Manual No.

: JCI-13

Jade Cargo International Co. Ltd. Crew Resource Management MANUAL (January 2008) Revision Status: Original

Approved By Flight Crew Training Section

Acknowledgement and credit for most of the content of this manual is hereby given to Emirates and SAA

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CRM Manual

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Table of Contents 1 CRM Training................................................................................................... 4 1.1 Introduction............................................................................................. 4 1.2 Courses...................................................................................................4 1.2.1 CRM Introduction Course.............................................................. 4 1.2.2 CRM Indoctrination Course........................................................... 4 1.2.3 CRM Update Course..................................................................... 4 1.2.4 CRM Recurrent Training................................................................5 1.2.5 CRM Upgrade Training..................................................................5 1.2.6 CRM Transition CRM.................................................................... 5 2 Modules Content.............................................................................................. 5 2.1 Threat and Error Management............................................................... 5 2.2 Culture.................................................................................................... 5 2.3 Automation.............................................................................................. 5 2.4 Leadership, Followership & Team Dynamics......................................... 6 2.5 Communication (Communication Styles & Conflict Resolution)............. 6 2.6 Problem-Solving & Decision Making.......................................................6 2.7 Cognition................................................................................................. 6 2.8 Stress & Alertness Management............................................................ 6 2.9 Situational Awareness............................................................................ 6 3 Threat and Error Management.........................................................................7 3.1 Introduction............................................................................................. 7 3.2 CRM Training in Aviation........................................................................ 7 3.3 Human Performance...............................................................................7 3.4 Evolution of CRM.................................................................................... 8 3.5 Human Error........................................................................................... 8 3.6 Human Factors In Design....................................................................... 8 3.7 The Error Chain...................................................................................... 9 3.8 Swiss Cheese......................................................................................... 9 3.9 Threat and Error Management............................................................. 10 3.10 Threat and Error..................................................................................10 3.11 Warning Flags.....................................................................................11 3.12 Avoid, Trap, Mitigate........................................................................... 11 4 Culture............................................................................................................12 4.1 Introduction........................................................................................... 12 4.2 National Culture.................................................................................... 12 4.3 Individualism/Collectivism (IDV)........................................................... 12 4.4 Effects on Crew Behaviors................................................................... 12 4.5 Uncertainty Avoidance (UA)................................................................. 13 4.6 Power Distance (PDI)........................................................................... 13 4.7 Organizational and Professional Culture.............................................. 14 5 Automation..................................................................................................... 14 5.1 Introduction........................................................................................... 14 5.2 Flight Deck Automation.........................................................................14 5.3 What to Automate................................................................................. 15 5.4 Fitts’ List................................................................................................ 16 5.5 The Automation Pyramid...................................................................... 17 5.6 The Irony of Automation....................................................................... 18

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5.7 The Automation Issue........................................................................... 18 5.8 Interfaces.............................................................................................. 18 5.9 Feedback.............................................................................................. 19 5.10 From an Aircraft Manufacturer............................................................ 19 5.11 Ergonomic Design Principles.............................................................. 19 5.12 Conclusion.......................................................................................... 20 6 Leadership and Team Dynamics................................................................... 20 6.1 Introduction........................................................................................... 20 6.2 Leadership............................................................................................ 20 6.3 Leadership Theory................................................................................ 21 6.4 Action-Centred Leadership................................................................... 21 6.5 Task...................................................................................................... 22 6.6 Team Building and Maintenance.......................................................... 22 6.7 Individual Development and Satisfaction.............................................. 22 6.8 The Role of Leader............................................................................... 22 6.8.1 Regulating Information Flow........................................................ 22 6.8.2 Directing and Coordinating Crew Activities................................. 23 6.8.3 Motivating Crew Members........................................................... 23 6.8.4 Leadership Styles........................................................................ 23 6.9 Cockpit Authority Gradient.................................................................... 25 6.10 Followership........................................................................................25 6.11 Team Dynamics.................................................................................. 26 7 Communication.............................................................................................. 27 7.1 Introduction........................................................................................... 27 7.2 Principles of Communication................................................................ 27 7.3 Communication Barriers....................................................................... 27 7.4 Communication Styles.......................................................................... 28 7.4.1 Assertive Behavior [a1]................................................................28 7.4.2 Aggressive Behavior [a2].............................................................29 7.4.3 Supportive Behavior [s1]............................................................. 29 7.4.4 Submissive Behavior [s2]............................................................ 29 7.5 Dealing with Aggression....................................................................... 30 7.6 Conflict Resolution................................................................................ 31 7.7 Problem Solving....................................................................................31 7.8 Compromising....................................................................................... 31 8 Problem Solving and Decision Making.......................................................... 32 8.1 Introduction........................................................................................... 32 8.2 Structured Decision Making.................................................................. 32 8.2.1 The Model “Footprint”.................................................................. 33 8.2.2 Providing “Seamless Integration”................................................ 33 8.3 A Problem-Solving Model..................................................................... 34 8.4 Time Management................................................................................ 35 8.5 The Jade Cargo International Decision-Making Model.........................36 8.6 Assess.................................................................................................. 37 8.7 Action.................................................................................................... 37 8.8 Manage................................................................................................. 37 9 Cognition........................................................................................................ 38 9.1 Introduction........................................................................................... 38 9.2 Models.................................................................................................. 38
Flight Crew Training Centre

