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CRM- Crew Resource Management. Rules of Engagement. Participation is Key Non-Attribution No Names – What Not Who. CRM – What is the Goal?. To achieve Optimal Performance from a team executing multiple, complex tasks. CRM – What is the Goal?.

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rules of engagement
Rules of Engagement

Participation is Key

Non-Attribution

No Names – What Not Who

crm what is the goal
CRM – What is the Goal?

To achieveOptimal Performance from a team executing multiple, complex tasks.

crm what is the goal1
CRM – What is the Goal?

Does Optimal Performance Equate to Perfection?

slide5
CRM…..

To Error is HumanYou Can Not Engage In Human Activity Without Introducing Human Error

So, Can We Reach The Goal of CRM Without Eliminating Error?

absolutely we manage our errors
AbsolutelyWe Manage Our Errors

We Incorporate

Error Managementinto Every Aspect of CRM

error management is the what intervention prevention crm is the how trap mitigate avoid
Error Management is the “What” Intervention/PreventionCRM is the “How”Trap, Mitigate, Avoid

GOAL: OPTIMAL PERFORMANCE

slide8

Error Mgt

Optimal

Peformance

CRM

error management
Error Management

Overview:

  • What it is… and, isn’t
  • What Error Management Seeks to Achieve
  • Where Error Lives
  • Where it Fits in Our Skills as Pilots/Aircrew
error management1
Error Management

Systematic Approach to Determining Common Errors & Contributing Factors

Drives Cultural Change to Accept:Error is Universal. Error is Inevitable.Shifts Focus from Who to What

Teach aircrews toTRAP, MITIGATE & AVOID Error.

error management2
Error Management

Errordoes not, has not, and will not cause an incident, an accident, or a fatality

So, what does?

Consequence

error management3

Error Management

ConsequenceConsequences are not universal or inevitable.Errors happen all of the time. Incidents, accidents, and fatalities do not.

EM targets the GAP between Error and Consequence!

where error lives
Where Error Lives
  • LATENT – present but not visible…hidden in the things we do routinely
  • ACTIVE – present, in use…individual error
the swiss cheese model reasons

Latent Errors

in System

Organizational Filters:

Training/Stan/CRM/ORM

Latent

Errors

at Mgt

Level

Trajectory of

Accident/Error

Unchecked

1

2

3

Individual Error

(Active Error)

4

Result/error

5

The Swiss Cheese Model (REASONS)
error management the crux
Error Management… The Crux

Mitigating the Consequence of Error

Employ Error Trapping in Every Aspect of:Training Standardization CRM & ORMError Trapping = Prevention & Intervention

6555 aug 94 practice auto
6555 Aug ‘94Practice Auto

Latent & Active Errors

What was EM Outcome

em crm

EM & CRM

Error Management must be imbedded in all four principles of CRM (SCAR)

crm principle s a
CRM Principle - S.A.

Situational Awareness…

…is the realistic understanding of all factors which affect the safety and effectiveness of your crew and aircraft.

crm principle s a1
CRM Principle - S.A.
  • Elements of Situational Awareness?

Spatial Orientation/attitudeOrientation to traffic, geography & timeAircraft status & capabilitiesAircrew status & Crew-life cycleMission concept & Mission-life cycle

crm principle s a2
CRM Principle - S.A.

Loss of Situational Awareness Still the Leading Cause of Aircraft Mishaps(NASA/FAA: causal factor in 65-80% accidents)Rarely is it Instantaneous!

crm principle s a3
CRM Principle - S.A.

Why do we lose Situational Awareness?

Mode confusion/Automation ComplacencyStress/FatigueStimulus Fixation Decision Making/Task Management Inadequate Error Management/Trapping

“Roadblocks”

crm principle s a what are the loss of s a flags
CRM Principle - S.A.What are the “Loss of S.A.” flags?

Not Communicating Ambiguity

No one flying the aircraft Failure to meet targets

Deviating from Standards Not addressing discrep’s

Violating Minimums Preoccupation

Confusion

crm principle s a4
CRM Principle - S.A.

What do you do when you suspect you have lostS.A.?

