The Error Chain

1
The Error Chain

• Human error accidents rarely, if ever, result
  from a single overwhelming cause.

2
CRM defined

• making the most effective use of all the
  available resources on the flight deck
• people, software, information, hardware

3
Resource Management

• People
• Software
• Information
• Hardware

4
Synergy

• When the total performance of the crew working
  together is greater than the sum of the
  performances of the crew members working
  independently.

5
Human and Cockpit

• Interfaces

6
SHEL Model
7
Software

• FARs
• Maps, Charts
• Instrument Approach Procedures
• Operation Specifications
• Company Policy and Procedures
• Minimum Equipment Lists

8
Hardware

• Physical equipment
• necessary for a flight.
• Aircraft
• Components, systems
• Pilot supplies
• Fuel
• Pen and paper

9
Environment

• Weather
• G-Forces
• Sound Cockpit and engine noise
• Airport
• Navigation communication facilities
• Ambient light (or lack of)
• Cramped or small spaces

10
Liveware (outer ring)

• Other people
• ATC, Flight Service briefer,
• dispatcher, other crewmembers, flight
  attendants, passengers

11
Liveware (inner ring)

• Self
• Hub
• Physical and mental health
• and well-being
• Education
• Skill level
• Decision making abilities

12
Interfaces

• Liveware Hardware
• Aircraft design seats, displays, controls
• Human tendency to adapt

13
Interfaces

• Liveware software
• Symbology, computer programs

14
Interfaces

• Liveware environment
• Temperature extremes, altitude, noise
• Match man to the environment
• Later matched environment to human needs
  pressurization, oxygen, air conditioning,
  soundproofing
• Circadian rhythms, ozone

15
Interfaces

• Liveware Liveware
• Team work
• Personality interactions
• Leadership
• Within flight crew
• Between flight crew and cabin crew, pax, ATC,
  other company employees

16
Other interfaces

• Outside of human factors concerns
• Hardware Hardware
• Plugs and connections
• Hardware Environment
• Equipment packaging, insulation
• Hardware Software
• Equipment instruction manuals

17
Human factors in aviation

• Safe flight by man involves the interfacing of a
  healthy, skilled man in control of an airworthy
  machine, while operating in a potentially
  hazardous medium to complete an assigned mission.

18
The 4 Ms

• Man the HUMAN factor
• Machine
• Medium
• Mission

19
Flying stages

• The Glamorous Years
• Few inhibitions
• Increasing Caution
• Aware of personal and aircraft limits
• Controlled Fear of Flying
• Increased conservatism, know can be killed
• The Safe Years
• Experience conservatism

20
Mans Limitations

• Physical factors
• Stress external stimulus or force requiring
  internal changes/adjustments/adaptation
• Fatigue retards or has erratic impact on motor
  skill, degrades performance
• Health Status illness or medication/drug
  influence on performance
• Aging increased risk factors of impairment or
  disability, experience offsets

21
Personal Checklist

• IM physically and mentally
• SAFE to fly not being impaired by
• Illness
• Medication
• Stress
• Alcohol
• Fatigue
• Emotion

22
Mans Limitations

• Psychological factors
• Mental Stress impairs reasoning, memory,
  cognitive skills, has negative impact on
  performance of complex tasks
• Emotional Stress disturbance in thoughts,
  feelings and behavior as a result of
• Anxiety
• Fear
• Anger
• Irritability
• Depression

23
Three types of human stress

• Physical Stress
• Mental Stress
• Emotional Stress

24
Physical Stress

• Impairs motor skills as a result of fatigue or
  muscle weakness.
• Coordination and endurance suffer.
• Treatment Rest and relaxation with minimal
  physical exertion or pressure to perform.

25
Mental Stress

• Problem solving and cognitive reasoning skills
  are diminished.
• Confusion with simple issues.
• Treatment Diversion and exercise with physical
  or recreational activities.

26
Emotional Stress

• Debilitating feeling of anxiety, fear, anger,
  sadness, or helplessness interfere with cognition
  (concentration / memory / learning).
• Treatment Leave from job duties. Supportive
  counseling with qualified therapist.

27
Role of Emotional Stress on Performance

• Life events scale
• Over 100 points double the risk of serious
  illness within 2 years.

28
Stress Management

• Not all stress is bad

29
Stress effect on performance
10
Optimum
Performance
5
Pleasure Boredom
Distress Panic
0
5
10
Stress/Anxiety/Fear/Anger
30
Vulnerability to stress

• Eating habits
• Sleeping habits
• Caffeine intake
• Alcohol intake
• How emotions are expressed

31
Stress prevention/management

• Managing stress can be learned goal is
  adaptation
• Alert stage aware of stressors, prepare
• Resistance stage optimal adaptation to defend
  against consequences
• Exhaustion stage adaptation lost, need respite
  if stressors persist adaptation suffers
• Its not the event or situation, but ones
  reaction that fuels the stress training

32
Techniques of Stress Management

• Autogenic relaxation
• Stress inoculation
• education
• rehearsal
• implementation
• Biofeedback tension reduction
• Assertiveness training
• Physical / recreational activities