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9.3 A Model of the Cognitive Brain............................................................. 38 9.4 Input functions.......................................................................................39 9.4.1 Senses.........................................................................................39 9.4.2 Attention.......................................................................................39 9.4.3 Divided Attention......................................................................... 39 9.5 Perception............................................................................................. 39 9.6 Processing Functions........................................................................... 40 9.6.1 Memory........................................................................................40 9.6.2 Sensory Memory......................................................................... 40 9.6.3 Short-Term Memory.................................................................... 40 9.6.4 Long-Term Memory..................................................................... 41 9.6.5 Flashbulb Memory....................................................................... 41 9.6.6 Central Processor/Decision-Maker.............................................. 42 9.6.7 Problems with Decision Making...................................................42 9.7 Conclusion............................................................................................ 43 10 Stress and Alertness.................................................................................... 43 10.1 Introduction......................................................................................... 43 10.2 Stress.................................................................................................. 44 10.3 Types of Stress................................................................................... 44 10.3.1 Acute Stress.............................................................................. 44 10.3.2 Episodic Acute Stress................................................................45 10.3.3 Chronic Stress........................................................................... 46 10.3.4 Sources of Stress...................................................................... 46 10.3.5 Life Stress..................................................................................46 10.3.6 Environmental Stress................................................................ 47 10.3.7 Cognitive Stress........................................................................ 47 10.4 Alertness............................................................................................. 48 10.5 Sleep Management.............................................................................48 10.6 Circadian Rhythms..............................................................................49 10.7 Stress and Alertness Management.....................................................50 10.8 Controlled Rest in the Flight Deck...................................................... 50 11 Situational Awareness..................................................................................50 11.1 Introduction......................................................................................... 50 11.2 Levels of Situation Awareness (SA)................................................... 50 11.3 Loss of Situational Awareness............................................................51 11.4 The Safety Window.............................................................................52 11.5 Situational Awareness and Error Management.................................. 53 11.6 Factors Affecting Situational Awareness............................................ 53 11.7 Communication and Shared Situational Awareness.......................... 53 11.8 Techniques for Better Situational Awareness Management...............54 12 Reference Notes.......................................................................................... 55

Flight Crew Training Centre

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CRM Manual

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1 CRM Training
1.1 Introduction
CRM training will be provided to all Jade Cargo International pilots in accordance with the policy contained within the Flight Operations Manual. CRM training provided to Jade Cargo International pilots is based on the requirements of the Chinese Civil Aviation Regulations (CAAC) and also meets the requirements of other regulatory bodies.

1.2 Courses 1.2.1 CRM Introduction Course
The Jade Cargo International CRM Introduction Course is a “CAAC” approved course conducted by Jade Cargo International staff. The course is not assessable. The Initial Course will be applied to all new pilots upon entry to Jade Cargo International. It is designed to introduce pilots who have received prior Human Performance training with other airlines to the concepts in use at Jade Cargo International. The required time is prior to transition training. It is designed to be complementary to the Transition Course (see below). The duration of the course is one day.

1.2.2 CRM Indoctrination Course
The Jade Cargo International CRM Indoctrination Course is a “CAAC” approved course conducted by Jade Cargo International staff. The course is not assessable. Most pilots joining Jade Cargo International will have completed Human Performance training as part of their license requirements; however CRM is viewed as specific to the airline. Therefore, the purpose of this course is to deliver Jade Cargo International perspective on CRM, expanding on the introductory course that has already been completed. The duration of the course is two days and is designed to be applied in isolation. The award of a Certificate of Completion and registration with Crew Records signifies successful completion of a course.

