Crm course 2010

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  • 1. The complete CRM solution From new recruits to experienced crew and senior ● Instructor Selection management, ITS can provide a solution to your ● Instructor Training CRM training needs. ● Course Materials And because the whole ● CBT Modules structure of our training is modular, it is possible to pick and choose from the COURSE complete range of options PREPARATION we offer, and buy into any of the elements as outlined in ● Pilot the diagram. ● Feed training outcome into course design REMEDIAL INITIAL CRM ● Cabin Crew CRM training is at its most ● Re-train crew TRAINING COURSES ● Maintenance effective if planned and CRM ● Management managed as a programme of continuous development. training cycle ITS is in a unique position to● CRM instructor course ● Crew Courses assist in the management of● Debrief skills course SIMULATOR RECURRENT this process and ensure that ● Integrated SEP/CRM● Core course INSTRUCTORS CRM COURSES all your CRM requirements ● Instructor Courses are met efficiently and cost● Integrated CRM effectively. BEHAVIOURAL MARKERS For support with any of these items, call ITS on ● Design BM Scheme +44 (0) 7000 251 252 ● Create Grading System ● Train Assessors
  • 2. www.aviationteamwork.com The Total CRM Package: The complete CRM training solution Instructor Training Courseware CBT Modules ITS offers a range of courses, training Initial Training Courses materials and support services which Recurrent Training Courses together form a complete CRM Integrated SEP/CRM Courses training solution. Behavioural Marker Schemes The modular format of our courses and CRM Assessment Training Courses courseware, along with our ability to SFI CRM Instructor Courses analyse your particular needs, enables us to tailor that solution to your precise Debrief Skills Courses requirements. Alternatively, we can Core Courses provide a full consultancy service to CRMIE Service identify your specific needs, create an appropriate CRM programme and assist Course design and Support in its implementation if required. For more information on any aspect of our CRM Training please contact us for an immediate response. ITS is a worldwide organisation working for 80 clients in 50 countries. We are a UK CAA accredited provider of CRM training and deliver courses to flight deck crew, cabin crew, ground crew and INTEGRATED TEAM SOLUTIONS maintenance crew. We also run CRM Integrated Team Solutions Limited, England courses for senior management. Tel: +44 (0) 7000 251 252 Fax: +44 (0) 7000 261 262 All our courses meet the requirements of JAR OPS, the FAA and the UK CAA. e-mail: sales@aviationteamwork.com Website: www.aviationteamwork.com INTEGR ATED TEAM SOLUTIONS
  • 3. CRM CoursewareThe CRM training packages available from ITS are designed to provideinstructors with all the material they require to deliver the appropriatetraining session. In addition to the course documentation they arecomplete with detailed notes to assist instructors during coursepresentation.The following sets of Initial CRM Courseware are available:Pilot, Cabin Crew, Joint, Rotary Wing, Pre-Command and Senior CabinCrewmemberCourse materials might include:● Lesson Plans● PowerPoint● Syndicate Exercises www.aviationteamwork.com● Questionnaires● Case studies● VideosEach set of courseware also includes all the background information necessary tosupport delivery of the course and to provide additional material covering topics whichmay be raised by crew for discussion.Individual ModulesITS also offers a range of CRM training modules covering the main elements of the CRMsyllabus. Modules are complete with training notes and supporting elements which mayinclude activities, PowerPoint slides or questionnaires etc. Instructors simply need towork through all the documentation and adapt the content and presentation to suittheir own presentational style and operational requirements. The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 4. Flight Deck Course ProgrammeThe following represents a typical Pilot Initial Course 2 day programme, though allcourses can be tailored to suit your specific requirementsDay 1Introduction – 30 MinutesGeneral introduction to CRM and Human Factor related incidents and statisticsAviation Safety ReviewCompany Safety Culture/SOP’s and Organisational Factors – 1 HourTo enhance awareness of our own organizationTo study the effectiveness of SOP’sTo define safety and risk in the context of CRMOrganisational Error and Error Management – 2_ HoursTo describe how organisations can create the opportunity for individual errorTo illustrate the error chain www.aviationteamwork.comTo use a case study to discuss the aboveTo discuss active errorTo introduce 5th generation CRM training and error managementStress, Fatigue and Vigilance – 1 HourTo identify Stress and its causes and effectsTo practice Stress management techniquesTo define Fatigue and discuss different coping strategiesTo discuss how Stress and Fatigue may affect vigilanceCommunication and Co-ordination – 1 HourTo review how we communicateTo identify barriers to effective communicationTo highlight essential verbal communication skillsTo discuss and practise scenarios involving communicationAutomation – 45 MinutesTo identify the potential hazards of automationExamine the human Error associated with Automation 1 Friary, Temple Quay, Bristol BS1 6EA Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303 email: sales@aviationteamwork.com
  • 5. Flight Deck Course ProgrammeThe following represents a typical Pilot Initial Course 2 day programme, though allcourses can be tailored to suit your specific requirementsDay 2Review of Day One – 30 MinutesLeadership, Followership and Teamwork – 1 HourTo illustrate the effectiveness of working in teamsTo highlight effective leadership/followership skillsTo evaluate teamwork and leadership using NOTECHS and a video case studyPersonality/Attitude and Behaviour – 30 MinutesTo discuss behaviour and its effects on other crew members www.aviationteamwork.comSituational Awareness and Information Processing – 1 _ HoursTo consider the stages of the human information processing systemTo explore the limitations to our information system in the context of ourworking environmentTo examine the elements of Situational AwarenessTo illustrate and discuss causes of lack of SA and how we can enhance our SATo examine situational awareness through a case studyDecision-Making – 1 _ HoursIllustrate a Simple model for Decision MakingDiscuss routine Decision MakingHighlight Barriers to Decision MakingTo discuss and practise scenarios involving decision makingIllustrate a process for decision makingCase Study – 45 MinutesTo examine a case study involving a decompressionCourse Review – 45 Minutes 1 Friary, Temple Quay, Bristol BS1 6EA Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303 email: sales@aviationteamwork.com
