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Example of a CRM presentation.


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  2. 2. ¿WHY  CRM?   It  is  a  JAA  requirement  (Subpart  N). Error  is  present  in  both  our  decisions  and  lives. It  is  an  accepted  tool  to  optimize  the  defenses  against   human  error. It  look  for  excellence  in  aviation,  but  CRM  needs  that   people  question  their  previous  thoughts. 2
  3. 3. Everglades,  Florida  (L-­‐1011).  All  crew  members  try  to  solve  a   problem  with  the  landing  gear   lights.  While  the  crew  is  focus  on  this   problem,  the  AP  disengages,   starting  a  soft  descend  ending  up   in  a  crash. 29  –  Dec-­‐1972 3
  4. 4. Portland,  Oregon  (DC-­‐8)  They  run  out  of  fuel  while  they  try   to  solve  a  problem  with  the   landing  gear.  The  F/O  and  the  F/E  showed  their   worries  about  the  quantity  of   remaining  fuel. 28-­‐Dec-­‐1978 4
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  6. 6. Los  rodeos,  Tenerife 22-­‐Mar-­‐1977  Dos  Boeing  747  crashed  on  the   runway,  killing  583  people.  The  “Error  chain” 6
  7. 7. CRM  AIMS Raise  the  level  of  safety  in  daily  operations Integration  of  crew  members Efficiency  in  operations. Learn  from  past  errors 7
  8. 8. How  CRM  concept  was  born? Crew   (or   Cockpit)   Resource   Management   (CRM)   training   originated  from  a  NASA  workshop  in  1979  that  focused  on   improving  air  safety.   The  NASA  research  presented  at  this  meeting  found  that  the   primary   cause   of   the   majority   of   aviation   accidents   was   human  error,  and   that  the   main  problems  were  failures  of   interpersonal   communication,   leadership,   and   decision   making  in  the  cockpit.   A  variety  of  CRM  models  have  been  successfully  adapted  to   different  types  of  industries  and  organizations,  all  based  on   the  same  basic  concepts  and  principles 8
  9. 9. ¿What  is  CRM?         CRM  is  an  operational  philosophy  looking  for   the   effective   use   of   all   available   resources:   h u m a n   r e s o u r c e s ,   h a r d w a r e ,   a n d   information.       (FAA  Advisory  Circular  1992) 9Felipe  Sánchez  for  flightline  BCN
  10. 10. What  is  not  CRM? A  system  you  can  install  in  one  day A  training  program  for  “bad  pilots” A  Magical  tool  that  is  going  to  salve  us  from  accidents A  psychotherapy   An  impossible  philosophy   10Felipe  Sánchez  for  flightline  BCN
  11. 11. Elements  of  CRM Communication Leadership  and  authority Situational  awareness Decision  making Stress  /  Fatigue  management Automatism  management   Assertivity Work  distribution Power  chain 11
  12. 12. Elements  CRM Vigilance  and  crosscheck   Standard  Operational  Procedures 12Felipe  Sánchez  for  flightline  BCN
  13. 13. ACCIDENTS Accidents  are  the  result  of  a  succession  of  events.  The   Links  of  this  chain  (which  lead  to  the  accident)  are  a   chain  of  errors. Lack  of   experience Weather Delays Pressure Fatigue Poor   Communication Mechanical   failures 13 Felipe  Sánchez  for  flightline  BCN
  14. 14. 14 0% 20% 40% 60% 80% 1950 1960 1970 1980 1990 2000 2010 Change in Accidents cause
  15. 15. James  Reason   Model 15 Company culture SOP´s Systems redundancy Piloting skills
  16. 16. Los  Rodeos  Accident   16
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  18. 18.  Situation awareness, or SA, is the perception of environmental elements within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.(Endsley 1988). KNOW WHAT IS HAPPENING AROUND YOU 17
  19. 19. Ambiguity Confusion Only fly the airplane or look outside Do not follow SOPs Stress and workload Focus your attention Routine and excess of confidence 19
  20. 20. Briefings Follow the SOP Teamwork Effective communication 20