1.2.3 CRM Update Course
Jade Cargo International designates a three-year training cycle for CRM. This cycle is deemed to begin when a pilot completes his transition training with Jade Cargo International. To revalidate a pilot’s CRM training at the end of the cycle, a one day update course is conducted.
Flight Crew Training Centre

The candidates will conduct their own debrief. The role-plays are designed to allow upgrade candidates to use the decisionmaking tools. The course consists of a review of decisionmaking. This will be delivered during the ground school phase. leadership and team management. and team management skills.1 Threat and Error Management       Nature of human performance & error A model of human error Threat and error defined Latent threats Defenses Managing error 2. 1. They will be conducted in a cockpit environment and videotaped where appropriate for debriefing purposes. assisted by the facilitator.Page: 5 CRM Manual Date: January 2008 1.2.2.6 CRM Transition CRM Jade Cargo International includes a CRM component in all type transition courses. This has proven to be a powerful tool to reinforce the learning process. and a series of role-plays.2. 2 Modules Content 2.4 CRM Recurrent Training Jade Cargo International pilots receive a recurrent CRM component as part of the recurrent training package approved by the (CAAC).3 Automation   Impact of automation Appropriate use of automation Flight Crew Training Centre .2 Culture     The characteristics of National culture Influence of Professional & Organizational culture Defenses against multi-cultural threats Safety culture within Jade Cargo International 2. The course is tailored to suit the specific requirements of each aircraft type. 1. The content of this CRM component is designed by the Head of Training in co-ordination with the CRM Instructor.5 CRM Upgrade Training Jade Cargo International requires all candidates for Command training to receive an intensive CRM course.

6 Problem-Solving & Decision Making     Problem identification Time management Company decision-making tool Reference accidents with decision-making issues 2.Page: 6 CRM Manual Date: January 2008  Reference accidents with automation issues 2.8 Stress & Alertness Management    Types and sources of stress Fatigue & sleep management Jade Cargo International policy and procedures 2.9 Situational Awareness     Types of situational awareness Skills affecting individual situational awareness Loss of situational awareness Reference accidents with situational awareness issues Flight Crew Training Centre .4 Leadership. Followership & Team Dynamics     Command authority Leadership styles Team effectiveness Reference accidents with leadership issues 2.7 Cognition      Overview of cognitive functions Perception Senses Memory Limitations 2.5 Communication (Communication Styles & Conflict Resolution)     Model for effective communication Source of Conflict Communication role-play Reference accidents with communication issues 2.

2 CRM Training in Aviation The relationship between Human Factors. and with other humans. environment. MCC starts to cover the practicalities of multi-crew operations. 3. Regulators and industry have sought to reduce the human effect by the introduction of non-technical training to address the human issues. Every airline has the anecdotal CRM immune Captain. Traditionally the focus of CRM has been on attitude. whereas CRM is focused at the level of the individual airline and is normally a customized program.3 Human Performance Human performance can be considered as falling into three categories. This includes everything from the design of a tool. in part. HPL. Flight Crew Training Centre . 3. who complains that it is all a waste of time and does not apply to him. This is a general overview and broadly theoretical. Human Performance and Limitations refers to those aspects that relate to human involvement in aircraft operations. to the design of a checklist. to the amount of air recirculation that is required in a pressurized aircraft. Human Factors or ergonomics is the broad science that covers human interaction in the workplace. The safe and efficient management of an aircraft requires a balance of both technical knowledge and skills. Despite improvements in technology. Threat and error management is at the core of current CRM practice. design and engine reliability. which has typically resulted in only temporary changes in behavior and is not universally accepted by the pilot population. completion of a Multi-Crew Co-ordination (MCC) course prior to airline employment and for an airline to run an approved Crew Resource Management (CRM) program for all phases of training. Regulators require knowledge of Human Performance and Limitations (HPL) for license issue. home. Human Factors still have a critical influence on the accident rate. with an understanding of the limitations of the human operator.Page: 7 CRM Manual Date: January 2008 3 Threat and Error Management 3. skill and attitude.1 Introduction Investigation of commercial airline accidents has identified that a significant proportion of these are due in some way to a human element. MCC and CRM is most easily described as one of specialization. This is due. to the brightness required of an electronic display. knowledge. because it encompasses all other areas of the discipline.

