Lecture Outline JUNE 2013

Crew Resource Management
Lecture Outline
NAVAVSCOLSCOM
CRM Director
181 Chambers Ave, Suite C
Pensacola, FL 32508-5221
850-452-2088 DSN 459
-XQH2013
COURSE OVERVIEW
School of Aviation Safety
Welcome Aboard
NAS Pensacola
Please fill out blue name tags with the

supplied black marker.
Please fill in CRM class information
sheet with your full social.
CRM Course Administration
TIMES / UNIFORM
FILL OUT NAME PLATES,
CLASS ROSTER, BOOKS, ETC
Off Limits:
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PHONES
SUPPORT
COFFEE
NASC
WELCOME
ABOARD
!!!
CRMI
Zero Tolerance
Guidelines
Speeding 15-20 over posted limit = 7 day suspension
Speeding 21+ over posted limit = 30 day suspension
Speeding in high student concentration areas 10 over = 7 day
suspension / 10+ = 14 day suspension
Fleeing / Attempting to elude = 1 year suspension
Racing on roadway = 1 year suspension
Failure to use child restraint system = 30 day suspension
Littering (including cigarette butts) = 7 day suspension
Driving while operating a Cell Phone w/o Hands-Free device / Illegal
Handicap Parking / Failure to use seatbelt:
1st Violation = 7 day suspension
2nd Violation = 30 day suspension
3rd Violation = 6 month suspension
Operating a Motorcycle w/o all required PPE, on or off base:
Same as Above (re-attend motorcycle safety course for 3rd
Violation)
Lunch
Food
Heads
Smoking
O Club
Lunch 1100-1400 Tues-Fri
Bar 1500 to close Wed-Fri
Take out available 452-2026
Subway, Asian, Italian NEX
Taco Bell & Pizza Hut, A&W Portside Club
The Oaks at the Golf Club
Naval Aviation Museum - Cubi Point Bar
Navy Yard Eatery Daily Specials
Off Base via front gate
Maps
Privileged
FOR OFFICIAL USE ONLY
BOQ
Naval Aviation
Museum
Aviation Plaza
Portside
O Club
Starbucks
Galley
Questions on admin?
THIS IS A PRIVILEGED, LIMITED-USE, LIMITEDDISTRIBUTION, SAFETY INVESTIGATION

REPORT. UNAUTHORIZED DISCLOSURE OF THE
INFORMATION IN THIS REPORT OR ITS
SUPPORTING ENCLOSURES BY MILITARY
PERSONNEL IS A CRIMINAL OFFENSE
PUNISHABLE UNDER ARTICLE 92, UNIFORM
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DISCLOSURE OF THE INFORMATION IN THIS
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PERSONNEL INSTRUCTION 752. THIS REPORT
MAY NOT BE RELEASED, IN WHOLE OR IN PART,
EXCEPT BY THE COMMANDER, NAVAL SAFETY
CENTER.
CRM
for
Instructors
LCDR Brendan T. OBrien
CRM Director
CRM Instructional Model Manager
CRM
School of Aviation Safety

Mission
To EDUCATE aviation officers at all levels to:
Identify hazards
Manage risks
Investigate and report mishaps
Develop and administer command safety programs
ASC - ASO - CRM

To foster and conduct safety-related research, and
provide assistance in support of the Naval Aviation
Safety Program
Thereby,
Enhancing Combat Readiness
through the Preservation of Human and Material Assets
CRM
Instructional Model Manager
CRM-I course
4 days
Twice a month
Mobile Training Team
4 times per year
Fleet concentration area
Assist Visits (30-40 per year)
FRS/Wing Program Manager
All T/M/S platforms (over 45)
Program Manager Conference
Conference Attendances
Fleet Support
What is CRM?
YOU
(7 skills)
CRM Is:
Use all available resources to Increase
Operational Mission Effectiveness
in order to
accomplish your
mission.
Ability to use all

available
resources
CRM and ORM

CRM is the foundational skill set that
enables proper use of ORM
The goal is to increase mission

effectiveness by :
Minimizing crew preventable errors

Maximizing crew coordination
System of behavior modifications
Optimizing risk management
CRM Is:
WARFIGHTING
CRM is about optimizing our ability to fly
our aircraft to best perform our mission,
and our mission is WARFIGHTING.
In depth ORM
Deliberate ORM
Time Critical ORM
Purpose Of The
CRM Instructors Course
Knowledge
Tools
Guidance
And enable you to take this to the fleet
CODVVURRP PDUWLFLSDWLRQ
RHVSRQVLELOLWLHV
YOUR
PARTICIPATION
IS THE KEY
Because in one week.

Your squadron is going to expect a:
Human factors expert

Stan / Eval expert for check rides
Curriculum development expert
Possibly a contractor interface expert
Scenario development expert and POC for
check ride and curriculum integration matters
All around CRM Guru
Why?...
CRXUVH EYDOXDWLRQ
1.
a.
b.
STUDENT/STAFF INTROS
(name, a/c, command)
SXPPDU\
Class Introductions
Administration
Syllabus Overview
Course Format
Classroom Participation Responsibilities
Course Evaluation
HISTORY
HISTORY OF CRM
C-050-1503A 5001 01
Terminal Objectives
Identify what drove the development of
CRM
Define and Understand some of the
errors made along the way
Understand the future of CRM
Aviation Is Inherently Dangerous
There will always be something or

somebody out there trying to kill you...
Enabling Objectives
Instruct CRM history per CNAF 1542.7
(series), and the Evolution of Crew
Resources Management Training in
Commercial Aviation
Discuss the growth and evolution of
CRM research in private and military
sectors per aforementioned applicable
instructions
Outline
Events that led to CRM development
Tenerife Case Study
Human error
CRM development in the civil sector
CRM development in the Navy and
Marine Corps
Challenges
Future
Purpose of CRM
Summary
Tenerife Background
A Tale of Two 747s

KLM Flight 4805
A runway collision involving two 747s
- 234 Passengers
14 Crew
- From Amsterdam,
chartered: Holland
International
- Captain: Jacob van
Zanten (Chief Pilot)
Face of KLM
- 11,700 hrs
583 fatal injuries, the most ever in any

single aviation related mishap
A major accident that led to CRM
development
Tenerife
A Tale of Two 747s

PAA Flight 1736
Tenerife
- 378 Passengers
- 16 Crew
- From Los Angeles via
NY
- Captain: Victor
Grubbs
- 21,000 hrs
- Clipper Victor
Las Palmas
Africa
55 tons of fuel
Crew day
30
12
12
Disembark passengers
Tenerife Summary
30
Tenerife Summary
Pan Am instructed to follow3rd taxiway?

RVR 500m with 700 required
Tenerife Summary
12
30
Tenerife
KLM immediately to full power

Copilot challenges
Departure vs takeoff clearance
Tenerife Summary
Holes in the Cheese
What caused the mishap?

Holes in the cheese
Divert
Unfamiliar airfield
Language barrier
Weather
Stress vs Time
Stepped on communications
Takeoff without clearance
International Investigation
70 crash investigators (Spain, Netherlands, US)
Mishap Findings / Probable cause:
KLM initiated take-off without clearance

Wx conditions caused poor visibility
PAA exited at incorrect taxi-way
Simultaneous radio transmissions blocked key instructions
Nonstandard instructions and phraseology
Disruption of normal procedures due to airport crowding
Human Error
Commercial
CRM 1977 - Current
Safety Response
Greater emphasis on English as international language of
aviation
Establishment of standard phraseology
FAA/ICAO: line up and wait.
Requirement for precise read-back instructions (no OK

or roger)
Phrase "take-off" is only spoken when the actual take-off
clearance is given (e.g. departure)
Development of Crew Resource Management theory
1977 Interviews with commercial

airline pilots reveal dissatisfaction with
training in non-technical skills
1979 NASA workshop: Resource
Management on the Flight Deck
- H/E major cause of accidents
1981 United Airlines DC-8 CRM /
Simulator (1st generation of CRM)
1993 Delta Chain of Events /
modular training (2nd generation)
1995 3rd and 4th Generations of CRM
1997 Continental Threat and Error
Management (5th generation)
CRM And The Military
Tenets of Commercial CRM

4 Critical Skills
Decision Making
Command
Leadership
Communication
Team Building
Briefing Strategies
Leadership
Communications
Situational Awareness
Stress Management
Standardized Crew Training
Begins to grow.everybody wants one,

and everyone has their own method
Difficult to duplicate Corporate Culture
Criticism of psychobabble
CRM 1987 - 1989

1987 Contract to modify civilian CRM courses for
Navy (Allen Corp.)
1989 CRM introduced to Naval Aviation
Slow to accept due to one size fits all approach
1989 Naval Air Warfare Center begins R&D

program to develop Navy CRM Program:
Theoretically driven, researched based

By aviators, for aviators
Instructional Strategies
Focus on entire aircrew
Skills relevant to tactical environment
Measurement and Feedback
Validated and Evaluated
1986 - NASA and USAF MAC CRM workshop:

Cockpit Resource Management training, focusing on
Communication, Leadership, Situational Awareness, and Crew
Coordination is just as appropriate, with some modification, to
pilots manning a flight of single seat tactical aircraft as it is to
the pilots, Flight Engineers, and Loadmasters operating a C5
transport aircraft".
Differences between civilian and military

aircrews:
Age
Experience
Rank
Mission Objectives
Mission Requirements
Crew Duties
Centralized training
CIV
OLDER
MORE
TENURE
TRANSPORT
BENIGN
SERVICE
FAA
MIL
YOUNGER
LESS
UCMJ
NUMEROUS
HOSTILE
TACTICAL
PLATFORM
Navy Research and Development

Naval Air Warfare Center
1992 NAWC published their findings:
CRM must be systematically incorporated
into all phases of crew training (i.e., initial
qualification, transition, upgrade, recurrent).
Must train the specific coordination skills
and behaviors required by aircraft type,
aircraft model, phase of flight, and overall
mission (e.g., transport, cargo) utilizing the
Seven Skill areas. The Navys CRM
program would be called Aircrew
Coordination Training (ACT).
CRM 1997 2012
CRM 1990 - 1995

1993 Navy implements Fam/Interim ACT
program, OPNAVINSTS 3710 & 1542.7A
1993 Tiger Team formed
sell it to the Fleet
begin T/M/S specific CRM program
1994 ACT School House created (7) day
course
1995 OPNAV 1542.7A signed
First Integrated ACT: S-3B Viking
Funding for Integrated and Recurrency for
all Navy and Marine Corps platforms
1998 1542.7B signed
CRM flight evaluation

Required topics for yearly qualifications.
History, seven skills, T/M case studies
2001 U.S. Navy changed ACT to

CRM (1542.7C)
2002 Integration complete for all
U.S. Navy and Marine Corps
platforms
2012 CNAF 1542.7 signed
Current CRM Principles

Research Based Not theory
Incorporates Existing Knowledge Base
Not reinventing the wheel
For Aircrew by Aircrew who better?
Emphasizes Evaluation and Validation
Realistic opportunity to learn
Mission Specific H-46 F/A-18
Skill Based specific training objectives
Integrated taught from the beginning
D.A.M.C.L.A.S
Decision Making
Assertiveness
Mission Analysis
Communication
Leadership
Adaptability / Flexibility
(DM)
(AS)
(MA)
(CM)
(LD)
(AF)
(SA)
throughout career, not an afterthought
Human Error Background

For the past four decades commercial
aviation, the federal government, and
more recently the military have expended
substantial resources in determining the
cause of mishaps
Information recovered from cockpit voice
recorders, SIRs, HAZREPS, and civilian
mishap reports indicate the number one
cause is
Human Error
NAVAL SAFETY CENTER

1991 Naval Safety Center Report
Human error is a contributing factor in
50% of all Class A mishaps
Human error is defined as any incident
involving crew pilot error which relates to
poor employment of aircrew coordination,
S/A, judgment, sub-optimal physiological
state, or a violation of NATOPS
Human Error Past
Human Error Past
USN/USMC, FY97-01
No. of Class A Mishaps

71 of 84
USN Aviation
40 of 48
USMC Aviation
USN/USMC, FY03-07
Human Error
Human Error
HE 85%
NonHE
15%
USN Aviation
81 of 86
HE 94%
HE 83%
NonHE
17%
USMC Aviation
52 of 57
HE 91%
Leading Causal Factors
Aircrew (breakdown in Crew Resource

Management, poor decision making, failure to
properly perform emergency procedures)
Supervisory (failure to provide adequate
guidance and training)
Material/Systems Malfunction (16%)
Material/component catastrophic failure (no
human
error involved)
NHA
Symposium.
April 14-17 2008

human
error involved)
NHA
Symposium.
April 14-17 2008
Human Error (84%)
NonHE
6%
NonHE
9%
Human Error (90%)
31
NSC Data: 22 Feb 08
Human Error Past
Human Error Today
USN/USMC, FY05-09
USN/USMC, FY10-12
Human Error
Human Error
USN Aviation
52 of 61
HE 85%
USN Aviation
19 of 26
HE 73%
USMC Aviation
32 of 33
HE 97%
USMC Aviation
10 of 17
HE 59%

human
error involved)
NHA
Symposium.
April 14-17 2008

human
error involved)
NHA
Symposium.
April 14-17 2008
Human Error (89%)
NonHE
27%
NonHE
41%
Human Error (67%)
NSC Data: 05 Oct 2010
Future:
Where is CRM headed?
33
NSC Data: 13 Nov 2012
IT IS NOT:
CRM/ORM integrated into NATOPS

More focus on individual error prevention/mitigation
Better data collection tools to spot trends
Integration of CRM concepts in other facets of Navy
Surface
Subsurface
Special Operations
Medical Practices
32
A SAFETY PROGRAM.
34
IT IS:
A program to effect a positive behavioral
change in individuals (as opposed to
attitude changes or management
theory) in order to prevent and/or
minimize human factor and crew errors.
YOU own the program.
Questions?
Summary
History
Commercial
Navy/MC
Challenges
Future
Your input and ownership
CRM
PROGRAM MANAGEMENT
Terminal Objective
Maintain a CRM Program in an
operational setting
CRM Program Management
C-050-1503A
Enabling Objectives
Review CRM instruction changes
State the requirements for documenting
annual CRM qualifications
Review CRM Programs
Manage a CRM Program
Explain the importance of integration of
CRM throughout flight operations
References
Instruction changes
Instruction changes (cont.)
CRM Qualification and Life Cycle Training Model

References:
OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it

does not need to be redone prior to first flight.
CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight
training shall be conducted in all Chief of Naval Air Training (CNATRA)
squadrons and at the Fleet Replacement Squadrons (FRS) prior to
first flight and is required for all students, instructors under
training and any NATOPS qualified aircrew members without
documented T/M specific ground training as defined by reference
(a): (OPNAVINST 3710.7 series).
CNAF 1542.7
OPNAVINST 3710.7 series
T/M/S NATOPS
Wing and Squadron SOP
Initial T/M Specific Training

OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be
conducted by a designated CRM instructor or facilitator
CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted
by a designated CRM Instructor (CRMI)
Some squadrons may initially be short CRM instructors to ensure this

new requirement is met.
Recommendations: Look through all NATOPS jackets and find personnel

that have attended CRMI and utilize them to help with the initial shortfall.
Send current CRMF personnel to attend CRMI.
Annual T/M Specific Recurring Training
CRM Instructor Training
OPNAVINST 1542.7C: Not specified.
OPNAVINST 1542.7C; e: Not specified.
CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet

their own annual requirements.
CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor

course is a prerequisite to designation as a CRM Community
Program Manager (PM) or CRMI. T/M CRM Facilitator training must also
be completed in order to be designated a CRMI in a specific T/M.
New requirement in the CNAFINST. This was seen as a best practice and
not specifically required in OPNAVINST 1542.7 (series). However, it was a
requirement in the Assist Visit Checklist.
Recommendation: Send current CRMF personnel to attend CRMI.
CRM Facilitator Training
Civilian Aircrew Members/Instructors
OPNAVINST 1542.7C; 7.f.: Not specified.
OPNAVINST 1542.7 (series): Not specified.
CNAFINST 1542.7; 6.g.(1)/(2):
CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall
maintain the same qualifications as a uniformed aviator. Non-flying
civilians that provide flight instruction to USN/USMC aviators are required
to maintain the same ground CRM currencies as uniformed aviators. If
they are providing CRM initial ground training they are required to be
a CRMI. If they are only providing CRM recurrent ground training they
are required to be a CRMI or CRMF.
(1) If the CRMF training is being administered with the intent of qualifying a
CRMF,
CRMI,
Provides specific guidance for CRM training topics for CRMI and CRMF
qualification that were not covered in OPNAVINST 1542.7 (series). This
section clarifies that CRMF training does not need to occur first to
become a CRMI.
This section provides specific guidance for Civilians mirroring the

requirements of uniformed aviators.
CRM Organization
Unmanned Aircraft Systems

Naval Safety Center

CRM Director
CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in
accordance with this instruction, to include training for UAS crewmembers
(UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO),
and Ground Maintenance Vehicle Operators (GMVO).
CRM IMM
This section provides guidance for UAS mirroring the requirements of

uniformed aviators.
Controlling Custodians
Curriculum Model Manager (CO)
CRM Instructors
Program Manager
CRM Facilitators
Designations
CRM Fleet Organization