  • React
  • Regain
  • Reconstruct
roadblocks
ROADBLOCKS
  • The common obstructions to good CRM!
  • A combination of negative human factors, ingrained habits, and our own personal attitudes and those of the crew-members we are working with.
roadblocks1
ROADBLOCKS
  • NORMS: unwritten rules that become pressures that act upon a group, be alert for “Killer Norms.”
  • ODD MAN OUT: Ignore input from a particular member of the crew. Results in a loss of total crew effectiveness.
  • HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.
roadblocks cont
ROADBLOCKS (cont):
  • CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation.
  • BREAK THE CHAIN
roadblocks cont1
ROADBLOCKS (cont):
  • HAZARDOUS ATTITUDES: Attitudes that impede effective CRM.
    • Macho - “I can do it.”
    • Anti-Authority - “Don’t tell me.”
    • Impulsivity - “Do something -quickly!”
    • Resignation - “What’s the use?”
    • Missionitis - “Let’s press on.”
fatigue widely recognized enemy of pilots crewmembers
FATIGUEWidely recognized enemy of pilots & crewmembers.
  • A low frustration threshold
  • Degraded coordination
  • Slowness in response
  • Carelessness
  • Acceptance of low standards of accuracy
roadblocks2
ROADBLOCKS
  • STRENGTH OF AN IDEA: Tendency to unconsciously make the available evidence fit a preconceived situation; to see or hear what we want to hear, and substitute that for reality. It can take 15 seconds to “break” an idea that has been ingrained, but is incorrect.
tools
TOOLS
  • Will help in assuring a good balance of;
  • Effective communication
  • Personal monitoring
  • Strong team work skills
error traps sterile cockpit cabin two challenge rule

TOOLS cont:

ERROR TRAPS

STERILE COCKPIT/CABIN

TWO CHALLENGE RULE

personal monitoring i m safe

PERSONAL MONITORING “I’M SAFE”

ILLNESS

MEDICATION

SLEEP

ALCOHOL

FATIGUE

EATING/EXERCISE

crm principle communication
CRM Principle - Communication

Elements of Communication SkillsThe most obvious of the CRM principles.And, the easiest to affect through training.“Say what you mean, mean what you say.”

crm principle communication1
CRM Principle - Communication

Apply the A-B-C’s of communication

Accurate Bold Concise

crm principle communication2
CRM Principle - Communication
  • Understand the communication loop

Idea-Encode-Xmit-Receive-Decode-Idea

Say what you mean, mean what you say.

But, “Have I been understood?”

crm principle assertiveness
CRM Principle - Assertiveness

Elements of Assertive Behavior

Authority with ParticipationAssertiveness with RespectThe genuine, complete & direct communication of ideas, wants & needs.

crm principle assertiveness1
CRM Principle - Assertiveness

The genuine, complete & direct communication of ideas, wants & needs.

crm principle assertiveness2
CRM Principle - Assertiveness

The Assertive Statement

Open-up; get their attentionState concern as “owned emotion”State the problem - real or perceivedOffer a solutionObtain agreement/closure

“Say what needs to be said”

crm principle risk
CRM Principle - Risk

Risk Management

RISK is a factor of:

Probability

Severity

Exposure

risk management m3710 1d
Risk Management - M3710.1D
  • What is an acceptable level of Risk?
  • …potential risks to the aircraft and crew shall be weighted against risks to the personnel and/or property in distress if the mission is not taken.
  • “probable loss of an aircrew is not an acceptable risk.”
operational risk management orm

Operational Risk Management (ORM)

History:

1996 - multi-dimensional workshop

Developed common risk mgmt process

Specifically tailored to our size and multi-mission nature.

operational risk management orm1
Operational Risk Management (ORM)

Identify Mission Tasks

7 Step Process

Identify Hazards

Assess Risks

Identify Options

Eval Risk vs.. Gain

Execute Decision

Monitor Situation

step 2 identify hazards
Step #2: Identify Hazards
  • Use the “PEACE” Model to remember the 5 risk factors:
    • Planning
    • Event Complexity
    • Asset Selection
    • Communications
    • Environmental Conditions
step 3 assess the risks
Step #3: Assess the Risks

SPE RISK ASSESSMENT MODEL

  • Risk=Severity x Probability x Exposure
      • Severity - Potential consequences measured in terms of degree of damage, injury, or impact on a mission. Could occur in one of these areas:
      • Injury or death, equip damage, mission degradation, reduced morale, adverse publicity, admin/disciplinary actions
step 4 identify the options
Step #4: Identify the Options
  • STAAR
    • Spread Out
    • Transfer
    • Avoid
    • Accept
    • Reduce
step 5 evaluate risk vs gain
Step #5: Evaluate Risk vs.. Gain
  • Analyze the operation’s degree of risk with the proposed controls in place
  • Determine if operational benefits exceed the degree of risk the operation presents
  • Consider cumulative risks
  • This is the “REALITY CHECK!”
step 6 execute the decision
Step #6: Execute the Decision
  • The risk control decision is made
  • Clear communication of decision clarifies rational behind risk management decision.
  • (Done it a hundred times, been there, etc.)
step 7 monitor situation
Step #7: Monitor Situation
  • Monitor situation to ensure controls are effective and in place
  • Identify any and all changes requiring further risk management and act on them
  • Risk management is a continuous process
crew resource management
Crew Resource Management

The empowerment of all crewmembers to promote safety and increase overall aircrew performance.

Think Error Management

Execute CRM Skills