  • 6. Cabin Crew CRMTypical Course Programme0830 Course IntroductionOverview of course, introductions, course aims and objectives. What is CRM?0845 The Aviation SystemDescription of preparation for departure, illustrating interdependence of different tasksand reasons why delays occur. Social structure of system.0930 Group ExerciseSyndicate exercise to illustrate teamwork1030 CommunicationDiscussion of output from syndicate exercise in terms of ways of communicating.Develop a model of communication and illustrate with examples of poorcommunication. Role of communication elements in CRM.1115 Decision-makingDiscussion of output from syndicate exercise in terms of how groups made decisions. www.aviationteamwork.comDevelop a model of decision-making and look at reasons for poor decision-making.Introduce stress as a factor in poor decision-making.1200 ReviewDiscuss lessons of mornings activity from perspective of ways of learning.Introduce concept of perception, limitations on information processing, etc.1230 Lunch1300 StressDevelop ideas about causes of stress. Discuss effects of stress and coping strategies.Fatigue.1345 Predictable BehaviourDiscuss concept of attitude and personality as predictable behaviour. Discuss the effectsof unacceptable behaviour in teams.1430 Case StudySyndicate exercise which looks at structural elements of team work.1530 Working in TeamsOutlines key elements of team structures and processes.1545 ErrorOutlines the skill, rule and knowledge categories of error with group exercise whichlooks at examples of types of error.1630 Review and Close The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 7. Helicopter CRM CourseTypical rotary wingTwo day Initial course programmeDay 10900 Course Introduction Overview of course, introductions, course aims and objectives. What is CRM? Statistical Justification0930 The Rotary Wing Operating Environment We examine the inherent dangers of the RW task, the operating requirements, and limitations of the equipment and often the training of the aircrew.1030 Break1045 The Search and Rescue Task www.aviationteamwork.com The elements of a SAR mission are discussed in syndicates. Once completed each syndicate delivers their plans1230 Lunch1330 Group Exercise Syndicate Team Work Exercise.1445 Communication Develop a communication model. Discuss Barriers to communication. Discuss the need for SOP’s and thorough training when limited time necessitates minimal time for briefing and lengthy uses of Advocacy and Inquiry. Discussion will focus on the previous SAR syndicate discussion.1545 Break1600 Who’s Flying the Aircraft? Discussion of the roles of the crew, task sharing, SOP’s and checklists.1650 Review of Day one The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 8. Helicopter CRM CourseTypical rotary wingTwo day Initial course programmeDay 20900 Stress The physiological effects. Discuss causes of stress. Stress Questionnaire. Discuss coping strategies and importance of recognition of stress. Fatigue. Discuss the dangers of the RTB after a stressful mission.1030 Break1045 Decision Making Case study group exercise and decision making models.1145 Errors and Mistakes www.aviationteamwork.com We discuss error recognition, the error chain and “The get the job done” RW mentality.1230 Lunch1330 Situational Awareness How can we get the difficult jobs done safely.1430 Behaviour Discuss the concepts of personality and behaviour. Discuss the concepts of the rogue aviator, the pilot that disregards limitations of himself and his machine. Why helicopter pilots are different.1530 Break1545 Exercise Problem solving, Leadership and teamwork exercise completed in syndicates.1630 Review and conclusion The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 9. CRM Instructor CourseUK CAA approved and JAR OPS compliantCRM Instructor Training CourseITS offers two standard CRM instructor training courses, a 5-day courseand an 8-day course.5-day courseThis course is suitable for those instructors who are already familiar with the CRMsyllabus and focuses primarily upon facilitation skills.8-day courseDesigned for those who are new to CRM, or have only limited experience of thesubject and syllabus. On the 8-day course the first three days are spent workingthrough the CRM syllabus in some detail. The objective here is to ensure that alldelegates have a common understanding of the subject matter. The next five days arespent in learning about, and practicing, CRM facilitation skills.Open Courses in the UKITS regularly holds open CRM instructor training courses in the UK, which are attended www.aviationteamwork.comby instructors from many different countries and from a wide selection of airlines.Contact ITS for a schedule of forthcoming courses.The ITS open instructor courses are non-residential and the course fee includes:● Classroom training● Course notes● Additional reading material● Courseware on CD● PowerPoint presentation● Copyright license to use our material within your company● Certificates on completion of the course● Refreshments and LunchPrivate coursesITS also offers private courses for individual clients and these courses are tailored moreclosely to the individual requirements of each client and can be held in the UK or onyour own base. Private CRM instructor courses may be held on any dates that areconvenient to your company, ITS will simply need sufficientadvance notice in order that suitable instructors are available for your preferred dates.We always assume that an instructor attending one of our CRMI courses will alreadyhave basic classroom instructional skills. The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 10. Management CRM TrainingThe ITS Management CRM Course is designed for senior managersfrom all support functions (finance, maintenance, operations,personnel, marketing etc.) and examines the relationship betweensenior management activity and risks in line operations.Typical Management CRM Syllabus● What is ‘safety’?