CRM Instructional
Model Manager
NSC
The PM and CRMIs are designated in

writing by the CRM T/M/S CMM per CNAF
CRM Director
SAS Divo
Controlling
Custodian
USN TacAir
Inst. Model Mgr.
CRM-I Instructor
T/M/S Curriculum
Model Manager
FRS CO
T/M/S Curriculum
Model Manager
FRS CO
Controlling
Custodian
USMC TacAir
Inst. Model Mgr.
CRM-I Instructor
USN Prop/Heavy
Inst. Model Mgr.
CRM-I Instructor
USMC Prop/Heavy
Inst. Model Mgr.
CRM-I Instructor
USN Helo
Inst. Model Mgr.
CRM-I Instructor
USMC Helo
Inst. Model Mgr.
CRM-I Instructor
Same
Organization
Same
Organization
Same
Organization
Same
Organization
Same
Organization
T/M/S Curriculum
Program Manager
FRS Instructor
CRM Instructor
CRM Instructor
CRM Facilitator
Squadron Level
CRM Facilitator
Squadron Level
Documentation
NATOPS Jacket
Designation Letter
Section 2, Tab C
(miscellaneous)
Enclosure 3
CRM IMM
Designation
(CRMI, ULM, and
CRMF)
Ground Training (T/
M/S)
Flight Evaluation (T/
M/S)
Training
All CRM ground training contains the
following common elements:
CRM history
7 critical skills
CNAFINST 1542.7
T/M specific case study
Enlisted
Inst. Model Mgr.
CRM-I Instructor
CRMFs are designated by their respective

Commanding Officers or Officers in Charge
as applicable they require endorsement
from the PM or CRMI
Documentation
NATOPS Jacket
Slash 7
Instrument Check
Paragraph on Command
Letterhead signed by the
Commanding Officer
Annual Flight CRM

Check/Training
Conducted CRM flight
evaluation per
CNAFINST 1542.7.
Note any CRM

observations
Proper flight code in the
logbook 2L3/2L4/2L5
Ensure the date matches
all 3 documents (Encl 3,
slash 7, and logbook)
Conducted CRM flight evaluation per CNAFINST 1542.7.
Types of Training
Initial ground training: Covers what
someone new to the platform should know
regarding CRM issues within the
community
Annual recurrency training: Similar to
initial, but more focus on community
specific issues and personal experience
Squadron instructor training: Tailored to
suit the needs of CRM during student
training (CNAFINST 1542.7; 6.g.(1)/(2))
Types of Training (Cont.)

CRMF training: Specific for those who
conducting annual training. CRMF: History,
7 skills, CNAF 1542.7, program admin,
facilitation and evaluation techniques,
workload management, teamwork, review
of community specific annual ground
training brief, and conduct grading of the
CRM flight evaluation
Training Techniques
Teach facilitators, and students,
platform specific cases that
demonstrate good and/or bad examples
of the seven skills and threat/error
management
Examine HAZREPs and Mishap
Reports as your resource
Personal experiences are valuable!
Training Techniques (Cont.)

Case studies should be crew position
specific
Include current equipment, especially
automation
Maintenance, operational, and
administrative impacts on CRM should
also be included
Types of Training (Cont.)

CRMI training: CRMI course graduate,
program admin, facilitation and evaluation
techniques, review of community specific
annual ground training brief, and conduct
grading of the CRM flight evaluation
Additional topics may be included by CMM
Remember this CRMI course is only one of
FIVE requirements to qualify (NATOPS
qualified; Designated by your CMM; CRMF;
and E5/03 and above)

Case studies should be T/M specific
Case studies from other aircraft can be
used provided there are common elements
between aircraft:
F-18 H-60
Transferability is the issue. Just ask
yourself does the case study have
anything to do with my platform?
H-53 SAR = H-60 SAR

Personal examples are invaluable
Old case studies and training materials
indicate a stale CRM program
Case studies can be developed by using
SIRs, HAZREPS, ASAP, MFOQA,
personal experiences, the FAA, and the
IMMs
Good CRM Programs

You will inherit the program
Know your squadron CRMIs and CRMFs
Maintain a contact list
Standardize training media
Know the state of CRM practices in your
T/M/S
Good CRM Programs (Cont.)

Designations in the NATOPS jacket and
also in the PM binder
Documentation of check-flight evaluations
on enclosure (3) in NATOPS jacket, on
NATOPS/Instrument/Stan check
paperwork, and identified in the flight
logbook with the correct codes
PM turnover binder

Developed CRM SOP
Tracking, scheduling, and monitoring of
qualifications
Have an effective number of
experienced CRMI and CRMF
CRM incorporated into procedures
including NATOPS, briefs/debriefs,
checklists, and FTI
Incorporates human error concepts and
Threat and Error Management

CRM ground training conducted prior to
the first flight and/or check-flight
evaluation:
T/M/S specific
Scenario intensive
CRM dedicated flight events, in a high
fidelity simulator if available, and evaluate
crew performance

CRM Programs should NOT be
Ground training focuses exclusively on 7
skills (DAMCLAS check in the block)
Ground training as part of Safety Stand
down
Evaluation documented as an afterthought
Not knowing or tracking the facilitators for
your model
Check-flight Grade Sheet

AIRCREW CRM CHECK FLIGHT EVAL WORKSHEET
OVERALL GRADE
EVALUEE:
_________________________________
OUTSTANDING
EXCELLENT
INSTRUCTOR: __________________________________ SATISFACTORY
_________ 3.5-4.0
_________ 2.8-3.4
_________ 2.0-2.7
UNSATISFACTORY _________ 0.0-1.9

1. Situational Aw areness OUTSTANDING
EXCELLENT
SATISFACTORY
2. Assertivness
OUTSTANDING
EXCELLENT
SATISFACTORY
UNSATISFACTORY
3. Decision Making
OUTSTANDING
EXCELLENT
SATISFACTORY
UNSATISFACTORY
UNSATISFACTORY
4. Communication
OUTSTANDING
EXCELLENT
SATISFACTORY
UNSATISFACTORY
5. Leadership
OUTSTANDING
EXCELLENT
SATISFACTORY
6. Adaptability/Flexibility
OUTSTANDING
EXCELLENT
SATISFACTORY
UNSATISFACTORY
7. Mission Analysis
OUTSTANDING
EXCELLENT
SATISFACTORY
UNSATISFACTORY
UNSATISFACTORY
COMMENTS:
INSTRUCTOR SIGNATURE _______________________
DATE ______________
FLIGHT EVALUATION DETERMINATION

1. A GRADE OF UNSATISFACTORY IN ANY CRM SKILL WILL
RESULT IN AN OVERALL GRADE OF UNSATISFACTORY.
Example
NATOPS
The following is an example of how to

incorporate CRM into T/M/S
instructions/SOPs.
Poor Practices
Poor Practices
Ground training focuses on 7 skills only

CRM ground training conducted in
conjunction with a Safety Stand-down
Evaluation documented as an
afterthought
Improper tracking of CRMI and CRMF
Improper designations or tracking
CRM not integrated into procedures
Chain of Command or culture does not
support CRM
CRM training not standardized or out of

date
No CRM turnover binder
Contractors teaching CRM differently
because they failed to attended CRMI
training
Summary
Ques%ons?
CRM organizational structure

Designations
Documentation
Training
Good program practices
Poor program practices
Reference
CRM Program Instruction

Changes
CNAFINST 1542.7
Instruction changes
CRM Qualification and Life Cycle Training Model
Initial T/M Specific Training

OPNAVINST 1542.7C; 7.b.: Initial and recurrency CRM training shall be
conducted by a designated CRM instructor or facilitator
References:
OPNAVINST 1542.7C; 7.b.: If CRM training is current in T/M, then it

does not need to be redone prior to first flight.
CNAFINST 1542.7; 6.b.(2): Initial T/M specific CRM ground and flight
training shall be conducted in all Chief of Naval Air Training (CNATRA)
squadrons and at the Fleet Replacement Squadrons (FRS) prior to
first flight and is required for all students, instructors under
training and any NATOPS qualified aircrew members without
documented T/M specific ground training as defined by reference
(a): (OPNAVINST 3710.7 series).
CNAFINST 1542.7; 6.c.: Initial T/M Specific Training. Shall be conducted

by a designated CRM Instructor (CRMI)
Recommendations: Look through all NATOPS jackets and find personnel

that have attended CRMI and utilize them to help with the initial shortfall.

Annual T/M Specific Recurring Training
Some squadrons may initially be short CRM instructors to ensure this

new requirement is met.
Send current CRMF personnel to attend CRMI.

CRM Instructor Training
OPNAVINST 1542.7C; e: Not specified.
CNAFINST 1542.7; 6.d. (1): CRMI/CRMFs conducting the training meet

their own annual requirements.
CNAFINST 1542.7; 6.f.: Successful completion of the CRM Instructor

course is a prerequisite to designation as a CRM Community
Program Manager (PM) or CRMI. T/M CRM Facilitator training must also
be completed in order to be designated a CRMI in a specific T/M.
New requirement in the CNAFINST. This was seen as a best practice and
not specifically required in OPNAVINST 1542.7 (series). However, it was a
requirement in the Assist Visit Checklist.
Recommendation: Send current CRMF personnel to attend CRMI.

CRM Facilitator Training

Flight Instructor CRM Training
OPNAVINST 1542.7C; 7.f.: Not specified.
CNAFINST 1542.7; 6.g.(1)/(2):
CNAFINST 1542.7; 6.h.: FRS and TRACOM units shall incorporate

formal CRM training into instructor indoctrination. This requirement
can be combined with initial ground training.
CRMF,
This section provides specific IUT guidance in FRS and TRACOM units.
CRMI,
Provides specific guidance for CRM training topics for CRMI and CRMF
qualification that were not covered in OPNAVINST 1542.7 (series). This
section clarifies that CRMF training does not need to occur first to
become a CRMI.
Civilian Aircrew Members/Instructors
Unmanned Aircraft Systems
CNAFINST 1542.7; 6.i.: Civilians that fly as active aircrew members shall
maintain the same qualifications as a uniformed aviator. Non-flying
civilians that provide flight instruction to USN/USMC aviators are required
to maintain the same ground CRM currencies as uniformed aviators. If
they are providing CRM initial ground training they are required to be
a CRMI. If they are only providing CRM recurrent ground training they
are required to be a CRMI or CRMF.
CNAFINST 1542.7; 6.j.: All UAS platforms shall conduct CRM training in
accordance with this instruction, to include training for UAS crewmembers
(UASC), Air Vehicle Operators (AVO), Mission Payload Operators (MPO),
and Ground Maintenance Vehicle Operators (GMVO).
This section provides guidance for UAS mirroring the requirements of
uniformed aviators.
This section provides specific guidance for Civilians mirroring the

requirements of uniformed aviators.
Documentation Requirements
Responsibilities
OPNAVINST 1542.7C; 7.g.:
OPNAVINST 1542.7C; 8.:
CNAFINST 1542.7; 6.m.: The CRM Training/Evaluation Record, enclosure

(3), shall be used to document CRM courses, designations, ground
training, and extensions in the individuals NATOPS Flight Personnel
Training/Qualifications Jacket in Section II, part C. All CRM
designation letters and flight evaluations shall also be filed in the
NATOPS Jacket. CRM flight evaluations shall be documented on an
applicable T/M approved form with the following statement included in the
write up; Conducted CRM flight evaluation per CNAFINST 1542.7A.*
CNAFINST 1542.7; 7.:
New requirement specifically for designations to be recorded and

designation letters to be filed in the NATOPS Jackets. Also provides a
standard statement for recording the CRM flight evaluation.
*CNAFINST 1542.7A is a typo and should be CNAFINST 1542.7.
Removed:
a. Chief of Naval Operations (N78)
b. CG Marine Corps Combat Development Command (C473)
c. Commander, Naval Air Systems Command (PMA-205)
e. Controlling Custodians
Replaced with:
a. Commander, Naval Air Forces
b. Commander, Naval Air Forces NATOPS Officer (N455)
c. Deputy Commandant for Aviation (DC AVN)
Responsibilities (cont.)
OPNAVINST 1542.7C; 8.h:
CNAFINST 1542.7; 7.d:
OPNAVINST 1542.7C; 8.f:
CNAFINST 1542.7; 7.f:
CRM Instructional Model Manager has been incorporated into Naval

Aviation Schools Command Program Officer. (This will change once we
transition to Naval Aviation Safety Center).
CRM Curriculum Model Manager changed to CRM T/M/S CMM (refer to

enclosure (4) ).
OPNAVINST 1542.7C; 8.d:
(8) Forward detailed copies of contractor-developed CRM materials to

the IMM for review and concurrence.
CNAFINST 1542.7; 7.e:

Naval Safety Center changed to Naval Safety Center CRM Program
Officer.*
(9) When a TRACOM air wing commander (CTW) is the CMM for
multiple T/M/S, the CTW may designate in writing a PM for each T/M/S
training aircraft.
*Typo Naval Safety Center CRM Program Officer should be underlined

in the instruction.
OPNAVINST 1542.7C; 8.i:
CNAFINST 1542.7; 7.g:
CNAFINST 1542.7; 7.h:
Unit Level
Individual Naval Aircrew Members
(1) Designate in writing a CRM Unit Level Manager (ULM). ULMs shall
be a qualified CRMF and should normally be the Unit NATOPS
Instructor.
(1) Ensure CRM is applied to all phases of flight planning, flight execution,
and debriefing.
(4) Ensure flow of pertinent CRM related issues to the CRM CMM via the
PM to include T/M/S lessons learned, documented CRM breakdowns, and
specific areas of concern for the T/M/S. Ensure appropriate material is
briefed to all aircrew members.
(2) Ensure the ULM is informed of all CRM-related incidents involving the
breakdown of CRM, as well as hazard mitigation that resulted from
effective CRM practices. The goal is to learn from our mistakes and our
positive CRM practices and behaviors that increase mission effectiveness
and mitigate preventable aircrew errors.
Provides specific guidance for all aircrew members.


Records Management
OPNAVINST 1542.7C; 9: The reporting requirements required by this
instruction are exempt from reports control per SECNAVINST 5214.2.
CNAFINST 1542.7; 7.h:

Individual Naval Aircrew Members
(1) Ensure CRM is applied to all phases of flight planning, flight execution,
and debriefing.
(2) Ensure the ULM is informed of all CRM-related incidents involving the
breakdown of CRM, as well as hazard mitigation that resulted from
effective CRM practices. The goal is to learn from our mistakes and our
positive CRM practices and behaviors that increase mission effectiveness
and mitigate preventable aircrew errors.
Provides specific guidance for all aircrew members.
CNAFINST 1542.7; 9.*: (*Typo should be 8.): Records created as a result

of this instruction, regardless of media format, shall be managed per
SECNAV M-5210.1C.
Forms and Reports
Definitions
Enclosure (1)
OPNAVINST 1542.7C
OPNAVINST 1542.7C; 7. g: Enclosure (4)

CNAFINST 1542.7
CNAFINST 1542.7; 10.* (*Typo should be 9.): Enclosure (3) of this
instruction shall be locally produced to document CRM qualifications and
be permanently maintained in the NATOPS Flight Personnel Training/
Qualification Jacket Section II, Part C.

