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Avia6120 Essay Allan Bradley

Trimester Two, 2010 Task 6 C 313 5319

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Student Details
Family Name: Bradley
Given Name: Allan
Student Number: c 313 5319

Course Details
Course Name: Crew Resource Management
Course Code: Avia6120

Assignment Details
Task Number: 6
Task Title: Essay: CRM/TEM Training

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thereof has not previously been submitted for assessment at this or any other University.
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Allan Bradley

1

In doing so. they have evolved through six generations to the current Threat and Error Management (TEM) model. KLM (Royal Dutch Airlines) provided the first Human Factors Awareness Course. CRM can be thought of as “the management and utilization of all the people. Developing an Effective Team Approach to Threat and Error Management In An Aviation Organization By Allan Bradley Abstract Crew Resource Management (CRM) training has developed in response to acknowledgement by the aviation industry that human factors contribute to more than half of all aviation accidents and incidents. 2 . As Hawkins (1987) explains. There were human factors in aviation incidents and accidents that needed understanding and mitigating. recognition of factors such as they types of cultures in which people work has to be taken into consideration. Human Factors (HF) in aviation has now developed into a serious field of academic research and Hawkins (1987) explains that in 1978. Introduction During World War Two. Beaty (1995) reveals some bombers lost during these flights were reported to have reached the point where they should have turned left (east) for Africa. CRM has expanded from its original client base of flight deck crew. the captain turned right and refused to listen to his crew’s exhortations to alter course. Several aircraft that survived the flight only did so because at the turning point. safety culture within the organization.Avia6120 Essay Allan Bradley Trimester Two. How can this be best achieved and monitored? Refer to relevant literature on the topic. freak events’. Allied bomber pilots flying from England to Africa were regularly issued flight plans which routed them due south over the Atlantic Ocean for several hours before turning east. regardless of how much sense they made. now Crew Resource Management (CRM). Beaty (1995) offers other examples of aircraft accidents caused by captains making decisions that defied logic. There were too many to ignore. but instead turned right (west) for the mid-Atlantic. objective and contextual record of how crews managed threats and errors on a flight deck. Eventually these crews overpowered their captain and turned the aircraft around. when the navigator reported that it was time to turn left. In the thirty years since CRM courses have existed. but also help develop a just. Eventually these aircraft would have run out of fuel and ditched mid ocean. heading for Africa’s west coast. HF has since developed several branches of study including one identified by Ruffell Smith (1979) and labeled by Lauber (1980) as (originally) Cockpit Resource Management. Subsequent debriefing revealed that the captain just got ‘bloody minded’ and refused to listen to anyone. to the great majority of aviation industry personnel. but it was apparent that these erroneous decisions could not be explained as ‘one off. The use of Line Operations Safety Audits (LOSA) was developed to provide a real time. 2010 Task 6 C 313 5319 An effective team approach to threat and error management is the aim of CRM training. Use of data obtained from LOSA can be used to improve not only the way flight crews manage threats and errors.