● Management involvement in creating ‘safety’● Motivation● Management view of workforce● Workforce view of management● Management motivation in terms of company performance● Organisational Factors in Aircraft Accidents● Measuring Outcomes www.aviationteamwork.com● Relationships between management activity and safety● Relationships between ‘risks’ and ‘costs’● Creating a Safety CultureCourse DurationThe Course can be run as a one-day event or, if management timeis at a premium, it can be run over two consecutive half-days The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 11. Recurrent CRM TrainingMost Regulators require that, once initial CRM training has been completed,recurrent training should refresh the entire syllabus over a given period; withJAR OPS for example it is a 3-year period. Assuming therefore that initialtraining is provided to all your crew during year 1, then during years 2-4recurrent training should cover the entire CRM syllabus.The usual approach to this requirement would be to take the main subject headings within thesyllabus (e.g. stress, communication, error etc) and to cover one third of these subjects in eachof the three years during the recurrent training cycle. This will ensure that, over the 3-year periodspecified by JAR OPS for example, the syllabus will have been fully refreshed.It would not be adequate to simply repeat the various sections from the initial course, however,and so it will be necessary to produce a new set of recurrent training materials each year. Thiswork can be undertaken in-house, or alternatively it is a service that can be provided by ITS.Of most importance to each client is to ensure that they derive maximum benefit from theprovision of recurrent training and so it will be essential that, whilst meeting the Regulator’srequirements, the recurrent CRM training also addresses those issues that are of specificimportance to the airline. www.aviationteamwork.comITS can provide a recurrent courseware design service that will identify the specific issuesrelevant to the airline and will then design and produce appropriate recurrent training materials.This is a collaborative exercise that will require input from the Client’s CRM instructors andtraining management. The process will normally involve visits to base, an approval processduring the design period and a final workshop at which the courseware will be demonstratedand handed-off to the CRM instructors.Based on a 3-year contract a fixed annual fee will be agreed for the production of thecourseware. Alternatively, without a 3-year contract, the courseware can be produced annuallyat prevailing charges.There are many advantages to outsourcing this service and they include:● Access to the substantial experience available from ITS● Courseware designed to your particular requirements● On-going design creativity● Making time for more productive tasks within the organisationIn addition to constructing the courseware ITS can also deliver the courses using our own highlytrained instructors. The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 12. Evaluation of CRM BehavioursUnder JAA requirements, it is now necessary for operators to introduceCRM assessment into recurrent training. To support you in meeting thisrequirement we have introduced a new service designed to assist you indesigning and assessing behavioural markers.Your instructors will need to evaluate such elements as teamwork, decision-making,communication etc, in addition to the more usual technical elements. In order to do this,you will need to develop behavioural markers and identify the appropriate operationaland training situations in which evaluation can take place.WE CAN HELP!ITS has practical experience of building behavioural markers for our clients and with thisknowledge, and our considerable experience in CRM course design and training, wehave produced a package designed to assist you in:● Deciding which elements you need to assess● Agreeing a means of assessment www.aviationteamwork.com● Setting relevant standards● Preparing assessment documentation● Ensuring standardisation of assessors● Identifying mechanisms for remediationThe objective is to identify behaviour that is clearly related to operational performance.The process therefore requires a detailed analysis of your operation to ensure thatindividual performance-related behaviours are being assessed.We can therefore offer you a complete solution to the design and operation ofa behavioural marker scheme to include:● Development of your Behavioural Markers scheme● Training your assessors in the use of the scheme● Standardisation of assessmentFor more information, or to ask us to visit your base for initial discussions, contact us byphone, email or visit our website at www.aviationteamwork.com. The Old Forge, Little Barrington, Burford OX18 4TE Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242 email: sales@aviationteamwork.com
  • 13. Implementing an SMS Training CourseBased on the ICAO SMS Manual Doc 9859 (Second Edition - 2009), this3-day course is designed to prepare organisations for the implementa-tion of a Safety Management System.Course Aims: To introduce delegates to the concept of structured safety management To outline the steps needed to implement an SMS To identify the factors that contribute to a Just Culture To establish an effective organizational learning capability www.aviationteamwork.comCourse Structure:Day One An Introduction to Safety Management Safety, Hazard and Risk Error and Violation What is an SMS? Management’s role in an SMS Roles and ResponsibilitiesDay Two Developing an Hazard register Assessing Risk Setting Safety Management Goals Feedback and Reporting SMS DocumentationDay Three Investigation and Analysis Emergency Response Planning Learning from Experience – Continuous Improvement Safety Education and Training Developing an Implementation PlanThe course comprises a series of integrated presentations, practical exercisesand case studies. 1 Friary, Temple Quay, Bristol BS1 6EA, England Tel: +44 (0) 7000 240 240 Tel: +44 (0) 117 344 5019 email: sales@aviationteamwork.com