CRM Training/Evaluation Record
OPNAVINST 1542.7C (Enclosure (4) )
Added more to clarify the existing definitions:

Crew Resource Management (CRM)
Crew Resource Management Critical Skills: AF, AS, CM, DM, LD, MA, SA
Time Critical ORM (TC-ORM)
CRM T/M/S Community Assistant Program Manager
CRM Unit Level Manager (ULM)
Naval Aviation Activity

CRM Training/Evaluation Record (cont.)
OPNAVINST 1542.7C (Enclosure (4) ): Annotation required T/M
CNAFINST 1542.7 (Enclosure (3) ).

CNAFINST 1542.7 (Enclosure (3) ): Annotation requires T/M/S
CRM Facilitator Course
replaced with
This ensures CRM training is created and tailored to identify the specific
CRM and Mission differences in multiple series aircraft in the Naval
Aviation inventory.
CRM Designations
(List all CRM Designations Attained to include Instructor, ULM and
Facilitator in this section).
Allows for all CRM qualifications, not just the Facilitator course.

CRM Training/Evaluation Record (cont.)

TABLE OF T/M/S CRM CURRICULUM MODEL MANAGERS AND
INSTRUCTOR REQUIREMENTS
OPNAVINST 1542.7C (Enclosure (4) ):

OPNAVINST 1542.7C: (Enclosure (2) ):
CNAFINST 1542.7 (Enclosure (3) ): Has typos. There is no difference
between the two instructions and should read as below:
Ground Training
Annual CRM Ground Training
expires the last day of the
current month plus one year.
accomplished 60 days
early
Flight Training
CRM renewal expires last
day of current month plus
one year and may be
CNAFINST 1542.7 (Enclosure (4) ):

Most of aircraft in the inventory were not removed from the inventory/table
have a change in one or more of the following: T/M/S, T/M/S
CURRICULUM MODEL MANAGER COMMAND, CONTROLLING
CUSTODIAN OR MINIMUM NUMBER/TYPE INSTRUCTOR.
7 CRITICAL SKILLS
LD AF MA
CRM SKILLS
Leadership
Adaptability/Flexibility
Mission Analysis
Terminal Objective
Implement CRM academics, in a
classroom setting, in accordance
with Instruction, Crew Resource
Management Program, CNAF
1542.7 (series); and Crew
Resource Management
Instructor Course Student Guide.
C-050-1503A PPT 5001 01
Terminal Objective
Upon completion of this unit of
instruction, the student will
demonstrate knowledge of the
purpose and goals of CRM, as
well as the importance of
leadership, adaptability/flexibility,
and mission analysis.
Enabling Objectives
Discuss and understand the
importance of Leadership.
importance of Adaptability/Flexibility.
importance of Mission Analysis.
Why CRM?
Philosophy
The leading cause of aviation mishaps is

due to human error.
Technology has developed to reduce
mechanical failure.
Human behavior has not developed to
reduce human error.
CRM is the method to modify human
behavior.
In the past the best way to learn good

CRM skills was to be fortunate enough
to fly with and learn by experience of
those who practice CRM well.
This a process which identifies the
successful traits of our best aircrew in
an effort to teach it in an academic
environment.
CRM Defined
CRM Program
CRM: The effective use of all available

resources by individuals, crews and teams to
safely and efficiently accomplish the mission
or task.
Program: A training program to effect

behavioral modification (as opposed to
attitude changes or management theory) in
order to prevent human factor and crew
preventable errors.
CRM also refers to identifying and managing

the conditions that lead to error.
CRM Goals
Purpose
Purpose: CRM is intended to improve
the mission effectiveness of all aviation
communities by enhancing crew
coordination through increased
awareness of associated behavioral
skills (Seven Critical Skills) and error
theory.
It is your program.
External Factors (Threats)
WEATHER
ENVIRONMENT
TERRAIN
ENEMY THREATS
AIRCREW COMPOSITION
MISSION DURATION
MISSION CHANGES
MISSION TASKING
MORE?
Increase mission effectiveness

Minimize crew preventable errors
Maximize crew coordination
Good Better
Seven Critical Skills
Decision Making
Assertiveness
Mission Analysis
Communication
Leadership
DM
AS
MA
CM
LD
AF
SA
Leadership
(l'dr-shp')
Definition: The ability to
direct and coordinate the
activities of crew members
and to encourage them to
work together as a team
Designated
Functional
Leadership
What makes a good leader?

What makes a poor leader?
Leaders Responsibilities
Directs actions
Also solicits input and asks for help.
Sets the tone professional

atmosphere
Delegates tasks and keeps group
focused
Leadership
DESIGNATED LEADERSHIP
Obtained by rank, crew position or title
Responsible for crew and mission
accomplishment; therefore, makes all final
decisions
FUNCTIONAL LEADERSHIP
Refers to leadership by knowledge or expertise
and occurs when expertise and need for info
becomes critical
Allows for most qualified crew member to take
charge / meet situational demands
Traits of an Effective Leader
Respected
Decisive
Delegates tasks
Provide feedback
Keeps crew informed
Open to suggestions
Builds team spirit
Leads by example
Directs and coordinates
Maintains professional atmosphere
Knowledgeable
Leaders Responsibilities
Keeps crew or section members aware of
mission information including:
Altered plans
Decisions that are made
Feedback on their performance
Defines boundaries & expectations

Ultimately responsible for performance of
crew
Followership
FOLLOWERSHIP
B-52 Crash
Followership
Independent Critical Thinking
EFFECTIVE
ALIENATED
Air India Express
Boeing 737-800
SURVIVORS
Passive
SHEEP
Active
YES PEOPLE
Dependent Uncritical Thinking

R.E. Kelley, 1992
ADAPTABILITY / FLEXIBILITY
(-dp't-bil-t) / (flk's- bil-t)
ADAPTABILITY/FLEXIBILITY
Definition: The ability to alter a course of

action based on new information,
maintain constructive behavior under
pressure, and adapt to internal and
external environmental changes.
The success of a mission depends upon the crews
ability to alter behavior and dynamically manage crew
resources to meet situational demands.
Importance of A/F
Every mission is potentially different
Even canned missions
React to unexpected
Priorities may change, but tasks still required
Counters rigidity
Less vs. more experienced crews
When is Adaptability / Flexibility required?
Unbriefed situations arise

Routine mission becomes an emergency
Interactions are strained
Aircraft is partial mission capable
WX changes
Joint Ops
What makes YOU successful at

adapting or flexing?
Recognize and acknowledge change
Anticipate Problems / Mission Analysis
Determine if an SOP or Habitual
Response is appropriate
Interact constructively with others
Can you go too far?
Setting the tone for A/F
Establish an open, professional atmosphere
Ensure the crew understands the mission
Communicate!
MISSION ANALYSIS
MISSION ANALYSIS
(msh'n -nl'-ss)
Definition: The ability to develop short
term, long term, and contingency plans
and to coordinate, allocate, and monitor
crew and aircraft resources.
Effective planning leads to flight conduct that removes
uncertainty, increases mission effectiveness, and
enhances safety.
Pre-Mission Analysis
Identifying Mission Objectives
Identifying Mission Constraints,
challenges and Options
Preparation
Contingency plans
Briefing
IN FLIGHT MISSION
ANALYSIS
Short Term Planning
Monitoring Mission Progress
Identifying and Reporting Challenges
or Changes
MISSION ANALYSIS
THREE PHASES
PRE FLIGHT
IN FLIGHT
POST FLIGHT
Pre-Mission Analysis
Characteristics of an Effective Brief
Planning
Professional
Focused
Assign
Responsibilities
Interactive
Complete
POST-MISSION ANALYSIS
Selective Review
Interactive
Timely
Lessons Learned
SUMMARY
Defined and explained the purpose of CRM

Identified the goals of CRM
Defined leadership
Stated the responsibilities of leadership
Stated the behaviors associated with effective
leadership
Stated the traits of effective leaders
Defined adaptability / flexibility
Identified the importance of adaptability /
flexibility
Questions?
SUMMARY
Identified situations that require adaptability/
flexibility
Explained how to set the tone and maintain
high adaptability/flexibility
Define mission analysis
Identified the importance of mission analysis
Stated the phases of mission analysis
Defined in-flight mission analysis
Discussed the importance of the debrief in
mission analysis
7 CRITICAL SKILLS
CM AS
Terminal Objective
SEVEN CRITICAL SKILLS

CM, AS
Implement CRM academics, in a classroom

setting, in accordance with Instruction, Crew
Resource Management Program,
CNAF1542.7; and Crew Resource
Management Instructor Course Student
Guide
CREW RESOURCE MANAGEMENT
C-050-1503A PPT 5006 01
Seven Critical Skills
Enabling Objectives
Instruct CRM critical skills

Define assertiveness
Discuss assertive behaviors
State the barriers to assertiveness
Describe situations requiring assertiveness
Define communication
Explain the importance of communication
Explain the process of communication
State the different types of communication
Explain the characteristics of effective communication
State the barriers to effective communication
Explain the methods to overcome barriers to effective
communication
Decision Making
Assertiveness
Mission Analysis
Communication
Leadership
DM
AS
MA
CM
LD
AF
SA
What Is Assertiveness?
(-sr'tv-ns)
ASSERTIVENESS
Definition: The willingness to actively

participate, state and maintain a position,
until convinced by the facts that other
options are better.
Requires the COURAGE and
INITIATIVE to act.
Lack of Assertiveness?
Comfort Level
Comfort level is an internal

anxiety gauge that alerts us
when something isnt right and
needs to be corrected.
Behavior Types
Passive
Assertive
Fired up!
Overly
Aggressive
Overly Aggressive
DOMINATION
INTIMIDATION
ABUSIVE /
HOSTILE
Passive
Overly courteous
Beats around the bush
Avoids conflicts
Along for the ride
Assertiveness
Active involvement during flight
Barriers To Assertiveness
Provides relevant information without

being asked
Readiness to take action
Makes suggestions
No fear of retribution
Creating An Assertive
Statement
3 Times You Have To

Speak Up
Will improve results of group
Gives others permission to speak
their truth
Costs of silence are too high
Position of authority
Experience
Rank
Qualifications
Personal characteristics
Lack of confidence
Fear of reprisal
Typically use active verbs or recommend

an action.
Get the attention of the receiver

State your concern
Offer a solution
Ask for feedback
Gobblin, I show us 300ft below assigned

altitude. Recommend we climb. What are
you showing?
Nilofer Merchant, 2011
Rules Of Thumb
Most Conservative Response
If disagreement in the aircraft exists, take the

most conservative action until more
information is available.
Two Challenge Rule
In extreme situations, if the pilot (flying) does

not respond appropriately to two demands,
the copilot (pilot not flying) should take the
controls.
COMMUNICATION
Communication
Communication
(k-my'n-k'shn)
Important, why?
Definition: The ability to clearly and

accurately send and acknowledge
information, instructions, or commands,
and provide useful feedback.
Verbal Communication
Words
Vital to mission accomplishment

Maintains Situational Awareness
Basic Communication Model

Message
7%
Meaning
(Intent)
Tone
38%
Non verbal cues
55%
Encode
Transmit
Receive
Decode
Meaning
(Interpret)
Noise
(e.g. gesture, posture,

facial expression)
* When communication is ambiguous.
Meaning
(Interpret)
Decode
Receive
Transmit
Encode
Meaning
(Intent)
Feedback
Dr. Albert Mehrabian, (1972)
One-way Communication
Rapid
COMMUNICATION
EXERCISE
Looks and sounds neater

Generally requires more planning
Responsibility lies with sender
The sender feels in control
Receiver may switch off
DIAGRAM #1
Two-way Communication
Potentially more reliable and effective

Permits correction of details
Requires less planning
Receivers have more confidence
Both sender and receiver have responsibility
Non-verbal communication more important
Generally takes longer
Can lead to frustration and anger
Sender can feel threatened
DIAGRAM #2
External Barriers
Noise
Low voice
Electrical interference
Separation in space, time
Lack of visual cues
(e.g. gesture, posture, facial expression)
Internal Barriers
Personality
Motivation
Expectations
Past Experience
Prejudice
Rank
Emotions/Moods
Language Difference
Culture
List The Barriers
Overcoming Barriers
Active Listening
Appropriate mode and decibel level
Pre-briefed Terminology
Professional Attitude
Compartmentalization
Resolving conflicts on deck
Avoid bad cockpit marriages
Most Effective
Effective Communication
Explicitness - Clearly stating the desired
action and who should do it.
Directness - Degree of pressure to

comply with the desired action.
Social appropriateness - Sensitivity to

the roles and status of speaker/addressees
and to the seriousness of the situation
Least Effective
Explicitly state what to do and maintain positive team

climate:
Obligation Statements: States an obligation or an
intention:
Waveoff, Gobblin.
Suggestions: Suggests an action to be taken, a
strategy, or an ability:
Too vague to identify problem or action

Mild Hints: Queries or observations that do
not refer directly to the problem:
How are things coming along?
We can ask them to go left of that if you want.

Relayed Requests: Restating a third-party request:
Now [ATC] wants us to go right.
Spatial D
Monitoring And Challenging

Essential elements of aviation safety
Monitor each others performance

Communicate observed errors to prevent
problems from escalating
Communication dilemma
How to communicate unambiguously and

encourage compliance
While maintaining positive team climate
(Fischer & Orasanu, 2000)
Air Florida Flight 90 (1982)

First officer: That dont seem right does it? Ah,
thats not right.
Captain: Yes it is, theres eighty (knots).
First officer Naw, I dont think thats right
Captain: (No response)
The first officer continued to show concern as
the aircraft accelerated through a hundred
and twenty (knots).
NASA Simulation Results

More effective communication
strategies used when risk was high.
FOs less likely to challenge when Face
Threat (degree of challenge to the other
pilots skill, judgment, or competence)
was high.
(NTSB, 1982: 64
Implications
Effective Communication?
Importance of challenging in teams

Promotes functional conflict
Supports team goals
Can improve performance
Dangers of not challenging errors

Avoiding relationship conflict may
undermine performance and safety
Communication
REMEMBER
Communication is vital!
Be aware barriers will happen and
overcome them.
The greatest enemy of effective
communication is the illusion of it.
Illusion Of Communication
Assertiveness Summary
Comfort level
The range of behavior types
Barriers to assertiveness
Situations requiring assertiveness
Communication Summary
The basic communication model
The differences between one and two-way
communication
Barriers to communication
Effective communication
Monitoring and challenging
Questions?
7 CRITICAL SKILLS
SA DM
Situational Awareness &

Decision Making
The Cognitive Components of CRM
Lesson Topic 2.5
Objectives
Terminal Objective
Instruct CRM Critical Skills
Enabling Objectives
Instruct CRM critical skills, in a classroom setting, in accordance with
Instruction, Crew Resource Management Instructor Course Student
Guide.
Define Situational Awareness, in a classroom setting, in accordance with
Guide.
Explain the difference between perception & reality, in a classroom
setting, in accordance with Instruction, Crew Resource Management
C-050-1503A PPT 5007 01
Describe the levels of SA, in a classroom setting, in accordance with

Guide.
Objectives (cont.)
Human Factors Research

Offshore oil production
Explain the cognitive mechanisms at work in the brain which enable

development of SA, in a classroom setting, in accordance with
Guide.
Nuclear power generation

Medicine
List factors that reduce SA, in a classroom setting, in accordance with

Guide.
Civil aviation
Navy divers, EOD, SEALs
State techniques for maintaining and recovering SA, in a classroom

setting, in accordance with Instruction, Crew Resource Management
Navy/ Marine Corps aviation
* The more discussion the better!
What do these industries have

in common?
Human Information Processing

Limitations of the human
information processing
system have an
enormous effect on the
ability of an aviator to
gather the information
required, and make a
good decision on the
basis of that information.
Memory Model
Long term
Memory
INPUT
Sensory
memory
Short term
memory
&
Working
memory
INFORMATION
RECALLED
Adapted from Atkinson & Shiffrin (1971)
Knowledge
Skills
Experience
Diagnostic rules
Procedures etc.
Information Processing Summary
Working Memory
People cannot remember large amounts of
information due to the size of working memory
Duration is 18 to 20 seconds without rehearsal
The amount of information retained can be increased
by rehearsal and by chunking
Susceptible to distraction, stress, and fatigue
Can be freed up through experience
Eventually becomes long term memory
Working memory is critical to:

