crew resource management 2008

Crew Resource Management Crew Resource Management 2008 2008

Adapted from theAdapted from the UNITED STATES COAST GUARDUNITED STATES COAST GUARDThis presentation is in response to an This presentation is in response to an

increase in helicopter crashes in 2008increase in helicopter crashes in 2008This is a presentation modified by the This is a presentation modified by the

NAEMT safety committee in response to NAEMT safety committee in response to an alarming rate of aero medical crashesan alarming rate of aero medical crashes

It is meant to strengthen safety on a It is meant to strengthen safety on a valuable resource, EMS providersvaluable resource, EMS providers

Use this as a safety refresherUse this as a safety refresher

Rules of EngagementRules of Engagement

Participation is KeyParticipation is Key

We Must Discuss ThisWe Must Discuss This

Non-AttributionNon-Attribution

No Names – What Not WhoNo Names – What Not Who

CRM – What is the Goal?CRM – What is the Goal?

To achieveTo achieveOptimal Optimal

Performance Performance from a team from a team executing executing multiple, multiple,

complex tasks.complex tasks.

CRM – What is the Goal?CRM – What is the Goal?

Does Optimal Does Optimal Performance Performance

Equate to Equate to Perfection?Perfection?

CRM…..CRM…..

To Error is HumanTo Error is Human

You Can Not Engage In Human You Can Not Engage In Human Activity Without Introducing Activity Without Introducing

Human ErrorHuman Error

So, Can We Reach The Goal of CRM So, Can We Reach The Goal of CRM Without Eliminating Error? Without Eliminating Error?

AbsolutelyAbsolutely

We Manage Our We Manage Our ErrorsErrors

We Incorporate We Incorporate

Error ManagementError Management into into

Every Aspect of CRMEvery Aspect of CRM

Error Management is the “What” Error Management is the “What” Intervention/PreventionIntervention/Prevention

CRM is the “How”CRM is the “How”Trap, Mitigate, AvoidTrap, Mitigate, Avoid

GOAL: OPTIMAL PERFORMANCEGOAL: OPTIMAL PERFORMANCE

Error ManagementError Management

Overview:Overview:– What it is… and, isn’tWhat it is… and, isn’t– What Error Management Seeks to AchieveWhat Error Management Seeks to Achieve– Where Error LivesWhere Error Lives– Where it Fits in Our Skills as Pilots/AircrewWhere it Fits in Our Skills as Pilots/Aircrew


Systematic Approach to Determining Systematic Approach to Determining Common Errors & Contributing FactorsCommon Errors & Contributing Factors

Drives Cultural Change to Accept:Drives Cultural Change to Accept:Error is Universal. Error is Inevitable.Error is Universal. Error is Inevitable.Shifts Focus from Shifts Focus from WhoWho to to WhatWhat

Teach aircrews toTeach aircrews to TRAP, MITIGATE & AVOID Error.TRAP, MITIGATE & AVOID Error.


ErrorError does not, has not, and will not does not, has not, and will not

cause an incident, an accident, or a fatalitycause an incident, an accident, or a fatality

So, what does?So, what does?

ConsequenceConsequence


ConsequenceConsequence

Consequences are not universal or inevitable.Consequences are not universal or inevitable.Errors Errors happen all of the time. happen all of the time.

Incidents, accidents, and fatalities do not. Incidents, accidents, and fatalities do not.

EM targets the GAP between EM targets the GAP between Error and ConsequenceError and Consequence!!