and humans have good error-correcting mechanisms to mitigate the effects of these errors. Flight Crew Training Centre .4 Evolution of CRM      1st Generation concentrated on attitudes and personal management style (Cockpit RM) 2nd Generation introduction of modular training. 3.Page: 8 CRM Manual Date: January 2008 It is now recognized that attitudes are difficult to change. Errors are defined as unintentional deviations from required behavior and are to be expected in everyday life with unavoidable regularity. Not only is this more predictable and measurable. 3. 3.term basis in the presence of contradictory influences. Violations refer to intentional noncompliance. Human Error) has developed a model of human error that classifies these according to the circumstances under which they occur. but avoiding the trap of undue emphasis on attitudes. Error cannot be avoided so the design must ensure that the most serious mistakes are prevented by trapping mechanisms and clearly forewarned by use of appropriate and timely feedback. J. Reason is the acknowledged expert on human error. which cannot be tolerated in the aviation industry. with aviation focus (Crew RM) 3rd Generation attempt at integration with technical training. encompassing the best of previous generations. focus on specific skills 4th Fourth Generation developed alongside the introduction of Advanced Qualification Program (AQP) and LOFT 5th Fifth Generation introduced the concept of error management This has now evolved into “threat and error” management. 1990. especially on a long. Most of these errors are small. but pilots are predisposed to accept knowledge and tools with which to improve performance. In particular this means designing for error. Current CRM thinking focuses on training knowledge and skills.6 Human Factors In Design The principle need for Human Factors in design is to account for individual differences and to produce a system that is better matched to real human performance.5 Human Error Reason (Reason.

the holes will line up. This does not mean that accidents can no longer occur. Each layer in itself is a rather flimsy defense. of which the operating crew are the last link. possibly as early as the design stage of a product. Without assigning a principle cause.Page: 9 CRM Manual Date: January 2008 3. Others were management failures. These are what Reason call “latent threats”. Flight Crew Training Centre . but placed together they form a robust wall.7 The Error Chain The introduction of automated systems has made it virtually impossible for a frontline operator to cause an accident in isolation. the last line of defense. some of the factors were as follows:         Lengthened 737-400 entered service requiring increased thrust Existing engines approved for higher thrust without flight-test Type certification granted Operator differences training approved Fleet operated with mix of different style engine instruments Significance of other operator’s engine defects not identified Engine malfunction during accident flight Incorrect identification of engine malfunction All of these factors were required for the accident to take place. Reason used Swiss cheese. occurring years ago on the drawing board. The holes in the cheese are the flaws that exist in each individual layer of defense. It was but it is not an isolated case. Occasionally. it snaps. Some were latent failures. the British Midland 737-400 that crashed in 1989 was a classic example of an error chain. a combined layer of defenses that can act as an effective shield. Reason has likened the multiple layers of defenses to slices of cheese. The accident is caused by the completion of a chain of events – the “error chain”. The crew was the last chance of avoiding this accident. Rather. In order to illustrate better the concept of latent threats. but when the mouse tries to take the bait. Accident investigation has therefore become much more complex with additional factors to consider. For example. the accident does not occur. There are similar events unfolding all around us in aviation. In isolation it is insignificant. If they can break the chain. leaving an opening in the defensive wall and allowing an accident to happen. 3.8 Swiss Cheese In the example above it might appear that this was one very unlucky scenario. existing conditions that might remain dormant for years. that the causes of most recent accidents have been found to be omissions or errors that occurred remotely from the operator who suffered the loss. A simple example of a latent threat is a mousetrap.

The latest statistics indicate that one accident occurs per million aircraft departures.) Threats .9 Threat and Error Management Aviation is a hazardous industry but it is not a dangerous one. at any level.10 Threat and Error Threat is defined as an influence. 3. A small percentage (8%) results in additional errors. The last layer of defense is the flight-crew. Some examples of common threats are:      Adverse weather Terrain Airport conditions Aircraft malfunctions Automation events. Threats and errors are unavoidable.Page: 10 CRM Manual Date: January 2008 We cannot have a foolproof layer of defense. Regulators etc are threats to the crew. external to the flight-deck that requires action to ensure safe operation. but as long as the holes do not line up. Management. performing a checklist from memory. because despite the risks. (Errors made by other people ATC. in fact almost half of all errors go totally undetected by the crew. The safety record in the airline industry is held in high regard. but they are well managed within a system that has countless checks and balances. Errors made by the crew during normal and nonnormal operations may require intervention to prevent an unsafe situation arising. flying to close to a thunderstorm Violations – intentional non-compliance – i. safe operations are the norm. the start of an accident chain.External influences Errors . 3. Engineering.Internal influences Safe operation depends on management of those threats and errors that cannot be completely eliminated.e. Most errors committed by the flight-crew are inconsequential. wrong altitude selection on MCP Communication – missing information or misinterpretation Decision – elective decision by crew that unnecessarily increases risk – i. There are four broad classifications of flight-crew errors:      Procedural – appropriate procedure followed but incorrect execution – i. the accident chain is broken. and it is up to us to break the chain. Line Operational Safety Audits (LOSA) observations have shown that over 70% errors are inconsequential.e.e. Flight Crew Training Centre .