Decision Making
Workload Management
Error???
Definition
As much as 88% of human

error is due to problems with
Situational Awareness.
What is the percentage of
mishaps due to human error?
Endsley, 1995
What is your definition of

Situational Awareness?
Navy Definition
Academic Definition
The degree of accuracy by which

ones perception of the current
environment mirrors reality
Only requires that we know:
What is currently happening
Where the aircraft is in threedimensional space
the perception of the elements in the

environment within a volume of time and
space, the comprehension of their
meaning and the projection of their status
in the near future
Endsley, 1995
Model of Situational Awareness
Level 1: Error
Perception of elements in the current situation
Data unavailable
Data difficult to detect
Failure to scan or observe
Perception
of elements
in current
situation
Comprehension
of current
situation
Projection
of future
status
Level 1
Level 2
Level 3
Decision
Making
Performance
of Actions
Omission
Attention narrowing (tunnel vision)
Distraction
High task-load
Misperception of data
Memory capability
Endsley, 1995
Level 2: Error
The Creation of Mental Models
Comprehension of current situation

Lack of/poor mental model
Mental models
are created by
Use of incorrect mental model

Over-reliance on default values in model
Memory failure
Experience
Briefing
Expectations
Mental
model
NFO
Interpretation A
NFO
Mental
Model
B
Interpretation B
Event
Mental
model
In What Levels are Errors

Occurring?
Level 3: Error
Level 3: Data
Projection
Level 2: Data
Comprehension
Level 2
17%
ve
Le
Projection of future status

Failure to accurately project the mental
model
Mental
Model
A
Common
Understanding
Event
Pilot
-5
Pilot
Everyones Mental Model Can be

Different
l3
Need a Shared Mental Model
Level 1
78%
Level 1: Data
Perception
Jones & Endsley (1996)
What is the Most Common Cause

of Level 1?
Situational Awareness Errors

A= Data not available
B= Hard to discriminate/detect data
C= Failure to scan
D= Misperception
E= Memory loss
F= Lack or incomplete mental model
G= Use of incorrect mental model
H= Over-reliance on default values
I= Other
J= Lack or incomplete mental model
K= Over-projection of current trend
L= Other
40
35
Data unavailable
Hard to discriminate/detect data
Failure to scan
Misperception
Memory capability
Percent of total SA errors
30
25
20
15
10
5
0
A
C
Level 1
Level 2
K
Level 3
Factors That Reduce SA
Insufficient communication
Fatigue/Stress
Task overload/underload
Group mindset
Press on regardless philosophy
Degraded operating conditions
Lead Up to Mishap
3 minutes into flight FE1 noticed a flickering
thrust reverser not locked light on #2 engine
MP2 shutdown #2 engine, advised Dover
approach that they were returning
MP3 (CO) suggested MP1 land, so MP1
assumed control
Two ICS Nets
New Glass Cockpit
Recent Hot Brakes HAZREP
C-5 Case Study
Location: Dover AFB

MPs arrived at 0340
Took off 0621 from Dover AFB (MP2 flying)
Date and time: 3 April 2006, 0639
Aircrew:
Pilot: Reservist, evaluator pilot, >4000 hours
Copilot: Reservist, Chief of training, instructor pilot,
>2300 hours
Jump seat: Reservist, CO, >3800 hours (observer)
3xFE: 2750-8200 hours
5x Loadmasters
How do you lose SA in

the aircraft?
What are the clues that you,
or a member of your team
has lost SA?
Clues to SA Problems
Ambiguity information from 2 or more sources
do not agree
Fixation focusing on one thing
Confusion
Lack of required information
Failure to maintain critical tasks (e.g. fly the A/C)
Failure to meet an expected checkpoint
Failure to resolve discrepancies
A bad gut feeling that things are not quite right
Retrospective Statements of lost SA
I didnt realize that

I didnt notice that
I was busy attending to
I wasnt aware that
We were very surprised when
We were convinced that
Civil Aviation Authority (2003)
Maintaining SA
How do you maintain

Situational Awareness in the
aircraft?
Good brief
Fitness for work
Minimize distractions and interruptions during
critical tasks
Sterile cockpit
Update regularly compare mental models
Monitoring be sensitive to clues of zoning
out
Speak up
Time management
Flin, OConnor & Crichton, 2008
Summary
Questions to Calibrate SA
Memory Model
What is the immediate goal of your team?
What are you doing to support that goal?
S/A has three levels

L1: Perception
What are you worried about?

What is the current problem, size, and
intention?
What do you think this situation will look like
in __ minutes, and why?
L2: Comprehension
L3: Projection
Failure of scan is the most likely to

affect you
London Fire Brigade
Questions?
Break
Decision Making
Objectives
Terminal Objective
Instruct CRM Critical Skills
Enabling Objectives
Define decision making, in a classroom setting, in accordance with

Guide.
Napoleon Bonaparte
Nothing is more difficult, and therefore
more precious, than to be able to decide.
List the steps in classical decision making and why they do not normally
apply to aviation, in a classroom setting, in accordance with Instruction,
Crew Resource Management Instructor Course Student Guide.
Describe some alternative models to classical decision making models, in
a classroom setting, in accordance with Instruction, Crew Resource
Management Instructor Course Student Guide.
Explain decision making in a time critical/high risk environment, in a

classroom setting, in accordance with Instruction, Crew Resource
Objectives (cont.)
Explain decision making where there is little or no experience with the
situation, in a classroom setting, in accordance with Instruction, Crew
Resource Management Instructor Course Student Guide.
Discuss rule-based decision making, in a classroom setting, in
accordance with Instruction, Crew Resource Management Instructor
Course Student Guide.
Decision Making
The ability to choose a course of action
using logical and sound judgment based
on available information.
Discuss some of the tools that enhance decision making skills, in a

classroom setting, in accordance with Instruction, Crew Resource
FA-18 Case Study

26 March 2004, Raleigh Durham
Second leg of a three leg cross-country
MP had recently joined the squadron
from the FRS, and had about 100 hours
in the Hornet
MP was dash 2, preparing for a 10
second separation takeoff
MP clears informational error code
Decision Point Failures
Failed to clear error codes

Failed to recognize the paddle switch
disengaged nose steering
Failed to abort on the tarmac
Failed to abort on the grass
Failed to retard throttles, and
disengage afterburner at any time
Stroop (1935)
This test illustrates the difficulty of humans
to inhibit one well-learned response and do
something else.
State the Colors
10
987654321
State the Colors
10
987654321
Row 1
Instructions: Start at row one, reading left to

right, then row two, and finally, row three.
Row 2
Task 1
Task 2
Task 3
Red
Blue
Row 3
State the Colors

Row 1
Red
Blue
Row 2
Yellow Green
Row 3
Green
Red
10
987654321
Green Yellow
Blue
Row 1
Red
Blue
Red
Row 2
Yellow Green
Yellow Blue
Row 3
Green
Stroop Take Away

Using heuristics is useful to free up our
working memory in normal situations.
However, in situations that are not quite
normal, our well learned response can
put us in difficulties.
Red
Green Yellow
Blue
Red
Yellow Blue
Aviation Decision Environment
Ill-defined goals
Uncertainty, ambiguity, missing data
Shifting and competing goals
Dynamic and continually changing conditions
Action feedback loops (real-time reactions to
changed conditions)
Time stress
Multiple players
Organizational goals and norms
Experienced decision makers
Klein, 1991
British Airways DODAR
How Do You Make

Decisions?
D Diagnosis
O Options
D Decision
A Assign tasks
R Review
Naturalistic Decision Making
Lufthansa FORDEC
Since the 1980s increased interest in

decision making in complex real world
settings
Navy / Marine Corps has been at the
forefront of this research
F Facts
O Options
R Risks and benefits
D Decision
E Execution
C Check
USS Vincennes shooting down Iranian

airliner in 1988
Tactical decision games
Naturalistic Decision Making

Stage 1. ASSESS THE SITUATION
(Whats the problem?)
Time risk pressures
Risk - high
Risk - low
Time - low
Time - high
Stage 2. MAKE A DECISION
(What shall I do?)
Intuitive
Rule-based
Analytical
Creative
What is the problem?

What are they?
What are we going to do?
Who does what?
What happened?
What are we doing about
it?
Stage 1: Assess the Situation
Time Limited
Risk High
F
E
E
D
B
A
C
K
Whats the problem?

How much time is available?
How risky (present and future)?
Problem
understood
OR NOT
understood
Problem
understood
Flin, OConnor, & Crichton, 2008
ACT
Problem NOT
understood
Rule
available
Multiple
options
available
Multiple
tasks
to do
No options
available
Apply
Rule
Choose
Options
Schedule
Tasks
Create
Solution
Stage 3. Select a course of action

Stage 4.Implement a course of action
Time available
risk variable
Gather More
Information
Stage 2: Make a Decision

The type of decision making strategy which is
most appropriate is dependent on the amount of
time, amount of information, and expertise of the
decision maker.
Intuitive Decision Making (RPD)
Time Limited
Risk High
Problem
understood
OR NOT
understood
Four decision making strategies are:

Intuitive
(Recognition Primed Decision RPD)
Rule based
Analytical (Choice decisions)
Creative
ACT

Actions and reactions based upon past
experience.
The emphasis is on reading the situation,
rather than on generating different options for
possible actions.
Experienced reading of a situation, so that the
selection of a course of action is obvious.
The generation of a solution that, while it may
not be the best, should result in a workable
course of action.
Rule Based Decisions

Time Limited
Risk High
Whats the problem?

Problem
understood
OR NOT
understood
ACT
Problem
understood
Problem NOT
understood
Multiple
options
available
Multiple
tasks
to do
No options
available
Apply
Rule
Choose
Options
Schedule
Tasks
Create
Solution
Time available
risk variable
Problem
understood
Problem NOT
understood
Rule
available
Multiple
options
available
Multiple
tasks
to do
No options
available
Apply
Rule
Choose
Options
Schedule
Tasks
Create
Solution
Gather More
Information

Positives:
Useful method where time is limited

Requires little thought
Can lead to a satisfactory and workable action
Useful in routine situations
Negatives:
Can only be applied in certain situations
Need to be an expert
Can lead to confirmation bias
Poor Procedures
Time available
risk variable
Rule
available
Whats the problem?

Gather More
Information
HAZREP: 27MAR06
MARAERIALRFLTRANSRON 352 - ALL
HERCULES AIRCRAFT ACTIVITIES
A review of EPs and PCL revealed over 260
items that were different, missing, incomplete,
or formatted differently.
PCL missing specific notes, cautions,
warnings or procedures that are in NATOPS.
Rule Based Decisions
Bird Strike
Positives:
Only need to follow a series of rules
Do not need to be an expert, or understand the
purpose of every step
Easy to justify action
Negatives:
It is easy to miss a step in the sequence
Poor diagnosis can lead to the wrong set of rules
Analytical (Choice) Decisions

Time Limited
Risk High
Whats the problem?

Problem
understood
OR NOT
understood
ACT
Time available
risk variable
Problem
understood
Problem NOT
understood
Rule
available
Multiple
options
available
Multiple
tasks
to do
No options
available
Apply
Rule
Choose
Options
Schedule
Tasks
Create
Solution
Analytical (Choice) Decisions

Focus of classical decision making
research
The decision maker generates a
number of possible courses of action,
and then compares them to determine
the best fit.
Time Critical ORM
A-B-C-D Model
Gather More
Information
Steps of Time Critical ORM

Assess your situation for hazards/risks
Balance your resources to control risks
Communicate your risks & intentions
Do & Debrief (act & monitor controls; provide feedback)
ORM
Analytical Decisions
Creative Decision Making

Whats the problem?
Positives:
Fully compares alternative courses of action
Easy to justify
More likely to produce an optimal solution
Negatives:
Requires time
Not suited to noisy, distracting environments
Can be affected by stress
May produce cognitive overload
Time Limited
Risk High
Problem
understood
OR NOT
understood
ACT
Time available
risk variable
Problem
understood
Problem NOT
understood
Rule
available
Multiple
options
available
Multiple
tasks
to do
No options
available
Apply
Rule
Choose
Options
Schedule
Tasks
Create
Solution
Gather More
Information
APOLLO 13
Devising a novel course of action

for an unfamiliar situation
United 232, Sioux City
Apollo 13

Positives:
Produces solutions for unfamiliar problems
Requires time
Untested solution
Can be affected by stress
May produce cognitive overload
May be difficult to justify
Stage 1. ASSESS THE SITUATION

(Whats the problem?)
Time risk pressures
Risk - high
Risk - low
Time - low
Time - high
Stage 2. MAKE A DECISION
(What shall I do?)
Intuitive
Rule-based
Analytical
FEEDBACK
Negatives:
Feedback
Creative
3. Select a course of action

4. Implement a course of action
Flin, OConnor, & Crichton, 2008
Factors Influencing DM
Anything effecting cognition
Stress
Fatigue
Noise
Distraction
Interruption
The Other Critical Skills:
SA, CM, AS, MA, LD, AF
Decision Making Summary

Unique decision making environment in
aviation
Adopt the appropriate decision strategy
Whats the problem?
Is the level of risk high or low?
How much time do I have available?
Decision strategies
Intuitive (Recognition primed) gut feel

Rule-based procedures
Analytical decisions (Choice) ORM & matrixes
Creative test pilot
Questions?
Finally
"When anyone asks me how I can best describe my
experiences of nearly forty years at sea, I merely say
uneventful. I have never been in an accident of any sort
worth speaking about....I never saw a wreck and have
never been wrecked, nor was I ever in any predicament
that threatened to end in disaster of any sort."
Edward J. Smith
(Captain of the Titanic)
Resources
www.satechnologies.com Endsleys company
www.raes-hfg.com/xsitass.htm Royal Aeronautical
Society conference on SA
Flin, R. (1996) Sitting in the Hot Seat.
Flin, R., OConnor, P., Crichton, M. (2008). Safety at
the Sharp End.
Gladwell, M. (2005) Blink.
Klein, G. (1999). Sources of Power: How People
Make Decisions.
Civil Aviation Authority (2006). Crew Resource
Management. www.caa.co.uk/docs/33/CAP737.PDF
WORKLOAD MANAGEMENT
A Very Loose Tie In
Workload
Management
C-050-1503A PPT 5001 01
Enabling Objectives
Implement workload management into CRM instruction, in a
classroom setting, in accordance with CNAF 1542.7 and A Guide to
Enabling Objectives
Explain the goal of automation in reducing workload in accordance
with A Guide to Human Factors for Naval Aviators.
Human Factors for Naval Aviators.

