Crew Resource Management

Table of Contents
INTRODUCTION
Crew Resource Management
Course Objectives
Crew Resource Management

STANDARD OPERATING PROCEDURES AND LINE ORIENTED FLIGHT

TRAINING
Standard Operating Procedures
Line Oriented Flight Training

COMMUNICATION
Communication
Definitions
Key Facts About the Way We Communicate
Modes of Communication
Communication Process

BEHAVIORAL STYLES
Behavioral Styles

FATIGUE

STRESS MANAGEMENT
Attitudes

SITUATIONAL AWARENESS
Elements of Situational Awareness
Clues to the Loss of Situational Awareness
Maintaining Situational Awareness
Summary

LEADERSHIP
What makes a Leader?
Leadership Skills
Analytical Decision Making
Intuitive Decision Making
The Fundamentals of Crew Resource Management
CRM Skills
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PROFESSIONALISM
Definitions
Law and Ethics
Safety is an Attitude

INTRODUCTION

Crew Resource Management

This Crew Resource Management (CRM) course has been developed by Transport Canada,
System Safety, Western Region.

CRM is a concept involving three main elements:

 Indoctrination and awareness training

 Practice, feedback and recurrent training
 Continuing reinforcement

This CRM course and manual utilize plain language in a non-technical format. Individual
participation is imperative to gain maximum benefit from the course.

The key to the success of a CRM program is the mutual respect and confidence that is
created among crew members which fosters an environment that is conducive to
openness, candor, and constructive critique. The result is a more professional
performance due to the synergy that is achieved in the cockpit, thereby decreasing the
risk of an accident or incident.

Course Objectives

 To gain a greater awareness of the concepts, philosophies and objectives of resource

management training
 To enable participants to utilize more resource management tools
 To enhance participants' abilities to utilize their most valuable resource - THEMSELVES

Crew Resource Management

For better recognition and utilization of all available resources, information, equipment
and people to achieve safe and efficient flight operations.

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Aircraft equipment, operating procedures, navigation methods, and airworthiness safety
standards have steadily improved over the last few decades. This may lead you to determine that
as a result, the accident rate has improved. It has not.

Accident investigations show that approximately 70% of air carrier incidents and accidents have
been caused by the failure of flight crews to make use of readily available "resources."

The concept called "Crew Resource Management" is intended to address the problem of pilots
making flawed decisions or acting inappropriately because they may not have had all the
information available to them at the time to complete a proper situational assessment. In many
accident investigations it was found that the information was available to the pilot-in-command
but tragically, it was not utilized.

The industry must address this high percentage of human factors performance errors and correct
the dichotomy that may still exist in many cockpits today.

This course is intended to be a "self-awareness" program. The objective of this course is to

explain the history and basic concepts of CRM, and how these concepts can improve your
effective communication and leadership skills and decrease the risk of an accident or incident.

History of CRM

From the beginning of our flying careers, pilot training programs have focused almost
exclusively on the technical aspects of flying and on an individual pilot's performance and
problem solving capabilities. But accident statistics show that many problems encountered by
flight crews have very little to do with the technical aspects of flying. It would appear that to
improve the safety of flight, the priorities must shift from operating independently in a multi-
crew environment to problem solving using all available resources.

CRM concepts are not designed to challenge the authority of the captain or the high degree of
technical proficiency essential for safe and efficient flight operations. But a high degree of
technical proficiency alone cannot guarantee safe operations. Studies have shown that marrying
technical proficiency with effective crew co-ordination will provide the best opportunity for a
successful flight.

Defining CRM

CRM refers to the effective use of all available resources. These resources are divided into four
broad categories - people, machinery, fuel/time and information. CRM is designed to optimize
the human/machine interface and accompanying interpersonal activities. These activities include
team building and maintenance, information transfer, problem solving, decision making,
maintaining situational awareness and dealing with automated systems.

CRM training is not limited to multi-crew pilots. Bear in mind that CRM is a concept, affecting
the way you think and the way you act.
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It is intended to heighten attitudes and behaviour, not to change personalities. Pilots flying
single-pilot, flight dispatchers, flight attendants or cabin medical attendants, maintenance
personnel and air traffic controllers can all benefit from CRM training.

CRM Synergy

The acceptance of CRM concepts has been shown to provide synergy, which is the combined
effect of teamwork in the cockpit which exceeds the sum of individual actions. The results of
cockpit synergy would be the mathematical equivalent of 1+1=3.

Pilots must have training, practice and feedback, and continuing CRM reinforcement for the
concept to be effective. It is unrealistic to expect a short training exercise to reverse years of
performance programming.

Management support of individuals who attempt to act in accordance with learned CRM
principles will help its success. CRM practices should also be incorporated into flight operations
manuals and standard operating procedures to provide crews with necessary policy and
procedures guidance.

CRM Skills

ICAO has identified six major areas that should be included in CRM training:

Communication/interpersonal skills

Specific skills associated with good communication practices include such items as polite
assertiveness and participation, active listening and feedback. Polite assertiveness is a skill
frequently ignored in communications training but vital to a healthy cockpit. In order to improve
the communication channel, cultural influences must be taken into account as well as factors
such as rank, age, and crew position, all of which can create communication barriers in the
cockpit.

For example, a pilot-in-command may ordinarily be open to communication, but at times could
be temporarily unable to receive information or comprehend situations. This partial or total
incapacitation should be identified and addressed by the other crew member.

Other crew members must be aware of the importance of the information they hold and have a
strong feeling of self-value. A crew member's failing to communicate important data constitutes
a failure to discharge individual responsibility. The pilot-in-command must constantly emphasize
this responsibility to other crew members.

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Situational Awareness

Situational awareness refers to one's ability to accurately perceive what is going on in the cockpit
and outside the aircraft. It further extends to the planning of several solutions for any emergency
situation which could occur in the immediate future.

Maintaining a state of awareness of one's situation is a complex process, greatly motivated by

the understanding that one's perception of reality sometimes differs from reality itself. This
awareness should promote on-going questioning, cross-checking, and refinement of one's
perception. Constant and conscious monitoring of the situation is required.

Problem-solving / Decision-making / Judgement

These three topics are broad in spectrum, and can interrelate with each other or other skills areas.
One may consider problem-solving as a cycle of events beginning with information input and
ending with making a final decision. During the phase in which information is requested and
offered, some conflicting points of view or differences of opinion may be represented. The
concept of "legitimate avenue of dissent" is an important vehicle for clearing the air, maintaining
lines of communication and maintaining self-image. Skills in resolving conflicts are therefore
especially appropriate at this time.

All decisions must come from the pilot-in-command and supported by all crew members. The
team will fail if command authority is not acknowledged at all times. The inflight, immediate
post-decision review is also a vital concept for promoting good decision-making.

Leadership/"followership"

In this area, there is clear recognition that the command role carries a special responsibility.

The pilot-in-command is responsible for accessing and managing all resources that are available
and pertinent for the safe completion of a flight. This process will ensure that informed decisions
are made and if required, specific duties delegated.

Similarly, every non-command crew member is responsible for actively contributing to the team
effort, for monitoring changes in the situation, and for being assertive when necessary. This is
especially important when flying with a pilot-in-command who does not subscribe to the CRM
concept.

Stress Management

Any kind of emergency situation generates stress, but there is also the residual stress (both
physical and mental) that a crew member might bring to a situation which may be difficult for
others to detect. A crew member's over-all fitness to fly may be affected because of fatigue,
mental or emotional problems, to the extent that other crew members should be on the alert for
any performance decline or subtle incapacitation.
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Skills related to stress management refer not only to one's ability to perceive and accommodate
the stress in others but primarily to anticipate, recognize and cope with one's own stress as well.

This would include psychological stresses such as those related to crew scheduling, anxiety over
check-rides, career and achievement stresses, inter-personal problems with either the cabin crew
or other flight crew member, as well as the home and work interface, including related domestic
problems. It would also include so-called life event stresses, such as those related to the death of
a spouse, divorce or marriage, all of which represent major life changes.

Several operators are attempting to alleviate stress problems by encouraging open and frank
communications between operational management and flight crew members, and by viewing
stress as part of the "fitness to fly" concept. Management must be open to understanding stress
problems and to encourage managers and other non-crew personnel to attend CRM training.

Critique

Skills of critique generally refer to the ability to analyze a future, current, or past plan of action.
Techniques for accomplishing critique vary according to the availability of time, resources, and
information. Three basis types of critique are distinguished:

 pre-mission analysis and planning

 on-going review as part of the in-flight problem solving process
 post-mission debriefing

All three are important but can sometimes be overlooked in either flight operations or during
instruction. The art of critique is not to dwell on the negative, but to accentuate the positive and
to encourage participation from the team.

Challenges of CRM

Pilots are conditioned to believe that they are automated, performance-oriented beings, capable
of amazing feats. The fact that pilots are now encouraged to acknowledge that they have
feelings, or to admit that they might be in a bad mood, seems to conflict with the very fibre of the
pilot's existence. To admit any "weakness" may appear to show a loss of confidence contrary to
the image of what a pilot is expected to portray. But the fact of the matter is, pilots are human.
Humans are not perfect 100% of the time, as we have seen in many accident cases.

As a pilot, the ability to tap another crew member as an available resource will help to
compensate for the subjective human factors performance errors involved in decision making
and risk management. Managing the crew resources will help to ensure that all decisions and
actions are in accordance with safe flight practices, and reduce the risk of an incident or accident.

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What CRM IS and IS NOT

CRM IS

 A comprehensive system for improving crew performance

 A process addressing the entire crew and other related staff
 A system that can be extended to all forms of air crew training
 A concentration on crew member attitudes and behaviors and their impact on safety
 An opportunity for individuals to examine their behavior and make individual decisions on how
to improve cockpit teamwork
 A utilization of the crew as the unit of training
 Active participation training that focuses on safety improvement
 Is self-convincing

CRM IS NOT

 A quick fix that can be implemented overnight

 A training program administered to only a few specialized or "fix-it" cases
 A system that occurs independent of other ongoing training activities
 A psychological assessment or personality profile
 A system where crews are given a specific prescription of how to work with others on the flight
deck
 Another form of individually-centred crew training
 A passive lecture-style classroom course
 An attempt by management to dictate cockpit behavior

Five Elements of CRM

Inquiry

Inquiry is every crew member's right and responsibility. Inquiry is a mode of behaviour that
causes an individual to question, scrutinize, and investigate all that is happening. It is curiosity,
skepticism, interest; it maximizes learning and awareness at all times and ensures larger gains in
knowledge from each experience. Inquiry is the opposite of complacency.

Crew members who practice inquiry, question or investigate what others are doing, believing or
proposing. In addition, they recognize that their own knowledge, beliefs, and actions could be
wrong and are continuously challenging them.

The undetected problem presents a unique difficulty for flight crews. Active inquiry is an
approach that stimulates early detection and definition of problems by helping crew members
sense a discrepancy between what is and what should be occurring.

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Inquiry is also useful in sorting out what is going on from what appears to be going on. Nothing
is taken for granted. Human errors are reduced by exposing and correcting them at an early stage.

Advocacy

The essence of advocacy involves a crew member accepting the obligation to speak out in
support of a course of action different from that is currently being planned or followed. At the
same time, it is listening to viewpoints that may be contradictory to one's own.

An inviting question such as "Does anyone have a problem with...?" Encourages others to bring
up alternatives that might be considered before a decision or course of action is finalized.
Similarly, the phrase "I have a problem with that..." Signals to other crew members that a
reservation exists that merits examination. This kind of concern is constructive questioning that
represents a respect and a desire to support authority, rather than a resentment of authority.

Verbal communication in a forthright and relevant manner increases the likelihood that
information will be understood and accepted; then problems can be anticipated and dealt with
soundly. Advocacy is the obligation to support a position firmly, but to also respond to a sound
alternative when one is put forth. For example, a crew member whose own proposed action has
proven to be unsound, accepts the sound action without reservation. This acceptance does not
detract from the responsibility to remain vigilant and continue to question others thereafter.

Conflict Resolution

Conflict is inevitable. In fact, it is often beneficial if handled properly and in a constructive

manner. Differences in feelings, opinions, thoughts, values, or action (actual or perceived) may
lead to disagreement or dispute. Sometimes differences in personality alone can create a source
of conflict.

A conflict will turn bad when a crew member is unable to cope with giving or receiving inquiry,
advocacy or critique constructively. This conflict can polarize crew members to the point that the
real problem or issue is not probed. Heated arguments can lead to bitter words or bad feelings
and will ultimately effect performance unless the disagreement is brought into the open and
resolved.

Alternatively, conflict can be transformed into a lively comparison of viewpoints that lead to
deeper thinking, better problem definition, and sound solutions. Under these conditions, conflict
resolution can provide a basis for mutual understanding and respect which strengthens, rather
than erodes, team effectiveness.

Conflict resolution which holds the underlying question of who is right is destructive, conflict
resolution which is focused on the question of what is right is constructive.

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Decision Making

Many types of decisions are made during the course of the flight. Some decisions of high quality
can be made singularly by one member of the crew; other decisions are of such complexity or
importance that the inputs from more than one crew member, or from an outside source, are
necessary to ensure higher quality decisions.

When all information is resourced and analyzed, the likelihood is increased that crew members
become aware of potential problems they otherwise would not have appreciated, thus can take
steps to deal with them in a sound way. In no way does the consideration of all appropriate
resources in the decision making process diminish the ultimate authority of the Captain. When
decisions are made in this optimum manner based on a maximum of information, there exists a
high potential for success, respect among crew members and commitment to full support in
implementing the decision.

Critique

Critique - used in the context of CRM - refers to discussions among crew members regarding the
conduct of the flight. It begins in the planning phase, continues throughout the flight, and
concludes in a post-flight debriefing. Properly utilized, critique can be initiated by any crew
member at any time when he/she believes it will be helpful to the safety and efficiency of the
operation. It is totally separate from the evaluation involved with line checks and proficiency
checks.

Critique is essential in producing useful future insights. When frank discussions are held among
crew members, misunderstandings and errors in perception can be clarified and resolved, and
conflict can be dealt with before serious problems arise.

Problems in the Cockpit

 Lack of support - where one crew member fails to back up another during a high workload
situation
 Standard Operating Procedures ignored -where the Captain or crew fail to complete a checklist
when under time or other pressures
 Stress problems - where a crew experiences difficult in adapting to unusual or emergency
situations
 Judgment problems - where management of priorities and cockpit distractions distort the
judgment process
 Emotional problems - where aggression or extreme submissiveness in the cockpit affect
personal relations; or where there is a carryover of domestic worries or job conflict
 Get-Home-Itis - where failure to divert or in making a go-around decision occurs
 Management pressure - where there is a deferral to management the authority to expedite
departure before the crew is sufficiently prepared
 Discipline problems - where corners are cut or where there is inadequate control of operations
in the cockpit

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  Communication problems - where there are misunderstandings or non-adherence to sterile
cockpit rule

Management Skills Required

To combat some of the human factors related problems identified in the cockpit, management
skills must be strengthened and reinforced to reduce or eliminate seemingly needless aviation
accidents:

 Use of checklists, SOPs

 Flight planning and progress monitoring
 Management of resources
 Judgment and decision making
 Communication
 Managing people
 Stress Management
 Workload assessment and time management
 Recognition and management of distractions

STANDARD OPERATING PROCEDURES

AND LINE ORIENTED FLIGHT
TRAINING

Standard Operating Procedures

Standard Operating Procedures (sops) are designed to enhance safety, to assist the flight crews to
manage risk and to ensure consistency in the cockpit. Consider them guidelines as to who-does-
what-and-when. At all times, these procedures should encourage effective communication and
teamwork in the cockpit. Sops can be either general in nature or aircraft specific. Although
aviation companies have a certain amount of latitude when creating their sops, under no
circumstances should they contravene aviation regulations or the procedures outlined in the
aircraft flight manuals.

