2. Objectives
1. To demonstrate Human Factors/CRM Concept (SHELL)
2. To increase safety awareness at any situation and condition
3. To demonstrate ability to detect and asses hazard around
work place.
4. Able to communicate effectively and accurately.
5. Able to make decision making.
6. To identify factor affecting human error.
7. Aware to hazardous attidtude.
8. The definition of Crew Resource Management
a flexible, systemic method for optimizing human
performance in general, and increasing safety in
particular, by (1) recognizing the inherent human factors
that cause errors and the reluctance to report them, (2)
recognizing that in complex, high risk endeavors, teams
rather than individuals are the most effective
fundamental operating units and (3) cultivating and
instilling customized, sustainable and team-based tools
and practices that effectively use all available resources
to reduce the adverse impacts of those human factors.
9. • A series of aviation disasters in the 1970's triggered the innovative shift
that led to Crew Resource Management. These included the 1977 Canary
Islands disaster in which two Boeing 747's collided on a runway, killing
582 people.
• In 1972, a Lockheed L-1011 (Eastern Air Lines Flight 401) crashed in a
Florida swamp, killing 99 passengers... as the crew worked to repair a
burned-out light bulb.
• United Airlines Flight 173, making its final approach to Portland
International Airport after a routine flight on December 28, 1978, ran out
fuel and crashed into a residential area, killing eight passengers and two
crew members, and seriously injuring 23 others.
May we can learn from past aircraft accidents, below:
10. In each case, tragedy traced back to human error:
Canary Islands: in his haste to take off, the captain of the Boeing 747, a highly
seasoned professional, mistakenly assumed a critical pre-flight step had been
performed and barreled down a foggy runway without first obtaining takeoff
clearance.
11. EAL 401: crashed, in essence, because someone forgot
to fly the plane. The National Transportation Safety Board
(NTSB), after investigating, found that the autopilot was
inadvertently switched from "Altitude Hold" to "Control
Wheel Steering" mode when the captain accidentally
leaned against a yolk, causing the plane to enter a
gradual descent. No one in the crew noticed or heard the
system's altitude alert warning because the crew was
distracted by the landing gear light and the flight
engineer was not in his seat when the alert sounded and
thus could not hear it.
12. UA 173: experienced a similar landing gear light problem. The experienced
captain noticed that the plane's nose gear light failed to turn green to
indicate it was properly deployed. With the control tower's permission, the
pilot circled the plane and ran through his checklists to troubleshoot the
problem, but the nose gear light stayed red. While circling, the first officer
and flight engineer told the pilot that the plane was running low on fuel.
The pilot apparently ignored the warnings. Post-crash analysis revealed
that the green light bulb for the nose gear had simply burned out; the
landing gear had been deployed the entire time. The NTSB found that the
crash was caused by the captain's failure to accept input from junior crew
members and a lack of assertiveness by the flight engineer.
13.
14. "We are embarking on an
adventure into the flight
training techniques of the
future. In recent years a
growing consensus has
occurred in industry and
government that training
should emphasize crew
coordination and the
management of crew
resources."
- Charles Huettner, FAA
28. UPS Flt. 1354 Crashed when landing approach due to CFIT. Contributing
factors is Pilot fatigue
29. Why accident still happen?
• Probable cause in 80% of accidents (NTSB):
– Unprofessional attitude 47%
– Pilot technique/decision making 26%
– Visual perception – situation misjudgment 19%
33. The Evolution of Crew Resources Management
CRM :
Emphasize the human attitude in responding
situation
TEM :
Threat and Error Management is a major safety
process in aviation.
It consists of detecting, responding,
avoiding/trapping threats and errors that
challenge safe operations. Where threats and
errors are not contained (resolved), the
resulting conditions must be managed and
adverse effects reduced.
34. Threat Management is managing YOUR FutuRe
Error Management is managing YOUR Past
35. 35
What is a Threat?
• Any condition that increases the complexity of the
operation.
• Threats, if not managed properly, can decrease
safety margins and can lead to errors.
• “Threats should serve as a Red Flag.”
– Watch out!
– Something bad can happen!
36. 36
What is Threat Management?
• Threat Management – There are two aspects to
Threat Management:
1. Recognizing that a threat exists
2. Coming up with a strategy to deal with the threat, so
that it does not reduce safety margins or contribute to
an error
37. 37
• There are two types of threats
– External Threats – Those outside of your control
(e.g., weather, lack of equipment, hard to
understand documentation, system errors,
inadequate lighting)
– Internal (Human) Threats – Those within our
control (e.g., fatigue, loss of situation awareness,
stress, disregard for following procedures)
Types of Threats
38. 38
What is an Error?
• The mistake that is made when threats are
mismanaged.
• There are 5 types of errors:
1. Intentional non-compliance errors
2. Procedural errors
3. Communication errors
4. Proficiency errors
5. Operational decision errors
39. 39
What is Error Management?
• Error Management – The mitigation or reduction in
seriousness of the outcome.
1. The resist and resolve filters or defense mechanisms may
be applied to an existing error before it becomes
consequential to safety.
2. By applying the resist and resolve filters in the analysis of
an error, you may:
Improve strategies or counter-measures to identify and manage
both internal and external threats, like fatigue, condition of
ground equipment, etc.
40. 40
Weather
New Agent
Cabin Crew
Passenger events
Late Bags
Time pressures
Heavy traffic
Unfamiliar gate
Flight Crew
Flight diversion
Distractions
Ramp slope
Late Cargo
Maintenance
System malfunction
Late Gate Change
Threats That Can Lead to Ramp Agent Error
42. INVULNERABILITY “It can’t happen to me”
Macho “Can Do” Risk taking
Impulsivity “Do something fast!”
Anti-Authority “Don’t tell me”
Resignation “What’s the use”?
Start thinking the
unthinkable
Risk taking is foolish
STOP! Think! Select the
best course
Follow the rules
You can make a difference
HAZARDOUS ATTITUDE ANTIDOTE
Pressing “Get-thereitis”
It’s better to get there
late than never
43. Your Project ……
You as engineer, identify the threat and error in aircraft
maintenance
You as pilot, identify the threat and error in aircraft
maintenance