  • 14. Case Study – DecompressionCASE STUDY – DECOMPRESSIONThis case study is based on two actual incidents, both on Boeing 737 aircraft; theincidents were on different airlines. All details, for both incidents, are exactly ashappened during the two events; the only changes to the data included are the flightnumbers and airlines’ names, which have been changed to maintain confidentiality.The case study is suitable for delivery to pilot, cabin crew or joint pilot/cabin crewCRM courses. The main objective for the case study is to support a session onCommunication and Co-ordination, although of course you may wish to use it as abasis for other CRM elements.You will see that the module contains the following sections: • Lesson Plan • Supporting Materials • PowerPointWithin the Supporting Materials section you will find the handouts and a detailedreport on the second incident. Also in this section are copies of pax letters, regardingboth incidents, which were sent to the airlines.We would recommend that you allow 40 minutes to run this module in the classroom.Objective: • To examine two case studies involving decompressionsTo be covered as follows: • Distribute Handout 1 for first case study and ask delegates to highlight communication and co-ordination errors • Facilitate and discuss scenario from a communication and co-ordination perspective • Distribute Handout 2 for second case study and ask delegates to highlight how this incident was handled differently, also from a communication and co- ordination perspective, • Facilitate and discuss scenario to highlight differences between both incidents. Lesson Plan – Allow 40 Minutes
  • 15. KEYWORD DETAIL AIDS Slide Case Study Case StudyObjectives Objective: To study two actual incidents from a communication and co- Slide ordination perspective ObjectiveBackground This depressurisation incident occurred in 2004 on a Boeing 737- 800 a/c There are many points for discussion in this incident, as indeed there are on any case study – however we would like to discuss this from a communication and co-ordination perspective.Task Issue the Investigators summary handout sheet Handout 1 Working in groups of 3, ask class to mark the communication and co-ordination problems that occurred – give 5 minutes to do this Bring class together and discuss the points raisedPoints for Listed below are the communication and co-ordination discussiondiscussion points • Flight crew did not brief for ‘no engine bleeds take-off’ • Bleed Air Duct Pressure indicator was not checked at any time • When seat belt signs came on, the SCCM interpreted this as turbulence and made this PA to pax • FO made RT call ‘requesting immediate descent’ instead of announcing ‘emergency descent’ and declaring an emergency • Therefore ATC did not give a descent clearance until 2 minutes after the initial call • Flight crew did not announce ‘emergency descent’ to cabin crew and pax • When levelled out, the FO used the cabin call button rather than the standard NITS format • Cabin crew failed to request a NITS briefing and therefore did not pass any information to pax Expect Time Pressure on the ground to be a factor This area often suffers turbulent weather, therefore the interpretation of the cabin crew when the seatbelt sign came on is a factor for discussion So we have looked at an incident whereby there were communication and co-ordination issues involving ATC, flight deck © Integrated and the cabin crew. Let us now consider the effect this can have on Team Solutions Limited 2006 2 other groups of people – in this case our payload – the passengers!
  • 16. communication and co-ordination issues involving ATC, flight deck and the cabin crew. Let us now consider the effect this can have on other groups of people – in this case our payload – the passengers! This incident resulted in 7 pax letters written. There is nothing unusual in that – a pax perception of time and what is happening is often exaggerated as we all know. However, having looked at the incident from the crew’s perspective, can we take a moment to consider this from the pax? This is an excerpt from a passenger letter following this incident: Instructor to read aloud ‘Probably about 30 to 45 minutes into the flight we were told toPax letter fasten our seatbelts, put our seat backs upright etc as we were about to experience some turbulence. On obeying these instructions the plane seemed to almost hit a brick wall then drop. Just at this point the O2 masks deployed and the a/c began a very steep descent. To be perfectly honest, I, my wife and the rest of the pax thought we were going down permanently. The steep descent seemed to go on for an age. The sight of a stewardess with a look of sheer fear on her face and tears in her eyes did nothing to calm the mood on board. We believed we were going to die!! At no point during this steep descent did any crew member offer any support to us! It was every man for himself! Eventually the plane levelled off but again no information was given to pax until a very shaky captain/FO told us that we were diverting to Charles de Gaulle to ‘find out what the problem was.’ Then the next piece of information that was offered was that ‘no we are not diverting to CDG but we are diverting to OLY instead. Why did this person not try to offer some explanation for what was happening? Even a simple explanation like ‘don’t worry, the engines are fine, it just appears to be a problem with the cabin pressure.’ No we were kept in the dark and made to suffer in silence. No information. No information. No information. The letter then goes on to discuss the lack of support the pax had at OLY High workload and stress of the crew are just some of the factors here that contribute to the lack of information experienced by the passengers. However, what we would like to discuss here is the impact that aDiscussion lack of communication and co-ordination from both the flight deck crew and cabin crew can have on passengers. © Integrated Team Solutions Limited 2006 3