Included in the sops should be a section on normal procedures, and it is to be considered an

enhancement of the aircraft flight manual. These normal procedures include all aspects of day-to-

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day flight, including the start-up and normal procedures checklist, the take-off briefing, go-
around procedures, IFR approaches, etc.

A section of the sops should be dedicated to emergency procedures, with the expanded version of
the emergency procedures checklists. Again, this should compliment the aircraft flight manual's
emergency section and streamline procedures removing any ambiguity.

Another section can include aircraft landing and take off distances charts, a JBI chart, or any
other references that the flight crews may require.

Sops should be reviewed periodically and amended to maintain their relevance in changing times
or aircraft fleet. Care should be taken not to include non-applicable items, as personnel may then
tend to view the whole package as being irrelevant. Sops should be written in simple terminology
leaving no room for subjective interpretation.

There are definite safety benefits from the use of Standard Operating Procedures but they must
first be adopted by the flight crews. Company check pilots should monitor for crew adherence to
the sops. Finally, there is no substitute for good judgment, and decisions made in the cockpit
should be supported by management.

Standard Phraseology

Standardization of crew communications is desired to increase the efficiency of crew

coordination during times of high crew workload such as take off, emergency conditions,
instrument approaches, landings and in detecting partial incapacitation. The normal call-outs are
one example of standard phraseology used to convey vital information with a minimum number
of words that have an exact meaning to all crew members. Some other recommended words and
phrases could be:

Thrust Settings Flap Settings

"Set Take off thrust" "Flaps up"

"Set go-around thrust" "Flaps five"

"Set maximum continuous thrust" "Flaps fifteen"

"Set climb thrust" "Flaps thirty"

"Set cruise thrust"

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Standard Call-outs

Objective

Ensure that all crew members are aware of airplane altitude, position and instrument indications.

Casual and nonessential conversation can be distracting and may interfere with normal
communications, thereby reducing crew efficiency and alertness to the task at hand, i.e. The
approach and landing.

Call-outs

The pilot not flying (PNF) will accomplish the appropriate call-out based on instrument
indications or observations for the condition indicated on the chart on the following page. The
pilot flying (PF) will verify the condition/location from their instruments and acknowledge. If the
pilot not flying does not make the required call-out, the pilot flying should make it.

Crew Concept

One of the basic fundamentals of the "Crew Concept" is that each crew member must be able to
supplement or act as a back-up for another crew member. Proper adherence to standard call-outs
will stimulate more meaningful and standardized crew communications and provide for early
detection of crew member incapacitation during critical phases of flight.

Standard Call-outs Examples

CONDITION/LOCATION CALL-OUT (PNF)

Approaching;
CLIMB AND DESCENT "Transition___,Altimeters reset"
Transition alt./flt lvl

1,000 ft. Abv/blo assigned "1,000 to level off" altitude/flt lvl

DESCENT 10,000 ft (reduce airspeed) "10,000"

1,000 ft abv initial app. Alt. "1,000 above initial"

First positive motion of

APPROACH "Localizer alive"
Localizer

First positive motion of Glide

"Glide Slope alive"
Slope

Final fix inbound (altimeter, "Outer Marker . . . Etc.,

instrument and flag Time,___,feet altimeters &
crosscheck) instruments crosschecked"

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 500 ft abv field elevation "500 ft, alt & inst. Crosschecked"

500 ft & blo on Final Approach "Airspeed" & profile deviations

100 ft abv DH "100 to minimums"

100 ft abv MDA "100 to MDA"

"Minimums" & Visual Reference

Reaching DH or MDA/MAP
or "No Contact"

Checking the Checklist

Checklists were created so that an aircraft can be operated by a pilot safely. It is ironic that
checklists are designed to cover omissions and oversights of pilots, but the built in redundancy
and repetition found in checklists can also make pilots complacent. This complacency is a
breeding ground for errors and negligence.

This catch-22 situation should be addressed to make checklists more efficient so that they can be
utilized as designed. These suggestions may help to revamp your checklists and make them more
"user-friendly."

Consult with the flight crews that fly on a regular basis to determine what changes should be
made to improve efficiency. Unnecessary items should be removed to avoid skipping over
checklist items and increasing the risk of omitting a critical check. For example, the "coffee pot"
check on a converted cargo aircraft can be substituted with "all switches" for brevity. The
chances are better that you will not miss the "boost pumps on" check if the items you are used to
seeing on the checklist are all pertinent. If an item on the checklist is useful on occasion, it
should be noted as "deferred" during the checklist execution, rather than purposely skipped.

The built-in redundancy in a checklist is for a specific purpose. The so-called "killer items" on
the checklist should be repeated twice, in different areas of the checklist in case they be
inadvertently missed. For example, if the aircraft flap setting is important to take off
performance, the flap check should be included in both the taxi checklist and again in the before
take-off checklist.

Items that are key to the safety of your flight, should be in the "challenge and response" format.
The pilot-not-flying must monitor the pilot flying, and confirmation of the checks through the
challenge and response method is an effective way to verify compliance. It is also important that
both flight crew members have an awareness as to the state of the aircraft, i.e. What switches are
on or off.

Non-critical items, such as the environmental setting or noting the take-off time, might be better
off completed by the pilot-not-flying. Once a checklist is complete, the pilot-not-flying must
advise the pilot-flying and announce ". . . Checklist complete."
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The checklists should be clear, easy to read plastic laminated sheets and easily accessible in the
cockpit. The emergency checklist should be uniquely marked so it can be quickly located. It is
also suggested that crews review an "emergency du jour" from this checklist.

Checklists were created to eliminate errors of omission in the cockpit. Involving the flight crew
and revising a tired checklist will result in a safer and more efficient cockpit.

Crew Briefings

A crew briefing is not limited to reviewing an instrument approach procedure, or detailing

aspects of the flight to the flight attendants. In fact, the cockpit crew briefing is an important tool
for improving safety during any critical phase of flight. In a somewhat modified form, it's of use
to the single-pilot flight operation as well.

In the simplest terms, your crew briefing is the verbalization of your plan for executing a critical
phase of your flight. Given a normal transport flight ops profile, most would agree takeoffs and
departures, as well as descents and arrivals, constitute critical flight segments. For the novice
briefer, verbalizing the elements of these two major events is an excellent beginning.

As you would expect, you will not easily brief something you have not planned. Also one must
avoid becoming too ritualistic or institutionalized with their crew briefing. Conducting
appropriate and meaningful briefing enhances individual as well as crew performance. It is a
learned art born of practice in identifying the key elements of every departure and arrival
conveyed with clarity and brevity.

A Brief Beginning

The takeoff and departure briefing is not as common as the arrival brief, yet it's no less critical.
In fact, given the pilot flying/pilot not flying discipline so widely accepted today, the departure
crew briefing goes far to establish or clarify what's expected of crew members in their respective
roles. This is the opportune time for the captain to establish or promote the atmosphere of
enlightened leadership within the confines of the workplace. Even if the captain is the pilot not
flying on a particular leg, the responsibilities of command dictate that he or she include
amendments or modifications to the pilot flying's crew briefing should it be warranted.

A typical takeoff and departure crew briefing should include:

 Weather and related precautions

 Any special modification to the standard takeoff and initial climb profile
 Initial routing via designated SID and/or vector fix
 Initial clearance altitude including the transition altitude
 Com and nav radio configuration to include the assigned transponder code
 Contingencies for critical emergency situations

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Weather conditions for your takeoff and departure should be part of every briefing. Special
procedural precautions such as the use of engine or wing anti-ice, modified takeoff
computations, or restrictions on the applicability of using a reduced power takeoff are examples
of weather-related modifications best reviewed before getting involved in the actual activity.

Include in your briefing any special noise abatement takeoff and climb profile to be flown, a high
terrain/obstacle clearance maneuver to execute, or a possible windshear complication.

When briefing the departure climb, either by reference to a published SID or radar vector
clearance, be sure to emphasize your initial clearance altitude. The nav radio setup should be
noted, crossing restrictions discussed, and any special switchology or pilot not flying duties
clarified.

Many different emergencies are possible during any takeoff and climb out. Reviewing the basics
of "who will do what" in the event of a reject or engine failure are commonly briefed.
Attempting to address further emergencies could run your brief too long to be effective.

Once cleared onto the runway for take-off, the pilot flying should re-brief (1) the initial heading
and/or route to be flown, (2) the initial clearance altitude, and (3) confirm the takeoff flap
settings and respective takeoff flap settings and takeoff speeds. Conducting this last chance mini-
brief will focus the crew on the details at hand.

Pilot workload increases relative to your distance from touchdown. For this reason, the best time
to conduct the approach briefing is before or soon after, commencing your initial descent. This
scheduling may not work in some situations but the intent is to avoid trying to brief and fly at the
same time. Neither is done well. As your briefings become more polished, you will be better able
to accommodate last-minute alterations like a runway change However, if what you have briefed
is rendered totally inappropriate, make the time to do an approach and landing briefing that's
relative to your actual situation.

Mindful of the intent to promote crew coordination and enhance communication with your
fellow pilots, the content of the approach and landing briefing should contain no more than 8 to
10 key elements beyond a common understanding of the current weather conditions;

 Name and effective date of the instrument approach procedure

 Minimum sector altitudes(s)
 Airport elevation
 Initial approach maneuver and respective minimum altitude(s)
 Final approach course and defining navaid
 Final approach fix minimum altitude
 Applicable approach minimums (DH or MDA)
 MAP for the non-precision approach
 Published missed approach procedure
 Approach lighting and runway information

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It is imperative to clarify the name and currency of the instrument approach procedure (IAP) to
be used. It is a good idea to state the airport elevation as an overall awareness factor.

If you anticipate radar vectors to intercept the final approach course, it is important to brief the
published minimum final approach fix (FAF) altitude. In the absence of radar vectors to final,
your briefing must be expanded to include depicted transitions, procedure turns, arcs or other
published routings and the associated minimum altitudes.

Focus attention on the frequency of the defining navaid as well as the published final approach
course. You may want to brief the pilot not flying on a special sequence for tuning and
identifying navaids specific to your radios.

All crew members must know the decision height(DH) or minimum descent altitude (MDA) and
the advisory minimum visibility. For non-precision iaps, step-down fixes and the corresponding
minimum descent altitudes and missed approach point (MAP) should be called out by the pilot
not flying. Brief the timing or DME fix for every IAP as a means of identifying the MAP.
Granted, the MAP for the ILS is the DH, but should you lose the glideslope signal inside the
FAF, you have the option to descend to the LOC minimums and a better reference for the
location of the MAP.

In the absence of ATC intervention, your clearance for the published IAP includes a clearance
for the published missed approach procedure. It is good practice to emphasize the initial route
and altitude in your briefing. Should nav radio changes be required, these are best included as
pilot not flying duties. And if the missed approach procedure culminates in a holding pattern, the
type of entry is worth mentioning.

Do not be too brief

Do not complete your briefing with just the approach. The airport chart contains an abundance of
valuable information. If you are faced with conducting an approach and making a landing in
IMC, or at night, or in particularly low-visibility situations, briefing the type of approach light
system available is critical. Whoever is not monitoring the instruments will be looking for the
lights, so it is appropriate to know what to look for. The lighting codes are deciphered in the
Canada Flight Supplement and the Canada Air Pilot. Also useable runway length and width are
worthy parts of every briefing you make.

A Brief Example

Departure Brief

"Let's plan on runway three five for takeoff. We're cleared via the Mccoy two and the Colliers
Transition. We'll use our standard takeoff and departure climb profile. With these rain showers
and wet runway, I prefer to use full power for takeoff. We'll maintain the assigned heading and
climb to cross the Orlando one one five at or above 2600 and the zero niner zero at or above
3000. Our initial altitude is 5000 and that's set in the altitude alerter. I've got Orlando tuned and

16
three three eight in my window. You're tuned to Orlando and please monitor those radials. We
should have no problem meeting the crossing restrictions. Let's stay with the number one comm
for ATC and our squawk is set on 3531.

"As far as emergencies go, if something happens prior to V1, i'll stop the aircraft, you call the
tower and i'll get on the PA after we've stopped. Beyond V1, we go. I'll continue to fly. Let's not
do anything in a hurry. I'll call for the checklists and let's stick with our procedures. If possible,
i'll use the autopilot and get in the loop ASAP. Any time you have a question about anything
we're doing or not doing, please ask. Any questions? Comments?

Arrival Brief

"Let's plan on the Pueblo two six right ILS and the glideslope is out of service. The effective date
on my chart is March 5th. The MSA's are 7700 to the northwest and 7100 to the southeast of
Aruba with an airport elevation of forty seven twenty six. Since we're cleared via Huner and the
10 DME arc, let's keep both nav radios on Pueblo and tune the ADF to Aruba. Once we're on the
arc, i'll descend to 7000. As we near the Pueblo zero eight niner radial tune and identify my nav
radio on one zero eight point three and i'll set two fifty seven in my window. Call me passing the
zero eight niner on your CDI and once i've turned to intercept the localizer, come on over on
your nav radio and we'll switch the RMI's to ADF. Established on the localizer, i'll descend to
the final approach fix altitude of 6600. Our minimums are five thousand sixty feet and one and a
quarter mile. Let's time the approach for two minutes and forty five seconds and call me two
minutes and five seconds after we pass Aruba.

"The missed approach is a climb to 7000 direct to Mertz. If we go around, tune Mertz on the
ADF. Let's keep approach flaps and i'll use a hundred and sixty knots max. We'll plan on a
teardrop entry to that holding pattern.

"Runway two six right has hirls, reils and VASI on the left side. That's not much in the way of
lighting. We'll likely see the reils first. That runway is over ten thousand feet long and 150 feet
wide. Any questions? Suggestions?

Line Oriented Flight Training

In analyzing airline accidents over the last 20 years, it was evident that approximately 70%
occurred as a direct result of inadequacies related to crew coordination, workload management
and decision making. It was also revealed that the causes of these accidents were unrelated to the
way pilots were being trained. They occurred not as the result of a lack of individual technical
proficiency in the cockpit, but because of a human failure.

