IATA CRM Course Threat and Error Management Captain Zhou Yizhi

Return
1515-1530 Break (approximate)
1700 - Finish

TEM
Countermeasure (CRM) Skills
DAY 2
Review
Error Avoidance
Threat Management
Error

that operational errors are normal, expected and a consequence of

“B” safely and efficiently.

from the real world…

make as pilots ...

to reduce Human Error

management style/interpersonal skills
Insure captain accept input from F/O
Addressed lack of

concepts
Situational Awareness
Stress Management
Modular
Teach the error chain
Train individual decision making, briefing

on evaluating human factors
Special training for Instructor/Check pilots
Broadened perspective
Flight attendants,

Training
Proceduralization of CRM
Checklists include CRM issues
Specialized curriculum topics
Automation, etc.
Reinforcement of

and matured

Diluted
Separation of technical and CRM training

Forgot the primary objective

have difficulty in monitoring their own performance

- Many new

from organizational or flight crew intentions or expectations.

Errors in

by trapping or mitigating
their consequences

“Error Management”

pilots have to deal with on the line?

managed by the cockpit crew during normal, everyday flights.

Such

Crew error
 
 Ground Crew error
 Maintenance error
 System Malfunctions
 Time Pressures
 Automation Events
ATC error

Crew error
 
 Ground Crew error
 Maintenance error
 System Malfunctions
 Time Pressures
 Automation Events
ATC error

line of defense!

A to B?
Avoid committing errors
Manage operational complexity
Manage their own errors
Manage

Safe
Flight

=

can handle all problems

Reality
Pilots are affected by various factors which

against threat and error
Error avoidance
Threat and error management
Undesired aircraft state

own errors
Manage aircraft deviations
Error Avoidance
Undesired Aircraft State
Management
Error Management
Threat

recognition

Adaptation of existing skills towards countermeasures in the real world

to
Threat and Error

and error countermeasures

Team building and climate
Planning
Execution
Review / modify

person knew something was wrong and did not speak up!



Least

and maintain a good communication environment

effective leadership

Important in all aspects

information and advice

Create climate for critique – give and take

Clarity - clear communication
Appropriate assertiveness – proper level for

the group

Direction -Define crewmembers responsibilities
-Good influence

Motivate -Build the team
-Give and receive

of the flight,
is the final authority and

-

briefings?
How do we accomplish this?

fully understood
Better to split the briefing into two parts if

abilities with available time
-Avoid distractions

Assign Work
-Assign actions based on

both pilots are monitoring
as much as possible during high

- Alternate plan is initiated when limits

your policy?
Missed Approach Policy

identify, knowledge, memory, problem solving skills
Generate solutions – find alternatives,

- Monitor / Crosscheck

ask:

“How often have I missed making the 1,000’ before

systems and mode status
- Aircraft systems and/or components

Inadequate flight crew

of “Pilot-Not-Flying” (PNF) to “Pilot Monitoring” (PM)

Describes what the pilot

the autopilot or other pilot is flying.

- monitor the flight

Complacency
- New in seat
-

reliability of crew
Detect work overload
Initiate assistance when required

time - hold, delay vectors

- Fatigue
- Distractions

manage the problem when not flying the aircraft!

prevent distractions?
Sterile cockpit
Locked cockpit door

workload and both pilots are monitoring as much as possible

happening, but what may happen
Anticipate problems
Gives you the ability to

what is normal
Anticipating what will happen
Prepare for problems that may

made by PM, below 10,000 or within 1000 ft of

an undesired state.

Evaluation of plans – review and modify

to asses if course of action appropriate to the conditions
-

seek information
- Question ambiguous or difficult situations until
there

position known when safety is in question
Sense persons concern

give us?
I'm uncomfortable.
We are off our heading/altitude.
I thought he gave

and process information
- vigilant – alert to situation

use of Checklists
Minimizing distractions
Planning ahead
Open two-way communication
Maintaining situational awareness

Avoidance

limitations is a vital prerequisite for adapting to our flying

training and expertise is lost if training is not maintained,

all items can be covered in a logical manner, easy

considerations

Non-flying pilot non-adherence to procedure

Embedded piloting skills

Design improvement

Captain or instructor

Percentage of Accidents
10 20 30 40 50 60

Primary Factor

Source: Boeing (1982-1991)

considerations

Non-flying pilot non-adherence to procedure

Embedded piloting skills

Design improvement

Captain or instructor

Percentage of Accidents
10 20 30 40 50 60

Primary Factor

Source: Boeing (1982-1991)

erred by not following SOP’s were 1.8 times more likely

for safe flight operation of complex equipment.