  21. 21. 1. 2. 3. 4. 5. 6. 7. 8. 21
  22. 22. Clear Brief Adapt to reality Logical Open to questions and changes 22
  23. 23. Before every flight When there is a change in a crew member When a significance change occurs 23
  24. 24. Controlled flight into terrain (CFIT) describes a collision whereby an airworthy aircraft, under pilot control, inadvertently flies into terrain, an obstacle, or water. The term was developed by engineers at Boeing in the late 1970s. The pilots are generally unaware of the danger until it is too late. 61% of aviation fatalities are caused by CFIT. (1979-1991) Flight Safety Foundation 24
  25. 25. CALI´S ACCIDENT 25
  26. 26. Causes? Solutions? Situational awareness? Crew CRM? 26
  27. 27. COMMUNICATION 27Felipe  Sánchez  for  flightline  BCN
  28. 28. COMMUNICATION  PROCESS Flightline   001  Ready   for   departure FEEDBACK 28
  29. 29. CommunicaZons  and  accidents • 37%  No  Communica4on • 36%  Broken  or  incomplete  message • 13%  Communica4on  not  in  4me • 11%  non  understand  communica4on • 3%  technical  failure 29
  30. 30. Elements  that  could  affect  communicaZon   between  crew  members • Different  cultures • Age  difference • Status • Physical  barriers   • Gender 30
  31. 31. • Transmit  the  informaZon  clear  and  loud. • Use  standard  terminology. • Express  our  suggesZons  and  worries  in  an   asserZve  way. • Demand  feedback. • Ask  for  confirmaZon  if  you  are  not  sure. How  can  you  improve  your   communicaZons? 31
  32. 32. CommunicaZon  failures • Do  not  use  open  communicaZon • Use  a  faulty  code • Code  ignorance • Aggressive  communicaZons • No  to  be  asserZve • Do  not  demand  or  give  feedback 32
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  34. 34.   Stress  is  the  emotional  and  physical  strain  caused  by  our   response  to  pressure  from  the  outside  world   It's  almost  impossible  to  live  without  some  stress.  But  if   stress  gets  out  of  control,  it  may  harm  your  health,  your   relationships,  and  your  enjoyment  of  life 34
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  36. 36.   The  seriousness  of  the  problem Personality Training Experience 36
  37. 37.  Sleep  disruption  Nicotine  poisoning  Abuse  of  alcohol  Aggressively  Emotional  bursting  Decrease  of  libido  Do  not  feel  hungry 37
  38. 38. Irritable Hostility Anxiety Low  self-­‐esteem. inferiority  complex Isolation  from  friends  and  family   Inability  to  enjoy  your  live Lost  of  Concentration   Abuse  of  drugs  and  alcohol 38
  39. 39. Tension,  headache Gastritis Insomnia Muscular  Pain Hypertension Fatigue “Breath  problems” Perspiration  (Hands) 39
  40. 40. Identify  the  stress  factors Use  relax  therapies Improve  your    diet Improve  physical  exercise develop    your  interior  balance In  case  you  can  not  control  it,  go  to  the  doctor 40
  41. 41. Weather  conditions Noises Hypoxia Fatigue Poor  physical  conditions Company  pressures   Problems  with  the  crew   Maintenance Lack  of  experience Work  instability 41
  42. 42.   Fatigue  is  a  lack  of  energy  and  motivation.     Fatigue  can  be  a  normal  and  important  response  to   physical  exertion,  emotional  stress,  boredom,  or  lack   of  sleep.  However,  it  can  also  be  a  nonspecific  sign  of   a  more  serious  psychological  or  physical  disorder.           42
  43. 43. PHYSICAL  (excessive  exercise) MENTAL  (excess  of  intellectual  work) PERCEPTION  (excess  of  stimulus) INADEQUATE  REST 43
  44. 44. It  is  one  of  the  most  important  aviation  threats In  a  NASA  research,  fatigue  was  a  contribute  factor  in   21%  of  the  studied  cases.   In  35%  of  aviation  accidents,  fatigue  is  mention  as  a   possible  factor. 44
  45. 45. 45Felipe  Sánchez  for  flightline  BCN
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