In the ten years since. Acceptance and implementation of CRM training is. The importance of Cabin Crew as a resource was highlighted when they weren’t used during a B737–400 accident in Kegworth. As CRM moves out of the Flight Deck. The implementation in 1999 of ICAO’s Universal Safety Oversight Audit Programme also held member states individually accountable for aviation safety oversight in their country. As part of this effort. ramp operations and cabin safety staff. Helmreich and Foushee (2010) suggest that the behaviours that exemplified effective CRM were being identified and highlighted. the number of serious airliner accidents had dropped to 1. By the end of the century. it is recognized that 60% of large jet transport accidents have flight crew errors as a causal factor (Duke 1991). to significantly reduce the number of aircraft accidents. Learmount (2010) suggests that this almost halving of the accident rate can be attributed to several factors including: rapid development of computer and communication technology making gathering and sharing data quicker and easier.Avia6120 Essay Allan Bradley Trimester Two. Since then. While technological advances must have contributed to aviation safety. The Department of Transport 3 . Therefore. By the beginning of this century. CRM was evolving through its third and fourth generation. The Flight Safety Foundation (2010) reports that between 1990 and 1994 there were 1. ICAO encourages the implementation of Standards and Recommended Practices (SARPS) as described in ICAO documents 8168 and 4444.32 serious airliner accidents per million departures. CRM was moving out of the Flight Deck into the cabin and beyond. becoming the norm in the aviation industry. but since then the idea has expanded to include ground. England in 1989. the number of serious airliner accidents has dropped to 0.06 per million departures. Aviation authorities in many countries now mandate that companies have. human factors had been concentrated on the Flight Deck. and establishment of organizations such as The US Commercial Aviation Safety Team (CAST) whose task is “to identify safety priorities and create an action plan”. the size and complexity of the team increases and identifying ways to achieve and monitor an effective team approach to threat and error management needs to be considered. as an integral part of their structure a Safety Management System (SMS). development of systems such as Enhanced Ground Proximity Warning Systems (EGPWS) and Traffic Collision and Avoidance Systems (TCAS). as a result of ICAO or State mandate. or by voluntarily embracing of its principles. The role of the SMS is to use tools such as CRM and TEM to “establish robust defences to ensure that errors do not result in incidents or accidents” (CASA 2004). The Team Shortly after Lauber (1980) first used the term Cockpit Resource Management. work had to be done to identify and mitigate flight crew errors. it was quickly realized that CRM was relevant beyond the cockpit and CRM became Crew Resource Management. security. Cabin Crew were the first team members outside the cockpit to be included in CRM. Maurino (2000) explains that until the year 2000. The current (sixth) generation is termed Threat and Error Management (TEM). By the year 2000.55 per million departures. 2010 Task 6 C 313 5319 equipment and information available to the aircraft”. CRM has evolved through six generations.

SOPs and personally developed techniques. Although it is conjecture. One response to an error that the error is trapped. Seemingly minor errors or hazards in one area can combine with others to result in an incident or accident. J. on a more practical level. If these strategies fail. Another response is that an error could be exacerbated because although it is detected. An example would be an airline dealing with other organizations such as ATC. caterers. The same report noted the role of Air Traffic Control who. identified and managed before it is of any consequence. increase operational complexity. While ideally this would include everyone involved in aviation. and which must be managed to maintain margins of safety”. a measure of the effectiveness of a team is their ability to anticipate and manage a threat. It therefore follows that any effort to identify and mitigate or negate threats and errors must include as many members of the aviation community as possible. unexpected or external errors. Utilization of all available resources was not optimized. Helmreich et al. Outcomes to these three responses are listed as inconsequential. It is only when the resistance is defeated that humans are called upon to resolve the threat or error. Regardless of how a threat is classified. In the examples of threats listed above. 2010 Task 6 C 313 5319 (1990) noted that attempts by cabin crew to inform the Captain of their observations regarding the remaining engine were summarily dismissed. An example of an expected threat could be high terrain surrounding an airfield. It became apparent that “hazards and errors can occur at all levels of an organization. When it comes to threat and error management (TEM). Threat and Error Management Maurino (2005) defines threats as “events or errors that occur beyond the influence of the flight crew. Maurino (2005) defines errors as “actions or inactions by the flight crew that lead to deviations from organizational or flight crew intentions or expectations”. An example of an unexpected threat could be an in-flight aircraft system malfunction. the threat or error is resisted by hardware and software such as GPWS and TCAS. anticipating and managing high terrain could include using full power takeoffs and terrain avoidance 4 . cleaners. or if ATC had not been a constant source of distraction. the accident might have been averted. Helmreich. Maurino (2005) prefers to classify threats as either environmental or organizational. The terrain is well documented and procedures developed to mitigate this threat. from the cockpit or the shop floor right through to the boardroom.Avia6120 Essay Allan Bradley Trimester Two. security and so on. (1999) have categorized errors into five types and offer three possible responses to any error. Klinect and Wilhelm (1999) suggest threats can be classified as expected. undesired aircraft state and additional error. it could be argued that if the Captain had listened to the Cabin Crew. refuellers. became distractions to the pilots. it should include everyone within an aviation organization and other organizations they deal with. An external threat could be a hidden or latent system shortcoming such as an electronic flight instrument that becomes unreadable in bright sunlight. 2000). In this situation the pilots must use their knowledge and skill to achieve a successful outcome. in their attempts to help. that is. Gunther (2003) proposes that threats and errors are initially handled by strategies such as corporate culture. Finally the flight crew could fail to respond to the error at all. As CRM evolved it began to include more personnel.” (Reason. the flight crew’s actions lead to an undesirable outcome.