Define workload management, in a classroom setting, in accordance
with A Guide to Human Factors for Naval Aviators.
Explain some of the factors that affect workload in a classroom
setting, in accordance with A Guide to Human Factors for Naval
Aviators.
Remember?
Our ability to handle
multiple tasks is a
function of our
information processing
capacity.
The main limitation is working
memory.
Describe how limitations of human performance affect workload and

automation management in a classroom setting in accordance with A
Guide to Human Factors for Naval Aviators.
Explain effective workload and automation management in a

classroom setting in accordance with A Guide to Human Factors for
Naval Aviators.
Workload Management
A WORKING DEFINITION
Workload:
The amount of work performed or capable of being
performed usually in the context of a defined period.
Management:
The act or art of supervising. Judicious use of
means to accomplish an end.
Factors Affecting Workload
Factors Affecting Workload
The nature of the task
Physical demands it requires

Mental demands it requires
The aviator and his/her state

Skills
The circumstances under which the task is

performed
Experience
Standards of performance
Time available
Requirements to perform more than one task
Environmental conditions
Crew composition
Current health and fitness

Emotional state
Signs of Overload
Signs of Underload
Difficulty adhering to performance standards
Boredom
Errors and erratic performance
Fatigue
Poor fundamental aircraft control
Frustration
Uncertainty, indecision, or discomfort
Dissatisfaction
Degraded scan, tunnel vision, fixation
Failure to Scan
Hesitant, confused speech
Arousal and Workload
Workload Vs. Performance

HIGH
To achieve an optimum level of task

performance should you be overloaded or
underloaded?
It is necessary to have certain levels of stimulation
or arousal.
UNDERLOAD
OPTIMUM
OVERLOAD
P
E
R
F
O
R
M
A
N
C
E
LOW
LOW
WORKLOAD
HIGH
KC-130 Case Study
KC-130 Case Study

CREW
T3P
TPC
Synopsis
FWAR / Crew Training / T3P initial Night Fam
T3P (400 hr) Left seat, TPC (2100 hr) Right seat,
FE (3100 hr) Jump seat
FWAR CANX. VFR Round-Robin, 2 Inst App off
airfield
Touch and go pattern during pinky time at NXP
expeditionary airfield
Work Overload. Bristol MOA/29 Palms
KC-130 Route of Flight
KC-130 Case Study

CREW
T3P
TPC
Flight engineer mismanages FUEL panel (gravity

feeding engines #1 & #4)
No. 1 and 4 engines lose power after rotation
No. 1 is shut down and 4 fails
TPC believes only #1 has failed
FE confused by #4 indications
TPC turns left (into dead engine/terrain)
KC-130 Case Study

CREW
T3P
KC-130 Case Study

TPC
FE Calls for more power

TPC discusses #1 air-start
TPC Doesnt order it, T3P holds condition lever to start (6-8 sec)
#1 lights off but stalls
TPC calls for flaps 20%
T3P complies without comment, takes hand off #1 condition lever
Aircraft impacts ground 106 sec after last takeoff
TPC workload rapidly went from low to extreme

Where? How? How did crew coordination break
down?
Counterproductive activities on the part of the

TPC, T3P and the Flight Engineer
How Was Their Workload

Managed?
KC-130 Case Study

Overload Caused:
Flight engineer unable
to properly diagnose No.
4 engine
TPC to fixate on No. 1
engine (working mem?)
T3P to become a voiceactivated copilot
What were the signs of overload?
All to not determine cause of dual flameout
Working Memory &

Attention
Can we attend to more than one thing
Divided Attention Example

Task: Follow a pace car through heavy traffic in
simultaneously?
No, although attention can move very quickly from one
item to another, it can only deal with one item at a time
Our attention is limited by working memory
a high-fidelity driving simulation.

Performance was compared between driving
without conversing, and driving while conversing
on a hands-free cell phone.
capacity
Strayer et al, 2003
Results: Driving and

Cell-Phone Use
Driving only
Driving and
talking
Brakes on
(msec)
933
1,112
Brakes off
(msec)
580
653
Following
distance (m)
26
29
Distracted Driving With

Hands-Free Device
Drove simulator and listened to spoken sentences for true /
false
Listening decreased brain activity by 37%
Not actual conversation may underestimate impact
National Safety Council,

March 2010
Attention Exercise
BREAK
Get some refreshment
Goals of Automation
Current Automation
Definition: The execution by a machine of a

function previously carried out by a human
Reduce workload
Help pilots focus on the most important
aspects of the job
Decrease errors, increase accuracy
Has automation achieved these goals?
Air France 447
TH-57C / D Cockpit
HUD/HMD
TAWS
EFB/iPad
Synthetic Vision
FMS with coupling and auto-land
ADS-B/ASDE-X Transponders
GPWS
TCAS
DC10 / 11 Cockpit
DC10
MD11
AH-64A / D Cockpit
Traditional (alpha)
Glass (delta)
EFIS MOVING MAP
EICAS Excedance
Chelton Synthetic Vision EFIS
Synthetic Vision
EICAS
Boeing 757 Crash

Cali Columbia
Prime example of the limitations of
automation
Poor workload management once crisis
ensued
Boeing 757 CFIT
Mode Awareness Errors
Common causes of mode failure

Pilots fail to verify the mode selections
Notice automatic mode failures
Process mode annunciations to understand
aircraft behavior
Nadine Starter, Human Factors, June 2008
Automation Bias
China Air Flight 140
Automation encourages pilots to adopt a natural

tendency to follow the choice requiring the least
brain power.
55% of the time pilots committed errors when
the automation presented incorrect information
in the presence of correct information. They
failed to detect the anomaly.
Mosier et al, 1998, 2001
Civilian Hull Loss Rate
Army Rotary Wing
(per million departures)
(per 100,000 flight hours)
Conventional
Advanced
Conventional
Advanced
A300-1/2/3/4
A300-600
1.18
1.33
B737-100/200
B737- 300/400/500
1.20
0.43
B747-100/200/300
B747-400
1.79
DC9
MD80
DC10
MD11
Traditional
Glass
OH-58 Kiowa
4.37
20.30
0.77
UH-60 Blackhawk
8.81
17.06
1.28
0.40
AH-64 Apache
18.36
23.00
2.67
0.00
CH-47 Chinook
6.97
3.94
Boeing, 1997
Rash et al, 2001
Reasons for an Increased

Mishap Rate?
Automation and Workload
AH-64 pilots acknowledge there is an

increased workload in the glass aircraft
Small margin of error if both pilots sucked

inside the cockpit
Transition pilots
Abnormal
Workload
AH-64 pilots acknowledge that it is harder to

remain proficient in the glass aircraft
Normal
New missions
Nevertheless, the majority of AH-64 pilots
preferred the glass cockpit
Hand-fly
Autopilot
FMS control
Chidester, 1999
Rash & Francis, 2003
Possible Impacts of
Cockpit Automation
Increased monitoring, less flying
Requires more heads - down time
Induces complacency and dependency
Loss/erosion of situation awareness
May cause erosion of flying proficiency
May introduce new forms of human error
Automation DependencyComplacency
Pilots may become complacent in highly
reliable automated aircraft
In high reliability systems, detection of
automation failures was low
In variable reliability, automation monitoring
was very efficient
Minor input error - serious consequences

Singh et al, 1993, 1997
Northwest 255
The Future?
Automation Take-Aways
Countermeasures
Potential for both decreasing and increasing

crew workload
Anticipate high workload periods
Can cause mode awareness error
Recognize onset of high workload
Can cause incidents of perceived control
Carry out what if scenarios during periods of low
SOPs are an effective means of avoiding many

automation pitfalls
Flight time is crucial to remain proficient
Crew Resource Management skills are more
important in automated cockpits
Summary
Our ability to manage workload is
dependent upon the limitations of attention
and working memory
Automation must be carefully managed and
CRM skills are of increased importance in
highly automated aircraft
Avoid distractions
workload
Be aware of signs that other crew members have
become overloaded
Be aware of distractions
Questions?
Civil Aviation Authority (2006). Crew
Resource Management. www.caa.co.uk/
Civil Aviation Authority (2004). Flight Crew
Reliance on Automation. www.caa.co.uk/
www.satechnologies.com Endsleys company
www.flightdeckautomation.com/about.aspx
Flight deck automation issues
THREAT & ERROR

MANAGEMENT
Terminal Objective
Threat & Error

Management
Lesson Topic 2.5
The student will demonstrate

knowledge of Threat and Error
Management, and be able to apply
those techniques to their specific
platform as the Program Manager
C-050-1503A PPT 5001 01
Enabling Objectives
Why Threat & Error

Management?
Implement error management into CRM instruction

Explain importance of Threat & Error Management
Explain information collection programs
Define threat
Describe categories of threats
Explain human limitations that lead to error
Define error
Describe categories of error
Explain T & E Management model and how to use it
inside and outside of the aircraft
Why Threat & Error

Management?
The idea behind all CRM Courses is to define the
best practices in applying threat and error
management counter-measures to reduce or
eliminate the consequences of threats and errors,
which are precursors of accidents and incidents.
Safer operations can be had by imbedding the best
practices of our pilots into our training and
everyday operations. Pilots learn many of their
positive traits from the sharing of ideas and
experiences with their peers and then applying
them to their own operational philosophy.
Why Threat & Error

Management?
Tenants of the original University Texas
Continental Human Factors Study (1996/2000):
To analyze adverse affects of errors within aviation
To define training needs to reduce crew related errors
To define organizational strategies to recognize and
manage threat and error
Why Threat and Error

Management?
To Err is Human
-Marcus Tullius Cicero 106-43 BC
Defines human fallibility

As long as humans remain a functional
component in any aviation system there
will always be errors
HUMAN ERROR has

posed threats to mission
accomplishment since
humans began to deal with
technology
Errors REPEAT even

with new technology
Even for the Military

Errors exist
..and some errors are

MORE COSTLY than
others
Why Threat & Error

Management?
In the past: We focused on eliminating
human error in aviation.
Contemporary acknowledgement: Errors
are inevitable, so
We must instead focus on ways to effectively
MANAGE and REDUCE errors
Why are we still doing CRM training?

Continentals T&E Mission:
Error management enhances mission
accomplishment and effectiveness.
Sound familiar?
Why are we still doing CRM training?

Have you ever said nice save?
Have you ever scared yourself on a flight?
Threat & Error = Mission Effectiveness
Have you ever thought Dont question me, I know

what Im doing?
CRM = Mission Effectiveness
You've done it a thousand times.
Threat & Error = CRM
It comes naturally to you.
Safety is a by-product!
Its what you've been trained to do your whole

career.
CRM Mission:
Supporting Mission Accomplishment
Through Enhanced Aircrew Performance.
Nothing could possibly go wrong. OR?
Because Errors Exist
THE PROGRAM
Error Reporting
Accidents/Incidents
Reactive
What is happening
here?
Proactive
Data Collection
Data Collection
Data Collection Programs
Why is it important?
Still making the same mistakes
Where do we start?
Information Collection
What kind of data are we looking for?

Find the common errors that are being
made by aircrew routinely!
Not just on check flights !
LOSA Line Operations Safety Audit

FOQA Flight Operations Quality Assurance
ASAP Aviation Safety Action Program
Need to acknowledge errors occur in order to

fix them
Data Collection Programs

ASAP
LOSA
Collect
Data
(Measure)
Line Operations Safety Audit

Do the concepts taught in training transfer to normal,
everyday flight operations?
Observations of flight crew performance during everyday flights
ere
Th e
W e
r
We
Le
Le sso
ar ns
ne
d
Observers unobtrusive collecting data not participating in flight
FOQA
Team of observers from different backgrounds
Line pilots / Union representatives

Check airmen
Safety and Training pilots
All data is DE-IDENTIFIED, CONFIDENTIAL, and NON-PUNITIVE
UT and Continental, 1996
First LOSA
Collaborative Results
FLIGHT OPERATIONS
QUALITY ASSURANCE
31% of flights had an Automation error

21% of flights had a checklist error
72% of flights w/at least one external threat
(adverse wx, ATC error, aircraft malfunction)
Average = 2, Most = 17
Of all errors committed:
85% were inconsequential
15% were consequential
3% caused additional errors

12% resulted in an undesired aircraft state
Used to collect, store, and

analyze recorded flight data.
FLIGHT OPERATIONS
QUALITY ASSURANCE
MFOQA Objective
Naval Aviation Enterprise
FA-18C-F, EA-18G (Wing)
MH-60R/S (Wing)
FA-18 C-F, EA-18G (Squadron)
Post Mission Aircrew Debrief (PMAD): flight visualization

and aircrew debrief
Aircraft Maintenance & Troubleshooting System (AMATS):
analysis and material fault isolation
Flight Data Analysis (FDA): monitoring the safe and
efficient operation of aircraft
MV-22B (Wing)
AH-1Z / UH-1Y (Wing)
CH-53E (Squadron)
AH-1Z / UH-1Y(Squadron)
T-45C (Wing)
MV-22B (Squadron)
Fixed Wing *
T-45C (Squadron)
Rotary Wing *
* CDD states All future DOD aircraft and all existing DOD aircraft unless a cost benefit analysis
(CBA) demonstrates need for exclusion.
UAVs *
MFOQA An Enterprise Wide Solution
One common tool used across the entire Naval Aviation Enterprise
Squadron: Enhancement/efficiencies in maintenance, safety, operations and training
Wing: Track maintenance, safety, operations and training
NAE: Enterprise wide analysis and decision making

No additional hardware required
Complements currently deployed systems (AME, IVHM, etc)
Aviation Safety Action

Program (ASAP)
CH-53E (Wing)
MH-60R/S (Squadron)
Software resides on NMCI / Marine Internet / IT21 / ONE-NET workstations and NFSA enterprise servers
All Navy ASAP Reports

as of 2/2/2011 (CNAF)
Navy ASAP Users Report that on

78% of their flights
"No Event Occurred" and no comments are
required.
On 7% of their flights "No Event Occurred",
but they have ORM, CRM, or
Command Safety Climate
inputs.
ASAP Sample Size: 212,856
Voluntary reporting of mistakes and incidents by

promising no reprisals
All "Actionable" Navy ASAP

Reports as of 2/2/2011
Aireld
1454
Airmanship
1116
Airspace
5703
CommunicaAon
5988
Compliance
2801
Maintenance
5612
Mission Flow
3118
Physiology
757
Recovery
1942
Runway Events
474
Unsafe PracAces
1014
Weather
1339
Other
412
No Event Occurred
(With Comments)
15,218
No Event Occurred
(No Comments)
165,908
ASAP Human Factors

2009-2010
Key Performance Indicators (KPIs) or Outcomes (What Happened)
6000
5000
4000
3000
2000
1000
0
Judgment or Decision
ASAP Sample Size: 212,856

Aireld
1454
Airmanship
1116
Airspace
5703
CommunicaAon
5988
Compliance
2801
Maintenance
5612
Mission Flow
3118
Physiology
757
Recovery
1942
Runway Events
474
Unsafe PracAces
1014
Weather
1339
Other
412
No Event Occurred
(With Comments)
15,218
No Event Occurred
(No Comments)
165,908
Skill Based
Misperception
Judgment or Decision
5670
Skill Based
3237
MispercepAon
2558
Total ASAP Reports
11465
ASAP Human Factors Judgment or

Decision Sub-Category
Sample ASAP Report
Key Performance Indicators (KPIs) or Outcomes (What Happened)
Im
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R
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au
to
tio
Ex
n/W
ec
ute
ar
nin
Pr
g
op
In
er
ad
Pr
eq
oc
u
ed
C
ate
on
ur
tin
e
R
ea
ue
lT
Be
im
yo
e
nd
C
R
Pr
M
oc
ed
ur
e
Lim
its
1800
1600
1400
1200
1000
800
600
400
200
0
Inadequate Real Time ORM

Improper Task PrioriAzaAon
Rushed a Necessary AcAon
Delayed a Necessary AcAon
Ignored a CauAon/Warning
Failure to Execute Proper Procedure
Inadequate Real Time CRM
ConAnue Beyond Procedure Limits
Other
1151
500
411
345
120
1128
246
93
1676
Feedback is Essential for Continued

Program Success
Date
20 Oct 2008
Report Type
Information
Category
Airspace
Subject
Near Mid Air
Collision
Report Status
Submitted
Workgroup of
Entry
VT-10IP
Ops Type
Flight
Stage
VNAV
Safety Related
Yes
Risk Factor
110
Phase of
Operation
Low Level
Action Taken
Evasive Action
Taken
Time of Day
Day
Weather
VMC
Comments
Had near mid-air on first leg of VR-1022. TCAS was showing the A/C coming from the east at
1000 ft above the T-1. The other A/C began to descend, down to co-altitude. All crew
members were aware of the threat and were actively looking for the other A/C. Pilot was
taking evasive action based on TCAS suggestions. Aft observer spotted the A/C first, then
the jumpseat called talley keeping eyes on as it passed slightly above and barely behind the
T-1. It was a civilian single engine prop, red and white in color, headed west. As far as the
crew could tell the civilian took no evasive action to avoid the T-1, maintaining course,
speed, and altitude. All proper procedures were followed by the T-1 crew and the entire crew
worked together to stay safe.
Feedback is Essential for Continued

Program Success
What are some methods of feedback at
your commands?
Safety Grams / Newsletters
Blue Brain Additions
MDG Changes
SOP Changes
NATOPS Changes
Legacy CAL before 2011 and UAL merger
Strategies
THREAT and ERROR

MANAGEMENT
MODEL
Resist
Resolve
New Model in 2011
MISSION
SafeEFFECTIVENESS
Operations
Safe Operations
Errors
Undesired
Aircraft
State
Repair
Recover
Incident/Accident
Prepare
Strategies
CRM/TEM Skills
EM
CR
M/
TE
Prepare
Errors
Planning and Decision

Making
Leadership
Effectiveness
CR
M/T
Threats
Threats
Repair
Resist /
Resolve
Situation Awareness
Communication
Monitor/Cross-Check
Workload Management
Undesired
Aircraft
State
Recover
Automation
Management
CRM/TEM
CRM 7 Critical Skills
Skills
Planning
and
Decision
Decision
Making
Making
Assertiveness
Leadership
Effectiveness
Mission Analysis
Situation Awareness
Communication
Communication
Leadership
Monitor/Cross-Check
Workload
Management
Adaptability
/ Flexibility
Incident/Accident
RISK
Automation
Situational
Awareness
Management
RISK
What are examples of acceptable/reasonable risk?
Why are these risks acceptable/reasonable?
What are examples of unacceptable/
unreasonable risk?
Why are these risks unreasonable?