The concept of crew resource management (CRM) was developed to address the deficiencies of
human behaviour in the cockpit. In conjunction, line oriented flight training (LOFT) began, and
allowed flight crews to combine their technical proficiency and CRM theory into practical skills
in simulator scenarios. As a result, flight crews become better problem-solvers and resource
managers in an effort to reduce the risk of an incident or accident.
17
The Benefits of LOFT

The objective of LOFT is to assess how a flight crew manages the operation of an "aircraft"
during a situation which is outside the parameters of what would be considered normal
operations. It is not an emergency situation per se, where the flight crew reverts to the
predetermined response of an emergency procedure. Instead it is a series of events impacting on
the conduct of the flight that must be addressed by the crew and for which there is no one correct
solution. Flight crews are required to demonstrate how they manage the operational environment
and process information available within the irregularity.

The goal for the flight crew is to make a series of low-risk, safe operational decisions resulting in
the successful termination of the exercise - normally a safe landing.

Spin-off benefits of LOFT include the validation of company training. Any weak areas in flight
crew training or those that require further emphasis are exposed. Standard Operating Procedures
(sops) can be assessed for their effectiveness and adaptation into the cockpit. If a variety of flight
crews make similar mistakes, it could be an indication of incorrect or conflicting manuals or
procedures. LOFT allows for improved flight crew aircraft transition or pilot upgrade training.

Problem Solving in the LOFT Environment

Humans have three different ways to solve a problem:

Skills-based actions are those actions that can be accomplished with little effort once the basic
skill is mastered (such as driving a car)

Rules-based actions are those that have well prescribed procedures (such as if X happens,
accomplish Y) similar to the flight crew's reaction to an emergency situation.

Knowledged-based actions are the ones addressed in LOFT sessions. They are usually the result
of an ambiguous situation, or one that does not have clearly prescribed procedures, and offer a
variety of options to the flight crew.

Because of uncertainty, knowledge-based actions can require considerable time and thought in
order to deal with the task.

This is where the evaluation of the flight crew's ability to assess all available information takes
place.

Malfunctions in the LOFT Environment

A recent study of NASA's Aviation Safety Reporting System (ASRS) incident reports evaluates
how flight crews manage malfunctions in the cockpit. Two types of malfunctions were
identified:

18
  Type A malfunctions were judged to be critical emergencies which triggered "by the book" (skills
or rules-based actions) responses by flight crews. Flight crew training and check rides
concentrate on the flight crew's ability to handle major aircraft malfunctions.

 Type B malfunctions are relatively minor, or abnormal. The malfunction resolution procedure is
less defined, requiring the flight crews to revert to knowledge-based actions and CRM principles
to properly assess and resolve the situation. This may require time-consuming thought,
discussion, and trial and error procedures.

The danger of a Type B malfunction response is that too much of the crew's time and attention
can be diverted from the normal duties involved in safe piloting and a loss of situational
awareness can occur (as in the infamous Everglades and Portland accidents.)

This is where the evaluation of a flight crew's ability to manage the operational environment
takes place.

A paradox is introduced - the less serious malfunctions appear more likely to induce flight crew
behaviour leading to a loss of situational awareness than do the serious malfunctions. Fixation,
distraction, no one flying the aircraft and work overload were found in a number of the ASRS
reports, and are of particular concern because they have been identified in many fatal aircraft
accidents. Flight crew training to prevent the loss of situational awareness must be addressed to
reduce the 70% of aviation accidents that occur as a result of a human failure.

Training to Prevent the Loss of Situational Awareness

Resolving Type A malfunctions often occurs quickly, leaving less time for distraction from sops
and a loss of situational awareness. When faced with a serious malfunction, the flight crew is
likely to be in a state of all around heightened awareness, referring to an emergency procedure
checklist or memory items. The loss of situational awareness is less likely to enter the error
chain.

Resolution of Type B malfunctions pose a risk to flight crews who become absorbed with
resolving the malfunction, often at the expense of proper aircraft control. Pilots should always fly
the aircraft, assess the situation, take appropriate action, and evaluate the results. Flight crew
training should emphasize that an aircraft malfunction can serve as an immediate red flag in
warning against the loss of situational awareness.

In analyzing the way that flight crews handle Type A and B malfunctions, significant differences
have been revealed in altitude and course/heading deviations denoting a possible loss of
situational awareness. Of the Type A malfunctions, flight deviations were observed in 23% of
the incidents. Of the Type B malfunctions, a loss of situational awareness occurred in varying
degrees in 100% of the incidents.

Further study of the ASRS reports provided evidence of crews using improper actions, such as
not completing a checklist because of haste, using the wrong checklist or activating the wrong

19
system control switches. Training should stress crew coordination and emphasize all crew
members verify intended actions before initiation.

LOFT Event Sets

A LOFT scenario comprises a staged event set, a group of related events that are part of the
scenario and are inserted into the LOFT session for specific CRM and technical training
objectives.

The event set is made up of one or more events, including:

 The event trigger is the condition under which the event is fully activated (example, landing gear
malfunction)
 The distracters are conditions inserted within the even set time frame that are designed to
divert the crew's attention from other events that are occurring or are about the occur
(example, course change)
 Supporting events are other events taking place within the event set designed to further CRM
and technical training objectives (example, ILS off at destination)

Simple events have no further consequences on the conduct of the flight once they have been
diagnosed and corrected. Overuse of simple problems or events detracts from LOFT realism.
Routine pre-start problems, followed by a start problem, followed by a taxi problem, intrude on
the crew's perception that the LOFT is an actual flight.

Complex events have ongoing consequences that must be dealt with in flight and cannot be
solved by simply selecting and executing an emergency or abnormal checklist. This requires the
coordinated actions of all crew members for successful completion, but not to the extent that they
induce complete crew failure. Complex event set problems tend to be relatively ambiguous, with
no simple corrective solution.

The properly designed event set uses both simple and complex events offering a number of
possible and reasonable solutions to promote the management of a complex situation. The
objective is for the flight crew to make low-risk, safe operational decisions and live with them
until landing.

One misconception that should be avoided is the belief that LOFT should continuously increase
crew workload until the crew becomes overloaded. This is not the purpose or intent of LOFT and
can actually help to defeat its effectiveness. LOFT scenarios are most beneficial if they are
realistic and straightforward, combining technical skills with CRM theory, in a marriage of
simple and complex events.

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Elements of LOFT

 LOFT is pure training; a learning experience designed to emphasize crew command,

coordination, communication and the full management of available resources

 LOFT is not the venue for assessing the performance of individuals, but the session should not
be artificially stress-free. Flight crew members should maintain reasonable performance
parameters applicable to their phase of training. If the LOFT facilitator identifies flight crew
member performance deficiencies, additional training or instruction would be provided with no
stigma or recrimination

 Scenarios consist of typical daily operations with reasonable and realistic difficulties and
emergencies. LOFT scenarios must last long enough for crew traits to become evident and
should require CRM skills to be displayed in response to specific circumstances

 LOFT sessions should not be interrupted, the simulator should not be repositioned or problems
repeated. The facilitator should not interfere regardless of developments; mistakes may be
made but flight crews should continue since there is no book solution to a LOFT exercise

 Choose scenarios that can have a wide variety of choices and outcomes. The flight crew must
live with their decisions and course of action until the situation is either resolved or the aircraft
is back on the ground. Scenarios must be kept current with respect to navigation,
communications, regulations, company procedures, manuals and aircraft modifications

 Pacing and tempo of a scenario must be appropriate to certain factors - location, departure
time, phase of flight, communications. Designers should avoid totally filling a flight period,
leaving time for lulls and inactivity

 Scripts should be designed in as much detail as possible in order to simulate the real world. A
lack of detail requires the LOFT facilitator to improvise, which takes considerable time away
from the observation and evaluation of the flight crew

 The flight crew is able to quickly appreciate the results of their operational decisions, whether
they be positive or negative. An accident should never be inevitable, although it is an outcome
that may occur

 The flight crews will benefit from a facilitator's immediate debriefing session afterwards using
video or notes; the flight crew normally is more critical in their own performance assessment
 Procedures and practices in the flight operations manuals that are frequently misunderstood
should be considered for inclusion in a LOFT scenario. Use incident reports from a variety of
databases, maintenance difficulty areas identified in line flying, and poor performance areas in
simulator proficiency checks and training

 Event set problems could include:

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Operational problems

 Pre-flight, dispatch release

 Hazardous cargo
 Fuelling operations
 NOTAMS
 MEL items
 Weight and balance
 Flight crew problems, incapacitation
 Cabin crew or passenger problems
 Duty day
 Alternate airports
 Low fuel during excessive vectoring
 Re-routing/amended clearances
 Air traffic control delayed approaches
 Similar call signs

Environmental problems

 Weather
 Wind
 Temperature
 Contaminated or closed runways
 Touchdown zone lighting problems

Equipment problems

 Airborne
 Autoflight incidents
 Ground support
 Nav aids

COMMUNICATION

Communication

True and effective communication occurs when there is a sincere and conscious effort by all
parties.

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Definitions

 Effective communication is being able to communicate your thoughts and feelings in such a way
that the other person shares the same meaning you do

 The imparting or interchange of thoughts, opinions, or information by speech, writing or signs

 The process of exchanging ideas and information by the use of a common system of verbal and
non-verbal signals

A good example of poor communication is from list of instructions from an aircraft electronics
manual as quoted by the Journal of the Institute of Scientific and Technical Communicators:

"The internal guidance system uses deviations to generate corrective commands to fly the
aircraft from a position where it is to a position where it isn't."

"In the event that the position where it is now is not the same as the position where it originally
wasn't, the system will acquire a variation. Variations are beyond the scope of this simple
explanation."

Key Facts About the Way We Communicate

 We tend to protect, maintain and enhance ourselves when we communicate

 We defend against looking ignorant or foolish for fear of ridicule
 We wish to maintain consistency, we tend to support our opinion even when we suspect that
we may not be totally correct
 We wish to feel valued, worthwhile, belonging and meaningful. This means that we must be
acknowledged with respect and trust
 Reality is second to perception - and our mindset may be very difficult to change
 People behave according to their perceptions; may not be aware of the level of risk
 Emotions always take first place, feelings are facts
 Commitment comes from self-determination, people have their own motivations

Modes of Communication

Verbal - verbal communication occurs when words are used to communicate, either orally or in
writing

Non-Verbal - non-verbal communication occurs when body language, eye contact, posture,
gestures, touch, silence - anything other than words - is used to communicate

Symbolic - symbolic communication occurs as a result of our appearance - clothes, hair, jewelry,
make of car, etc.

7% of all communication is accomplished Verbally.

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38% of communication is the result of unconscious signals and readings, such as tone or sound
of voice

55% of all communication is achieved through Non-Verbal And Symbolic means (body
language.)

Communication Process

There are four elements in the communication process - the sender, the message, the receiver and
the feedback.

Human beings acting as the sender or receiver are influenced by many factors - their
perceptions, attitudes, values, knowledge, expectations, language skills, experience and their
relationship to "the other person." These influences act like filters and can impact on the process
of sending and receiving messages.

Identifying Assumptions

Crew members' clear understanding of cockpit communication is imperative to effective CRM

and the ultimate safe operation of the aircraft. Obstacles in the communication process must be
identified before they can be addressed and removed. Are you guilty of these assumptions?

Assumption #1

Do you assume that the message sent is the same as the message received? Or do you consider
that the message sent is rarely the same as the message received? If you operate under the first
assumption, you would be correct if you were communicating with a machine. However, almost
all communication in organizational settings involves the sending of messages from one human
to another. Consequently, the message sent is rarely the same as the message received. Each of
us has our own unique set of attitudes, motivations, and perceptual frames and we filter incoming
messages to some extent. The message we think we are sending may be substantially different
from the message that is received.

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Assumption #2

Do you assume that you communicate only when you consciously choose to do so? Or do you
assume that communication is often unplanned and unconscious? The truth is, you cannot not
communicate. Simply being in the presence of another person is to communicate with that
person, even if you choose not to do so. Such non-verbal stimuli as physical stature, dress and
gestures may all serve as unintended messages in the communication process. Furthermore, what
others have heard about you and their mental image of you often contradicts the message you
hope to transmit. The total message sent incorporates not only the intended messages, but the
unintended messages as well. Remember, you cannot not communicate.

Assumption #3

Do you assume that meanings are inherent in words? Or do you assume that meanings originate
in people? When structuring messages we often assume that the words constituting the message
have a fixed, predictable meaning. We are surprised when others do not understand what we
believe to be obvious.

If we assume that others may attach their own definitions and connotations to words, then we
are not so surprised when semantic confusion arises. For example, "impending layoff" may mean
"tomorrow I get axed" to one person, and "I wonder who will be cut" to another. Words have a
fixed meaning only when one machine communicates with another.

Assumption #4

Do you assume that the communication process ceases after the message has been received? Or
do you assume that feedback is an essential element of the communication process? Many people
assume that the communication process ends when the message reaches its destination.
Unfortunately, this assumption ignores the fact that feedback is necessary if the sender is at all
concerned about the impact of that message. Has the message been understood? Has action been
taken? How should the message have been structured in order to achieve the desired results?
Each of these questions can be answered only by feedback from the receiver. Sending the
message is only part of the communication process; the other part is being responsive to
feedback from the receiver.

Assumption #5

Do you assume that if a communication breakdown occurs, it is invariably the recipient's fault?
Or do you assume that a communication breakdown may be a function of your own
communication style? There is a saying popular among public speaking teachers, "if the
audience is falling asleep, someone should wake up the speaker." Is the communication problem
with the sender's behaviour rather than with the receiver's behaviour? How can the message best
be adapted to the receiver's attitudes, motivations and perceptual frame?

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Assumption #6

Do you assume that most communication problems in your organization could be prevented with
communication hardware? Or do you assume that most communication problems in your
organization could be prevented with communications software? Hardware includes gadgets,
gimmicks, procedures and techniques designed to facilitate information exchange. For example,
information routing slips, suggestion boxes, and periodic feedback sessions are types of
communication hardware. Software includes the assumptions, attitudes and knowledge you have
about the communication process.

After analyzing the six common assumptions you have concluded that effective communication
does not just happen, you have taken the first step in changing your own communication style. If
you have concluded that effective communication requires concerted effort, you have taken the
next step.

"The wonder is not that we communicate so well the wonder is that we communicate at all."
Samuel Johnson

Essential Verbal Communication Skills in CRM

Communication can affect the safety of the operation. Using five aspects of effective verbal
communication will assist crew members to communicate in a clear and precise manner.

Inquiry: Good decisions are based on the quality of information that is assessed. In the cockpit
environment we scan instruments to gain information. In varying degrees, the same seeking of
information from flight crew, cabin crew, dispatch and ATC should also be brought under
consideration when making complex cockpit decisions. One drawback of asking questions in the
cockpit is the fear of embarrassment. Clarification of an action or intended action is a right
among crew members.

Advocacy: Advocacy is the clear stating of one's position, even if it is contrary to the accepted
position. Should a crew member disagree with an action or an intended action, it is the crew
member's responsibility to advocate their position. Advocacy is also the attitude of an individual
accepting another crew member's perspective and rationalizing the different points of view for
the best operational decision.

Listening: The art of listening appears to be a reoccurring failure in many accident reports.
Active listening is an action, it is not a passive function. It requires the listener to actively inquire
and respond, confirm to the transmitter that the message has been received and understood.