  • 17. Therefore looking at this incident – yes – we are just sitting in the classroom with the benefit of hindsight. If we consider some of the communication and co-ordination points we raised before – here are 3 examples Show slideSlide Slide • Flight crew did not announce emergency descent to cabin crew and pax • When levelled out, the FO used the cabin call button rather than the standard NITS format • Cabin crew failed to request a NITS briefing and therefore pass any information to pax Link into your Company SOP’s here regarding who is going to make the PA to pax If these communications had been given, how do you think thisQuestion situation from the pax perspective may have been different? Expect answers such as: Pax would have known there was a loss of cabin pressure if the PA had been made. They would have known the pilots were dealing with the situation. Even though they are briefed on the ground, understanding the problem when faced with the situation is completely different! There would have been greater co-ordination after the descent and the pax would have been briefed by the cabin crew following the NITS briefing We have looked at an incident in which there might have beenSummary better communication and co-ordination between the flight deck and cabin crew. So now let’s have a look at a second decompression and see how it is different from the first. This decompression incident occurred in August 2005 on a 737-300 en route from Malaga to London Gatwick.Slide Slide Issue the handout sheet and again, working in groups of 3, ask the class to compare the communication and co-ordination problems in © Integrated this incident with the first incident – give 5 minutes to do this Team Solutions Limited 2006 4
  • 18. Task class to compare the communication and co-ordination problems in Handout 2 this incident with the first incident – give 5 minutes to do this Bring class together and discuss the points raised. Establish the differences both from a flight deck/cabin crew and pax perspective. In contrast to the previous incident, this event resulted in several pax letters written to the company praising and thanking the crew. Here is an excerpt from one of these letters: Instructor to read aloudPax letter I was a passenger on flight ABC 123 from Mahon to London Gatwick yesterday. I am writing to convey to you my enormous admiration for the crew during our emergency descent. The cabin crew were completely calm and professional. They were an enormous help to us both practically and emotionally. It goes without saying that I am so very grateful to the pilots who got us safely to the ground While in the aircraft on the tarmac at Brest Airport, the F/O came through the cabin to speak to all the passengers which was extremely helpful and reassuring to us all. He took a great deal of time over this and I feel it was invaluable. The cabin crew were marvellous while we were waiting to disembark a very hot aircraft. They were patient and calm and very friendly. Later in the lounge at Brest Airport they were very happy to talk with us and showed great concern for our recovery. I hope you will be able to pass on these sentiments to the entire crew. It was of course an extremely frightening experience but I do not believe the crew could possibly have been more helpful to us. They were marvellous. I would also like to say how understanding and helpful the crew were on the 757 which took us to London Gatwick. A further letter reads: Whilst the experience was extremely distressing, we would like to thank the captain & crew for their professionalism during the incident, when they were clearly distressed themselves. Their support was exemplary, particularly the way they managed to look after everybody once we had landed. © Integrated Team Solutions Limited 2006 5
  • 19. Special thanks to the pilot, who got us down safely & then for talking to us individually during our time at Brest airport. We hope it hasnt put the young cabin crew staff off flying again! They were all fantastic & should be proud of the way they conducted themselves. Thanks also to the crew of the 757 who rescued us & brought us home safely. They made us feel a lot more at ease than we ever expected to be. Instructor note: See report if more information required© Integrated Team Solutions Limited 2006 6
  • 20. SUPPORTING MATERIALSContent: • Handout – Decompression 1 • Handout – Decompression 2 • Report – Decompression 2 • Pax Letters© Integrated Team Solutions Limited 2006 7
  • 21. Handout – Decompression Incident 1Investigator’s summaryThe aircraft departed London Gatwick 10 minutes early at 09:30 and after anuneventful flight arrived at Malaga at 12:16, 19 minutes ahead of schedule. Inaccordance with a request from the ramp agent, the Captain prepared to depart fromstand ahead of schedule to facilitate handling a delayed inbound flight.A check on the expected take-off performance requirements, by both crew, confirmedthat a Bleeds-Off (no engine bleeds) take-off would be required... Shortly afterwardsthe ramp agent presented the load sheet and again emphasized the urgency in vacatingthe stand. The aircraft closed up and started engines at 12:42, 18 minutes ahead ofschedule and was airborne at 12:57. No special brief was given for the bleeds-offtake-off nor was the ‘Supplementary Procedures’ section of the FCOM consulted.The crew reported that they made the standard checks on the pressurization systemevery 5000 feet during the climb including a full panel scan passing Fl.100 (10000 ft)and all parameters checked appeared normal. It has been established that the checkson the pressurization system centered on the Cabin Altitude/Differential indicator ;indications here would certainly approximate to ‘normal’ for as long as the APUcontinued to supply a useful flow of bleed air. Limitation for APU with bleed air is17000feet. At no time did anybody check the Bleed Air Duct Pressure indicator. Thiswould have indicated a bleed air supply problem, with zero indicated in the right handduct and a slowly reducing pressure in the left hand duct as the aircraft climbed.After about 10-15 minutes in the cruise at Fl.320, (32000 ft) the cabin altitude hornsounded. The crew performed the ‘recall items’ for Cabin Altitude Warning Horn’and noted the cabin altitude at 10000feet climbing at approximately 1500fpm (feet perminute) The Captain called for Emergency Descent and the crew then set about therecall items for this manoeuvre. When the Captain switched on the seatbelt sign, theSCCM interpreted this as an indication of impending turbulence and duly made theappropriate ‘turbulence’ PA to the passengers. The oxygen masks then dropped. Atthis point the FO made an RT call “Air Link 176 requests immediate descent” only toreceive “I’ll call you back’ The Captain then advised “Now. Emergency Descent”,ATC responded with “Squawk 7700” which the FO set and then announced “Air Link176 descending Fl.270” (27000 ft). Approximately 2 minutes after the initial call,ATC gave their first descent clearance “Air Link 176 you can descend Fl.200” (20000ft).All subsequent RT communications were without complication .During the descent,the system misconfiguration was spotted and corrected and the aircraft’spressurization was thereafter controlled normally. When level at Fl.100 (10000 ft),the FO called the cabin using the cabin call button. The SCCM was informed thatthere had been a rapid decompression and they were diverting to CDG, this wassubsequently changed to OLY. The remainder of the flight and landing at OLY waswithout incident.© Integrated Team Solutions Limited 2006 8
