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Flight Operations Safety Awareness Seminar (FOSAS)

Human Factors (HF) and

Crew Resource Management (CRM)
Airbus Flight Operations Support and Training Standards
Nairobi, 19-21 Sep. 2017
 HF and CRM

The Importance of Threat & Error CRM Best Practices

Human Factors Human Factors Management and
CRM PM role

2 Sept. 19-21, 2017 ICAO/Airbus FOSAS

 HF and CRM

The Importance of Threat & Error CRM Best Practices

Human Factors Human Factors Management and
CRM PM role

3 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Importance of Human Factors
 One event
Two B747 collided on the runway, due to Take Off without clearance, and poor
Tenerife 1977 visibility.
› Communication, teamwork, leadership, decision making
 This accident had a huge influence on the industry, particularly in the area of communication.
 Emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots.
 The word "takeoff" was removed from general usage, and is only spoken by ATC when actually
clearing an aircraft to take off.
 Less experienced flight crew members were encouraged to challenge their captains when they
believed something was not correct,
 Captains were instructed to listen to their crew and evaluate all decisions in light of crew
concerns.
 Finally, was implemented what is known today as Crew Resource Management (CRM).

4 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Importance of Human Factors

But every day there are good ones!

5 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Importance of Human Factors

› Successive Threats:
Jakarta June 1982 Volcanic ash – loss of 4 engines – Loss of pressurization – ATC misunderstanding
B747-200
– F/O oxygen mask broken – Mountainous area – Windscreen pollution – Glide
slope inoperative
› Successive positive actions
Flying: Gliding
Navigating: Keeping the high terrain in mind
Communicating (Distress message + A7700)
Managing remaining systems: Applying restart drills, using oxygen masks, etc…
Situation awareness (terrain, loss of pressurization, oxygen mask failure…)
Teamwork (3 crew members)
Captain leadership
Decision making (high V/S due to F/O oxygen mask failure, type of approach…)
See also Video "Falling from the Sky" from the TV series Mayday (Air Emergency, Air Crash Investigation) [documentary TV series].
6 Sept. 19-21, 2017 ICAO/Airbus FOSAS
Importance of Human Factors
 Near Jakarta 1982…
› Cruising FL 370, 4 engines failed due to volcanic ash.
› The flight crew quickly determined that the aircraft was capable of gliding for 23 minutes and covering 91
nautical miles (169 km) from its flight level of 37,000 feet.
› Emergency was declared. The crew squawked A7700. However, Jakarta Area Control misunderstood the
message, interpreting the call as meaning that only engine number four had shut down.
› A Garuda Indonesia flight relayed the message to Air Traffic Control so that it was correctly understood.
› As pressure dropped in the cabin, F/O oxygen mask was broken; the delivery tube had detached from the
rest of the mask. Captain decided to descend at 1,800 m per minute.
› Reaching 13500 ft, after several engine restart procedures, the crew finally re-started 4 engines.
› After a while, engine number two surged again and was shut down.
› As Flight 9 approached Jakarta, the crew found it difficult to see anything through the windscreen.
› An ILS approach was planned. However, the glide slope was inoperative, so the F/O monitored the descent
using DME.
› After landing the aircraft could not taxi by its own, due to poor visibility through the wind screen. It was towed
to the gate. Source…
7 Sept. 19-21, 2017 ICAO/Airbus FOSAS
 HF and CRM

The Importance of Threat & Error CRM Best Practices

Human Factors Human Factors Management and
CRM PM role

8 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Human Factors Model

What are Human Factors?

 We will develop, but before, let’s go for a concentration exercise

9 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Human Factors Model

 Human Factors are:

Anything that affects a person’s

performance

10 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Human Factors Model

Performance

Good
Standard
Poor

11 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Direct Factors
 The acts or omissions that directly affect performance

Decision Awareness

Performance

Dexterity Distraction

12 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Potential Factors
 Things that have the potential to influence the direct factors

Design System failures

Environmental Psychological
Fatigue Negative attitudes
Illness Physiological
Visual illusions Language
Memory Performance
Poor
Performance
Procedures
Performance
Time Alert systems
Ergonomic Emergencies
Organizational Relationships
Commercial Documentation
Automation Cultural
Faulty equipment Stress