Conflict Resolution: If crew members are effectively advocating their positions, eventually
there will be a conflict of opinion. An effective resolution process will help the flight crew to
operate efficiently. Conflict can be constructive if cockpit issues are dealt with rationally.
Problems may arise when the conflict becomes external to the task at hand. Outside issues should
be deferred until another time while the crew deals with the task at hand.

26
Critique: Proper critique is an important element of the successful operation of flight. It begins
in pre-flight, continues during the operation of the flight and ends in a post flight debriefing.
Critique is an analysis of events, past or future. It is an impersonal survey of how the operation
can be improved. All crew members' input to the critique process will improve total crew
performance and ultimately improve the safety and efficiency of the operation.

Active Listening

The active listener attends to the words and projects their mind into that of the speaker, so that
they can align their thoughts and feelings more closely to those of the speaker. Active listening
consists of the following two skills:

Non-Verbal - Attending (to build and maintain rapport)

 Face the speaker, smile, look relaxed

 Maintain eye contact
 Encourage the other to speak

Verbal - Questions

A. Closed Questions (for short answers)

 Restrict the range of possible responses

 Useful in getting specific information quickly
 Improper use can make a person feel like hey are being interrogated

Example:

How many duty managers are there?

How long are your shifts?

B. Open-Ended Questions (for long answers)

 Allows the person a lot of freedom of response

 Useful for identifying attitudes and beliefs
 Can be quite time consuming

Example:

What is your observation on the pilot's techniques in this area?

Which other areas would you like to draw our attention to?

C. Probe Questions (for more information)

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  Ask the person to clarify or elaborate
 Can be verbal or non-verbal

Example:

Tell me more about that?

I see...how did it work out?

D. Paraphrasing (to show understanding and encouragement)

 Putting the other person's ideas or feeling into your own words

Example:

So, if I understand correctly, you've outlined two problems; double exits and the lack of a
stop bar on the runway

Active Listening Is:

 The genuine desire to understand another person's perception

 Listening and expressing - understanding of what another person has said
 Sensitivity to another's thoughts and feelings

Active Listening Is Not:

 Passive or token
 Advice given
 Agreement or disagreement
 Judgmental or critical
 Argumentative

The Art of Effective Listening

Being an effective listener takes practice and a sincere effort on behalf of the listener. Problems
in effective listening are:

 We speak at approximately 125 words per minute

 We have the capacity to listen at 900 words per minute

Our brain spends this excess time:

 Pre-planning (anticipation) - preoccupation with formulating a response and not listening to

what the sender is saying

28
  Detouring (wandering) - waiting for a key word and when it comes up, take the conversation
into another area of interest

 Debating - playing the devil's advocate; regardless of what was said, they take the opposite
point of view

 Tuning Out - when a message has been heard repeatedly, after a while the receiver does not
listen because it is felt that the message is not important

The effective listener is:

 Caring
 Trustworthy with integrity
 Accepting
 Lets you talk
 Focuses on thoughts and feelings
 Constructive, focuses on problem solving, not blame
 Encourages self-determination
 Is capable of active listening

Listen to More than Words

Effective listening takes into consideration all aspects of communication - verbal, non-verbal and
symbolic. For pilots, most communication takes place in the cockpit. This environment is ripe
for communication error and misunderstandings because words exclusively represents just 7% of
total communication. The communication process can be enhanced by an additional 38% by
paying particular attention to the individual's speech characteristics:

 Rate of speech Is the individual speaking quickly or slowly? Generally, people speak more
quickly when they are excited, angry or upset. Speaking slowly generally suggests calmness and
control

 Inflection Which words does the individual emphasize? Inflections can help indicate what is
most important to the individual

 Tone of Voice Is the individual's voice loud or soft, harsh or smooth? Tone of voice can help to
determine the individual's emotional state. It can be critical in determining the stress level of
other crew members

Critique

Critique is an efficiency or performance analysis of future, current or past events.

All crew members should be encouraged to give critique to enhance the flight operation. Critique
is constructive. It is what we think will work best, monitoring of our decisions to ensure

29
performance is as expected, and a debrief as to what will improve total crew performance next
time. Critique is a continual process that challenges the dynamic environment of flight.

Communicating Criticism

Occasionally, mistakes happen. Bear in mind that people do not make mistakes on purpose but
they are the result of a multitude of factors that may be influencing the individual at any one
time. Miscommunication, task overload, misunderstanding of targets, stress or fatigue are some
of the factors which could induce errors. Perhaps just letting the person know the consequences
of his or her behaviour is enough the make the point. Other times, criticism must be
communicated. The most effective way to do this is

 Avoid criticizing the person; focus on the behaviour exhibited instead

 Describe the specific behaviour you observed
 Avoid being sarcastic or parental
 Avoid using vague or general statements
 Avoid using anger
 Avoid asking questions for which you already know the answer
 Describe the impact of the behaviour on others in the working environment
 Describe the consequences of the behaviour. It is important to help the person see what type of
consequences it might have for him or her personally over a period of time
 Reach an agreement on how to change behaviour. If the person chooses not to change the
behaviour after being made aware of its negative impact and consequences, the person is either
an intentional trouble maker or under severe emotional strain. Proper disciplinary action should
be taken. If the person agrees to modify his or her behaviour, then a process should be agreed
upon to provide supportive and positive feedback.

Do

 Encourage others to talk

 Be tentative, explore
 Express your feelings objectively
 Focus on other's self-determination
 Use problem-sharing approach

Do Not

 Degrade the other person, especially in public

 Be dogmatic or self-righteous
 Ignore other's feelings or ideas
 Argue
 Interrupt

Conflict Resolution

The key principle in resolving conflict in the cockpit is the determination of

30
 What is right, not who is right
When crew members advocate their position, a difference of opinion in the cockpit arises. CRM
principles recognize this conflict as not only healthy, but expected. All crew member's input is a
required ingredient for synergy to become active.

A problem begins when outside conflict enters the cockpit, when heated emotion, bias, or lack of
respect taint the real issue.

 Is it a cockpit issue or does it pertain to something beyond the confines of this cockpit?
 If it is not a cockpit issue, set it aside and deal with it once you are on the ground. Maintain a
professional attitude.
 If it is a cockpit issue, resolve it based on what is right and not who is right. Rely on an impartial
source of information if possible, an Aircraft Operations Manual or Air Regulation. This is a
constructive method of resolution versus the destructive method of who is right.

How to Manage Angry Conflict

There will be times, inside or outside the cockpit, that angry conflict will take place.

Should this angry conflict take place during a critical phase of flight, it will constitute a serious
hazard to safety. The following tips will help you to manage the angry conflict until the problem
can be resolved at a more convenient time.

Maintain Control

 If possible, suggest another time (cool off)

 Avoid sharing the anger
 Objective: To Listen

Listen

 Objective: Allow other to explain

 Use listening skills
o Open ended questions
o Probe questions
o Paraphrasing

Use Problem Sharing Approach

 Guide discussion to clarification of problem and constructive exploration of ways to resolve it

o We have a problem
o Define the problem-is it cockpit related? Cause vs effects
o Explore the alternatives and consequences - elicit and suggest
o What action should we take - pick the safest one
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 o Mutual commitment
o Follow-up

Maintain respect

 The use of personal insults and put-downs must be eliminated. "I wonder if we can approach
this issue without attacking each other."
 Objective: To clarify the issue as objectively as possible
 Feelings are facts - do not deny the other's experience
 Separate the facts from opinion; mentally separate facts from irate expressions

Avoid Hasty Responses

 Allow time for issues (facts vs opinions) to settle

 Wait and go back later

Seek Constructive Solutions

 Explore alternatives
 Have other choose, if possible

Effective Communication

Effective communication encompasses the entire scope of the sender's verbal, non-verbal,
symbolic message

Effective communication is a recognition that a variety of assumptions and other filters

potentially could distort the message that is sent or received

Effective communication involves active listening for clear comprehension

Effective communication completes the circuit of sending, receiving and feedback with all
parties sharing a common understanding of the message

Barriers to Communication

There are many factors which block effective communication. They are organized into three
distinct categories:

1. Physical Barriers

The physical barriers are normally barriers that prevents the communication from being received
- items such as noise, hearing loss, confusion, fatigue, poor radio equipment. The pilot has some
control over these barriers.

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2. Psycho-social

The psycho-social barriers are much harder to detect and control; stemming from inside an
individual, they encompass attitudes, feeling, bias and prejudice. For example, strong negative
feelings in the cockpit can lead to a total lack of communication. Hostile environments create a
safety hazard. Pilots must maintain a professional attitude to help to overcome the psycho-social
barrier.

3. Technique-related

The technique employed to process information can be a barrier in itself. The professional who
processes information does it the same way every time. The individual answers two questions
before responding or acting on any information:

 What is the literal meaning?

 What is the contextual meaning?

If these questions cannot be answered to the receiver's satisfaction, then clarification should be
sought. After this, the next question should be:

 What action is appropriate in response to this communication?

This type of controlled response creates a professional atmosphere and no matter what the
feelings are between the crew members this professionalism cuts through much of the
personality problems.

The bottom line for Crew Resource Management skills

In promoting good communication in the cockpit

NASA tested 7,500 flight crews and determined that the two most significant
factors in the promotion of good CRM principles were:

The Captain giving a thorough briefing

The First Officer making inquiries and advocating his/her position

BEHAVIORAL STYLES

Behavioral Styles

The purpose of behavioral analysis is to provide you with an awareness of your individual
behavioral style. With this awareness, we will have a better understanding of why we react in a
33
specific way to people or to situations. Our reactions also affect the people around us, and in turn
they react to us. This human interaction can be either healthy or dangerous in the flight
environment.

A knowledge of your behavioral style will ultimately benefit aviation safety.

Behavioral Styles and Leadership

All individuals have inherent leadership qualities which are manifested in their behaviour. It is a
matter of how these leadership qualities are utilized that gives us the strength in our leadership
abilities.

List some qualities which can make a person a "Good Leader."

List some qualities which can detract from "Leadership" ability.

Knowing our own behavioral style will also help us to understand others. This will lead to:

 Mutual respect
 Mutual trust
 A willingness to adapt
 Better communication
 Safer flight

34
BEHAVIOURAL PATTERNS

35
Assertiveness

Psychologists divide behavioral styles into two basic categories:

Relationship Oriented - first consideration is the feelings of others which rank high in the
decision making process. A person who is high relationship oriented and low task oriented is
considered to have a caring or nurturing style of behavior.

Task Oriented - first consideration is given to the task or goal in the decision making process. A
person who is high task oriented and low relationship oriented is considered to have an
aggressive style of behavior.

Combinations - Low relationship oriented traits combined with low task oriented traits are
individuals considered to be loners or autonomous in behavior style.

The person who is both high in

Relationship and task
Orientation is considered to have an
Assertive
Style of behavior

The definition of "assert"

 To put into words positively and with conviction

 To defend, maintain, or insist on the recognition of one's own rights
 To state to be true

It is interesting to note that the weaknesses in behavior styles indicate an excess use of a strength.
We must do less of our weakness to achieve the desirable assertiveness behavior style.
Developing the strengths of the three styles allows for a high degree of task orientation in
conjunction with a high degree of caring.

Behavioral Styles - Body Language

Non-verbal behavior in relation to the various behavioral styles:

Aggressive

 General: exaggerated show of strength, flippant and sarcastic style, air of superiority
 Voice: tense, shrill, loud, shaky, cold, deadly quiet, demanding, superior, authoritarian
 Eyes: expressionless, narrowed, cold, staring, not really seeing you
 Stance: hands on hips, feet apart, stiff and rigid, rude, imperious
 Hands: clenched, abrupt gestures, finger pointing, fist pounding

36
Non-Assertive

 General: actions instead of words, hoping someone will guess what you want, looking as if you
do not mean what you say
 Voice: weak, hesitant, soft, sometimes wavering
 Eyes: averted, downcast, pleading
 Stance: lean for support, stooped, excessive head nodding
 Hands: fidgety, flutter, clammy

Assertive

 General: Attentive listening, assured manner, communicating, caring, strong

 Voice: firm, warm, well-modulated, relaxed
 Eyes: open, frank, direct, eye contact without staring
 Stance: well balanced, straight-on, erect, relaxed
 Hands: relaxed motions

Assertive Behavior

Assertive behavior is intended to be the middle ground by taking the best of aggressiveness
(without the put-down negatives) and the best of non-assertiveness (without loss-of-self.) The
action is genuine, complete and a direct communication of ideas, wants and needs. It is the
conviction that one's position can be expressed strongly without dominating the other. Social
grace can be maintained without weakening the position or request.

Assertive behavior is based on the fact that every individual has rights and can act on behalf of
these rights:

 The right to have and express your own feelings and ideas
 The right to be listened to and taken seriously
 The right to ask for what you want
 The right to get some of your own needs met
 The right to be treated with respect
 The right to say "no" at times and not feel guilty
 The right to ask for information from others
 The right to make mistakes
 The right to be assertive
 The right to choose not to assert yourself

When we act assertively, we recognize these rights as legitimate. Assertive behavior becomes
easier the more an individual recognize these rights. When we respect these rights in ourselves,
we are also more likely to act in a manner that respects these rights in others.

Aggressive behavior denies the rights of others, and non-assertive behavior overlooks these
rights in ourselves.

37
Characteristics of Assertive Behavior

 Expressing statements of one's own feelings, needs and ideas

 Standing up for your rights in ways that do not violate the rights of others
 The behavior is honest, direct, expressive and self-enhancing
 The person feels confident about themselves during a situation and afterwards
 A high level of respect is maintained for the other individual
 There is a positive impact on the interaction
 Direct statements of agreement or disagreement
 Direct refusal or statement of "no"
 Compromising behavior
 Statements which communicate what you mean; "I" messages

In a conflict situation, the difference between dealing with the issue and not with the person must
be recognized. There is a directness and a problem-solving quality in assertive behavior that is
not present in aggressive or non-assertive behavior. Negotiation as a problem-solving tool
becomes a method of resolving differences. Ideas, wants, and needs are heard and explored
openly. Collaboration and integration are seen as positives, and compromise could be an
acceptable position. (Note - negotiation and compromise in problem solving is encouraged,
however it is not the recommended option for cockpit decision making. Please note the
difference.)

Most individuals are more skillful or at ease with either aggressive or non-assertive behavior.
While there are some who are naturally assertive, most need to acquire assertive skills.

If assertiveness must be learned, what needs to change?

Transforming Yourself into an Assertive Person

Aggressive individuals need to learn skills that will allow the strong expression of feelings, ideas
and wants without offense to others. This may require some revision of their basic beliefs. The
aggressive person feels that they must stay on top, diminish the other person and be on guard,
lest anyone take advantage of them. They might also fear that unless they are aggressive, they
must be passive or non-assertive. This need not be the case. The aggressive individual needs to
begin to trust themselves and their abilities to cope with differences or disagreements without
necessarily winning or always having their own way. The aggressive person is entirely motivated
by their own self-interests.