...a countermeasure to mistakes

items when under pressure
Good reminder when we are fatigued
Standardization

completing
- Not getting any responses
- Accepting incorrect response
-

missing item when fatigued we prioritize tasks in order of

team climate
Develop planning strategies

developing and maintaining a good communication environment
effective leadership

Important in all

– distractions
Contingency management?

external to the flight deck, that must be managed by

mechanical failures, adverse weather conditions, and ill passengers.


errors made by

mechanical failures, adverse weather conditions, and ill passengers.


errors made by

operations
ATC command events/errors
Cabin events/errors
Maintenance events/errors
Dispatch events/errors
Ground crew events/errors

prior knowledge of their consequences.

People unwillingly create conditions for

Latent Threats

culture
Aircraft characteristics
Qualification standards
Regulatory practices

procedures – SOP’s
-
Inadequate training – company

clearance
Captain will verbalize any hold short instructions, FO to request

Modify
(Unexpected Threat)
Threat Management
Planning
(Expected Threat)
Training / Proficiency

skills relevant to threat management with examples

strategies

when First Officer is pilot fling
Captain can manage situation
Use automation

necessary
Inquiry – asked questions to clarify
Assertiveness – stated critical information

times during each flight, most of which are unimportant
However it

in books

negative aspects
Positive
Strong motivation to do well
Pride in profession
Negative
Training that stresses

good in emergencies as in normal situations
Their performance is not

/ Descent
transition
Descent, approach
and landing
Taxi-in

training
Most accidents occur during the approach & landing phase
The approach

worldwide (ALAR)
CFIT
Errors dealing with automated systems represent the largest source

Ex) Checklist from memory
Procedural –

catch (trap) your own error
Other people are more likely to

management

- Constructive intent
- Specific

Guidelines and Techniques for
EFFECTIVE CHALLENGING

to accomplish this
Team Building
leadership
Communication environment
Execution
Monitor / crosscheck
Workload management
Vigilance
Automation management

the

Incorrect aircraft configurations
Vertical deviations
Lateral deviations
Speed too high
Speed too low
Abrupt aircraft handling

Path/glide slope deviations
Unstable approach
Long landing
Firm landing
Wrong taxiway/runway
Runway incursion

Modify
Undesired Aircraft State
Management
External Alerting

Threat

Intentional Non-Compliance

Crew Error

Threat

be due to mismanaged threat and/or error

Crew Error
Threat

threat and error

“the tip of the iceberg”

State
Management

climate behaviours such as active leadership and establishing a team

capability
Limits imposed by stressors
Tunnel vision
Limits imposed by fatigue or other

behaviours such as active leadership and establishing a team environment
planning

Threat Management
Team Climate, Planning
Review /Modify

limitations such as fatigue and other physiological factors, limited memory

Threat Management
Error Management
Team Climate
Execution

and modify countermeasures which include evaluation of plans, inquiry and

Management
Error Management
Undesired Aircraft
State
Undesired Aircraft
State
Management

Team Climate
Review

Crew Error
Undesired Aircraft
State
Incident

Error Avoidance

Error Management

Undesired Aircraft
State
Management

Threat and Error
Management Model

Crew Error
Undesired Aircraft
State
Incident

Error

Threat Management

Error Management

Undesired Aircraft
State
Management

Threat and Error
Management Model

“B” safely and efficiently.

adjust resources
Better use of training

on the line?

By fostering a culture where

a commitment to reduce
error-inducing conditions.

adopt

information, not only from the crew but from the other

Crew Error
Undesired Aircraft
State
Incident

Error

Threat Management

Error Management

Undesired Aircraft
State
Management

Threat and Error
Management Model

SMS by bringing in hard data
Linkage between Safety and CRM

training in threat and error management

Understand limitations of crew

Collect

“real” problems that line pilots face

Cannot prevent the creation of

countermeasure skills to crews

Feedback-help management understand

- strategies put forth by the company

Training - Technical

of flight crews during regularly scheduled flights
Provides feedback of threat