Where Error LivesWhere Error Lives

LATENT – LATENT – present but not visible…present but not visible…hidden in hidden in the things we do routinelythe things we do routinely

ACTIVE – ACTIVE – present, in use…present, in use…individual errorindividual error

The Swiss Cheese Model The Swiss Cheese Model (REASONS)(REASONS)

Latent Errorsin System

1

2

3

4

Latent Errorsat MgtLevel

Individual Error(Active Error) Result/error

Organizational Filters: Training/Stan/CRM/ORM

Trajectory ofAccident/Error

Unchecked

5

Error Management… The CruxError Management… The Crux

Mitigating the Consequence of ErrorMitigating the Consequence of Error

Employ Employ Error TrappingError Trapping in Every Aspect of: in Every Aspect of:

TrainingTrainingStandardizationStandardization

CRM & ORMCRM & ORM

Error Trapping = Prevention & InterventionError Trapping = Prevention & Intervention

What was EM Outcome What was EM Outcome

Latent & Active ErrorsLatent & Active Errors

Flagstaff PD Photo/APFlagstaff PD Photo/AP

EM & CRMEM & CRM

Error Management must be Error Management must be imbedded in all four imbedded in all four

principles of CRM (SCAR)principles of CRM (SCAR)

CRM Principle - S.A.CRM Principle - S.A.

Situational AwarenessSituational Awareness……

……is the realistic understanding of all is the realistic understanding of all factors which affect the safety and factors which affect the safety and effectiveness of your crew and aircraft.effectiveness of your crew and aircraft.


Elements of Situational Awareness?Elements of Situational Awareness?

Spatial Orientation/attitudeSpatial Orientation/attitudeOrientation to traffic, geography & timeOrientation to traffic, geography & timeAircraft status & capabilitiesAircraft status & capabilitiesAircrew status & Crew-life cycleAircrew status & Crew-life cycleMission concept & Mission-life cycleMission concept & Mission-life cycle


Loss of Situational Awareness Loss of Situational Awareness

Still the Leading Cause of Aircraft MishapsStill the Leading Cause of Aircraft Mishaps(NASA/FAA: causal factor in 65-80% accidents)(NASA/FAA: causal factor in 65-80% accidents)

Rarely is it Instantaneous!Rarely is it Instantaneous!


Why do we lose Situational AwarenessWhy do we lose Situational Awareness??

Mode confusion/Automation ComplacencyMode confusion/Automation ComplacencyStress/FatigueStress/FatigueStimulus Fixation Stimulus Fixation Decision Making/Task Management Decision Making/Task Management Inadequate Error Management/TrappingInadequate Error Management/Trapping

““Roadblocks”Roadblocks”


What are the “Loss of S.A.” flags?What are the “Loss of S.A.” flags?

Not CommunicatingNot Communicating Ambiguity Ambiguity

No one flying the aircraftNo one flying the aircraft Failure to meet targets Failure to meet targets

Deviating from StandardsDeviating from Standards Not addressing discrep’s Not addressing discrep’s

Violating MinimumsViolating Minimums Preoccupation Preoccupation

ConfusionConfusion


What do you do when you suspect you What do you do when you suspect you have have lostlost S.A.?S.A.?

ReactReact RegainRegain ReconstructReconstruct

ROADBLOCKSROADBLOCKS

The common obstructions to good CRM!The common obstructions to good CRM!A combination of negative human A combination of negative human

factors, ingrained habits, and our own factors, ingrained habits, and our own personal attitudes and those of the crew-personal attitudes and those of the crew-members we are working with.members we are working with.

ROADBLOCKSROADBLOCKSNORMS: unwritten rules that become NORMS: unwritten rules that become

pressures that act upon a group, be alert pressures that act upon a group, be alert for “Killer Norms.”for “Killer Norms.”

ODD MAN OUT: Ignore input from a ODD MAN OUT: Ignore input from a particular member of the crew. Results particular member of the crew. Results in a loss of total crew effectiveness.in a loss of total crew effectiveness.

HIDDEN AGENDA: Intentionally HIDDEN AGENDA: Intentionally withholding information about intentions withholding information about intentions or plans from the rest of the crew.or plans from the rest of the crew.

ROADBLOCKS (cont):ROADBLOCKS (cont):

CHAIN OF ERRORS: Often the key is to CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a recognize the chain developing-then a crewmember can act to change the crewmember can act to change the situation. situation.