Assertive skills allow individuals to achieve results. This helps people to be clear on what they
want and to pursue goals in a positive way without demeaning the other person. These skills
allow one to be strong in their views while remaining open to other viewpoints and alternatives.
The aggressive person need not become more passive. Assertiveness will allow positive parts of
aggressive behavior to be continued without the negative consequences of aggressiveness. The
result can be strong expression with corresponding effectiveness.

38
Non-assertive individuals need to learn skills that will allow respect for others to be
communicated without a diminishing of one's self, ideas or position. This may also require a
revision of some basic beliefs. The non-assertive person feels that they must be condescending to
others or overly respectful of the other person's rights at the expense of their own. They fear their
behavior may be taken as aggressive unless they act in a non-assertive manner.

Assertiveness is never aggressiveness. The non-assertive individual needs to begin to believe that
others can accept and deal with disagreements and candor. The rights possessed by individuals
can be acted upon without being offensive to the other. The non-assertive individual must begin
to believe that helpfulness at the expense of self may not be helpful at all.

Assertive skills allow individuals to achieve results. They help individuals to be clear on what
they want and to act in a positive way without diminishing self. They allow a person to be
sensitive to other individual's viewpoints and positions without diminishing their own ideas and
alternatives. Non-assertive persons need not become more aggressive.

Assertive skills will allow the positive aspect of non-assertive behavior to be continued without
the negative consequences of passiveness. The result can be caring about the other with
corresponding effectiveness.

Summarizing Assertive Behavior

 Assertive behavior is the only way to defuse aggressive behavior

 It lessens heavy feelings when dealings with passive people
 It develops the possibility of receiving assertive responses
 Assertive behavior helps you get what you want and need
 It increases self-worth, self-esteem and self-confidence
 The assertive individual shares control and responsibility with others
 Assertive individuals are respectful to others as well as to themselves
 They make a strong impression without negative impact on others
 Assertive behavior enables a person to deal with negative and or passive responses
 The assertive individual is seen as a person who can be independent or dependent
 The assertive individual relies on others without loss of self-esteem
 Assertive people have better problem-solving abilities
 They feel good about themselves and others
 They increase the probability of workable solutions and effective decisions
 They produce more good ideas, opinions and feelings

In the Cockpit

As a crew member, you have the right to assure that your life will not be compromised by any
action/inaction, miscommunication or misunderstanding. Assertive behavior in the cockpit does
not challenge authority; it clarifies position, understanding or intent, and as a result enhances the
safe operation of the flight.

39
 Assertive behavior will enhance the effectiveness
Of the Five Elements of CRM

Inquiry
Advocacy
Conflict Resolution
Decision Making
Critique

FATIGUE

Fatigue in aviation is recognized as a serious safety concern. Fatigue poses a threat to the
principles of CRM and induces human error. Human error is a contributing factor in 80% of all
aviation accidents.

The NASA-Ames Fatigue Countermeasures Program has been conducting studies on pilot
fatigue for the last 10 years. Their research can be confirmed by interviewing any pilot that has
ever flown fatigued.

The Danger of Fatigue

Pilots may be of the opinion that because they can stay awake for extended periods of time, they
escape the adverse effects of fatigue. This is not the case. Fatigue is insidious; individuals cannot
readily feel the onset of fatigue. The fatigued person may not be aware of it's gradual and
cumulative effects and consequently, may be unaware that their performance has become
degraded. The fatigued pilot may not easily accept an assessment of their degraded performance
or be able to improve their performance despite increased effort.

Fatigued pilots are less vigilant, more willing to accept below par performance, and show signs
of poor judgment. They may find it increasingly difficult to make decisions; they may have to
recheck information several times as a result of an impaired memory or inability to process
information. Alertness and reactions times are decreased. Irritability and mood swings easily
block communication and hamper CRM principles.

One of the worst dangers of pilot fatigue is apathy. The fatigued pilot can be indifferent
as to the outcome of the flight and their operational performance.

The NASA-Ames studies show that a person who goes without sleep for 18 - 20 hours
experiences the same effects as if they had had two or three beers. They are euphoric, punchy,
display decreased response time and motor control skills, segmented from their surroundings,
impaired thinking.

40
Causes of Pilot Fatigue

The main causes of pilot fatigue are

 The disturbance of circadian rhythms

 Continuous wakefulness
 Cumulative sleep loss

Circadian Rhythms

The aviation industry maintains a schedule that is 24 hours a day, 7 days a week. Humans
operate on a different schedule, a circadian rhythm, which can conflict with a crew member's
required work periods. This clash of schedules can affect pilot performance, behaviour and
attitude. There are two circadian low periods where an individual will experience increased
sleepiness - between 3 and 5 o'clock both a.m. And p.m. A combination of the circadian low
period and fatigue could reduce pilot performance by up to 35%.

During sleep, the body's core temperature, often used as a biological marker, drops markedly. If
you are forced to stay awake during the time normally allotted for sleep, the disruption of the
circadian cycle produces the effects of fatigue.

The more time zones that are crossed, the longer it will take an individual to adjust. It is easier to
adjust to a westbound time zone change than eastbound.

Sleep Loss and Microsleeps

The loss of as little as one hour sleep begins a person's sleep debt. Eight hours of disrupted sleep
can also produce the effect of too little sleep. You cannot indefinitely deny your body of its
required sleep, nor can you substitute it with anything else. The only cure for a sleep debt is to
sleep.

Acute fatigue is severe, and could result from the loss of a night's sleep. Chronic fatigue is the
result long term sleep debt. It is usually not recognized by the individual and is more difficult to
counteract. Acute or chronic fatigue can lead to a microsleep.

Microsleeps are uncontrolled spontaneous episodes of sleep that could last for seconds or
minutes. During a microsleep, a person disengages from reality and becomes unresponsive. They
fail to respond to outside information.

 There is a 10 times increase of a microsleep at night than during the day

 There is a 10 times increase of a microsleep relative to each hour worked
 Microsleeps increase with cumulative sleep debt
 A microsleep does not decrease a sleep debt

41
Other Fatigue Inducers

There are other factors that can cause or contribute to pilot fatigue

 Length of duty day

 Time of day, shift irregularities
 Schedule, consecutive duty days
 Multiple layovers in quick succession
 Restricted time available for sleep
 Quality of sleep
 24-hour layovers following a night arrival
 Easterly direction flights traversing several time zones
 Poor cockpit seat design or ergonomics
 Stressors such as noise, vibration, flicker, heat/cold, wearing headsets
 Accumulation of operational factors such as bad weather, congested airspace
 Boredom, waiting, monotony, monitoring instruments
 Poor diet, hypoglycemia
 Skill fatigue - a progressive loss of performance ability due to prolonged or extreme mental or
physical activity
 Vision fatigue - the eye's inability to maintain effective functioning from prolonged visual
exertion
 Illness
 Physical exertion
 Dehydration
 Self-medication
 Caffeine, smoking, alcohol
 Hangover
 Hypoxia, flights with cabin altitude over 5,000 ft
 Unresolved stress

Symptoms of Pilot Fatigue

Be aware that these are some of the symptoms that may affect you, but also watch for them in
other crew members

 Slowed reaction time, both physically and mentally

 Increased errors despite increased effort
 Individual's underestimation of their performance degradation
 Performance variability and unpredictability
 Preoccupation with a single task
 Fixation on a single source of information
 Perseverance of an ineffective solution
 Short-term memory loss, such as a frequency change
 Impaired judgment and decision making
 Easily distracted by unimportant items
 Sloppy flying

42
  Loss of initiative
 Depressed, apathetic, lethargic or moody
 Willingness to accept below standard performance
 Limited situational awareness
 Poor communication skills

Common Misconceptions

A pilot suffering the effects of fatigue will not be able to counteract them by

 Skill
 Increased effort
 Stamina
 Physical conditioning
 Education
 Training
 Experience
 Will
 Professionalism
 Motivation

Alcohol and Fatigue

Alcohol is the most widely used sleep aid, but quantities can interfere with quality of sleep
therefore increase sleepiness. Pilots on short haul trips consume three times the amount of
alcohol on a layover than they consume at home.

Scheduled rest periods allow for required sleep

It is difficult for the body to quickly adjust to required periods of sleep and alertness. The time
allotted for sleep on a layover may not coincide with the flight crew member's circadian rhythm.

Subjective analysis

The individual may have a false sense of confidence about their performance abilities when
operating in a fatigued state. It is difficult to reliably estimate your own alertness and
performance, especially if the individual has a history of flying fatigued and feels motivated
enough to overcome the adverse effects.

Artificial enhancers

Caffeine is the most popular artificial stimulant, and can be useful after waking up. Continued
caffeine intake will deter sleep during the time allotted for sleep. Caffeine is also a diuretic and
causes dehydration.

43
Melatonin is a depressant currently being promoted in the United States as a natural hormone
which allegedly induces sleep in shift workers or elderly people.

Melatonin is not legal in Canada. There are problems with quality control, potency and
monitoring of this supplement. The biological effects and the long term use of Melatonin is not
known.

Fatigue Countermeasures

Some causes of fatigue are controllable, and pilots should make every effort to avoid flying
fatigued when possible.

 Do not begin a flight with a sleep debt, make this a priority over outside activities. NASA studies
have shown that an individual who received 8 hours of sleep was better able to carry out pilot
duties after being awake for 20 hours, than that of a pilot who received just 6 hours of sleep
 Pre-planning for a known sleep disruption is essential for managing alertness. Develop a regular
pre-sleep routine, sleep in a comfortable environment
 Proper diet, physical conditioning, avoiding alcohol and smoking will help the body to stay
healthy and be better able to cope with the effects of fatigue. Do not exercise or eat a large
meal directly before sleep
 Use caffeine sparingly during flight as it may keep you awake later when you are trying to sleep.
Water is favoured to counteract dehydration effects.
 If you wake up spontaneously and cannot go back to sleep within 15 - 20 minutes, or have
trouble falling asleep, get up and try again later
 During a layover, get as much sleep as you would normally in a 24-hour period. Trust your own
physiology - if you feel sleepy and circumstances permit, sleep
 A 40-minute nap, dubbed the NASA-nap, will help to rejuvenate an individual without them
entering into a deep sleep, which is more difficult to wake-up from

Summary

 The only remedy for a sleep debt is to sleep

 No amount of will-power will overcome the effects of fatigue
 Pilots retain a level of control over their fatigue levels
 Fatigued pilots must be aware of the gradual and cumulative effects of fatigue, which degrades
their performance

STRESS MANAGEMENT

Stress is a necessary evil in a pilot's life. In moderation, it is a key factor in the achievement of
peak performance. Too much stress will detract from the pilot's ability to reason and function.
Not enough stress causes complacency. Either not enough stress or too much stress can lead to a
lack of situational awareness.
44
What is Stress?

The definition of "stress" originated from the engineering field

A force placed upon an object to cause straining, bending or breaking

Related to humans, the term stress is used to describe the body's response to demands placed on
it.

There are three types of stress:

Physical - environmental conditions, noise, vibration, stages of hypoxia

Physiological - fatigue, lack of physical fitness, improper eating habits

Emotional - social and emotional factors related to living and intellectual activities, such
as solving difficult problems in flight

There are also two categories of stress

Chronic Stress - the result of long term demands of lifestyle or personal situations
(health, relationships, job security)

Acute Stress - the result of demands placed on the body by a current issue (time
constraints, bad weather, equipment failure)

Effects of Stress

Stress is cumulative. The body does not differentiate between the type of stress it feels, but there
is a biological differentiation between the category of stress.

Acute stress injects adrenaline into the bloodstream and becomes a source of energy. Heartbeat,
breathing rate and blood sugar levels all increase. The body is charged into a "fight or flight"
mode which enables the individual to quickly react to the situation.

Chronic stress is the more dangerous of the two. It can make a situation that normally should be
controllable seem more difficult to handle. Chronic stress will exaggerate the effects of acute
stress. Long term chronic stress may cause illness, insomnia, irritability, ulcers, and high blood
pressure. It can threaten an individual's health.

45
Stress is cumulative. High levels of stress over a period of time will push the individual on the
back side of the stress curve and affect the pilot's ability to deal with complex or difficult tasks.
Performance will be progressively degraded. Communication and CRM principles will be
adversely affected.

STRESSORS IN AVIATION

 Medicals
 Checkrides
 Illness
 Pay
 Conflict
 Fears related to flying
 Time schedules
 Passengers
 Noise and vibration
 Temperature and humidity
 Diet
 Dehydration
 Altitude changes
 Confined space
 Poor visibility

46
  Fatigue

SYMPTOMS

 Muscle tightness
 Aches & pains
 Upset stomach
 Anxiety
 Depression
 Feelings of depletion
 Emotional burnout
 Emotional outbursts
 Withdrawal
 Conflict in relationships
 Lack of energy

Recognizing Stress Levels

Either monotony or over-stimulation have the potential to increase the rate of human error. Pilots
require some stress to maintain peak performance. How much stress is too much? Stress levels
change from day to day, from individual to individual. An awareness of what our stress levels
are, and a lookout for an indication of what other crew member's stress levels are, will provide an
indication of what performance level can be anticipated.

With reference to the pre-course material, Question Sets #4, #5, and #6 relate to gauging your
stress level.

Question Set #3 is a Stress Barometer and will gauge how susceptible an individual is to stress
based on personality type.

Personality Type

Type A "Hot Reactor" Susceptible to stress

Type B "Cool Reactor" Low susceptibility to stress

Question Set #4 provides an indication of your Stress Level. It may shed some light on why
some people cope with stress - consciously or subconsciously - better than others.

If your score on the high stress indicators test is:

8 or less, you have mild stress

9 to 24 is moderate stress
47
 Higher than 24 indicates the high stress range

If you scored high on Question Set #3 Stress Barometer, it shows that you are coping well with
your present level of stress.

Question Set #5 is a Life Event stress evaluation for chronic stress levels. It provides a broad
indicator of some of the stressful situations you may have recently encountered. The higher the
score, the better the chance of experiencing a significant illness in the near future. If you score
high, it makes sense to avoid further stressors.

Scores of:

100 - 150 = 30% chance

150 - 300 = 50% chance

Over 300 = 80% chance

Signs of Stress

It is relatively easy to see the signs of stress in yourself and in others - if you know what to look
for. Is this profile recognizable in anyone you know?

Do they

 Rush speaking
 Complete other people's sentences
 Rush eating
 Hate waiting in line
 Never seem to catch up
 Schedule more activities than they have time available
 Detest wasting time
 Drive too fast most of the time
 Often try to do several things at once
 Become impatient if others are too slow
 Have little time for relaxation, intimacy, or enjoying the environment

Stressed-Out

On the back side of the stress curve, pilot performance will be degraded. Too much stress leads
an individual to distress. As the pilot suffers from over-stress, it could lead to

 Eroded judgment
 Compromised or accepting of lower performance levels
 Inattention

48
  Loss of vigilance and alertness
 Preoccupation with a single task
 Fixation on one instrument or procedure
 Forgetting or omitting procedural steps
 Greater tendency toward spatial disorientation and misperceptions
 Misreading charts or checklists
 Misjudgment of distance or altitude
 Loss of time perception
 Loss of situational awareness

Attitudes

Definition: Attitude (noun); a frame of mind affecting one's thoughts and behavior; a general
cast of mind with regard to something.