46 of 20
Risk and Threats

Do you think humans do things they know are risky?
Why?
risky
behavior
Why ?
and/or
Because we have done it
before without any consequences?
Incident/Accident
47 of 20
Because we do not identify THREATS!
48 of 20
What makes aviation risky?

We call these risks
Risk Assessment
How do we assess risk?
We identify the THREATS and our ability
to effectively manage them
Threats
How do we assess the risk?
Threats
When the THREATS become unmanageable

the risk is unacceptable
We maintain MISSION EFFECTIVENESS
in a risky
environment by identifying and effectively managing

THREATS!
50 of 20
Whats the bottom line?
Threats
A THREAT is anything that increases operational
complexity that, if not managed properly, can decrease
the safety margins.
ACTIVE Threat:
Factors that increase the likelihood of an error
being committed, or of not accomplishing the
mission.
These may be:
Environmental (Wx, terrain, enemy)

Internal Cockpit (Fatigue, stress)
External Cockpit (ATC, Other A/C)
Aircraft (EPs, Systems)
51 of 20
THREATS
LATENT Threat: aspects of the Squadron or Strike
Group organization, or individual that are not always
easily identifiable, but that predispose the commission of
errors, or the emergence of overt threats
Organizational / Professional culture (squadron / type wing level)

Regulatory practices and oversight (SOP)
Training philosophy and practices
Qualification standards (qualifications, currency, proficiency)
Aircraft characteristics
Equipment design issues
Flawed procedures (SOP, FTI, MDG, NATOPS, etc)
Scheduling practices
Preparation for duty / tasking / event (personal responsibility)
Personal stress, preoccupation or illness
Threats
Threats
Do not equal errors
Increased potential for error
Threats = Red Flags
Examples of Threats
Distractions
Other Aircraft
ATC
Aircrew
Terrain
Weather
Maintenance
Similar call sign
Threats
Ground Crew
Time pressures
Flight
diversion
Heavy traffic
Unfamiliar airport /
Landing environment
System malfunction
Automation event
What Threats have you faced?

Think back to a recent flight,
describe a threat you may have
encountered?
What types of different threats do
you face in different areas?
CONUS
Training
Overseas
Combat
Missed approach
Threats
Threats
Can we eliminate THREATS from aviation?
What is our strategy to manage threats?
No, unless we dont fly!

How do we operate in spite of the fact that we
cannot eliminate the THREATS from aviation?
We EFFECTIVELY manage
(prepare for) them.
MISSION EFFECTIVENESS
Safe
Operations
Threats
Identify and Prepare
57 of 20
Strategies to Prepare for Threats

Things we can use in our tool bag to
counter threats:
CRM / ORM / TEM

Clearly defined roles of aircrew members
Complete briefing and effective communication
Limit being heads down at critical times
NATOPS / System Knowledge
What strategies do you use to counter

threats?
Verbalize, Verify, Monitor

VVM
Break the chain by recognizing errors and fixing them.
Dont hope someone else will notice!
VVM is a key element of Threat and

Error Management process.
The verbalization by both pilots verifies a shared
understanding of what is expected and then both pilots
monitor to ensure strict adherence to all instructions.
Why is Monitoring so Important?
CRM/TEM Skills
What tools do we have to help us IDENTIFY
and MANAGE (PREPARE for)?
Accident Data
Factor in 84% of 37 crew-caused air
carrier accidents
Threats
76% of the monitoring/challenging

errors failed to catch something that
was causal
Mission Analysis
Factor in 50% of the CFIT accidents
Communication
Decision Making
62 of 20
Errors
Questions?
What can happen if we ignore or mismanage a THREAT?

Safe
Operations
Threats
Errors
Errors: Crew action or inaction that

leads to deviations from expectations,
reduces safety margins, and may occur
from either mismanaged threats or
mistakes.
63 of 20
Take 5
Human Error
Categories of Error
Definitions
Error:
Procedural - Following procedures but wrong execution
Crew action or inaction that leads to deviations

from expectations, reduces safety margins, and
may occur from either mismanaged threats or
mistakes.
Error Management:
Process of correcting an error before it
becomes consequential, i.e. Undesired Aircraft
State and Incident/Accident.
Operating with Errors

How do we operate in an environment
where we cannot eliminate human errors?
Minimize and Manage Them!
69 of 20
Exercise
How many passes did the White team make?
Notice anything other than the players?
A GorillaReally?
How many Black team members
were playing at the end of the game?
(wrong altitude setting dialed into the FCP)
Communication - Missing info or misinterpretation

(miscommunication with ATC)
Proficiency - Error due to a lack of knowledge/currency

(lack of automation knowledge)
Decision - Crew decision unbounded by procedures that

unnecessarily increased risk (unnecessary navigation through
adverse wx)
Intentional Noncompliance - Violations (checklist from

memory)
SJU Intl Airport Lagoon

Visual Rwy 8
Pattern Matching
Crew planned and set for

ILS 10
Clearance change to
Lagoon Visual Rwy 8
Captain airport in sight
3 Go-around calls from
Tower
Rate of descent at 1000
AGL is 2170 fpm
SIG Tower uses red
signal light
Airplane successfully
lands on 4150 runway
You see what you expect to see

It happened like this last week
It happened before, it will happen again
73
Minimizing Pattern
Matching Pitfalls
Isla Grande Pattern Matching

Pattern Match
Runway same basic

orientation as SJU
Pitfalls
Expectancy
Defense
SOP
Brief two airports in vicinity
Anticipate clearance
changes
Crew cross check
Hangar fly the approach
Adequately define the problem.

Use Standard Operating Procedures.
Get confirmation by another crewmember.
Error Management
CRM/TEM Skills
What skills do we have to
help us Manage Errors?
Errors
Does managing an error so that

there are no consequences achieve
the same result as no error?
Communication
Assertiveness
Adaptability/Flexibility
Leadership
77 of 20
78 of 20
Error Management
Error Management
There are two categories of Error Management Tools
What are some examples

of
RESIST
&
RESOLVE
Tools?
RESIST:
The hardware and software built into the

system that trap ERRORS
RESOLVE:
The human skills that are used to trap and

correct ERRORS
79 of 20
80 of 20
Strategies for Errors

ar
she
nd ction
i
W te
De
Autopilot
AS
TC
Ma
GPWS
Resist
GPS
isp
Ra
lay
da
Monitoring
Challenging
What Tools Are

You Bringing To
The Fight?
e
nc
Threats
Errors
Prepare
Repair
pe
rie
ud
tit
At
What Are Your

Systems
Doing For
You?
Ex
Human-ware
s
m e
ste dg
Sy wle
o
Kn
Resolve
Mission Effectiveness
Hardware
Warning Systems
Professionalism
What is our strategy to manage errors?
FMC
pD
Identify and Repair
Health
82 of 20
Your Goal
Prevent / Manage / Correct Errors
SOPs
Resist
NATOPS
Checklists
Aircraft Warnings
Effective Communication
Resolve
Resolve to follow
SOPs / NATOPS
Good Briefs
Avoid Unwanted Consequences
Your Goal
Prevent / Manage / Correct Errors
Trap the Error: It is detected and managed
before it becomes consequential
Exacerbate: It is detected but the crews
actions or inaction leads to a negative
outcome
Fail to respond: The crew fails to react to the
error either because it is undetected or
ignored
Avoid Unwanted Consequences
How do we Manage an
Undesired Aircraft State?
What can Happen if We Dont

Repair the Error ?
Threats
Threats
Errors
Errors
Prepare
Prepare
Prepare
Repair
Undesired
Aircraft
State
Undesired
Aircraft
State
Undesired Aircraft State: A position, speed,

attitude, condition, or configuration of an
aircraft that reduces safety margins.
Repair
Repair
Recover
Identify and Recover

86 of 20
85 of 20
What if we do not Recover?
Undesired Aircraft State

Undesired
Aircraft
State
Incident/Accident
Threats
Errors
Undesired
Aircraft
State
Prepare
Prepare
Repair
Repair
Incidents/Accidents that result from

pilot error are always the result of an
Undesired Aircraft State.
Recover
Incident/Accident
87 of 20
88 of 20
Planning and Decision

Making
Does an Undesired Aircraft
State always result in an
Accident Rate Since 1959
The overall accident

rate has improved
Incident/Accident
dramatically from
1959 2010!
Can the RATE be 0
Why ?
89 of 20
What do want YOUR

Incident/Accident
How are the skills related ?

What do they have in common ?
Decision Making
rate to be ?
Situation
Awareness
Assertiveness
Mission
Effectiveness
Adaptability /
Flexibility
Mission
Analysis
Leadership
Communication
91 of 20
What is a norm?
What is a norm?
Unwritten practice accepted by most
members of a given group
Can be positive or negative
Effective/Ineffective
What have you seen in your previous

flight experience?
What are your expectations?
Compliant with SOP
At Risk Behavior
Reckless Behavior
Norms
Drift is the gradual
departure from an
intended course
due to external
factors.
Compliant with SOP
At Risk Behavior
Reckless Behavior
How much drift do they expect?
Unexpected or Unfamiliar
Routing
Verbalize, Verify
And Monitor
Compliant with SOP
Waypoint Not Input

Correctly
At Risk Behavior
Map Display and

SOPs
Reckless Behavior
Crew action
DRIFT?
Phone call / Violation
AH-64 / F-16 / H-60
F-16 Case Study
Case Study
Identify Threats
Identify Strategies
Identify Errors
Identify Resist/Resolve
H-60 Case Study
http://www.youtube.com/watch?v=qYExH8hpgXI
http://www.youtube.com/watch?v=0fnAkb_jGoc&feature=related
http://www.youtube.com/watch?v=Ql0-xDne42U&feature=related
AH-64 Case Study
Summary
Threats
Prepare
Safe
Operations
EM
Strategies
CR
M/T
Errors
Repair
Resist /
Resolve
Identify:
Threats
Strategies
Errors
Resist/Resolve
Undesired
Aircraft
State
CRM 7 Critical Skills

Decision Making
Assertiveness
Mission Analysis
Why Threat & Error Management (TEM)

Data Collection
Threat Categories
Error Categories
TEM Model
Communication
Recover
Leadership
Incident/Accident
References
SAFETY ACROSS HIGH-CONSEQUENCE INDUSTRIES
CONFERENCE, St. Louis, MO
09 Mar 10 Mar, 2004
The University of Texas Threat & Error Management Model:
Components & Examples
Robert L. Helmreich Ph.D., David M.Musson, MD.
Models of Threat, Error and CRM in Flight Operations

Robert L. Helmreich Ph.D., James R. Klinect, John A. Wilhelm
UNIVERSITY OF TEXAS TEAM RESEARCH PROJECT
THE UNIVERSITY OF TEXAS AT AUSTIN
DEPARTMENT OF PSYCHCOLOGY
Questions?
INTRODUCTION TO
CASE STUDIES$1''(9(/23(0(17
Terminal Objective
CASE STUDY
DEVELOPMENT
Conduct CRM Instruction, in a classroom

setting, in accordance with Instruction,
Crew Resource Management Program,
CNAF 1542.7 (series)
Lesson 3.7
Enabling Objectives
Build case study scenarios for CRM
explanation and training
Assemble sources and media into a
complete case study
Presentation
TRANET (Cont.)
TRANET Computers
Verify:
Use your CAC Card and log onto the
TRANET computers.
That you can save data in your student

access assigned class folder.
Open student share drive folder on your

desktop: O:\CRM\Production\Student
Access\(Assigned class folder e.g. 13-01)
That you have internet access.

That you have access to the Roxio
program (CD burner program).
Case Study Template

1. Go to O:\CRM\Production\7 Skills Case
Study Templates
A/F Word Doc Template

Instructor Guide
Title of your case
study
Case Study Template

O:\CRM\Production\7 Skills Case Study
Templates
Open A/F Word Doc Template

Instructor Guide
Type of A/C
Where you got the info
List your EOs
All this is provided for

you in the template
Brief description

Instructor Guide

Instructor Guide
Synopsis with skills

identified
Items to add to the

synopsis during the
class discussion
Provided for you on

your template
Your questions with

answers
Provided for you on
your template

Student Handout

Student Handout
Type of A/C
Title of your case
study
Where you got the info

Questions without
the answers
Synopsis without
skills identified
Case Study Template
A/F Case Study PP

Template
Open A/F PP Template
A/F Case Study PP

Template
A/F Case Study PP

Template
A/F Case Study PP

Template
Presentations
Summary
Build case study scenarios for CRM

explanation and training
Assemble sources and media into a
complete case study
Time limit is 20 minutes!

Burn templates to CDs.
Issued student disks are not RW.
Save files on computer under:
Production\Student Access\Class 13-XX
(videos need to be saved in same folder by
0830 Thursday).
Be complete by Thursday morning.
Print 1 copy of the Instructor Guide.
First person covers all 7 skills.
Lunch options: Break or in house Pizza
Questions?
FATIGUE & STRESS
SA
S
SA
S
Background
AOCS
Aeromedical
SH60-B
Recruiting Duty
Med School
Internship
CAPT Jack Bags Wyland
Flight Surgery
Command Flight Surgeon, School of Aviation Safety

John.j.wyland@navy.mil
(850) 452-5140; DSN 459Room 161C
Naval Aviation Mishap History
SA
S
Residencies in Aerospace and Family Medicine

3D MAW
NAVHOSP Pcola
SAS
SA
S
USN/USMC, FY50-06
776 aircra(
destroyed in
1954
VMMT-204
FY 2011
11 Aircra(
Destroyed
60
Jack Sr & Betty say I do
Sister Janet born

Sister Joyce born
50
40
The June
Cleaver effect
Bags born
Tricycle to bicycle transition
Firecracker Mishap
30
Sister Mary Alice

HS/College
20
CRM Aeromedical Topics
Class A
Mishap Rate
USN USMC
FY07: 0.98 2.05
FY08: 1.51 2.26
FY09: 1.17 1.41
FY10: 0.78 1.46
FY11: 0.96 2.44
Fatigue and Stress
AOCS
Wench
10
Med School
0
50
55
60
65
70
75
80
85
90
95
00
C-050-1503A PPT 5010 01
NSC Data: Oct 06
The mechanization of modern war has

produced a chain of health problems. One
of the greatest of these is fatigue. In the
complicated meshwork of speed and
change, many factors make for fatigue.
Scarcely any key man in modern war is
more subject to stress and strain, to
demands on his body and mind making for
fatigue, than the military pilot.
Dr. Martyn Kafka, 1942.
Kafka, M. Martyn. Flying Health. Harrisburg, PA: Military Service Publishing Company, 1942.
SA
S
Terminal Objectives
Become familiar with the leading

aeromedical causes of mishaps and
HAZREPs to further understand how
CRM can prevent mishaps through the
use of an effective ASO-FS team.
SA
S
Learning Objectives
DESCRIBE the science and physiology of sleep

and stress, and their effects
DESCRIBE symptoms/signs of fatigue and stress
DESCRIBE performance decrement from fatigue
and stress
DISCUSS the prime causes of fatigue and stress
DESCRIBE effects of circadian cycles in fatigue
RECOGNIZE mishaps where fatigue or stress
may be a factor
IDENTIFY key countermeasures for fatigue and
stress
UNDERSTAND performance-maintenance
pharmaceuticals
SA
S
Fatigue and Related Human Factors in

the Near Crash of a Large Military
Aircraft.
Do you feel yourself wanting to

doze after lunch?
Do you fall asleep within ten
minutes after lights out?
Do you sleep more on weekends
than during the week?
52 recognized
cases
Do you sleep more on vacation

than when you are working?
The Brain
Massively parallel, electrochemical digital computer
~ 100 billion neurons;
trillions of logic gates
(synapses)
Clock frequencies of 1/3 to
> 100 Hz.
Runs on oxygen & glucose
2% of body mass
25% of resting energy use
The Science of Fatigue
Neurons
Synapses:
the logic
elements
Facilitated
transmission
and structural
changes at
synapses:
learning &
memory
The brain is a digital

computer:
Electro-chemical
It cannot run
continuously awake
It requires scheduled
recharge &
maintenance intervals
The brain
accumulates
fatigue when
operating
Its computing at less
than 100%
Fatigue is a
physiologic state
Not due to rank, rate,
experience, motivation,
or attitude
http://www.pfizer.com/brain/images/neuron_large.gif
Brain Functions
Signs and Symptoms of Fatigue