BREAK THE CHAINBREAK THE CHAIN

ROADBLOCKS (cont):ROADBLOCKS (cont):

HAZARDOUS ATTITUDES: Attitudes HAZARDOUS ATTITUDES: Attitudes that impede effective CRM.that impede effective CRM.– Macho - “I can do it.”Macho - “I can do it.”– Anti-Authority - “Don’t tell me.”Anti-Authority - “Don’t tell me.”– Impulsivity - “Do something -quickly!”Impulsivity - “Do something -quickly!”– Resignation - “What’s the use?”Resignation - “What’s the use?”– Missionitis - “Let’s press on.”Missionitis - “Let’s press on.”

FATIGUEFATIGUE Widely recognized enemy of pilots & crewmembersWidely recognized enemy of pilots & crewmembers ..

– A low frustration thresholdA low frustration threshold– Degraded coordinationDegraded coordination– Slowness in responseSlowness in response– CarelessnessCarelessness– Acceptance of low standards of Acceptance of low standards of

accuracyaccuracy

ROADBLOCKSROADBLOCKS

STRENGTH OF AN IDEA: Tendency to STRENGTH OF AN IDEA: Tendency to unconsciously make the available unconsciously make the available evidence fit a preconceived situation; to evidence fit a preconceived situation; to see or hear what we want to hear, and see or hear what we want to hear, and substitute that for reality. It can take 15 substitute that for reality. It can take 15 seconds to “break” an idea that has been seconds to “break” an idea that has been ingrained, but is incorrect.ingrained, but is incorrect.

TOOLSTOOLS

Will help in assuring Will help in assuring a good balance of;a good balance of;

Effective Effective communicationcommunication

Personal monitoringPersonal monitoring Strong team work Strong team work

skillsskills

ERROR TRAPSERROR TRAPS

STERILE COCKPIT/CABINSTERILE COCKPIT/CABIN

TWO CHALLENGE RULETWO CHALLENGE RULE

TOOLS cont:TOOLS cont:

PERSONAL MONITORINGPERSONAL MONITORING “I’M SAFE”“I’M SAFE”

ILLNESSILLNESS

MEDICATIONMEDICATION

SLEEPSLEEP

ALCOHOLALCOHOL

FATIGUEFATIGUE

EATING/EXERCISEEATING/EXERCISE

CRM Principle - CommunicationCRM Principle - Communication

Elements of Communication SkillsElements of Communication Skills

The most obvious of the CRM principles.The most obvious of the CRM principles.

And, the easiest to affect through training.And, the easiest to affect through training.

“Say what you mean, mean what you say.”“Say what you mean, mean what you say.”


Apply the A-B-C’s of communicationApply the A-B-C’s of communication

AccurateAccurateBoldBold

ConciseConcise


Understand the communication loopUnderstand the communication loop

Idea-Encode-Xmit-Receive-Decode-IdeaIdea-Encode-Xmit-Receive-Decode-Idea

Say what you mean, mean what you say. Say what you mean, mean what you say.

But, “Have I been understood?”But, “Have I been understood?”

CRM Principle - AssertivenessCRM Principle - Assertiveness

Elements of Assertive Behavior Elements of Assertive Behavior

Authority with ParticipationAuthority with ParticipationAssertiveness with RespectAssertiveness with Respect

The genuine, complete & direct The genuine, complete & direct communication of ideas, wants & needs.communication of ideas, wants & needs.