With reference to the pre-course material Question Set #6, transpose your scores in sequence
from columns one through five on the lines below.

Col 1 Col 2 Col 3 Col 4 Col 5

________ ________ ________ ________ ________

Anti-Auth Impulsive Invulnerable Macho Resignation

It is recognized that the choice of responses forced you to select what could be an unsatisfactory
alternative to the situation. The profile indicates your potential for each of the five hazardous
thought patterns.

The situations presented were written in the third person so that you would apply your attitudes
and judgments to another person's decision. Keep in mind that when you evaluated these
situations your response was based upon your attitudes and your judgment of the situation. In
other words, if you ever do exercise poor judgment, this profile will help you to understand your
reasons.

The higher the relative number, the greater the probability of that particular hazardous thought
pattern. Many accidents involve pilots who allow themselves to be influenced by one or more of
the five hazardous thought patterns, and are enticed to takes chances as a result.

5 Hazardous Attitudes

Anti-authority: "Don't tell me" This hazardous attitude is found in someone who does not like to
be told what to do. They may either be resentful of having someone tell them what to do or may
just disregard rules and procedures. An assertive person will question authority if warranted.

49
Impulsivity: "Do something quickly" Someone who does not stop and think about what they are
about to do. They do not select the best alternative, they do the first thing that comes to mind.

Invulnerability: "It won't happen to me" Many people feel that accidents will happen to others
but not to them. People who think this way are more likely to be risk takers beyond acceptable
levels.

Macho: "I can do it" People who are always trying to prove themselves take risks to try and
impress others. Both men and women are susceptible.

Resignation: "What's the use" People who have this hazardous attitude do not see themselves as
making a great deal of difference in what happens to them. They attribute events to either good
or bad luck; they leave actions to others. They can go along with unreasonable requests to be a
"nice-guy."

PROFILE GRAPH

There are five columns for each of the attitude scores. Place a mark on each line at the height that
matches your score. Draw lines between the columns to create a profile.

(Insert Profile Graph here)

The profile graph shows which patterns you would tend to use when your judgment becomes
influenced by certain circumstances and hazardous thinking. The inventory does not show that
you are bound to act in the manner of one or more of the hazardous thoughts all the time. Having
thoughts similar to the ones described as hazardous is common and normal, but it is important to
know that you can improve your ability to balance all your thoughts against possible outcomes
so that you act only in a non-hazardous manner. Whether you engage in one or more of these
thought patterns, often or rarely, learning to control them will be worthwhile.

Stress Management

If we don't manage stress, stress will manage us. Life events do not create stress; we create the
stress in our minds. You can let it consume you - or you can eliminate or reduce it - and change
stress into an energy source instead of an illness. The source of stress must be identified before it
can be addressed and reduced, or eliminated. Take a rational look at the stressor. Ask yourself

 Is my emotional mind working to lesson or increase my stress level?

 What is the reality of the situation?
 What is the very worst thing that is likely to happen to me?
 Am I over-reacting to the problem?
 Can I change the situation for a positive outcome?
 If I cannot, what is the best way to cope with it?
 Has this ever happened to me before?
 If so, what did I do and what can I do better?

50
  If not, then what is the best rational plan?

Make a plan and act on it. The goal is to control or to eliminate the effects of stress, recognizing
that the stressor itself may not be under your control. Ensure sure that your solution contains the
"I" word at the beginning, because that is the one thing you control. "We" or "they" may be part
of the solution but "I" will have to work towards the solution.

Stress causes an unnecessary expenditure of energy through adrenaline production. The best way
to rid the body of excess adrenaline is with physical exertion, or exercise. When it is not possible
to exercise, a walk is an good way to relieve the effects of high stress, and also provides a mental
time-out from the stressor. Vitamin C also helps rid your body of adrenaline.

Weight control, diet, use of alcohol or tobacco will affect the body's ability to control stress. Get
the proper amount of sleep.

Be realistic and practical. This may call for you to be flexible and willing to adapt. You can
reduce the effects of stress and cope with it better if you take a break from the problem. Stress
relief is one of the main reasons why we take a vacation, but if that is not possible, sometimes a
change is as good as a break. Discussing the stressor with a sympathetic ear will help you to cope
with the situation, and input can be provided from someone who may not be emotionally
involved.

A positive attitude and a sense of humor will help an individual to cope with stress. Perseverance
with a plan of attack, and a look at the "big picture" will also help to modify the effects of stress.

Summary

 Identify, recognize, eliminate or reduce too much stress

 Cope actively with demands
 East, sleep and exercise properly
 Communicate
 Avoid mind altering substances
 Check your attitude, sense of humor and general emotional state
 Stress is associated not only with distress but also with excitement, achievement, and effective
performance
 One of the major reasons for learning effective stress management is long-term preventive
health care
 In addition to helping our lives work better, stress will help us to achieve peak performance

The greatest discovery

of mankind is that
human beings can alter
their lives by altering
their attitudes

51
SITUATIONAL AWARENESS

True situational awareness is an individual's accurate perception of reality. The "Theory of the
Situation" is what one assumes to be true for a specific period of time. If a discrepancy exists
between the individual's Theory of the Situation and the Reality of the Situation, a loss of
situational awareness occurs and an error chain could begin.

Elements of Situational Awareness

Theory of the Situation - A set of beliefs about what is happening and what action and
individual should take. It is based on the interpretation of available information. It is a human's
perception of reality.

Reality of the Situation - Actually reality, without human perceptions

Theory of Practice - a person's concepts and skills developed over time used to build and
respond to Theories of the Situation. It is the sum of experience.

It is normal for people to defend their Theory of the Situation rather than to change it, or inquire
about possible error. Many accidents have occurred where a crew was using a faulty Theory of
the Situation and overlooked data that indicated otherwise.

52
You are MOST likely to change your Theory of the Situation when you

 Operate under low stress

 Have access to and accept feedback
 Develop inquiry skills into your Theory of Practice. Guard against interpreting information to
support your Theory of the Situation

You are LEAST likely to change your Theory of the Situation when

 Your Theory of Practice is over-learned

 You have a complacent attitude - "we've always done it that way"
 It is a crisis situation
 The Theory of the Situation is central to your self esteem, ego

In attempting to change your Theory of the Situation, as in Conflict Resolution, the important
factor is

What is right, not who is right

The CRM principles of inquiry, advocacy, conflict resolution and critique will assist in clarifying
the Reality of the Situation, and provide the basis for higher quality decision making.

Fatal Accidents
Worldwide Commercial Jet Fleet - 1959-1990

Exposure percentage based on average flight duration of 1.6 hours

Excludes:
Sabotage
Military action

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Clues to the Loss of Situational Awareness

Low Stress Level - When the amount of information being processed is significantly low, the
level of situational awareness is low. Low stress level is common on long flights when we
become bored or when we are fatigued. This lack of alertness will result in a loss of recognition
of warning signals and reduce our ability to react quickly and correctly in an emergency.

High Stress Level - When the amount of information being processed is significantly above an
individual's capacity. If our stress level is very high, we operate at low levels of situational
awareness. This is commonly referred to as information overload.

Ambiguity - When information can be understood in more than one way, there can be a fifty per
cent chance of an accident occurring. A classic example is the captain calling "take-off power"
and the first officer reduces the power to idle.

Confusion or Unresolved Discrepancies - When information is unclear, or two or more pieces

of information do not agree, we must search for information until the discrepancies are resolved.
A simple example with catastrophic consequences is the acceptance of a clearance to descend
below published minimum safe altitudes.

Fixation or Preoccupation - The ability to detect other important stimuli is lost when an
individual is fixated, preoccupied or distracted. This situation can easily result in no one flying or
looking outside the aircraft unless there is proper assignment of responsi-bilities essential to safe

54
flight. The entire crew's preoccupation with a malfunctioning nose gear indication light resulted
in an L-1011 crashing into the Florida Everglades. No one was monitoring the flight instruments;
no one was flying the aircraft.

Departures from sops/Regulations - Violating minimums or using improper procedures puts

pilots into a gray area without being able to predict safe outcomes with certainty. Consistent and
blatant violations of rules often reveals other systemic problems within an organization.

Failure to Meet Planned Targets - In flight, pilots are constantly setting planned targets such as
airspeeds, altitudes, checkpoints, times, etc. When planned targets are not met, like being high
and fast on an approach, we must question why and recognize the consequences of not meeting
set targets.

Gut Feeling - This is often the most detectable and reliable clue to the loss of Situational
Awareness. Our bodies are able to detect stimuli long before we have consciously put the big
picture together. Learn to recognize your own signs, such as stomach butterflies, muscle tension,
mood swings, etc. Trust your feelings; policemen sometimes place their lives on gut feelings.

Maintaining Situational Awareness

The following eight skills will favourably contribute to gaining and maintaining Situational
Awareness

Experience - Experience creates a mental file. Pilots draw upon it every time they fly and use it
to assess conditions and make decisions. Under pressure, people tend to revert to previous
patterns of behaviour. An individual's experience file helps establish how one will interpret and
respond to a given set of conditions.
55
Training - Training does far more than perfect skills. Training adds to a pilot's experience file by
creating events that rarely happen in real life. For example, a flight simulator session can
generate a lifetime of experience in a very short period of time. Few pilots will ever actually
have an engine fail at V1. Yet through training, it can become part of a pilot's experience so that
if and when it does occur, there will be something to draw upon.

Spatial Orientation - Spatial orientation is position awareness; knowing where the aircraft is in
relation to VOR's, airports, runways, terrain, or other aircraft. It is knowing where you are and
where you are going.

Physical Flying Skills - As the pilot's role becomes that of a cockpit manager, it must be
remembered that pilots still have to be able to fly the aircraft proficiently. Flight control
manipulation continues to be an important part of a pilot's job.

Ability To Process Information - This is an ability to use information from sense inputs,
instruments, and other sources to form an accurate picture of what is happening. It is the ability
to integrate all the elements that contribute to Situational Awareness.

Cockpit Management Skills - These contribute to a pilot's ability to manage the total of the flight
environment.

Personal Attitude - Professionalism is a matter of attitude. Safety does not just happen; it is a
conscious effort. To be safe, one must think safe.

Emotional / Physical Conditions - An individual's emotional and physical condition affects their
perception of the environment. Emotional problems, mental illness, physical conditions, and
frame of mind can cloud or distort an accurate perception of events or conditions.

Summary

Crew Resource Management principles stress that all resources must be considered before a
quality decision can be made. Therefore, the quality of the decisions are directly related to the
amount and the accuracy of information gathered pertaining to the crew, aircraft and the
environment.

If a pilot suspects that a loss of Situational Awareness has occurred, revert immediately to the
basics

 Maintain Control - Fly the Aircraft

 Assess the Problem in the Time Available
 Gather Information from All Sources
 Assess All the Options - Choose the Best
 Monitor the Results - Alter Plan as Required

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Continual use of the 5 CRM principles will assist crew members to retain their Situational
Awareness at all times

Inquiry
Advocacy
Conflict Resolution
Critique
Decision Making

LEADERSHIP

The best way of combating low morale is to exercise strong leadership, which can be applied
using three keys: communication, consolation and co-operation. I strongly support this formula.
Leadership is a perishable skill that we must preserve in today's world of management initiatives
and business planning. We manage resources, we must lead people.

Air Commodore Peacock-Edward

Inspector or Flight Safety (RAF)
Flight Comment No.1, 1995

At the heart of Crew Resource Management is effective leadership. Each member of the crew
must recognize that he or she has a leadership responsibility that is important to effective
decision making.

No matter which position you occupy in the crew you must learn to become a leader in that
position

There is a fundamental difference between leadership, which is acquired, and authority, which is
assigned. An individual's position as captain does not automatically assume that he or she is an
effective leader. Leadership skills are a function of learning. An optimal situation exists when
leadership and authority are combined.

A first officer (or other crew member) has equal opportunity for leadership in their position.
Acquired leadership skills can enhance any position, regardless of the assigned authority, as
everyone has their position to fill. These leadership skills are also important when the first officer
takes the "Pilot Flying" role, with the captain assuming the "Pilot Not Flying" role.

Leadership is a reciprocal process. There are behaviours that both a leader and a follower must
apply to ensure effective performance. One leader's behaviour might be to provide direction for
carrying out a task. The follower behaviour might be to provide feedback on performance of the
task. Leader behaviours are less effective without complementary follower behaviours.

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What makes a Leader?

A leader is a person whose ideas and actions influence the thought and the behaviour of others.
This is accomplished through the use of examples, persuasion, and an understanding of the goals
and desires of the group. The leader becomes a catalyst for change and a master of influence.

Leadership skills should be developed throughout a crew member's career. Leadership involves
teamwork, and the quality of a leader depends on the success of the leader's relationship with the
team. The quality of the team will be affected by the quality of the leader.

Leadership is needed to effectively understand and cope with a variety of situations. Personality
or attitude clashes within a crew complicate the task of a leader and can have an influence on
both safety and efficiency. Aircraft accident and incident investigations have demonstrated that
personality differences can influence the behaviour and performance of crew members.

Leadership Skills

1. Regulating Information Flow

The leader must regulate, manage and direct the flow of information, ideas and suggestions
within the crew members and outside sources

 Communicating flight information

 Asking for opinions, suggestions
 Giving opinions, suggestions
 Clarifying communication
 Providing feedback
 Regulating participation

2. Directing and Coordinating Crew Activities

The leader must function as crew manager to provide orientation, coordination and direction for
group performance

 Directing and coordinating crew activities

 Monitoring and assessing crew performance
 Providing planning and orientation
 Setting priorities

3. Motivating Crew Members

The leader must maintain a positive climate to encourage good crew member relations and to
invite full participation in crew activities

 Creating proper climate

58
  Maintain an "open" cockpit atmosphere
 Resolving/preventing angry conflict
 Maintain positive relations
 Providing non-punitive critique and feedback

4. Decision Making

The leader is ultimately responsible for decisions

 Assuming responsibility for decision making

 Gathering and evaluating information
 Formulating decisions
 Implementing decisions
 Providing feedback on actions

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Analytical Decision Making

The principles of CRM recognize that the captain retains the authority and the responsibility for
the decisions made during flight operations. However, the synergy created by considering all
resources in the decision making process heightens the quality of the decisions made by the
captain. Decisions made in isolation will most likely be of lesser quality.
60
There are a number of resources that can be accessed in the decision making process; namely
other crew members, ATC, dispatch, Flight Operations Manuals and Aircraft Operating
Manuals. A team working in synch will be able to make quality decisions faster than a team at
odds.

The decision making process can be broken down into 5 steps

Recognize or identify the problem: Does a problem exist that requires action?

Gather information to assess the situation Determine what information is needed, where the
information can be located, how it can be verified

Identify and evaluate alternative solutions Evaluate the risks associated with the advantages and
disadvantages, select the optimum alternative

Implement the decision Execute action with appropriate feedback

Review consequences of the decision Evaluate consequences and revise decision if necessary.