2010 Task 6 C 313 5319 departure and arrival procedures. Errors can be avoided or resolved by crew members by being proficient in their job. Culture Sincere efforts to reduce threats or errors may mean changes being made within an organization both structurally. organizational and professional. organizational and professional work together to encourage and support safe work practices and then a Safety Culture can establish itself within the organization. for instance supporting an attitude of ‘near enough is good enough’.Avia6120 Essay Allan Bradley Trimester Two. Professional culture is well described by Helmreich (2002) and acknowledges that individual professions have norms. Hofstede (1983) identified four cultural dimensions which vary between nations. If the national culture is otherwise. Anticipating and managing in-flight malfunctions could be achieved by Abnormal Procedures Checklists. it should develop strategies to modify such norms within the organization. While little can be done by an organization to change a national culture. monitoring and challenging. As Gunther (2003) says “because flying is our business. A senior management which does not take safety seriously. Alternatively a professional culture might not be such a positive influence. While Lonner (1980) identifies seven psychological universals common to all cultures. exercising leadership skills and taking advantage of previous experience (Gunther 2003). patterns of behaviour and other characteristics which make their profession unique. such as reorganizing departments. good CRM that utilizes the other crew member’s instruments could be a strategy to manage the threat. Helmreich and Merritt (1988) identify three cultures types influencing flight crew. At the airline I work for efforts are ongoing to create an effective safety 5 . national. any attempt by subordinate officers to install such a system will not be taken seriously by co workers. If all three aspects of culture. will create a culture that suggests ‘safety isn’t important’ and this will permeate through all ranks. being vigilant. then the organization should reward and encourage this. The highest levels of management must be committed to installing and visibly supporting a system which exists to minimize or negate threats and errors. it should be cognizant of the effect national culture has on the way threats and errors are managed and develop appropriate strategies. If a national culture places great value in safe work practices. such as modifying Power Distance gradients. threats must be identified and reduced/eliminated while errors must be avoided and managed”. and in the way personnel interact. Sometimes a professional culture can be a positive influence for improving safety. Numerous organizations including CASA (2004). The national culture in which an organization and individual exists will inevitably exert influence in the workplace. Helmreich (2003) notes that resistance to such changes can be due to cultural issues. These cultures are national. For the example of an unreadable flight instrument. such as refusing to accept incomplete or substandard work. If they are not. ICAO-IATA (2003) confirm this. An organization’s culture will have a major effect on how threats and errors and managed.