CRM Principle - AssertivenessCRM Principle - Assertiveness

The Assertive StatementThe Assertive Statement

Open-up; get their attentionOpen-up; get their attentionState concern as “owned emotion”State concern as “owned emotion”State the problem - real or perceivedState the problem - real or perceivedOffer a solutionOffer a solutionObtain agreement/closureObtain agreement/closure

““Say what needs to be said”Say what needs to be said”

CRM Principle - Risk CRM Principle - Risk

Risk ManagementRisk Management

RISK is a factor of:RISK is a factor of:ProbabilityProbability

SeveritySeverityExposureExposure

Risk ManagementRisk Management

What is an acceptable level of Risk?What is an acceptable level of Risk?……potential risks to the aircraft and crew potential risks to the aircraft and crew

shall be weighted against risks to the shall be weighted against risks to the personnel and/or property in distress if personnel and/or property in distress if the mission is not taken.the mission is not taken.

““probable loss of an aircrew is not an probable loss of an aircrew is not an acceptable riskacceptable risk.”.”

Identify Mission Tasks Identify Mission Tasks

Identify HazardsIdentify Hazards

Eval Risk vs.. GainEval Risk vs.. Gain

Assess Risks Assess Risks

Identify OptionsIdentify Options

Execute DecisionExecute Decision

Monitor SituationMonitor Situation

Operational Risk Management Operational Risk Management (ORM)(ORM)

7 Step Process 7 Step Process

Step #2: Identify HazardsStep #2: Identify Hazards

Use the “PEACE” Model to remember Use the “PEACE” Model to remember the 5 risk factors:the 5 risk factors:– PlanningPlanning– Event ComplexityEvent Complexity– Asset SelectionAsset Selection– CommunicationsCommunications– Environmental ConditionsEnvironmental Conditions

Step #3: Assess the RisksStep #3: Assess the Risks

SPE RISK ASSESSMENT MODELSPE RISK ASSESSMENT MODELRisk=Severity x Probability x ExposureRisk=Severity x Probability x Exposure

• Severity - Potential consequences Severity - Potential consequences measured in terms of degree of measured in terms of degree of damage, injury, or impact on a damage, injury, or impact on a mission. Could occur in one of these mission. Could occur in one of these areas: areas: • Injury or death, equip damage, Injury or death, equip damage,

mission degradation, reduced morale, mission degradation, reduced morale, adverse publicity, admin/disciplinary adverse publicity, admin/disciplinary actionsactions

Step #4: Identify the OptionsStep #4: Identify the Options

STAARSTAAR– Spread OutSpread Out– TransferTransfer– AvoidAvoid– AcceptAccept– ReduceReduce

Step #5: Evaluate Risk vs.. GainStep #5: Evaluate Risk vs.. Gain

Analyze the operation’s degree of risk Analyze the operation’s degree of risk with the proposed controls in placewith the proposed controls in place

Determine if operational benefits exceed Determine if operational benefits exceed the degree of risk the operation presentsthe degree of risk the operation presents

Consider cumulative risksConsider cumulative risksThis is the “REALITY CHECK!”This is the “REALITY CHECK!”

Step #6: Execute the DecisionStep #6: Execute the Decision

The risk control decision is madeThe risk control decision is madeClear communication of decision clarifies Clear communication of decision clarifies

rational behind risk management rational behind risk management decision.decision.

(Done it a hundred times, been there, etc.)(Done it a hundred times, been there, etc.)

Step #7: Monitor SituationStep #7: Monitor Situation

Monitor situation to ensure controls are Monitor situation to ensure controls are effective and in placeeffective and in place

Identify any and all changes requiring Identify any and all changes requiring further risk management and act on further risk management and act on themthem

Risk management is a continuous processRisk management is a continuous process

Catastrophic Events Rarely Catastrophic Events Rarely Result From A Single ErrorResult From A Single Error

Crew Resource ManagementCrew Resource Management

The The empowermentempowerment of all crewmembers of all crewmembers to promote safety and increase to promote safety and increase overall aircrew performance.overall aircrew performance.

Think Error ManagementThink Error Management

Execute CRM SkillsExecute CRM Skills

crew resource management 2008

Documents

error managementerror

isntwhat error management

error liveslatent present

achievewhere error liveswhere

goal of crm

crew resource management

aspect of crmerror management

loss of situational