Intuitive Decision Making

In an emergency, some decisions must be made under an extreme time pressure with very little
time for the analytical decision making process. The intuitive decision making process is based
on gut reaction, past experience and training. Luckily, these emergency situations are relatively
rare. A good leader will have the support of the team in critical situations, bearing in mind that
the CRM principle still apply in the intuitive decision making process.

The Fundamentals of Crew Resource Management

In 1985, NASA conducted a study of major airline accidents to determine human factors "cause"
as a priority. From their results, they developed a set of six principles applicable to multi-crew
cockpits

 Separate and delegate flying and monitoring responsibilities

 Positive delegation of monitoring is important
 "Pilot Flying" avoids secondary tasks
 Any crew member having doubts about a clearance, procedure or situation must make that
doubt known to the rest of the crew
 Conflicting interpretation of a fact must be resolved through an external source
 Conflicting information from two sources must be cross-checked with an independent source

The challenge is to take these concepts and place them into useable, straight-forward pilot skills:

 Asking the right questions and stating your opinions factually, on professional matters, reduces
stress
61
  When stress is reduced there is less chance of interference with the judgment process
 This enhances sound decision making

CRM Skills
Manage (use) Resources

 Yourself
 Others (first officer, flight engineer, flight attendants, ground crew, ATC)
 Information
 Fuel/time
 Aircraft

Ask the Right Questions - Inquiry

 Asking questions will provide valuable information that might otherwise be lost

State your Opinion - Advocacy

 This is all crew members' responsibility, but be prepared to change your opinion when facts or
circumstances warrant it

Resolve Differences - Conflict Resolution

 This is a crucial element in management risks in the cockpit (not who but what is right)

Make Decisions

 Ultimately you must make a decision

Evaluate Constructively - Critique

 Critique is a skill that stimulates feedback in flight operations and in personal relations

Evaluate Constructively

 Most effective if company culture supports CRM principles

 Reinforces good decisions and discourages the repetitions of errors
 Depersonalized and tactful technique is generally accepted
 Evaluation is an antidote for complacency

Effective Feedback

 Constructive feedback, should be helpful

 Descriptive rather than evaluative, non-judgmental
62
  Specific rather than general
 Well timed

Inquiry
Advocacy
Conflict Resolution
Decision Making
Critique

PROFESSIONALISM

Definitions

The conduct, aims or qualities that characterize or mark a profession or a professional person

One of the best definitions of a professional is given by the U.S. Congress in the Labor
Management Relations Act, amended 1947. According to this Act, a "professional employee" is
one who is:

 engaged in predominantly intellectual work, and is varied, as opposed to routine mental,

mechanical, physical work
 involved in the exercise of discretion and judgment in his or her work
 the output produced or the result accomplished cannot be standardized in relation to a given
period of time
 requiring knowledge of an advanced type in a field of science or learning customarily acquired
by a prolonged course of specialized intellectual instruction and study in an institution of higher
learning, as distinguished from a general academic education or from an apprenticeship

In addition to these criteria, other requirements are frequently added

 professional registration requirements (tests, experience)

 activity in a professional society and other professional activities
 public service nature of the occupation
 adherence to a professional code of conduct and ethics

The FAA notes the following in the Aviation Instructor's Handbook

Professionalism...is achieved only after extended training and preparation...is based on study
and research...requires the ability to reason logically, accurately, and make good judgmental
decisions...cannot limit their decisions to standard patterns and practice...

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Finally, a profession is not seen as a stepping-stone to another career, but rather the pinnacle of
many years of disciplined study, research and examinations. Professionals are normally expected
to rise within the ranks of their peers.

Law and Ethics

Non-compliance with regulations can subject you to enforcement action. Pilots are responsible to
see that all regulations are upheld in flight operations.

A violation of ethics does not bring about punitive action from the government, but rather a
formal or informal reproof from others in the profession. Sometimes the informal reproof can be
more detrimental to one's career. A reputation earned as a compulsive "risk taker" can come back
to haunt that person. The aviation community is small and reputations stick.

Being a professional can be summed up as being completely dedicated to your field and devoting
as much time, energy, and care into your endeavor as possible. Fulfilling a checklist of the items
above does not automatically make anyone a professional, and the inability to complete one or
two of them does not automatically disqualify someone as a professional.

Most importantly, professionalism is found in an attitude.

Safety is an Attitude

Safety is an attitude, a frame of mind. It is being aware of your environment and actions at all
times

Safety is knowing what is going on, knowing what can injure, knowing how to prevent that
injury and then acting to prevent it. It requires intelligence and a reasonable ability to see, hear,
smell and think

Safety is not something you can take or leave alone. It is not an activity that you participate in
only when being watched or supervised

Safety is not posters, slogans or rules, nor is it movies, meetings, investigations or inspections

Ignoring safety does not indicate bravery, only foolishness. Conducting business in a safe and
correct manner is the mark of a wise person, not a timid one

In the end...
it is the attention to detail

64
 that makes the difference
It is the center-fielder's
extra two steps to the left,
the salesman's memory for names,
the lover's phone call,
the soldier's clean weapon.
It is the thing that separates
the winners from the losers,
the men from the boys, and very often
the living from the dead.

Please review this accident case study prior to the second day of CRM training.

Excerpts from the Transportation Safety Board of Canada (TSB) accident investigation help to
compose this case study. Data was obtained from the Cockpit Voice Recorder (CVR), the Flight
Data Recorder (FDR) and ATC radar tapes.

AVIATION OCCURRENCE REPORT

SKYLINK AIRLINES LTD.
TERRACE AIRPORT, BRITISH COLUMBIA
REPORT NUMBER 89H0007

SYNOPSIS

On September 26, 1989, a Fairchild Metro III was on a scheduled flight from Vancouver to
Terrace, British Columbia with two pilots and five passengers on board. The aircraft crashed one
quarter mile to the west of Terrace Airport while the crew was attempting to carry out a missed
approach in IFR conditions. The aircraft was destroyed by the impact and a post-crash fire. All
seven occupants were fatally injured in the crash.

The accident occurred at 0829 local time during the hours of daylight, an elevation of 713 feet
ASL. The aircraft was new to the fleet, receiving its Certificate of Airworthiness just five days
prior to the accident.

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History of the Flight

Skylink Flight 070 took off at 0651 from Vancouver on a scheduled domestic flight to Terrace,
B.C. The flight was scheduled to take-off at 0631; however when taxiing out for take-off, the
aircraft returned part way to the ramp for an undetermined reason and then returned to the take-
off position. This resulted in 20-minute delay in the departure time.

Meteorological Information

The Terrace terminal forecast (FT) issued at 0330 and valid at the time of the accident was sky
condition partially obscured, visibility two miles in smoke and fog variable to six miles in
smoke. The smoke was the result of slash burning in the local area.

Immediately following the occurrence, fog completely covered all of runway 15/33. The
helicopter pilot who located the crash site estimated that the fog bank was 300 feet thick.

Commencing the Initial Approach

There were three comments made by the captain regarding to the weather conditions while the
aircraft was en route to Terrace. The nature of these comments indicated that, at this stage of the
flight, the captain did not appear to be particularly worried about the Terrace weather and that he
expected few problems in this regard.

At 0811, the crew requested and received descent clearance to 15,000 feet. At 0812 the captain
briefed the co-pilot on the approach into Terrace. The briefing given was deficient in many areas,
in particular it did not include a complete description of the approach, the missed approach
procedure, the status of the aircraft navigation aids, or the speeds to be flown. In addition, the
Minimum Descent Altitude (MDA) was briefed to a Category C aircraft, when Category D
would have been more appropriate. The lack of company sops meant that there were no company
standards governing when and how such a briefing would be given.

On three occasions, the captain asked the co-pilot for information which had just been passed to
them over the radio or for clarification of the situation. At 0816, the captain asked about the
surface wind at Terrace even though this wind information had just been passed to them by the
Terrace FSS.

At 0818 the flight was cleared to hold at the KITIMAT NDB because a Lear Jet had missed their
first approach, and was commencing a second approach. At 0820, the Lear Jet discontinued their
approach and landed on runway 15. Flight 070 was then issued their approach clearance.

At 0820, the captain commented "What's going on?" Just after the radio calls between the Lear
Jet and the FSS regarding the Lear Jet's missed approach and between the accident aircraft and
the FSS regarding the holding clearance. At 0820, twice the captain questioned whether the Lear
Jet had landed even though the FSS had just indicated this when they had passed the approach
clearance.
66
In all these cases, the responses from the co-pilot indicated that he was fully aware of the
situation. All these queries from the captain illustrate a certain confusion in the mind of the
captain over the developing situation at Terrace and an inability to fully assimilate all the
information being presented to him. In addition, the fact that the Lear Jet had missed the
approach should have been enough to alert the crew to the fact that the weather might present a
problem and prompted them to revise their approach briefing.

At 0821, the aircraft crossed the KITIMAT NDB outbound and commenced the descent

For the approach. During the descent, at 0824 at an altitude of 6,800 feet, the landing gear was
selected down and the flaps were selected to one half.

At 0822, the crew altered their intended landing runway from 33 to 15 based on information
received from the FSS. The circling procedures for runway 15 are significantly different from
those for 33, involving a turn through approximately 190 degrees, and yet there was no
additional briefing to cover this. Again this is an indication of inadequate training or a lack or
standardization or both.

At 0822, the Lear Jet informed Flight 070 that there was a "hole" in the cloud over the localizer
transmitter which would allow them to descend and land on runway 15. The crew of Flight 070
had not voiced any concerns or made any preparations which indicated that they had considered
any possibilities other than landing at Terrace. This transmission from the crew of the Lear Jet
would have reinforced the impression in the minds of the crew that, although the weather
conditions were deteriorating, a successful landing was still expected. The fact that the crew still
did not brief for the possibility of a missed approach also indicates that the crew was expecting
to land.

This segment of the approach was poorly planned by the crew. They commenced the approach at
15,000 feet ASL, and the aircraft was well above the published approach altitudes throughout
this segment. Although these published altitudes are minimum altitudes, remarks made by the
captain clearly indicate that he was aware that the aircraft was high. He attempted to rectify this
problem by selecting flap early and by lowering the landing gear at 6,800 feet, presumably to
increase the drag and expedite the descent. As a result, the captain was constantly trying to
establish the aircraft on a more acceptable descent profile throughout the approach. He did not
succeed in doing this as the aircraft crossed the TERRACE NDB at 3,050 feet rather than the
published altitude of 2,200 feet.

Period from the TERRACE NDB to the Initiation of the Missed Approach

At 0825, the captain had to query the co-pilot about a radio transmission from the FSS regarding
the approach light setting on runway 15; at 0826 he asked what the reference speed was. In both
cases, the copilot responded with the correct information, indicating he was aware of the
situation.

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There were three occasions during this segment, at 0826, 0827, and 0827 when the copilot
uttered exclamations of surprise and concern. Although the weather conditions were not
specifically mentioned in these comments, it appears that all three were associated with the

Co-pilot's perception of the weather conditions and that he perceived these conditions to be
worse than he had anticipated. There was no response from the captain to any of these
comments, and the co-pilot did not pursue them further.

At 0826:34, 0827:19, and 0827:33, the captain called visual contacts with the ground. The
second visual call by the captain at 0827:19 was "OK, I got the button here" at approximately
one minute and 50 seconds after the aircraft reached MDA. Based on this timing, it is likely that
the button referred to was the button of runway 33 or 27.

The aircraft was observed on what corresponded to a downwind leg for runway 15 at about 500
feet AGL (FDR shows 1,100 ASL), flying straight and level over the threshold of runway 27 at
140 knots.

Approximately 30 seconds after crossing the localizer transmitter, the aircraft commenced a
descent out of 1,100 feet. At 0827, the captain cautioned the co-pilot to get ready to extend full
flap. The aircraft further descended to 900 feet ASL with full flaps on an approximate one and a
half mile base leg for runway 15. The aircraft position at this time was likely in the vicinity of
the "hole" reported by the Lear Jet crew, and that the captain presumably descended through
this area for landing. Once again there were no indications the landing runway was visual and
in light of the other visual calls that had been made, it is logical to assume the crew would have
called visual with the landing runway. Throughout the approach there were no indications on
the CVR that the altitude alert system was being used.

Period Following the Initiation of the Missed Approach

Twenty-six seconds after full flap was selected, a missed approach was initiated. At 0828:49, the
captain called "gear up" and then repeated this call three seconds later despite a clear
acknowledgement by the co-pilot of "gear's coming up" between the two calls.

Within five seconds of the initiation of the missed approach, the aircraft began to accelerate and
a rate of climb of approximately 1,200 feet per minute was established. This rate of climb
quickly diminished to zero, followed by the start of a descent which quickly increased to 3,000
feet per minute.

The missed approach procedure was not carried out in accordance with the Canada Air Pilot
procedure. There was no verbal indication on the CVR that a positive rate of climb was
established prior to the gear-up selection. The FDR indicates that the altitude began to increase
six seconds after the initiation of the missed approach and four seconds after the gear-up call.
Given the FDR indications, it is unlikely that the crew had established a positive rate of climb
prior to the gear-up call.

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Another deviation from the correct procedure was a "flaps up" call by the captain rather than a
"flaps to one half" call. It is possible that the captain elected to give this call because the airspeed
was such that the flaps could be safely retracted to the fullup position. However, the co-pilot's
response to the flaps up call was "Flaps coming up to half." It appears that either the co-pilot was
complying with the checklist despite the captain's command or had complied with the captain's
command, but was indicating that the flaps were beginning to cycle toward the half position.

As the aircraft descended, the co-pilot called "descending" twice. A few seconds later,

The aircraft struck trees on the west side of runway 15 just inside the airport perimeter.

There are continuous trim beeps recorded on the CVR from 0828:54 to 0829:00 (17 beeps) and
from 0829:05 until impact (7 beeps). As the trim beeps during both of these intervals are
continuous, the trim input in the cockpit would have been continuously applied during each
interval and would have been in the same direction throughout each interval.

The first series of beeps commenced just following the gear-up calls by the captain and ended
just prior to the first descending call by the co-pilot. This first series of beeps occurred in
response to the power and configuration changes initiated during the first seven seconds of the
missed approach. As all these changes would have produced a nose-up pitching moment, it is
logical to assume that these 17 beeps were associated

With a nose-down trim input. This assumption is supported by the FDR data which indicate an
aircraft pitch change appropriate to a nose-down control input and a vertical acceleration of
slightly less than one "G".

The second series of trim beeps began as the captain acknowledged the first descending call by
the co-pilot. It is likely that, in response to this call, the captain began to apply nose-up trim. This
is also supported by the FDR data which indicates increasing positive vertical acceleration
during this interval. The fact that the aircraft appeared to have been in a nearly level attitude
when it initially struck the trees also tends to support the fact that a nose-up control input was
being applied.

During the last five seconds, the co-pilot twice informed the captain that the aircraft was
descending. There was some indication of concern in the voice of the co-pilot in the first call,
and this concern appeared to increase in the second call. Certainly, the second call was more
emphatic than the first. The captain's response to the first call was a calm, level "OK". There is
no indication in this response that the captain was aware of the gravity of the situation.