Page: 11 CRM Manual Date: January 2008 Over 20% of the time though.11 Warning Flags Aircraft accidents tend to have many similarities. Trap. 3. 3. nine common factors existed. such as an unstabilized approach. research has shown that flight-crew error led directly to an undesired aircraft state. We have already determined that we cannot expect to work in a risk-free industry. The NTSB identified in 1994 that of 37 commercial aviation accidents reviewed. presence of several of these warning flags should alert us to the possibility of danger. the crew failed to see the threats and usually compounded them by making additional errors. and correct them Mitigate Identify errors that have occurred and limit the damage Flight Crew Training Centre . great care should be taken to avoid compounding the problem by making additional errors. However in all cases. These have been termed warning flags.12 Avoid. Mitigate How we deal with these threats and errors depends on the phase of flight:    Avoid Identify potential threats/errors in advance and avoid them Trap Identify current threats/errors that are developing. The flags can be loosely divided into threats and errors: Threats Captain flying Experience gradient First duty day Time since awake Operational stress Errors Procedural error Poor tactical decision Failure monitor/challenge Improper checklist use Those accidents described below and covered during Jade Cargo International CRM courses have many of these warning flags clearly identifiable. The purpose of the NTSB review was to enable flight-crews to recognize that when multiple warning flags exist. However.

4. 4. aunts and grandparents) which continue protecting them in exchange for unquestioning loyalty. The last two do not typically apply to pilot groups. collectivism.4 Effects on Crew Behaviors     High IDV – Personal gain and protection of oneself are the main priorities. regarding all societies in the world. Hofstede carried out the principle research in this area1. (which are predominantly male).3 Individualism/Collectivism (IDV) Individualism on the one side. Again. such as organizational. Jade Cargo International has identified that cultural issues represent a significant difference from a typical airline CRM program. Uncertainty Avoidance. professional and safety culture. The word “collectivism” in this sense has no political meaning: it refers to the group. He identified five dimensions where cultures differ. is the degree to which individuals are integrated into groups. having left their country of domicile for economic advantage. 4. A compromise between the two extremes is what is desired for safe operation Flight Crew Training Centre . we find societies in which people from birth onwards are integrated into strong. often extended families (with uncles. Expatriates are typically of a more individualist nature. not to the state. This chapter identifies the key concepts that differentiate national cultures and also examines the influence that may occur as a result of particular sub-cultures. Power Distance. cohesive in-groups. the issue addressed by this dimension is an extremely fundamental one.1 Introduction Due to the diverse nature of the workforce. On the collectivist side.2 National Culture Most discussion about culture tends to centre on the effects of national culture.Page: 12 CRM Manual Date: January 2008 4 Culture 4. On the individualist side we find societies in which the ties between individuals are loose: everyone is expected to look after him/herself and his/her immediate family. The five dimensions are Individualism/Collectivism. “Look after number 1” regardless of the effect on the operation Low IDV – Focus is on the gain for the collectivist whole regardless of personal inconvenience or benefit. versus its opposite. Long-term/ Short-term orientation and Masculinity/Femininity. The remaining three dimensions are discussed below.