  • 22. Handout – Decompression Incident 2During the cruise at 36000’ the RH Bleed Trip Off illuminated and the cabin pressurestarted to climb. The QRH drill was called for and a descent to 25000’ requested. Asthe cabin approached 10000’ the cabin altitude horn sounded and therefore the rapiddepressurisation drill was performed. The cabin altitude climbed to 16000’ and themasks deployed at 14000’. A MAYDAY was declared and Brest airport wasrequested as the diversion field.The depressurisation drill was followed, including an announcement over theaircraft’s Public Address system to alert the cabin crew members – PA ‘EmergencyDescent’The cabin crew immediately commenced their decompression drill, passing throughthe cabin from rear (where they were in the galley at the time of the incident) to thefront and once the decompression drill had been conducted, assembled in the forwardgalley for a briefing from the SCCM and checked the drills had been completedcorrectly through reference to the Cabin Crew Safety Manual.The rapid descent was carried out as per SOP’s and the aircraft levelled off at 10000’. A further PA to calm the pax was made during the last few thousand feet of descent –pax were told all was ok and a normal landing would take place at Brest.Approach and landing were normal.The aircraft was inspected at Brest and a cabin pressure run carried out after the RHpack was reset.A replacement 757 was dispatched to Brest and the 737-300 returned to LondonGatwick at an altitude of 10000’© Integrated Team Solutions Limited 2006 9
  • 23. Investigation into loss of cabin pressure August 2005Aircraft : Boeing 737-300Occurrence Date : August 2005Flight Number : ABC 123Flight Routing : Malaga, Spain to London Gatwick, UKNature of flight : Public transport – fixed wingOccupants : 140 passengers plus 4 infants and 6 crew membersCrew : Captain, First Officer, Senior Cabin Crew Member [SCCM], 3 Cabin Crew MembersLocation of incident : Approx 60 nautical miles to the east of Brest, France, at thetime of incidentBrief summary : Loss of cabin pressure whilst at cruising altitude of 36,000ft ledto rapid descent and precautionary, safe landing atBrest, FranceHistory of the flightThe aircraft was operating the return sector of a roundtrip between London Gatwickand Malaga. Its outward flight left London Gatwick at 11.44 hrs Greenwich MeanTime [GMT] (used throughout1) and landed in Malaga at 14.23 hrs. This was 14minutes behind the planned schedule as a result of a delay in leaving LondonGatwick due to passengers arriving late at the boarding gate.The turn-round at Malaga was routine, albeit shorter than usual as the crew sought tomake up the earlier delay. The aircraft departed Mahon at 15.00 hrs (5 minutesbehind schedule as a result of the late inbound aircraft), becoming airborne at 15.12hrs, for the return flight to London Gatwick with 140 passengers and 4 infants aboard.Estimated flying time was 2 hours and 44 minutes and a fuel load of 10,200 kgs wasaboard, in excess of the minimum 9,458 kgs (including statutory reserves and diversionfuel) required for the flight. The aircraft departed at a weight of 53,633 kgs, some7,602 kgs below its maximum take-off weight.Departure from Malaga was uneventful; the aircraft followed a MJV2D StandardInstrument Departure route and was given progressive climb clearance by Spanish AirTraffic Control [ATC] to climb to its requested cruising altitude of 36,000ft for the sectorto London Gatwick. During the climb and cruise phase of the flight, cabinpressurisation was maintained normally by the aircraft’s automatic pressurisationcontroller and this item was routinely checked and found satisfactory in the “Climb”checklist by the flight crew.1Local time in Malaga and Brest is two hours ahead of GMT; local time at London Gatwick is one hourahead of GMT© Integrated Team Solutions Limited 2006 10
  • 24. Control of the aircraft passed from Spanish to French Air Traffic Control 48 minutesafter departure and the aircraft was given a direct clearance to the navigationalbeacon at Agen (AGN).At 16.42 hrs, whilst the aircraft was approaching a position abeam the navigationalbeacon at Monts d’Arree (ARE) [near the French town of Lorient], a “BLEED TRIP OFF”caution light illuminated on the Automatic Centralised Warning System panel. Theflight crew conducted the checklist drill and requested initial descent clearance fromAir Traffic Control to descend to 25,000ft, which is in line with Boeing’s StandardOperating Procedures [SOP] if the aircraft has partial failure of its pressurisationsystem.During this initial descent, the flight crew noted that the cabin altitude (the pressurelevel in the cabin relative to the outside air) was rising rapidly. As the cabin altituderose above 10,000ft, the cabin altitude warning horn sounded on the flight deck andboth flight crew members placed on their own oxygen masks in accordance with theairline’s SOP. The depressurisation drill was followed, including an announcementover the aircraft’s Public Address system to alert the cabin crew members.The flight crew requested clearance from ATC and then initiated an emergencydescent to 10,000ft. The cabin altitude continued to rise; further attempts weremade by the crew to control the pressurisation by switching from automatic tomanual mode but these were unsuccessful.As the cabin altitude rose through 14,000ft, the passenger oxygen masks deployedautomatically. In accordance with the pre-flight demonstration, passengers weredirected to pull the masks towards them to open the oxygen supply, place the maskon and then breathe normally. The cabin crew immediately commenced theirdecompression drill, passing through the cabin from rear (where they were in thegalley at the time of the incident) to the front and once the decompression drill hadbeen conducted, assembled in the forward galley for a briefing from the SCCM andchecked the drills had been completed correctly through reference to the