None of them explain ‘what is happening’. operational complexity and flightcrew performance. confidentiality of reporting is respected. The FAA Advisory Circular 120-90 (2006) explains in detail the process for planning and conducting a LOSA and then goes on to summarize the ten operating characteristics of LOSA. The issue with all of these tools is that they are ‘backward looking’ and do not necessarily allow a context for a situation. and regular simulator assessments of pilots. The observer can not only identify threats and errors. the Line Operations Safety Audit (LOSA) was developed. Quick Access Recorder (QAR) downloads for Flight Operations Quality Assurance (FOQA). distraction or fatigue. accident investigation reports often identify procedures or systems that failed. Line Operations Safety Audits Even with a determined and sincere desire within an organization to develop and improve a just and effective safety culture. Maurino (1998) explains that accident investigations rarely provide data which can be applied in future training and while they can tell us what went wrong. The unique characteristic of LOSA which makes it so useful is the trained observer. Characteristics of a ‘just culture’ include: accepting that safety is everyone’s responsibility. some staff may be engaging in unsafe practices or making decisions which erode safety without being aware of it.Avia6120 Essay Allan Bradley Trimester Two. Confidential data collection and non-jeopardy assurance for pilots are fundamental to the process. errors or violations committed or normalization of deviance from Standard 6 . poorly designed procedures. regulatory mandates or rule changes. In order to give real time data which can be constructively used in the future to improve flight safety. which may be a result of training errors. Furthermore. but rarely have the ability to report human conditions such as confusion. and acceptance by everyone that mistakes happen but it is everyone’s responsibility to try to minimize them (RBA 2010).” Escuer (2003) stresses that for any LOSA to succeed. LOSA is a tool for helping to develop an effective safety culture within the aviation industry. If a LOSA identifies threats occurring. 2010 Task 6 C 313 5319 culture. any staff member can report threats and errors free from fear of reprisal. The observer is able to identify threats which would otherwise remain unnoticed such as overloaded radio frequencies or regularly missed callouts or checklists. FAA Advisory Circular 120-90 (2006) describes LOSA “as a formal process that requires expert and highly trained observers to ride the jumpseat during regularly scheduled flights to collect safety-related data on environmental conditions. but also record how the crew manage them. corporate pressures or a poor safety culture. Last week I attended an in-house workshop where it was stressed that the company’s safety culture needed to be seen as a ‘just culture’. Gunther (2003) lists some as: accident and incident reports. flawed technology – human interfaces. there is mutual trust between a reporter and the person to whom they report. There are already some devices available to the aviation industry which can highlight problem areas. they give little or no opportunity to identify what pilots do right. Trust between the pilots and the LOSA observers in the confidentiality of any data gathered is essential. pilots involved must be confident that any data gathered during a flight will be confidential and not used as evidence for punitive action by the company. forgetfulness. All of the tools listed explain ‘what happened’.

a professional culture may hold high standards of work in high esteem. Alternatively. Alternatively it might impose a negative influence such as belittling attempts to upgrade or improve procedures. National. for example a national culture which encourages high Power Distance (PD) gradients across a flight deck thus inhibiting a First Officer from challenging a Captain. intelligence. National culture may also enhance CRM if it encourages attention to detail and adherence to procedures. equipment and information available to the aircraft” (Hawkins 1987). increase operational complexity. organizational and professional cultures all influence personnel. Errors are considered 7 . Humans do not always behave logically or rationally and they can make errors. CRM skills are an important tool that can be used to help manage threats and errors. that safe practices are not considered as important as a balance sheet with no red ink. An organization may have a culture which encourages safe practices such as assertiveness from junior staff when they notice threats or errors within the organization. navigators and radio operators) however it soon became apparent that the team members beyond the Flight Deck needed to be included in human factors awareness and coping strategies. Conclusion For more than sixty years the aviation industry has been aware that regardless of the reliability. because people are involved. Professional personnel such as flight crew may also have a culture of their own. as the FAA AC says ‘be action-focused and data driven.’ As well as being able to identify threats and errors. (2003) note that by conducting a LOSA. Evidence confirms that more than half of all aircraft accidents and incidents have human errors as a causal factor. Originally the courses were provided solely for flight deck crew (pilots. a ‘snapshot’ of the current situation within an organization can be developed. Any changes made should. LOSA can also identify positive behaviours such as techniques pilots have developed to manage regular threats or frequent errors. Culture can be an obstacle to good CRM. “the management and utilization of all the people. simplicity or complexity of any equipment. CRM has evolved over the years and is now thought to be in its sixth generation which is identified as Threat and Error Management (TEM). Whichever cultural aspect is considered.Avia6120 Essay Allan Bradley Trimester Two. An important consideration when dealing with people is the culture in which they live and work. and which must be managed to maintain margins of safety” Maurino (2005). Threats are considered to be “events or errors that occur beyond the influence of the flight crew. Further LOSA in the future will provide data to identify if any changes have been beneficial and if further changes are needed. flight engineers and in some cases. Developing systems and techniques to cope with the human component in a system has been an ongoing field of research. Kriechbaum and Alai. an organization’s culture might be so profit driven. The result was the development of Crew Resource Management (CRM) which has as a basic premise. the human component must also be considered. improvements can then be developed and implemented. In a positive light. Efforts by the aviation industry to make flight crews aware of human factors and develop strategies to cope with them have been present for more than thirty years. 2010 Task 6 C 313 5319 Operating Procedures (SOPs) then an organization with an effective safety culture should take action to improve safety.

