Threat and Error Management in Aviation

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Threat and Error Managementin Aviation

• Center of Excellence
• October 28th 2002
• Captain Mark Auerman

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Topics

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

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What is Crew Resource Management (CRM) ?

• Crew Resource Management
• effective use of all resources, to achieve the
  highest possible level of safety and efficiency.
  (Transport Canada)

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Historical Development of CRM
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Aircraft accident rates were extremely high post
WWII to the 1970s
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These high accident rates were largely
attributable to unreliable aircraft equipment
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Caused accident rates to decline significantly
until the mid 1970s
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Since then the accident rate has leveled off
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Now we must address deficiencies in Crew
Performance with Crew Resource Management
Training
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Goal of CRM

• Provide resources and strategies to allow airline
  crews to effectively manage threats and errors.

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Latent and Active Errors
Active errors are caused by the crew mismanaging
the resources
Latent errors are errors we inherit
POLICIES PROCEDURES
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What is CRM training all about ?
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CRM Training develops skills and strategies in
the following areas

• Communication
• Crew Performance
• Leadership
• Situational Awareness
• Decision Making

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Proactive Error Management Tools

• CRM training mandated by Transport Canada
• Initial 3 day course
• Periodic refresher training focused on topical
  issues
• Practical based training

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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

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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

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Line Checks

• Assess and evaluate crew performance during line
  operations
• Technical CRM Crew Performance

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Challenges

• Very difficult to grade
• Are we making a difference?

• Cost issue
• Changing Attitudes and Culture

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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