CabinCrew Safety Manual.The flight management computer [FMC] indicated that the nearest available airfieldwas at Brest and the crew requested clearance to land at Brest. The remainder ofthe flight was uneventful and the aircraft landed at Brest at 17.14 hrs and engineswere shut down on the parking stand at 17.16 hrs.Injuries to Aircraft OccupantsThere were no injuries to passengers arising from the incident. Three passengersrequired medical attention at Brest for conditions including an asthma attack andpainful sinuses and were attended by paramedics called by Brest Airport. All were fitto continue their journey later that evening aboard a replacement aircraft.NotificationThe airline’s 24-hour Operations Control Centre [OCC] was notified of the air diversionby Air Traffic Control at 17.08 hrs and further confirmation was given at 17.15 hrs thatthe aircraft had landed safely at Brest. This was confirmed by the Captain who useda mobile telephone to contact the OCC at 17.25 hrs.A plan was formulated to dispatch one of the airline’s Boeing 757 aircraft fromLondon Gatwick to carry an engineering team out to Brest and then to fly all© Integrated Team Solutions Limited 2006 11
  • 25. passengers from Brest to their desired destination of London Gatwick. This wasinstigated at 18.04 hrs and crew members were called from home standby toundertake this new operation. London Gatwick Airport was advised at 18.15 hrs ofthe revised expected time of arrival of the flight at 23.45 hrs so that any personsmeeting the flight at London Gatwick could be given up-to-date informationregarding the delay.Passengers remained on the 737 aircraft at Brest for a period of time until clearinformation could be given of the onward flight. During this ground time, the FirstOfficer and crew were present in the aircraft’s cabin to reassure passengers andexplain the situation. Passengers later disembarked normally into the terminalbuilding at Brest and Brest Airport made provisions for food and beverages to beprovided at the airline’s request pending the arrival of the replacement aircraft.The 757 aircraft landed at London Gatwick from its previous sector from Egypt at20.04 hrs and was airborne to Brest at 21.08 hrs. All passengers elected to continuetheir journey to London Gatwick and the aircraft landed in London Gatwick at 23.46hrs to complete service from Malaga.Crew detailsThe Aircraft Commander is a 52-year old male (Australian national) who holds a validUK Air Transport Pilot’s Licence [ATPL(A)]. He is an experienced 737 Captain who hadpreviously flown the type in Australia; joined the airline in April 2003, completedtraining in May 2003 and was promoted to the role of Training Captain in October2003.The First Officer is a 38-year old male (UK national) who holds a valid UK CommercialPilot’s Licence [CPL]. He joined the airline in April 2005 and completed training inMay 2005.Both pilots were licensed on 737-300 to -900 aircraft variants and held valid medicalcertificates. The crew were properly licensed, trained and rested to undertake theflight duty.The four cabin crew members had all undergone initial training with the airline in April2005 after joining the airline. The SCCM held appropriate previous flying experienceas Cabin Crew on a fixed-wing aircraft to operate in that capacity. All cabin crewmembers were trained in accordance with the airline’s approved trainingprogramme, had undergone medical examinations and were rested to undertakethe flight duty.All crew members were interviewed by the airline’s flight crew and cabin crewmanagement teams following the incident.Aircraft & EngineeringThe aircraft joined the airline’s fleet in April 2003 and has completed a total of 40,537hours and 25,998 flight cycles since new. It underwent a major maintenanceoverhaul (C Check) in November 2004 and its most recent intermediatemaintenance check (A Check - required every 250 flying hours) was undertaken atLondon Gatwick in August 2005. The aircraft daily inspection was conducted on themorning prior to the aircraft’s departure to on its first sector of the day.© Integrated Team Solutions Limited 2006 12
  • 26. Flight crew members completed routine pre-flight walk-round checks of the aircraftbefore both sectors with no defects or issues noted.The aircraft was properly maintained in accordance with Boeing MaintenancePlanning Document and the airline’s maintenance procedures, which are approvedby the UK Civil Aviation Authority.Flight recordersThe aircraft’s Cockpit Voice Recorder was retained by the French DepartmentGeneral de l’Aviation Civile inspectors who visited the aircraft on arrival at Brest. TheQuick Access Recorder [QAR] data was removed from the aircraft by the airline’sengineers on the day after the incident and analysed.The data is consistent with the account from the flight crew. The descent profile wasanalysed and in the graph below, the blue line shows the profile of the aircraft. TheQAR indicates that the aircraft descended from its cruising altitude of 36,000ft to analtitude of 10,500ft over a period of 6.5 minutes.Fig 1 – QAR data of descent profile between 16.42:00 hrs and 16.51:30 hrsThe average descent rate was 4,300ft per minute versus 2,000ft per minute in aconventional descent. The maximum angle of descent recorded by the QAR was4.92º2 and the maximum rate of descent reached at any point was 6,200ft perminute.Engineering examination of the aircraftThe aircraft was examined by the airline’s engineering team at Brest after their arrivalfrom London Gatwick aboard the 757 aircraft dispatched to carry passengers hometo London Gatwick. This indicated the presence of a problem within the air system2 This is equivalent to a 1 in 7 gradient in a land-based descent© Integrated Team Solutions Limited 2006 13