In this way an effective team approach to threat and error management can be achieved and monitored. Australia B Beaty. In an attempt to overcome these shortcomings. D. safety culture within the organization. knowing what threats and errors are actually occurring.Avia6120 Essay Allan Bradley Trimester Two. monitoring and challenging.nasa. the Line Operations Safety Audit (LOSA) was developed. J. It can identify what the pilots get wrong (ignore or miss threats. commit violations. Strategies can be improved or put in place. Lauber.gov/19800013796_1980013796. White. Initial countermeasures to threats and errors are strategies already developed such as a corporate safety culture and SOPs. By conducting LOSA on a regular basis.. In Cooper. It is only when strategies and resistance have been overcome that the flight crew are called upon to resolve the situation using techniques such as vigilance. &. assertiveness and leadership skills. E. Retrieved 27 July 2020 from World Wide Web http://ntrs. K (Eds). Accident and Incident reports or Flight Data Recorder downloads only offer an ‘after the event’ perspective and do not give much opportunity for context. why they are occurring and how they are being resolved. The data obtained from LOSA can then be used to make changes for the better. Cultural issues can be addressed in such a way as to develop a just.gov/archive/nasa/casi. an independent. faults corrected and good ideas incorporated. the human factor in aircraft accidents Shrewsbury. Canberra. During a LOSA. threats must be identified and reduced/eliminated while errors must be avoided and managed”. objective observer sits on the Flight Deck jumpseat recording threats and errors as they occur and how the flight crew manages them. CA: NASA-Ames Research Center. it can also identify what the pilots get right. If these strategies are defeated. Weaknesses can be identified and strengthened.ntrs. Moffett Field. D. 2010 Task 6 C 313 5319 to be “actions or inactions by the flight crew that lead to deviations from organizational or flight crew intentions or expectations” Maurino (2005). J.nasa. G. England: Airlife Publishing Department of Transport Air Accidents Investigation Branch (1990) Report on the accident to Boeing 737-400 G-OBME near Kegworth.pdf 8 . K (1980) Resource management on the flightdeck. References Australian Government (2004) Safety management systems an aviation business guide Civil Aviation Safety Authority. make errors) but just as important. (1980). levels of resistance can be enhanced and the ability of humans to resolve threats or errors developed. Leicestershire on 8 January 1989: Farnborough: Author (AAIB 04/90) Lauber. M.. Proceedings of a NASA/industry workshop (NASA CP- 2120). As Gunther (2003) says “because flying is our business. then the threat or error is resisted by hardware or software such as EGPWS or TCAS. (1995) The naked pilot. The advantage of a LOSA is that it can give a real time analyses of what is happening and why. Some of the issues that must be addressed when considering TEM are.

