and tasks are antici- vres. RECOGNISES AND MANAGES THREATS pated and completed in the time avail- MAINTAINS SITUATION AWARENESS 1 Identifies environmental or opera- able. tional threats that could affect the safe- 6 Uses technology to reduce work- 1 Monitors all aircraft systems using ty of flight. load and improve cognitive and manip- a systematic scan technique. 2 Analyses threats and develops op- ulative activities. 2 Collects information to facilitate tions to mitigate or control threats. 7 Avoids fixation on single actions or ongoing system management. 3 Implements an option (action) that functions. 3 Monitors flight environment for mitigates or controls threat. deviations from planned operations. MAINTAINS EFFECTIVE 4 Monitors and assesses flight prog- 4 Collects flight environment infor- COMMUNICATIONS ress to ensure a safe outcome; or modi- mation to update planned operations. 1 Establish and maintain effective fies actions when a safe outcome is not 5 Analyses aircraft systems and flight communications and interpersonal re- assured. environment information to identify ac- lationships with all stakeholders to en- tual and potential threats or errors. RECOGNISES AND MANAGES ERRORS sure the safe outcome of a flight 2 Applies standard phraseology to ASSESSES SITUATIONS AND MAKES 1 Applies checklists and standard DECISIONS operating procedures to prevent aircraft radio communication 3 Communicates with stakeholders 1 Identifies and reviews problem handling, procedural or communication in an effective and efficient manner to causal factors. errors; and identifies committed errors achieve all requirements for safe flight 2 Systematically and logically breaks before safety is affected or aircraft en- 4 Defines and explains objectives to down problems or processes into com- ters an undesired aircraft state. applicable/involved stakeholder ponent parts. 2 Monitor aircraft systems, flight en- 5 Demonstrates a level of assertive- 3 Applies analytical techniques to vironment and crew members, collects ness that ensures the safe completion identify solutions and considers the and analyses information to identify po- of a flight value and implications of each. tential or actual errors. 6 Encourages passengers to partici- 4 Generates, in the time available, as 3 Implements strategies and proce- pate in and contribute to the safe out- many solutions as possible. dures to prevent errors or takes action in the time available to correct errors come of a flight. 5 Assesses solutions and risks.

30 FLIGHT SAFETY AUSTRALIA SEPTEMBER–OCTOBER 2006 COVER

SINGLE-PILOT OPERATIONS MULTI-CREW OPERATIONS MULTI-CREW OPERATIONS key issues and relationships relative to tion to update planned operations. achieving determined roles. 5 Identifies environmental or opera- OPERATES AS A CREW MEMBER 12 (CO-OPERATION) Monitor aircraft systems, flight en- tional threats that could affect the safety vironment and crew members, collects of flight. Analyses threats and develops 1 Establishes an atmosphere to en- and analyses information to identify po- options to mitigate or control threats. courage open communications. tential or actual errors. 6 Analyses threats and develops op- 2 Listens critically and provides feed- 13 Implements strategies and proce- tions to mitigate or control threats. back to clarify information. dures to prevent errors or takes action in 7 Reports aircraft systems and flight 3 Applies assertive strategies when the time available to correct errors before environment information for analysis. working with others. the aircraft enters an undesired aircraft 8 Analyses aircraft systems and flight 4 Presents ideas in a way that shows state. environment information to identify ac- respect for others. 14 Applies checklists and standard tual and potential threats or errors. 5 Conveys information that is appro- operating procedures to prevent aircraft priate to the receiver. MAKES DECISIONS handling, procedural or communication 6 Considers the condition (capability) errors; and identifies committed errors 1 Identifies problems causal factors of other crewmembers to perform crew before safety is affected or aircraft enters and reviews these with crew members. duties. an undesired aircraft state. 2 Breaks down systematically and 7 Monitors and appraises crew mem- 15 Recognises undesired aircraft state. logically problems or processes into bers performance. 16 Manipulates aircraft controls or sys- component parts. 8 Interacts with crew members in a tems, or procedures to correct undesired 3 Employs analytical techniques to supportive and constructive way. aircraft state in the time available. identify solutions and considers the val- 9 Assists other crew members in de- 17 Breaks down goals and establishes ue and implications of each. manding situations. courses of action to accomplish specified 4 Generates, in the time available, 10 Motivates and encourages other goals. as many solutions as possible amongst crew members. 18 Ensures that all crew members have crewmembers. 11 Identifies the signs, stages and pos- role clarity and relevant information to 5 Implements an option (action) that sible causes of conflict. achieve goals. mitigates or controls threats. 12 Implements strategies to deal with 19 Allocates sufficient resources and 6 Assesses solutions and risks with conflict. time to complete workload. other crew members. 13 Establishes communications that 20 Maintains patience and focus when 7 Decides on a course of action. encourage constructive responses to processing large amounts of data or mul- 8 Communicates plans of action and conflict. tiple tasks. directs crew members to clearly speci- fied tasks. LEADERSHIP AND MANAGEMENT 21 Manages time and resources to en- 9 Takes actions to achieve optimum 1 Manages cockpit gradient relative to sure that work is completed safely and outcomes for the operation. task. effectively. 10 Monitors progress against agreed 2 Ensures that all crew members have MAINTAINS SITUATION AWARENESS plan. a clear picture of the objective. DURING MULTI- CREW OPERATIONS 11 Monitors and assesses flight prog- 3 Manages changing priorities and if 1 Monitors all aircraft systems using a ress to ensure a safe outcome; or modi- necessary, re focus crew members to ac- systematic scan technique. fies actions when a safe outcome is not commodate the changed priorities. 2 Collects information to facilitate on- assured. 4 Maintains crew members commit- going system management. 12 Re-evaluates plan in line with ment to task. 3 Monitors flight environment for de- changing circumstances and is im- 5 Monitors the crew to ensure that viations from planned operations. provement focused to achieve opti- they achieve specified standards of per- 4 Collects flight environment informa- mum outcomes. formance. 6 Corrects individual or crew mem- bers deviations from standards. 7 Insists on clarification of roles and functions. 8 Establishes and maintains clear, or- derly systems. 9 Sets realistic performance stan- dards. 10 Monitors outcomes, evaluates and measures performance. 11 Collects information and identifies Getty Images Note: CRM competencies should be customised to re!ect the speci#c operating environment, culture and standard operating procedures of individual operators. SEPTEMBER–OCTOBER 2006 FLIGHT SAFETY AUSTRALIA 31