  • 27. which uses outside air from the right-hand engine and compresses it in order to supplythe cabin air conditioning and pressurisation system whilst in flight. The structuralintegrity of the aircraft’s fuselage and all external doors and hatches was assessedand found to be intact.A low-level ferry flight (i.e. unpressurised) with a minimum safety crew aboard wasundertaken late on the evening to return the aircraft to London Gatwick; during thissector, a pressurisation check was carried out during which the fault was repeatedand found to be consistent with the earlier crew’s accounts.Engineering AnalysisThe 737 has two independent bleed air systems one from each engine, feeding twototally independent air-conditioning supply systems. Under normal circumstanceseach air conditioning system is designed to maintain the cabin pressure with a highlevel of extra capacity in reserve.On investigation, the airline’s engineers reset the right-hand bleed air system andcarried out a cabin pressurisation system check. This test revealed a broken clampround the Auxiliary Power Supply [APU] air duct sealing skirt, allowing air to leak out ofthe cabin. This high leak rate explains why the flight crew were unable to maintainthe cabin altitude using only the left-hand air conditioning supply system as shouldnormally have been possible.The automated safety alert systems functioned correctly in notifying the flight crew ofthe bleed air valve failure and the rising cabin altitude.The automated oxygen mask drop out system deployed correctly as designed. Eachset of four masks (left-hand side of the cabin) and three masks (right-hand side of thecabin) is supplied by an individual oxygen generator and the passenger action ofpulling the mask towards themselves pulls the firing pin out of the oxygen generatorand thus commences a flow of oxygen. Subsequent inspection of the oxygensystem indicated that all oxygen generators had fired correctly and producedoxygen. A small number of oxygen generators (including those in the forward andone aft toilet, which were not occupied at the time of the incident), were not used.Passenger reports of a burning smell towards the rear of the aircraft prior to theincident have been investigated. No evidence of fire or smoke has been found, butthe engineering investigation indicated some residue in the aircraft’s centre reargalley oven consistent with food debris from passenger meal service. None of thecabin crew members recalled any such issue and all had been in the rear galleyaround the time of the incident.The individual oxygen generators above each seat row normally produce heat and alight acrid haze when fired and it was concluded that the passenger reports of smokeafter the deployment of oxygen masks were consistent with the normal functioning ofthe oxygen generators.Repairs were effected to restore the integrity of the pressurisation system throughreplacement of the air duct clamp and the aircraft was test flown two days leter witha full pressurisation check undertaken. It was found to be functioning correctly inboth automatic and manual control modes. Further work was undertaken toreplace the oxygen generators above each passenger seat, replace all oxygenmasks (standard procedure after use), re-stow oxygen masks and then conduct a© Integrated Team Solutions Limited 2006 14
  • 28. final function check on the oxygen mask system. The next day a further test flightwas conducted before the aircraft was cleared to return to passenger service.Incident historyNo other comparable incidents of decompression have been recorded on theairline’s fleet of aircraft. The airline operates a total of five identical Boeing 737-300sand two Boeing 737-700 aircraft and has undertaken over 21,000 sectors without anyevent of this nature.Follow up actionThe aircraft manufacturer, Boeing Airplane Company, has been notified of the failure.The airline has undertaken a full inspection of its aircraft fleet to ensure that no similardefects exist. There is no requirement from Boeing or the UK Civil Aviation Authority toreplace the failed component on the aircraft as part of routine maintenance checks,but the airline is formulating procedures to replace these during each annualoverhaul of the aircraft as a precautionary measure.© Integrated Team Solutions Limited 2006 15
  • 29. INCIDENT 1 - PAX LETTER‘Probably about 30 to 45 minutes into the flight we were told to fasten our seatbelts, put ourseat backs upright etc as we were about to experience some turbulence. On obeying theseinstructions the plane seemed to almost hit a brick wall then drop.Just at this point the O2 masks deployed and the a/c began a very steep descent. To beperfectly honest, I, my wife and the rest of the pax thought we were going down permanently.The steep descent seemed to go on for an age. The sight of a stewardess with a look ofsheer fear on her face and tears in her eyes did nothing to calm the mood on board. Webelieved we were going to die!!At no point during this steep descent did any crew member offer any support to us! It wasevery man for himself! Eventually the plane levelled off but again no information was given topax until a very shaky captain/FO told us that we were diverting to Charles de Gaulle to ‘findout what the problem was.’ Then the next piece of information that was offered was that ‘nowe are not diverting to CDG but we are diverting to OLY instead.Why did this person not try to offer some explanation for what was happening? Even asimple explanation like ‘don’t worry, the engines are fine, it just appears to be a problem withthe cabin pressure.’ No we were kept in the dark and made to suffer in silence. Noinformation. No information. No information.© Integrated Team Solutions Limited 2006 16
  • 30. INCIDENT 2 - PAX LETTERDear sir/madam,We were passengers on flight ABC123 which had to emergency land in France on Friday.Whilst the experience was extremely distressing, we would like to thank the captain & crewfor their professionalism during the incident, when they were clearly distressed themselves.Their support was exemplorary, particularly the way they managed to look after everybodyonce we had landed.Special thanks to the pilot, who got us down safely & then for talking to us individually duringour time at Brest airport.We hope it hasnt put the young cabin crew staff off flying again! They were all fantastic &should be proud of the way they conducted themselves.Thanks also to the crew of the 757 who rescued us & brought us home safely. They made usfeel a lot more at ease than we ever expected to be.Please keep us informed regarding the cause of the emergency & once again well done to allconcerned!© Integrated Team Solutions Limited 2006 17
  • 31. CONTACT ITSFor more information or support with courseware, case studies, videos/DVDs or fortraining courses please contact:ITS1 FriaryTemple QuayBristolBS1 6EAEnglandTel: +44 (0) 7000 240 240 +44 (0) 1451 844 303Fax: +44 (0) 7000 241 242 +44 (0) 0117 344 5001email: sales@avaitionteamwork.comwebsite: www.avaitaionteamwork.com© Integrated Team Solutions Limited 2006 18