error and CRM in flight operations.com. organizational and professional influences. B. Retrieved 30 July 2010 from World Wide Web http://www. D. Proceedings of the first ICAO-IATA LOSA & TEM conference. Ohio: The Ohio State University Helmreich. 2010.pdf Flight Safety Foundation (2010) Serious accidents rates. Ashgate Helmreich. Learmount. Director. Crew Resource Management. In Procedings of the Tenth International Symposium on Aviation Psychology (pages 677 – 682). J.A. A. Dublin 2003 Retrieved 28 July 2010 from World Wide Web http://www.L. Retrieved 28 July 2010 from World Wide Web http://rgl..L. R. and Foushee (2010) Why CRM? Empirical and Theoretical Bases of Human Factors Training. T. (1993) Human factors in flight.. San Diego. Global airline accident review. CA: Academic Press Helmreich. Flight Standards Service. (2003) Ten years of change – crew resource management 1989-1999.G.int/anb/humanfactors/icaojournalist. (November 2003). L. threat. (1988) Culture at work in aviation and medicine: National. & Anca. J. C. 10 (7). Aldershot. J.aspx?liArticleID=336920&printerFriendly Gunther.com/articles/article. Just what are flight crew errors? Flight Safety Digest. Culture. Klinect. Washington.K.int/anb/humanfactors/icaojournalist.(1999) Models of threat. (2003) The safety change process following Line Operations Safety Audits (LOSA).R.htm Federal Aviation Administration (27 April 2006) Advisory Circular: Line operations safety audits. D. UK: Ashgate Helmreich.L.htm 9 . and error: Assessing system safety.nsf/list/AC %20120-90/$FILE/AC%20120-90. (July 1991).icao. (2002). 1-15 Escuer. Columbus. R.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular. Flight Global.. R.icao. In Kanki. LOSA experience within Futura. R. London: Royal Aeronautical Society Helmreich. (Eds). Aldershot.flightglobal. Proceedings of the first ICAO-IATA LOSA & TEM conference.L. L. and Wilhelm. DC: Author.htm Hawkins. In Safety in Aviation: The Management Commitment: Proceedings of a Conference.faa.A.Avia6120 Essay Allan Bradley Trimester Two. Dublin 2003 Retrieved 28 July 2010 from World Wide Web http://www. 2010 Task 6 C 313 5319 Duke. Dublin 2003 Retrieved 28 July 2010 from World Wide Web http://www. U. R. and Merritt. R. Proceedings of the first ICAO-IATA LOSA & TEM conference.icao. R. A. Helmreich. F.int/anb/humanfactors/icaojournalist.

Retrieved 29 July 2010 from World Wide Web http://www. Canadian Aviation Safety Seminar.int/anb/humanfactors/icaojournalist. H. P.icao. (April 2005) Threat and error management. Author: Senior Vice President: Quality. W.htm Lonner. Dublin 2003 Retrieved 28 July 2010 from World Wide Web http://www. 17 Maurino. Vancouver. The ICAO Journal. 2010 Task 6 C 313 5319 Hofstede. J.org/archives-and-resources/threat-and-error-management-tem Reason. Dublin 2003 Retrieved 28 July 2010 from World Wide Web http://www. D. Safety. March 1980 11: 7 . (2000) Human error models and management. 23. Security & Environment.int/cgi/goto_anb.htm Kriechbaum.icao. Brunei Darussalam. Proceedings of the first ICAO-IATA LOSA & TEM conference. G. (2003) Air New Zealand’s LOSA Programme. (1983) The cultural relativity of organizational practices and theories.34 Maurino.pdf Submitted 12:52 BST Thursday 05 August 2010 10 . Journal of International Business Studies. (1980) A decade of cross-cultural psychology: JCCP. January / February 2000. (January 1979) A simulator study of the interaction of pilot workload with errors vigilance and decisions. Ruffell Smith. Retrieved 27 July 2010 from World Wide Web http://ntrs. NASA Technical Memorandum 78482. (2000 ) ICAO human factors programme expands scope beyond the flight deck and ATC facility. British Medical Journal (320) pages 768 -770 Royal Brunei Airlines (2010) Safety management workshop notes.gov/archive/nasa/casi.icao. J. Bandar Seri Begawan. D.Avia6120 Essay Allan Bradley Trimester Two. 18.pl?soa ICAO-IATA (2003) Proceedings of the first ICAO-IATA LOSA & TEM conference. ICAO (2010) Universsal safety oversight audit programme. (1998) Human factors training would be enhanced by using data obtained from monitoring normal operations.J. Canada: Retrieved 28 July 2010 from World Wide Web http://flightsafety. D.int/anb/humanfactors/icaojournalist. ICAO Journal January / February 1998 pages 17. and Alai. Fall 1983.ntrs.gov/19790006598_1979006598. E. 24 Maurino. 1970 – 1979 Journal of Cross Cultural Psychology. pages 15.nasa. 16.nasa. C.