13 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Potential Factors Interaction
 Interactivity between Potential Factors will increase

Performance
Poor
Performance

14 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Managing Factors
 Things that manage the effect of the Potential Factors and improve Direct Factors

Performance

15 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Managing Factors - Organizational

Performance review Briefings

Training Tools
SOPs Culture change
Checklists Motivation
System review Performance …

16 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Managing Factors - Individual

Threat & Error Management Problem solving

Discipline
Communication Decision making
Teamwork Concentration
Leadership Stress
Positive attitudes management
Performance
Behaviour Monitoring
Planning
Problem prevention
Workload management Fitness
Situation awareness Knowledge
Technical skills

17 Sept. 19-21, 2017 ICAO/Airbus FOSAS

Human Factors Model

Direct Potential
Factors Factors

Performance

Managing
Factors

18 Sept. 19-21, 2017 ICAO/Airbus FOSAS

 HF and CRM

The Importance of Threat & Error CRM Best Practices

Human Factors Human Factors Management and
CRM PM role

20 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

What is CRM?

 We will develop, but before, let’s explore what is Airmanship

21 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

What is Airmanship ?

 Airmanship is the Technical and Non technical Knowledge, Skills and Attitude
that pilots need to ensure that aircraft is operated:
 Safely, Airmanship
Airmanship
 Efficiently, Technical Non-Technical
 Effectively Knowledge Knowledge
Skills Skills
Attitude Attitude

What is CRM?

 CRM is the Non-technical Knowledge only

22 Sept. 19-21, 2017 ICAO/Airbus FOSAS
CRM and Threat and Error Management

THREATS

Undesired Aircraft State

Come to the crew

Errors come from

Threats or are
independent.

ERRORS
Come from the
crew

23 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

THREATS

Undesired Aircraft State

Come to the crew

outcome
Errors come from
Threats or are
independent.

ERRORS
Come from the
crew

Not avoided, not managed, poor CRM….

24 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

THREATS A

Undesired Aircraft State

Come to the crew V
O
I

outcome
Errors come from D
Threats or are
independent.
-----
T
ERRORS R
Come from the
A
crew
P

Good CRM helps…

25 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

THREATS A

Undesired Aircraft State

Come to the crew V
O M

outcome
I A
Errors come from D N
Threats or are
----- A
independent.
T G
ERRORS R E
Come from the
A
crew
P

Good CRM helps…

26 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

THREATS A

Undesired Aircraft State

Come to the crew V
O M

outcome
I A
Errors come from D N
Threats or are
----- A
independent.
T G
ERRORS R E
Come from the
A
crew
P

Good CRM helps

27 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

Life of a Hazard

Mismanaged Mismanaged
Mismanaged Errors Mismanaged UAS
Threats Situation

28 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management

Life of a Hazard

Flying high and heavy

with Tropo T° Change
Letting speed drop
Buffet
Stalling
Crash

OAT increase Mismanaged Speed Mismanaged Stall

Mismanaged Buffet
not detected drop Recovery

29 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM and Threat and Error Management – Crew Perfomance

Safety Performance  SAFETY PERFORMANCE

› Effectiveness of the Defence Barriers

30 Sept. 19-21, 2017 ICAO/Airbus FOSAS
CRM and Threat and Error Management – Crew Perfomance

Crew Performance

Breach of Breach of Breach of Breach of

Barrier Nº1 Barrier Nº2 Barrier Nº4 Barrier Nº4

31 Sept. 19-21, 2017 ICAO/Airbus FOSAS

How to recognize, avoid, trap and manage Threats and Errors

Communication

Leadership & Teamwork

Workload Management

Situation Awareness

Problem solving & Decision Making

32 Sept. 19-21, 2017 ICAO/Airbus FOSAS

 HF and CRM

The Importance of Threat & Error CRM Best Practices

Human Factors Human Factors Management and
CRM PM role

33 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM Best Practices & PM role

CRM Best Practices

 Ensure clear delegation of tasks

 Manage competing activities ( i.e., prioritize )

 Use all appropriate system resources

 Use on-board documentation

 Assess time-critical situations

 Verbalize with other crewmember

 Manage risk of tunnel vision ( narrow-focus )