Decision
Making
Adaptability;
Irritability, mood Flexibility
Complex reasoning
Leadership
Mood, personality
Problem-solving
High-level
reasoning
Body sense and
Movement
Memory
Speech
Vision
Balance &
Coordination
Consciousness
Breathing
Heart rate
Fatigues Effects are Task-Dependent

More CRM,
sensitive
to Fatigue
Sense of well-being
ORM
Judgment & decision
making
Vigilance & attention
Well-learned/simple
More resistant to Fatigue
intellectual or physical
tasks
deterioration,
& decision making

Conservation of
effort, reduced
Mission
communication
motivation Analysis
Assertiveness
Reduced vigilance,
Forgetfulness
inattention
Increased reaction
Threat &
times
Situational
Task fixation
Error
Awareness
Tolerance for error
Lapses
and
Management
and risk
microsleeps
reduced patience
Communicatio
n
Impaired
The Problem:
SA
S
Performance Degradation
Truck accidents 30-40% by NTSB

Daylight Savings Time: +8%, -9%
Challenger, Exxon Valdez,
Chernobyl, Three Mile Island,
Roosevelt-Leyte Gulf?
WRAIR Restricted Sleep Study:

Adaptation to Chronic Sleep Restriction
Mean Speed on Psychomotor Vigilance Task
(as a % of Baseline)
Three Days of Sleep Deprivation
Adapted from Steven R. Hursh, SAIC
Baseline
7 Day Restricted Sleep
Recovery
110
95
9 Hr
80
7 Hr
5 Hr
3 Hr
65
SAFTE/FAST
R2 = 0.94
50
0
T1
T2
R1
R2
R3
Day
Baseline
Recovery
110
95
9 Hr
80
7 Hr
5 Hr
3 Hr
65
SAFTE/FAST
R2 = 0.94
50
0
T1
T2
Day
R1
R2
R3



Baseline
Recovery
110
95
9 Hr
80
7 Hr
5 Hr
3 Hr
65
SAFTE/FAST
R2 = 0.94
50
0
T1
T2
Day
R1
R2
R3
USN Recruits Test Scores by Year

6 vs. 8 hours sleep
How Much Sleep Do You Need?

New-thinking
8 hr
6 hr
Old-thinking
6 hr
Dr. Nita Miller, Research Asst. Prof., NPS
10
11
Lapses / Microsleeps in a Taxi Driver
Humans are the only animals that

willingly deprive themselves of
sleep.
Eve Van Cauter
Sleep researcher
University of Chicago
Microsleeps in Military Security
Velocity: 14 mph
12
Roosevelt - Leyte Gulf
SA
S
Mishap Board Findings:

HUMAN ERROR: CG CO:
HUMAN ERROR: CVN OOD:
... failed to recognize the

seriousness...
... in disregard of nautical rules

of the road...
...unable to recognize or
unwilling to act....
...without communicating
intent.
...did not act with appropriate
dispatch...
...did not advise CO that ...
...did not advise CO of
conflicting concurrent
events...
...did not advise CG in a timely
manner...,
... failed to sense the urgency
of...
...did not notify the CO...
...became overly involved in
managing...
Identifying Fatigue
If we cant measure it, we miss it
Self assessment of fatigue unreliable
The greater the impairment, the poorer the assessment
Can be inferred from performance measurement

But other things also affect performance stress, illness, hypoxia, alcohol, drugs, etc.
Hours of continuous wakefulness

Circadian rhythm effects
Sleep debt = (Ideal - Actual) x days
Sleep disorders (sleep apnea, RLS, narcolepsy, etc.)
Based on evolution and the

orbital motion of planet Earth
a 24-hour day
...failed to properly analyze the

movements of...
...was not proactive ... in
communications, ...was focused
on...
...failed to demand proper support
from ...
...failed to prioritize bridge
duties...
HUMAN ERROR: CG TAO:

...focused on the ... scenario,
failed to supervise, ... did not
recognize,...
Oxygen ?
Water ?
Nutrition ?
Sleep ?
4-10 minutes
5-7 days
1-2 months
2-3 weeks
Sleep Facts
Sleep
Complex activity
Scheduled by circadian rhythms
HUMAN ERROR: CG OOD:
Sleep-deprived animals die from insulin

resistance, immune system failure and sepsis.
Sleep is a physiologic requirement for survival.
Sleep is a fundamental drive, powerful enough
to interrupt any waking activity.
Fatigue can be modeled and predicted:
Sleep is the set of maintenance

& recharge procedures the brain
uses to eliminate fatigue.
...failed to properly analyze the

movements of...
...failure to consider the possibility
of ...
How Long Can You Live Without
No simple measurement of fatigue
HUMAN ERROR: CG XO:
Sleep is the recharge procedure to alleviate fatigue

Based on genetics and Earths 24 hour rotation
Normal amount of sleep 8 8 1/4 hours
Min 5 hours/night to maintain performance? NO!
~ 2 hrs of performance for each 1 hr of sleep

6 > sleep > 10 hours - higher mortality
Sleep cannot be banked but deficits accumulate
Rest does not replace sleep
Sleep Research
Sleep Architecture
Ultradian Cycles ~ 90 mins
NREM deep sleep important in cellular

recharge/health?
REM sleep important in memory storage?
The brain wakes up out of REM
Ratio of REM/NREM sleep varies with need

The brain must have both
Sleep induction and maintenance tied to

circadian rhythms
Efficiency of sleep deteriorates with age
MSLT less than 5 minutes is pathologic
Sleep Stages vs. Age
MSLT Averages
anesthesia
residents
10%
6 hr TIB
x 4 nights
9%
8%
Mean
11.4
8 hr TIB x 5 nights
Sleep
apnea
7%
10 hr TIB x 14 nights
(full alertness)
6%
Narcolepsy
5%
0 hr TIB
x 1 night
4%
3%
2%
excessive daytime
moderate
sleepiness (7.7%) sleepiness (29%)
1%
0%
0
10 11 12 13 14 15 16 17 18 19 20
Latency in Minutes
Adapted from Dement; Sleep Medicine
Pilot Performance
Long Haul vs. Naps
Without naps
With 40 minute nap
Rosekind MR, et. al. Crew Factors in Flight Operations IX:

Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations.
SA
S
Nap Rules
Naps are good
More naps are better
Long naps are best
Expect sleep inertia
Take a nap!
The Circadian Cycle
Circadian Rhythms
The brain energy

level
The circadian alerting

signal
Circadian Rhythms
Over 300 circadian rhythms (temp,
pulse, immune function, hormones, etc.)
Entrained by light, period ~24 hours
Time zone travel requires clocks to
phase-shift/ speed up or slow down
Week or more to normalize:
1 1/2 hrs phase shift/day west
1 hr phase shift/day east
SA
S
Circadian Rhythms
SA
S
Biological Circadian Fluctuations
JA & JL Caldwell. Understanding and Managing Fatigue in Operational Aviation Contexts.
SA
S
Internal Synchronosis
Core
temperature
Gastric acid
secretion
Liver
function
Glucose Gut Hydration Growth
level activity
hormone
Immune
function
Stress
hormones
SA
S
Kidney
flow
Metabolic
rate
Lipids
Desynchronosis
External desynchronosis
A time shift occurs (transmeridian travel)

The circadian clocks are all off by the same amount of
time, but are together, in phase.
Internal desynchronosis
Following a time shift (generally 6 hours or greater)

The circadian clocks start to drift in opposite
directions at different rates theyre out of phase
with each other
Takes days to weeks to resynchronize to the new
time zone
During this time the brain is fatigued and

performance suffers
Fatigue and Visual Illusions
Fatigue and Spatial Disorientation
Spatial Orientation is
80-85% visual
Brain takes 2-D images
from retinas and
interprets 3-D world:
requires high-level
cognition and
computing speed
Visual illusions result
from misperception of
reality hypnagogic
hallucinations
Vestibular & seat-of-thepants senses conflict

with reality
Spatial Orientation in
aviation depends on
high-level cognitive
power
Loss of visual cues, task
saturation, scan
breakdown all lead to SD
Fatigue impairs
visual interpretation!
Fatigue aggravates
all of these!
SA
S
Lets take a break
When you have fully grasped the big picture
SA
S
Animal Modeling of Fatigue
FAST
Computer Modeling
of
Fatigue
SA
S
24-hour
period
Afternoon
circadian
dips
Performance
drop
Work
Sleep
BAC
equivalent
scale
Night shift
Exxon Valdez 00:15

Bhopal 01:00
Chernobyl 01:23
Kuwait H-46 Mishap 02:33
Roosevelt Leyte Gulf 02:52
Three Mile Island 04:00
HSL SH-60B Mishap 05:30
The midnight to
0600 window is a
very dangerous
place to do
business!
Day-night cycles
Wrist Activity Monitor

Actiwatch
Reasonably Good Sleep
Wristwatch-like device
Identifies awake and
sleep periods
Measures acceleration
(movement) also light
(some models) vs.
time
Records up to one
year
Download data to
computer program
Poor Sleep
FAST Graph: USS Stennis # 03
FAST Graph: USS Stennis #52
SA
S
Mishap Analysis
with FASTTM
SA
S
Fatigue and Related Human Factors in

the Near Crash of a Large Military
Aircraft.
Recommended Fatigue
Countermeasures
Thanks to Maj. Jeffrey Armentrout for slides and graphics

Armentrout JJ, et. al. Fatigue and Related Human Factors in the Near Crash
of a Large Military Aircraft. Aviat Space Environ Med 2006; 77:963-70.
Go into high OPTEMPO

evolutions well-rested
Pre-plan; minimize changes
Schedule with knowledge of
circadian effects
Minimize shifts > 12 hours
Schedule/ encourage naps
Sleep etiquette
Diet/ meals and feeding
Exercise and activity
Shift work how to handle?
Who knows when to quit?
NAVMED
P-6410
Adjuncts
Comprehensive
Guide for Fatigue
Management in
Operational Settings
Includes medication
use re: stimulants &
sedatives
http://
navymedicine.med.n
avy.mil/
instructions/external/
6410.pdf
Stimulants
and
Sedatives
Pharmacologic Agents:
Stimulants
Go-pills
Modafinil (Added Apr 2012) or Dextroamphetamine
Will forestall fatigue, and maintain performance

Will not alleviate need for sleep, just postpone
it.
Required in increased quantities to overcome
fatigue
Limited by hallucinations, psychosis, etc.
I said, One of us is hallucinating!
Pharmacologic Agents:
NATOPS, Ch. 8
Sedatives
No-go Pills
Ambien or Sonata (changed Apr 2012)
Will enable sleep, but may interfere with

normal sleep efficiency
Rebound sleep difficulty possible for 1-2
days
May produce hangover effects
Require grounding following use
Limited by amnesia, etc.
NEVER carried in aircraft!
NATOPS, Ch. 8
8.3.2.1 Rest & Sleep:

Must have opportunity for 8 hours sleep
per 24 hours
Should not schedule continuous awake
periods over 18 hours (or else shall give
15 hours off afterward)
SA
S
Take-home Points:
Fatigue / Circadian Rhythm Disruption
8.3.2.1.1 Circadian Rhythm:

accommodation period
estimated by allowing 1 day for
every hour over three (of time
zone shift)
expect to perform at less
than optimal level
Fatigue is a physiologic state; not due to

motivation, or attitude
Normal need for sleep is 8 8 hours/day
High-level problem solving is most susceptible
Emergency procedures, SD susceptibility, etc.
Stick & rudder skills relatively resistant
Naps help
Beware sleep inertia
Expect circadian rhythm disruption, difficulty in

getting sleep when times available, higher
fatigue, and poor performance
Mechanical Stress
SA
S
Material placed under a load;

measured as force per unit area
STRESS
Material deforms slightly, bulges,
and responds to stress
What is Stress?
STRAIN
Once STRESS is removed, if the
elastic limits haven
t been
exceeded, the material returns to
it
s normal shape, unchanged.
If material is overstressed
it
undergoes plastic deformation, or
may even fail completely.
Hooke
s Law - 1658
Stress
Strain
Human Stress
Dr. Hans Selye

1907 1982
Neuro-endocrinologist
at Montreal
The Einstein of
Medicine
Discovered the
common reactions to
all stressors
Coined the term
stress but really
meant strain.
The weight is
the STRESS
How does the
body react?
Stress Reaction
Origin of the Stress Response

Brain sends out alerting/alarm
messages
In response to physical stressors

In response to psychological stressors
Brain (hypothalamus) sends

messages to the pituitary
ACTH
Adrenals start pumping out
Norepinephrine, adrenalin
Adrenocorticoids; mineralocorticoids
Combination of hormonal and

neural signals drastically alters the
body physiology
Heart rate goes up

Blood pressure, breathing rate goes up
Muscle tension increases
Perspiration goes up, saliva decreases
Mental alertness and senses increase
Blood flow to brain, heart, muscles goes up
Blood flow to skin, gut, and kidneys goes down
Blood sugar, cholesterol, clotting factors go up.
The fight or flight response
Stress is:
The non-specific
response of the
body to any
demands made
upon it
Is it really
better to be
the boss?
The Non-specific Response

The General Adaptation Syndrome
Resistance
Fat loss
Temperature
Blood lipids
Liver fats
BMR
Glucose
Cholesterol
Urea
Glycogen
Lactic acid
Amino acids
Ketoacids
Blood enzymes
Stress & Performance Relationship

Tissue minerals
Sulfates
Proteins
Serum protein
Optimal
Diuresis
Cell water
Creatine
Uric Acid
Sodium
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memory to open the image, or the image may have been corrupted.
Restart your computer, and then open the le again. If the red x still
appears, you may have to delete the image and then insert it again.
Performance
Acid-base level
Potassium
Tolerable
Demand
Excessive
Demand
Overload
Underload
Minerals
STRESS Level
Physical Stressors
When flight
mechanisms
become
flooded
Illness, infection, fever

Trauma, hemorrhage
Burns
Surgery
Dehydration
Physical exertion
Etc.
Other Stressors
Environment
Other Stressors (contd)

Major life events
Noise, crowding, clutter

Cold, heat, humidity, vibration
Bright or low light levels
Heights or confined spaces
Social
Relationship problems
Work relationships
Crowds, parties, strangers
Rude, aggressive, critical, or competitive people
Other Stressors (contd)

Institutional
Rules, red tape, regulations
Deadlines, schedules, meetings, office
politics
Training!
SA
S
Death of spouse, parent, or child

Marriage, divorce
Moving, PCS, deployments
Crime victim
Winning the lottery
Promotion or job loss
Aircraft mishap
Etc.
Selye Quotes
Every stress leaves an indelible scar, and

the organism pays for its survival after a
stressful situation by becoming a little older.
Man should not try to avoid stress any more
than he would shun food, love or exercise.
Adopting the right attitude can convert a
negative stress into a positive one.
Hans Selye
Well,its a
delicate situation,
sir.
Sophisticated
firing system,
hair-trigger
mechanisms,
and Bobs wife
just left him last
night,
so you know his
heads not into
this.
Chronic Stress
Fatigue
OPTEMPO
Family
stress
Financial
diffs
Stress
Overload
Passed
over
Breakdown in
compartmentalization
Performance
deterioration
Behavioral
problems
Emotional
instability/
deterioration
Chronic health
problems
Deploy
Symptoms of Stress
(contd)
Symptoms of Stress
Physical
Palpitations, pounding heart