69
At the time of the first descending call, the aircraft was at an altitude of 940 feet ASL, or
approximately 160 feet above the tops of the trees, and descending at approximately 900 to
1,000 fpm. It is possible that a large, aggressively applied elevator input at this time might
have prevented the aircraft from striking the trees; however, the captain did not do this and
therefore was likely unaware of the developing situation. The only action on the part of the co-
pilot at this time which might have prevented the accident would have been to seize control of
the aircraft and apply the necessary elevator input. The co-pilot did not take his action and
therefore was not fully aware of just how critical the situation was and/or was not assertive
enough in reacting to the situation.

Related Factors

Captain's History

The captain and the co-pilot flew together on Sunday 24 September and Monday 25 September.
On arrival back in Vancouver at 2010 on the night of the 25th, the captain was described as
exhausted by a company technician. In addition, he declined an invitation to join his co-workers
for a coffee at a local restaurant, stating that he was tired and that he had a long day ahead of
him. The company Operations Manager stated that he spoke with the captain on the morning of
the accident around 0600 and that the captain appeared to be in good spirits.

Although it could not be definitely determined, it is likely that the captain left the airport at about
2100 after his flight on the 25th, and, assuming that he went straight home, he would have
arrived there around 2200. It was determined that he attended a pre-flight briefing at 0545 on the
morning of the accident. He would have left home at about 0445 in order to arrive at the airport
at 0545, so that it is likely that he got up at 0415. Based on this schedule, he could have had a
maximum of just over six hours rest.

Attitude Reference Systems

The other Metro III aircraft that Skylink had been operating was equipped with a basic attitude
indicator (AI) for pilot attitude reference whereas the accident Metro III was equipped with a
more complex flight director (FD) system. Neither the crew nor any other of the company pilots
had received any formal training in the use of this FD system, and there was no reference
material available at the company to allow the pilots to study the system. The crew had flown the
accident aircraft on this same scheduled route on the two previous days. These trips would have
been the only exposure that the crew would have had to the operation of the FD system.

There were significant differences between the AI and FD systems. The FD system had features
which the AI system did not: command bars; an altitude scale tied to the radio altimeter; a glide
slope marker; an inclinometer; a decision height light; and a localizer scale and runway symbol.
In addition to the above differences between the two Metro III aircraft, the accident aircraft was
equipped with an autopilot, a radar altimeter, and an altitude alert system. There was no
information or training provided by the company on these systems.

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The most significant difference between the two aircraft was in the method of presentation of roll
attitude information. On the FD system, the bank reference was a fixed scale located on the outer
part of the face of the instrument and the bank pointer rotated on the inside of this scale to
indicate the roll attitude. On the AI system, the bank reference was a rotating scale locate on the
inside of the instrument and the bank pointer was a fixed index on the outer face of the
instrument. The bank reference for the same roll attitude was taken from different locations on
the two instruments.

The crew's flying in the past few months had been almost all on the other Metro III aircraft
which were equipped with an AI which displayed roll attitude in a different manner from the FD.
As a result, the crew would have been used to the AI roll display. There could have been a
tendency for the captain to revert to the system with which he was most familiar, specifically the
AI system, during the stressful and high workload circumstances of the missed approach.

Distraction

In the Aircraft Flight Manual (AFM), the pilot flying is required to set the power during a balked
landing procedure and also ensure that the engine limitations are not exceeded. The AFM
requirement for the captain to set the power during the missed approach procedure provided a
distracting influence at a critical stage of flight.

It is possible that, despite the AFM procedure, the co-pilot tuned the engine power after the
power levers were advanced by the captain. If this was not the case, the captain not only had to
fly the aircraft and initiate the co-pilot's actions, but he also had to ensure that the engine
operating limitations were not exceeded while he advanced the power. This would have been a
significant distraction at a critical phase of flight and could have diverted or partially diverted the
captain's attention from the task of flying the aircraft. This may indicate the captain was so
occupied with flying the aircraft at this time that the co-pilot's acknowledgement to "gear-up" did
not register.

Company Operations

The company did not employ Standard Operating Procedures (SOP's), nor were they required to
do so. It was determined that the company was in the process of drafting a set of sops; however,
company personnel were unable to indicate the exact status of these sops. Interviews with
company pilots indicated that there was often confusion among the pilots about what operational
policies or directives were in place. Pilots indicated that they would often get different direction
from different supervisory personnel.

Spatial Disorientation - Somatogravic Illusion

If one considers an aircraft flying straight and level and accelerating along the direction of flight
because of an increase in power, for example, then the direction of the inertial force due to the
acceleration is to the rear of the aircraft and for the purposes of this discussion can be assumed to
be along the longitudinal axis of the aircraft. This inertial force combines with the force of
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gravity to produce a resultant which is inclined to the rear of the aircraft. If this resultant is then
used by the pilot as the vertical reference, then the pilot will incorrectly sense that the aircraft is
in a nose-up attitude. If the pilot then trims or eases forward on the control column to correct for
this nose-up perception, the nose of the aircraft will drop and the airspeed will increase. This
change in attitude will change the direction of the resultant force vector in such a manner as to
maintain and perhaps magnify the illusory perception of a nose-up attitude.

As a result of the acceleration and pitch changes of the aircraft which occurred during the initial
12 seconds of the missed approach procedure, the captain likely experienced a somatogravic
illusion which resulted in a significant difference between the pitch attitude which he perceived
and that of the aircraft. The captain applied pitch trim and possibly elevator based probably on
his perception of the aircraft pitch which resulted in a descent toward the terrain. The descent
was recognized by the co-pilot, and corrections were made by the captain to arrest the descent;
however, these control inputs were not sufficient to prevent the aircraft from striking the trees.

AVIATION OCCURRENCE REPORT

SKYLINK AIRLINES LTD.
TERRACE AIRPORT, BRITISH COLUMBIA
REPORT NUMBER 89H0007

From the information provided, please give your opinion on:

1. What was the cause of this accident?

_______________________________________________________________

2. What do you think of the Captain's behavior? What were his influences?

_______________________________________________________________

_______________________________________________________________

3. What do you think of the First Officer's behavior? Any influences?

_______________________________________________________________

4. What lights lit up on the Situational Awareness Master Caution Panel and at what time during
the sequence of events? Were they strong enough cues?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

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_______________________________________________________________

5. Was it just the flight crew at fault in this accident?

_______________________________________________________________

_______________________________________________________________

6. What would you do differently had it been you in either of those seats?

______________________________________________________________

7. Comment on the usage of the 5 CRM Principles in this accident.

Inquiry

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Advocacy

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Conflict Resolution

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Decision Making
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_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Critique -

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Sky-Links in the Chain of Events

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

New Aircraft

Attitude Indicator was different and opposite to the one familiar to the flight crew; other
unfamiliar instrumentation with no company training. This was the third time that the flight crew
had flown this aircraft. The aircraft was over 12,500 lbs, which was heavier than the other
company Metro III. The company was granted "grouping authority" by Transport Canada, which
as a result of this accident, can no longer be granted to aircraft in different weight categories. The
maneuvering speed of 140 knots would have kept the Metro III in Category C "minimums",
however the aircraft was flown at a higher speed during most of the approach, so Category D
"minimums" would have been more appropriate.

Delay in Departure

A 20 minute delay was incurred before takeoff. The report gave no reason for this delay, but the
aircraft sat for 20 minutes and did not return to the ramp. We are left to speculate on the reason
for this. It also placed the crew 20 minutes behind schedule.

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Weather Conditions

The flight crew was familiar with the Terrace airport and approach. Complacency could have
been a factor in not assessing the weather as limiting, or in considering the area slash burning as
a factor in the visibility limitations.

Lack of SOPs

The approach briefing was initially inadequate, and was not updated with the change of runway.
The initial approach began at 15,000 ft, when a shuttle descent to 5,500 ft was indicated on the
CAP procedure. The aircraft was 800 feet high over the FAF, 5 miles away from the MAP. The
altitude alert system, radar altimeter, or autopilot was not utilized by the crew, however they
received no company training on these systems.

Violation of Air Regs

The aircraft flew below the Minimum Descent Altitude (MDA) without having established
visible contact with the intended landing runway. In fact, the aircraft was less than 200 feet AGL
on a one and a half mile base leg for runway 15.

Company Procedures Inadequate

Skylink did not provide adequate training for the flight crews on the new aircraft systems. There
were no sops in place, and no clear definition of cockpit duties. The flight crew's schedule did
not allow for adequate rest. The company allowed flight crews to break Air Regs - we can only
assume that this was not the first time the captain had broken minimums and it is possible the
company culture expected such. There may have been company pressure for the flight crews to
keep to schedule. The pilots reported that they would get different direction from different
supervisory personnel.

Captain's Confusion and Mindset

On several occasions, the captain did not mentally process radio information, and sought
clarification with the First Officer. The Lear Jet that missed their first approach, then got in after
abandoning their second approach could have given the captain a false sense of security about
his landing possibilities. The captain fell for the "sucker-hole" trick. The reason why the captain
made the decision to switch from runway 33 to runway 15 was not reported, but we still must
question if it was sound.

The Captain called for gear up twice within a few seconds, therefore he either forgot, or did not
register the First Officer's reply. He called for flaps up when the call should have been one half.
The Captain most likely was overloaded during the unanticipated missed approach and resetting
max power, and possibly confused by the unfamiliar attitude indicator.

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The Captain did not establish a positive rate of climb. Most likely, he experienced a
somatogravic illusion of excessive nose-up attitude, hence the 17 nose-down trim input just prior
to the accident. The Captain did not react appropriately to the First Officer's "descending" call
even though the situation was critical.

Fatigue may have affected the captain's behavior and lack of communication skills.

Non-assertive First Officer

The First Officer made weak exclamations about the visibility, but did not communicate his
concern - if any - to the captain about their chances of landing. He did not clarify the inadequate
approach briefing, or request an updated plan on their circling procedure. It was never verified
who would monitor the instruments, and who would be visual, or what their respective roles
were in the event of a missed approach. The first officer did not question the captain on his
apparent confused state of mind as a possible subtle incapacitation, nor did he compensate for the
captain's inadequate climb attitude during the missed approach. The First Officer seemed aware
of all proceedings, yet did not act on the critical cues when they presented themselves.

A Conceptual Model of Human Factors

SHELL Model

The SHELL Model provides a conceptual framework to help us to understand Human Factors. It
illustrates the various constituents and the interface, or points of interaction, which comprise the
subject. The study of Human Factors can be broken down into four conceptual categories:

Software - documentation, procedures, etc.

Hardware - machinery, equipment

Environment - both internal and external to the workplace

Liveware - the human element

Interaction between human beings and the other elements of the SHELL model are at the heart of
Human Factors which involves interaction between:

Liveware - The Liveware is the hub of the SHELL Model. This is the most valuable as well as
the most flexible component in the system. The edges of this block are not simple and straight,
so other components of the system must be carefully matched if stress and eventual breakdown
in the system are to be avoided.

The Human Factor elements under the Liveware category include those relating to the
psychological state and the physical well-being of operational personnel themselves. (The

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Liveware element (human) should not be confused with the Liveware-Liveware interface which
deals with interpersonal contacts.)

Successful Liveware (Human) Skills:

 Recognition/coping; disorientation, stress

 Fatigue prevention and coping techniques
 Pressure effects
 Self-discipline/control
 Perception
 Attitudes and the application of knowledge
 Exercise of judgment

Liveware-Hardware - This Liveware-Hardware interface is concerned with ergonomics, such

as seat designs, panel displays, location of switches and controls. This interface provides routing
by which energy and information are exchanged between the hardware and the human.

The L-H interface addresses the mismatch in the human-machine design relationship and the
source of confusion and error caused by poorly designed or located equipment.

Successful Liveware-Hardware Interface Skills

 Scanning
 Detection
 Decision-making
 Cockpit adjustment
 Instrument interpretation
 Situational Awareness
 Manual dexterity
 Selection of alternative procedures
 Reaction to breakdown/failures/defects
 Emergency warnings
 Workload, physical allocation of task
 Vigilance

Liveware-Software - This Liveware-Software interface encompasses the non-physical aspects

of the system, such as procedures, manuals, checklist layout, and computer programs. Problems
in the L-S interface are often less tangible than those associated with the L-H interface and more
difficult to resolve.

The L-S interface addresses issues that cause delay and error while seeking vital information.

Successful Liveware-Software Interface Skills

 Computer literacy
 Self-discipline and procedural behavior
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  Interpretation
 Time management
 Self-motivation
 Task Allocation

Liveware-Environment - Encompassed within the Liveware-Environment are the factors which

designers of aviation systems have no control, such as temperature, radiation, weather and air
pressure. In addition, the aviation system operates within the context of broad political and
economic constraints and the system must be designed to survive and prosper within this
element.

The L-E interface is associated with environment factors (noise, heat, lighting and vibration) and
the disturbance of circadian rhythms. In addition, the L-E interface encompasses effects of the
political, social and economic environments and their impact on operational efficiency.

Successful Liveware-Environment Interface Skills

 Adaptation
 Observation
 Situational Awareness
 Risk management
 Stress management
 Prioritization and attention management
 Coping/emotional control
 Decision-making

Liveware-Liveware - The Liveware-Liveware interface is concerned with leadership, crew

cooperation, teamwork and personality interactions. The L-L interface addresses the crew
performance in flight and the characteristics of the individual pilot or crew member. Flight crews
function as a group and so group influences can be expected to play a role in determining
behavior and performance.

In the L-L interface, the focus is on the interaction among people because this process affects
crew effectiveness. This interaction also includes leadership and command. Shortcomings at this
interface reduce operational efficiency and cause misunderstandings and errors.

Successful Liveware-Liveware Interface Skills

 Communication skills
 Listening skills
 Observation skills
 Operational management skills
 Leadership and followership
 Problem solving
 Decision-making

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Mismanagement in the SHELL Concept

Software

 Maps (difficult to read, colour contrast, too much information, etc.)

 Flight manuals (graphs, charts, etc.)
 Let-down plates (open to interpretation)
 Checklist layout

Hardware

 Instruments (hard to read, poorly located, inaccurate)

 Control knobs (difficult to reach, distinguish, operate)
 Seats (adjustment, comfort, harness nonstandard)
 Crashworthiness (40 G body, 9 G aircraft)
 Glass cockpit (people not good monitors)

Environment

 Weather limits (marginal)

 Runways (wires, trees, birds, vehicles, etc.)
 Helipads (debris, wires, trees, etc.)
 Departure (noise-abatement procedures)
 ATC (intimidate, too fast, nonstandard R/T etc.)

Liveware - Other People

 Passengers' expectations - a safe unexciting trip

 Customers, in charter operations - maximum value
 Employers attitude (staff/management) - maximize production
 Group influence - do as we do
 Instructor/student - complex relationship, role model

Liveware - Pilot:

 The clash between the trained pilot and their personality.

SHELL CONCEPT

SOFTWARE
HARDWARE
ENVIRONMENT
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LIVEWARE
LIVEWARE (Pilot)

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