34 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM Best Practices & PM role

Tasksharing - Captain

Leadership role of Captain :

 Manage priorities
 Distribute tasks
( if non-standard task sharing )
 Consult
 Share situation analysis
 Decide
 Assure final authority and decision making
 Ensure that everyone contributes to communication / information and backup /
crosscheck
35 Sept. 19-21, 2017 ICAO/Airbus FOSAS
CRM Best Practices & PM role
Attitude
Good Monitoring
Knowledge Skill
Requires Knowledge Skill
Knowledge
 Through Training
Experience
 Application of Knowledge
Skill
Experience
 Both knowledge & Experience
Attitude Experience
 Conscientiousness– Vigilance– Assertiveness
Communication Communication
36
 Intra-cockpit / ATC / cabin – Sharing Goals & Intents
CRM Best Practices & PM role
› A Key Safety Element in the J. Reason
‘Swiss Cheese Model’ of Error Detection
Tasksharing - PM & Management

Support and monitoring roles of PM:

 Relay critical information for PF awareness
 Provide timely inquiry statements before deviations develop
 Provide standard and excessive deviation callouts
(as applicable) and ensure PF response on intended corrective action(s)
 Propose precise solutions if PF does not respond
 Provide emergency statement if required
 Take over control, if conditions warrant such action

37 Sept. 19-21, 2017 ICAO/Airbus FOSAS

CRM Best Practices & PM role › Unexpected tailwind
› Runway condition
“Don’t you think › Visibility change
Tasksharing - PM we are high and fast ?”

“Shall we extend gear

to reduce speed ?”

Taking over
“Go-around / flaps”

“V DEV, airspeed and

GS high, Sir” “500 ft, not stabilized,
Go-around !”
38 Sept. 19-21, 2017 ICAO/Airbus FOSAS
CRM Best Practices & PM role

Training & Evaluating Monitoring Skills

Reinforce the responsibility of PM

 Explain WHY inefficient monitoring reduces TEM performance
Develop clearly defined PM tasks, Training Objectives
and proficiency standards. Ensure Instructors &
Evaluators proficiency
 Explain HOW clearly defined PM standards, training objectives,
and instructor proficiency are necessary to enhance pilot’s
monitoring performance
Incorporate Monitoring training into training exercises
 Suggests methods of incorporating monitoring training into
training modules and instructors guides (Refer to Airbus OTT)
39 Sept. 19-21, 2017 ICAO/Airbus FOSAS
CRM Best Practices & PM role

Training & Evaluating Monitoring Skills

Flight Safety Foundation Airbus

CAA Paper 2013 ICAO DOC 9995
Flight Path Monitoring Operations Training Transmission
Monitoring Matters EBT
(OTT) Ref. 999.0027/15
Guidance on the Development of Pilot Monitoring Skills Recommended training for the PM Role
40 Sept. 19-21, 2017 ICAO/Airbus FOSAS
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CRM and Threat and Error Management

What is a Threat?  “Events, or errors, that occur beyond the influence

of the crew, increase operational complexity and
workload, and which must be managed to
maintain safety margin”

› Threats come to the crew

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CRM and Threat and Error Management

What is an Error?  “Actions or inactions by the Flight Crew, that

lead to deviations from organizational or Flight
Crew intentions or expectations”
 Errors are: spontaneous, linked to threats, or
can be part of error chains.”

› Errors come from the crew

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CRM and Threat and Error Management

What is a Hazard?

 “A condition or an object with the potential of causing :

 Injuries to personnel
 Damage to equipment or structures
 Loss of material, or
 Reduction of ability to perform a prescribed function.”
ICAO (SMM 3rd version)

› In TEM Concept Threats & Errors are considered as Hazards

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CRM and Threat and Error Management

What is an Undesired Aircraft State?

UNDESIRED AIRCRAFT STATE

 “Flight Crew-induced aircraft position or speed deviations, misapplication

of flight controls, or incorrect systems configuration, associated with a
reduction of safety margins”

 Undesired aircraft State is not an outcome:

 It is a transitional situation between normal situation and outcome.

 Restoring margins of safety is still possible.

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45 Sept. 19-21, 2017 ICAO/Airbus FOSAS