Tense muscles, tension headaches, soreness
Dry mouth, grinding teeth
Chest pains
Indigestion, acid reflux, constipation, diarrhea,
appetite changes, nausea
Weight change
Back pain
Hands and feet sweating (dishydrosis)
Fatigue, sleep difficulties
Decreased libido
Symptoms of Stress
(contd)
Behavioral
Fidgety, nail biting, knee jiggling

Acting-out behaviors, aggressive
Smoking, compulsive eating
Talking loudly, swearing
Alcohol abuse, drug usage
Eating disorders
Inappropriate concern over health
Fear of flying
Mental
Forgetfulness, memory problems

Indecision, poor prioritization
Lack of concentration
Difficulties in switching off
Emotional
Loss of sense of humor

Nervous, jittery, on edge
Irritable, easily frustrated, short-tempered
Apathetic, depressed, sad, tearful
Some Diseases of the Stress Response
Hypertension
Diabetes
Peptic Ulcer, Irritable Bowel Syndrome
Asthma
Headaches
Sleep Disorders
Depressed immune function
Coronary Artery Disease
Death, etc.
At Risk Aviators
1. Below-average Nugget or New
Transition Aviator
2. Overconfident Senior Aviator
3. Best Pilot/ Aviator/
Aircrewman
4. Consistent Poor Performer
5. Overstressed Aviator
Reasons Swiss-cheese Model of Human Error

Inputs
Organizational
Factors
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Failed or
Absent Defenses
Accident & Injury
Adapted from Reason (1990)
Overstressed Aviator
Key Characteristics
Possible Interventions
Major stressors, such as death

of family member, divorce,
failed relationship, financial
setback, poor job performance
Noticeable change in mood or
personality
Frequent, out-of-proportion
anger, resentment, hostility
Distracted, mentally
preoccupied, loss of focus.
Uncharacteristic breakdown of
flight discipline or high riskseeking behavior
Command counseling
Flight surgeon review
Selective scheduling
Close supervision and
monitoring
Temporary grounding or
flight restrictions
Reduce workload or stress
Send to Family Services or
Stress Management clinics
Refer to HFB
Coping With Stress

Recognize the problem
Stress
Management
As usual, self assessment is poor

The sufferer is the last to recognize the problem
Eliminate as many stressors as possible:
Eliminate alcohol, tobacco, caffeine

Adequate sleep
Let it out?
Meditation
Get exercise
Take time out, snivel
Counseling, professional help
SA
S
Take Home Points: Stress
Stress is a psychological and physiological condition.

Sources of stress can be external or internal.
Stress has long-term detrimental effects on health
Stress manifests itself as changes in emotional state
and/or overt behavior (performance).
The nature and scope of psychological aspects of stress
are in-part culturally defined.
Stress impacts personal relationships and work
environment.
Stress can be managed.....to a point!
SA
S
Learning Objectives
DESCRIBE the science and physiology of sleep

and stress, and their effects
DESCRIBE symptoms/signs of fatigue and stress
DESCRIBE performance decrement from fatigue
and stress
DISCUSS the prime causes of fatigue and stress
DESCRIBE effects of circadian cycles in fatigue
RECOGNIZE mishaps where fatigue or stress
may be a factor
IDENTIFY key countermeasures for fatigue and
stress
UNDERSTAND performance-maintenance
pharmaceuticals
NATOPS, Ch. 8
8.3.2.9 Emotional Upset:
COs must remain alert to the
emotional & physical status of
personnel and take corrective
action
Questions???
QUESTIONS???
SA
S
Aeromedical
Feedback or questions, please!

Take critiques seriously!
Email, call any time
CAPT Jack Bags Wyland

Command Flight Surgeon, School of Aviation Safety
John.j.wyland@navy.mil
(850) 452-5140; DSN 459Room 161C
TEAMWORK
Terminal Objective
Upon completion of this unit of
instruction, the student will
demonstrate knowledge of teams,
team developmental stages, team
leadership, and associated team
performance and maintenance
techniques
TEAMWORK
C-050-1503
Enabling Objectives
Enabling Objectives
Conduct teamwork instruction, in a classroom

setting, in accordance with Crew Resource
Management Instructor Course Lecture
Outline.
Describe the relationship between teamwork

and leadership, in a classroom setting, in
accordance with Crew Resource
Outline.
Define team, in a classroom setting, in

accordance with Crew Resource
Outline.
Describe team performance strategies and

maintenance strategies, in a classroom
setting, in accordance with Crew Resource
Outline.
Identify team developmental stages, in a

classroom setting, in accordance with Crew
Resource Management Instructor Course
Lecture Outline.
3
Teamwork
Teamwork Exercise
Put all the facts together to solve the
mystery.
Find the MURDERER, WEAPON,
TIME, and PLACE.
Organize yourselves as you want
(Group Leader etc.).
You cannot write anything down,
pass clues around or show them to
anyone else, or walk around the
room.
How do Teams differ from

Groups?
Level of performance
Interdependence
Shared mental models
Attitudes
5
Level of Performance
Interdependence
HIGHER
The crews success depends on

each member knowing and
executing his/her job in an
accurate and timely manner.
What is a TEAM ?
Shared Mental Models
A group of people working

together to a common purpose
Great minds thinking alike
Group of people (2 or
more) working together:
Teams need to consider
the handling of people
within the team, of
communicating, of
keeping people together,
of motivating them, so...
To a common purpose
(goal):
Suggests clarity of goals,
responsibilities, and
objectives, with everyone
involved committed to
successful completion of
task.
ALL teams have

people (teamwork)
aspects.
ALL teams have task

aspects.
Groups go through
Phases...
10
Team Formation Stages
Groups which form around tasks

go through definite stages during
their life.
1. Forming
2. Storming
These stages help define the role of the

group, determine if the group will form
further into a Team.
3. Norming
4. Performing
Sets standards, expectations,

roles, leaders, etc., for the group.
5. Adjourning
11
12
(FSNPA) Forming:
(FSNPA) Storming:
The first stage includes all of the

discomfort found in any new situation in
which ones ego is involved in new
relationships. This initial stage is one of
caution.
As individuals react to the demands of

what has to de done, they become more
comfortable with other members and
become more themselves.
(Prior to this point persons may
present themselves differently than
they normally act.)
13
14
(FSNPA) Norming:
(FSNPA) Performing:
Now, the rules of behavior appropriate

and necessary for the team to accomplish
tasks are spelled out both implicitly and
explicitly, and a greater degree of order
begins to prevail.
Energies focus on the task(s), having

worked through issues of
membership, orientation, leadership,
and roles.
The team is now free to develop
working alternatives to the problems
confronting it.
15
16
Advantages/Disadvantages
(FSNPA) Adjourning:
Finally, with the task nearing
completion, the team moves to what is
called the adjourning period, in which
closure to the task and a changing of
relationships is anticipated.
Advantages:
Disadvantages:
Sharing of Information
and ideas
Stifling of Individuality
Mutual Performance
monitoring
Improved learning and
decision making
Synergy
17
Overcome individual
biases
Cost in time and effort

to build a team
Decision making
difficulties
Group pressure
Involves more complex
communications
18
Leadership
Effective Teamwork Includes

Behaviors such as mutual
performance monitoring
Intra-team communication and feedback
A willingness to both criticize and accept
criticism constructively
What Impact will Leadership

Style have on a Team?
Rank Gradient
Tailoring
19
Team Performance Strategies
20
Set the Tone

Use good briefing techniques to set the
tone for the crew.
Stress the crews importance to the
mission of the Detachment/ Squadron/
Wing/Organization.
Examine individual values and different
viewpoints, skills, abilities.
Ensure that everyone knows why they, in
particular, are part of the crew.
Set the tone

Define and brief objectives
Communicate
Implement
Monitor/Review
21
Define and Brief Objectives
22
Communicate
Clearly define objectives

Prioritize goals:
Must have
Nice to have
Map out course of action
Be innovative
Keep the big picture
Strive for structure and schedule, but

maintain flexibility
Keep all team members informed
Solicit inputs / keep lines of
communication open
23
24
Monitor/Review
Implement
Execution
Conduct performance reviews
Meet agreed targets
Search for possible improvements
Communicate results of actions
25
Team Maintenance Strategies
26
Involvement
Stay involved at the appropriate
level
Clear obstacles for the team
Anticipate and prevent problems
whenever possible
Neither over-react nor under-react
When in doubt as to what the team
needs or wantsask
Involvement
Attitudes
Conflict Management
27
28
Attitudes
Conflict Management
Keep your team members fresh

but focused
2 Types of Conflict:
Reward performance
Operational
Respect individuality
Personal
29
30
Personal Conflict
Operational Conflict
Safety
Interpersonal
Reliability
Coordination
Legality
31
Conflict Management
32
Conflict Management
Stress a Crew/Mission first attitude

Recognize the difference between
healthy disagreement and disruptive
feuding
When well-managed, conflict can be
highly constructive especially in
problem solving situations
It is each crew members

responsibility to manage conflict.
Disagreements focus on issues,
not personalities.
33
Summary
34
Summary
Teamwork, why its important
and vital for effective CRM
Higher level of performance
FSNPA (stages of teamwork)
Leadership and its role
Conflict management
35
36
Questions?
37
,16758&7,21$/7(&+1,48(6
)$&,/,7$7,21
Terminal Objective
INSTRUCTIONAL
TECHNIQUES &
FACILITATION
CONDUCT CRM Instruction, in a classroom

setting, in accordance with Instruction, Crew
Resource Management Program, CNAF
1542.7 (series)
Lesson 3.2
C-050-1503A PPT 5001 01
Instructional Techniques
Enabling Objective
Implement CRM ground training

instructional techniques.
Explain the basic process of lecture
preparation.
State the aspects of classroom
interaction.
Explain techniques of effective
information presentation.
State techniques for dealing with
adverse conditions.
1960 Presidential Debate
ADULTS #1
FEAR
Public Speaking
5
Communicating the Message
Principles of Communication
Desire to communicate
Believe in what you say
Know your subject
Know your audience
Deliver with enthusiasm
Rehearse, Rehearse, Rehearse
7%
Verbal Content
55%
Visual Stimulation
38%
Tone of Voice
Developing
Presentations
"It takes 3 weeks for me to
prepare an impromptu speech."
--Mark Twain
Audience Analysis
Presentation Development
3 basic questions for presentation development
Audience - Who am I teaching?

Material - What do they need to know?
Instructor - How am I going to present it?
10
11
Motivation
Interest
Familiarity
Capability
12
Building the Presentation
Material
Read references
Talk to the experts SMEs
Of course, just Google it!
Intro.
20%
Body
70%
Summary
10%
13
14
Familiarity
Introduction
Facts
Quotes
Joke
Video
True Story
Current Events
Spaces
Equipment
Why should your audience listen?

15
Have Your Opening Nailed
16
Visualize Your Success
"Being able to start is more

than half the whole."
--Aristotle
17
18
BODY
Reduced to it's most
Basic form...
Youre only talking...

You do that everyday!!!
The MEAT
Built on main points or a premise
Supporting Analogies, Images, References
5WH who, what, where, when, why, how
19
20
Presentation Techniques
Summary
"You can't just end it"
RECAP
REVIEW
REINFORCE
DO
DONT
Complete Memorization
Partial Memorization
Approximate
Memorization
NEW INFORMATION
21
22
Notes
A
P
P
R
O
X
I
M
A
T
E
Stealth fighter
M
E
M
O
R
I
Z
A
T
I
O
N
Use printed PowerPoint note slides if

needed to refresh your memory
23
There is no substitute for

rehearsal!
24
Visuals
Simple
Readable
Accurate
A picture is worth 1000

words, but 1000 items in one
picture is worth nothing.
25
26
Delivering Presentations
Video
ENTERTAINING IS
EFFECTIVE
Great to illustrate a point

Great attention-getter
Great at getting people stimulated
but.
A GREAT DOUBLE-EDGED
SWORD!!
IT IS NOT REQUIRED
27
28
Body Language
NEVER APOLOGIZE !
Your audience will be
very distracted and
few people can rejuvenate an
atmosphere littered with
self-proclaimed weakness
29
The Hands
Props
Movement /
Eye Contact
All amount to the

audiences initial
assessment of you,
and their continued
re-assessment of
what you're saying
30
Hands Humor
Use of the Voice
Quality
Intelligently
Variety
31
Instructional Challenges
32
Dealing With Distractions
Dealing with Special People

Classroom distractions
Audience Analysis
Questioning technique
Continuous
Eye-Contact
Terminal nervousness
Movement
33
34
Definition of Facilitation
Dealing With Distractions

# 1 - Ignore or Dismiss
Facilitation is the design and management of

structures and processes that help a group do
its work and minimize the common problems
people have working together.
# 2 - Subtle Confrontation
Get Physically Close
Make Eye Contact
SAY "STOP!"
Redirect your attention

towards the audience
35
36
Facilitation Fundamentals
Facilitation Objectives
A process management
How you do something

Minimizing problems of people working in groups
Its asking a question

Its about guiding a group from a problem to a
solution
Not entirely about content
Remain neutral
Detach oneself from and relinquish control of the groups

work
Be engaged
Maintain good eye contact
Stay focused on the process
Be a facilitator, not a performer
Encourage everyone to participate
Interpret verbal and nonverbal
behavior
Manage differences
37
Be Yourself
38
Evaluator Vs. Facilitator

Facilitator
Evaluator
Evaluates performance
Be comfortable
Show your personality
Model the behavior you want

your students to exemplify
You were ten knots fast, 50 high,

5 degrees off
Lectures (passive / one way)

You need to improve your
landings
One size fits all
Promotes self-evaluation
How do you think it went? Tell
me what you were thinking at
this point?
Encourages reflection
and self improvement
(active/interactive)
How can we improve your
landings?
Adapt for individual

student needs
39
Review
40
Questions?
Good Vs. Bad instructional technique

Public speaking
Communication
Presentation development techniques
Instructional challenges
Facilitation as a method of teaching
41
42

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Crew Resource Management

School of Aviation Safety

Please fill out blue name tags with the

CRM Course Administration

THIS IS A PRIVILEGED, LIMITED-USE, LIMITEDDISTRIBUTION, SAFETY INVESTIGATION

School of Aviation Safety

ASC - ASO - CRM

Ability to use all

CRM and ORM

The goal is to increase mission

Minimizing crew preventable errors

Time Critical ORM

Because in one week.

Human factors expert

Aviation Is Inherently Dangerous

There will always be something or

A Tale of Two 747s

A runway collision involving two 747s

583 fatal injuries, the most ever in any

A Tale of Two 747s

Pan Am instructed to follow3rd taxiway?

KLM immediately to full power

Holes in the Cheese

What caused the mishap?

70 crash investigators (Spain, Netherlands, US)

Mishap Findings / Probable cause:

KLM initiated take-off without clearance

Requirement for precise read-back instructions (no OK

1977 Interviews with commercial

CRM And The Military

Tenets of Commercial CRM

Standardized Crew Training

Begins to grow.everybody wants one,

CRM 1987 - 1989

1989 Naval Air Warfare Center begins R&D

Theoretically driven, researched based

1986 - NASA and USAF MAC CRM workshop:

Differences between civilian and military

Navy Research and Development

CRM 1997 2012

CRM 1990 - 1995

1998 1542.7B signed

CRM flight evaluation

2001 U.S. Navy changed ACT to

Current CRM Principles

throughout career, not an afterthought

Human Error Background

NAVAL SAFETY CENTER

Human Error Past

Human Error Past

No. of Class A Mishaps

No. of Class A Mishaps

Leading Causal Factors

Leading Causal Factors

Aircrew (breakdown in Crew Resource

Aircrew (breakdown in Crew Resource

Human Error (84%)

Human Error (90%)

NSC Data: 22 Feb 08

Human Error Past

Human Error Today

No. of Class A Mishaps

No. of Class A Mishaps