33
The Concept of Wellness

• Diet Nutrition
• Physical conditioning
• Stress Management
• Substance abuse

34
Substance abuse

• FAA drug testing for
• Marijuana
• Cocaine
• Amphetamines
• Opiates
• PCP (phencyclidine)

35
Testing occasions

• Pre-employment
• Post accident
• Reasonable cause
• Return to duty (post treatment)
• Periodic physicals
• Other randomized times

36
Pilot capability and workload
37
When how are cockpit operations effective?

• 2 ways
• Each crew member is trained, fit, ready they
  operate within SOPs, need to interact little,
  recognize use available resources routine ops
  and emergencies for which crew is trained
• Crewmembers (experts in aviation) work together
  in problem-solving way combined efforts are
  synergistic

38
Need frame of reference to

• understand differences
• comprehend why and how people behave the way they
  do
• construct ways to deal with conflicts and
  stresses of working with different, perhaps less
  than effective behaviors
• learn new ways of behaving

39
Personality and Behavior

• Grid is framework for studying behavior
• tool for describing attitudes and behavior
• not for labeling individuals
• Grid plots
• Concern for People
• vs.
• Concern for Performance

40
The Grid
Concern for people
Concern for performance
41
Grid
42
1,1 Avoid

• Avoidance
• Be visible, look occupied without being
  productive
• Contributes as little as possible without getting
  into trouble

43
1,1 Avoid

• Approach
• Communication is message passing
• Directions are general crew are left on their
  own to figure it out
• Errors are inevitable and best way to handle them
  is to not see them
• Complaints are heard in a special way hope
  complainer will drop it

44
1,1 Avoid

• Approach
• Hostile feelings are heard with no reaction get
  it out of their system and end it
• Avoids critique or treats it superficially
• They blend into the background

45
9,1 Control

• Competition
• Wants maximum performance
• Little concern for thoughts, feelings
• Uses authority to drive and control

46
9,1 Control

• Approach
• Communication is one way any incoming is
  expected to indicate compliance
• Directions are clear-cut no opportunity for
  misunderstanding or questions
• Blames others to prevent mistakes
• Complaints are a sign of weakness
• Suppresses hostile feelings
• Fault-finds when there is poor performance

47
1,9 Accommodate

• Accommodation
• Emphasizes the overriding importance of good
  relations
• If crew is happy they will cooperate

48
1,9 Accommodate

• Low concern for flight
• Leaves cockpit activities to other crew members
• Warm and friendly feelings preclude criticism
• Will be liked but not respected

49
1,9 Accommodate

• Approach
• If crew can talk freely and informally all else
  will be right
• Any topic will do
• Directions are general so that others will ask
  questions but answers are not helpful
• Dont treat errors as problems give sympathy
  and understanding
• Smooth over differences
• Hostile feelings if expressed are devastating
  make amends and restore good relations

50
1,9 Accommodate

• Approach
• Critique by emphasizing strengths improve on
  what they do well rather than talk about
  deficiencies
• Compliment rather than criticize

51
5,5 Compromise

• Compromise
• Adjusts to tempo of others
• Does not push for more some progress is made
• Splits the difference to settle differences
• Seems to put out a reasonable amount of effort
• Action is initiated but does not go far enough

52
5,5 Compromise

• Approach
• Uses formal and informal communication channels
  tries to anticipate difficulties through the
  informal ones
• Directions are general tasks are accomplished
  at acceptable level
• Errors are inevitable and tolerated to limited
  degree work by manual but knows which rules can
  bend

53
5,5 Compromise

• Approach
• Reacting to complaints is delicate matter keep
  emotions for erupting by changing subject or
  cooling off
• Hostile feelings are avoided if possible
• Encourages others to acknowledge faults and
  promise to change. Uses compliments to take
  sting out of criticism
• Gets people to perform not to high degree

54
9,9 Collaborate

• Collaboration
• Leadership is based on involvement,
  participation, commitment by all

55
9,9 Collaborate

• Approach
• Communication is open, candid, free exchange
• Directions are not given on task by task basis.
  Directions arise from goals and objectives to
  which all have agreed
• Errors are looked at for causes, educational
  opportunity, and to eliminate cause

56
9,9 Collaborate

• Approach
• Complaints are treated in serious manner,
  understood, dealt with
• Hostile feelings are danger signal understand
  them, take actions to resolve
• Critique looks at performance vs. previous goals.
  Evaluation is objective can identify what
  caused them to excel or miss
• Standards are realistically high

57
Personality factors

• Personality factors were found linked to the
  likelihood of attitude change and success in crew
  coordination and resource management.
  Researchers from NASA, FAA, and NTSB described
  the categories as
• Right Stuff
• Wrong Stuff
• No Stuff

58
Right Stuff

• Traits were positive, expressive, interpersonal,
  and superior in performance in experimental
  simulations.
• 9,9

59
Wrong Stuff

• Traits were autocratic or dictatorial and
  negatively expressive
• 9,1

60
No Stuff

• Factors were described as the wimp factor
  wherein as crew members, they were unwilling or
  unable to practice effective, positive
  leadership.
• 1,9 5,5 1,1