An introduction to Crew Resource Management (Human Factors) Training

by Captain John Wright

Collision between a KLM Boeing 747 and a Pan Am Boeing 747

Tenerife,March 27, 1977

CRM Background

Crisis

ExcessStress

Normal

CRM Course Objectives

Sea Empress

Human Error and Accidents

80%

20%

Accidents caused by human error?

Error Enforcing Conditions

Underlying Causes of Accidents

TrainingHardware

Maintenance Management Housekeeping

Communication Incompatible Goals

Proc

edur

es

Des

ign

Organisational Culture

Defences

2,000,000 Unsafe acts

Accident Triangle

Data sources: Heinrich, Bird, HSE, John Ormond

240,000 Near misses

20,000 Minor injuries

400 Reportable Injuries

1 Fatality

0

20

40

60

80

Percentage

Yes Notsure

No

Near misses are always reported here

ManagerSupervisorWorkforce

0102030405060

Percentage

No Notsure

Yes

Sometimes it is necessary to take risks to get the job done

ManagerSupervisorWorkforce

Error & Safety

Accidents can be triggered when criticalerrors remainundetected anduncorrected

1+1>2

Requires high levels of coordination, support and understanding

Acting in a synchronized manner and supporting each other

Synergy

Everybody singing (playing) from the same song sheet!!

Synergistic Team: The Ideal situation

1+1= -250!!

Catastrophe

The style depends on the ratio between the leader’s authority and the team’s assertiveness

Management Style

The leader’sauthority

Team member’sassertiveness

Authority Gradient

error

error

The effects of an error depend entirely on the structure of the system in which it occurs

Two main characteristics:

- error tolerance

- visibility (error detection)

Protected system

Vulnerable System

Individual reliability and system safety

The Practical effects of Errors

The Role of Management in the Injury Rate

• Injury rates depend on the strength of the Safety Culture

So Management decide the injury rateSo Management decide the injury rate

• Management decides the safety culture theywant either consciously or by default

Attitudes

BehaviourVisible

HiddenBeliefsValues

Actions

Your stress Jug

Get up late

Car won’t start

Traffic Jam

Get Caughtfor speeding

Forgot securitypass

PERFORMANCE

Performance by Time of Day

12 14 16 18 20 22 24 02 04 06 08 10

Time of Day

Performance candrop in tune withthe PLD

Lack of sleep can reduce our ability to:

Communicate by 30%

Make valid judgements by 50%

Remember facts & figures by 30%

Keep our attention by an alarming 75%

Sleep

The Importance of Effective Communications

0 5 10 15 20 25 30 35 40 45

Communication

Design

Maint.

Procedures

Primary Causes of 119 Fatal Accidents

38%

7%

55%

Way Body Language

Words

Communication

Workload Versus Listening Capability

0

20

40

60

80

100

120

WorkloadListening

Communication Blockers

Short Term MemoryDefinition: STM, or working memory, is the store where essential information relevant to the current situationis retained only for a short period of time

Major drawback: Storage capacity is limited. Information heldin STM is sensitivity to interruption and can easily be lost

It is also the entrance to, and the exit from, long term memory

Used as a mental blackboard

Decision Making - Key Elements

• Make a DIAGNOSIS• Consider the OPTIONS &

Consequences• Make a DECISION• ASSIGN Tasks• REVIEW your decision

Confirmation Bias (Mind Set)You have a mental picture of what is expected, whenthe glaringly obvious is there in front of you but stillthe mental picture wins

It’s not me that’s wrong, it’s the real world that’s wrong!!

This is the most dangerous bias. It effects ourability to objectively review whether the decisiontaken is indeed the correct one

Insured Costs

Uninsured Costs

Employers liabilityThird party liabilityCo-operate liabilityProperty damage

Product & material damagePlant & building damageTool & equipment damageLegal costsClearing the site Temporary labour & additional overtimeClerical & investigators timeFines

The Costs of Accidents at WorkWhy should safety be ranked equally with allother management objectives?

Economics of Management Control

Intangible costs due to failure include:

Loss of business imageLoss of customer satisfactionEmployee moraleGoodwillReduced productivity

The Challenger Shuttle Disaster

Piper Alpha 1988

An introduction to Crew Resource Management (Human Factors) Training

by Captain John Wright