safety and security measures. they try to have as few rules as possible. People within these cultures are more phlegmatic and contemplative. People in uncertainty avoiding countries are also more emotional.5 Uncertainty Avoidance (UA) Uncertainty avoidance deals with a society's tolerance for uncertainty and ambiguity.6 Power Distance (PDI) Power-Distance is the extent to which the less powerful members of organizations and institutions (like the family) accept and expect that power is distributed unequally. This represents inequality (more versus less).   4. but defined from below. but some are more unequal than others. Effects on crew behaviors:   High PDI – can lead to an autocratic leadership style by the Captain – a steep cockpit gradient Medium PDI – a consultative style where input is sought but the final decision is made by the Captain Flight Crew Training Centre . and different from usual. as much as by the leaders endorse a society’s level of inequality. Uncertainty avoidance is the extent to which members of a culture feel threatened by the uncertain or unknown. Effects on crew behaviors:  High UA Rigid adherence to procedures and SOPs. and motivated by inner nervous energy. are extremely fundamental facts of any society and anybody with some international experience will be aware that all societies are unequal. “there can only be one Truth and we have it”. Power and inequality. and not expected by their environment to express emotions. of course. and on the philosophical and religious level by a belief in absolute Truth.Page: 13 CRM Manual Date: January 2008 4. uncertainty accepting cultures. Unstructured situations are novel. and on the philosophical and religious level they are relativist and allow many currents to flow side by side. It indicates to what extent a culture programs its members to feel either uncomfortable or comfortable in unstructured situations. “I know better than the people who wrote the books” style of operation. not from above. unknown. It suggests that the followers. are more tolerant of opinions different from what they are used to. it ultimately refers to man's search for Truth. Medium UA is optimum for the flight deck. The opposite type. Low UA Disregard for SOPs and procedures. “A rule for every situation” approach to flying and a marked reluctance to deviate from SOPs even if the situation demands it. Power distance can be related to cockpit gradient. surprising. Uncertainty avoiding cultures try to minimize the possibility of such situations by strict laws and rules.

it is those automatic functions relating to flight path control and navigation with which we are primarily concerned. either physical or cognitive. (Norbert Wiener) 5.2 Flight Deck Automation Early jet transport aircraft had a crew of five or six on the flight deck. against a conflicting trend. or an organizational culture can prevail. and also provide some guidance for the management of automation issues. navigators and flight engineers. In Jade Cargo International we have a structure that emphasizes “Safe and efficient”. It is not the policies themselves that are a potential problem. though the Air Safety Report and Confidential Human Factors Reporting schemes.1 Introduction Automation is defined as the replacement of a human function. not what we thought we told them to do. This chapter investigates the benefits and the traps associated with automation. there can be anomalies where a professional group. In particular. Although there are numerous examples of the introduction of automated systems on the flight deck. 5. promotion of a safety culture might be encouraged for the pilot group to resist a perceived weakness in any national characteristic.7 Organizational and Professional Culture Although national culture tends to dominate in most circumstances. this may or may not conflict with a Company’s management style.Page: 14 CRM Manual Date: January 2008  Low PDI – decisions arrived at by consensus with all crew having equal Input 4. This is endorsed by an open-reporting policy for safety and human factors issues. Furthermore. such as pilots. The aircraft manages and self-monitors many of the functions that were previously in the domain of the other crewmembers. but the pilots’ perceptions of the Company’s intent. The reason that this has been acceptable is that the residual workload has remained at a manageable level. including radio operators. by a machine function. Flight Crew Training Centre . Improvements in technology (automation) have resulted in only the two pilots remaining as required crew. 5 Automation The problem with computers is that they do what they are actually told to do. An “On time departure” policy or a “Minimum Fuel” policy might lead to unnecessary pressure to compromise.

“Dekker and Woods” highlighted the apparent benefits of automation against the real effect: Table 1: Benefit of Automation: Intended Benefit Better Results. The latter will not be discussed here. 5. The problem with automation is therefore how man and machine interact – the interface. often at the wrong time Difficulties with Situation Awareness New knowledge and skills required New error associated with communication The table above illustrates how the intended benefits of automation will not be achieved without additional effort.3 What to Automate Prior to deciding on what to automate. In practice this does not always happen. it would be a good idea to determine the comparative advantages of humans and machines. roles of humans change Creates more cognitive work. In particular.” This may be the intention but the statement doesn’t provide the whole story. it is the understanding of the automation that causes concern. same system (substitution) Reduction in workload Focuses user attention Less knowledge required Reduces error Reality Transforms practice. Flight Crew Training Centre . There are (system) performance issues associated with the introduction of automation.Page: 15 CRM Manual Date: January 2008 Why automate? “Automation brings increased safety. engineers automate what they are able to automate and the rest is left for the human operator to manage. The issue of automation is not whether a machine is capable of doing the job. accuracy and reduced costs. not to mention the human (social) effects. it is that humans are still required for the part of the task that cannot be automated.

Poor at at detecting messages in noise. Good quantitative assessment.Good inductive. Fitts identified those skills where machines exceeded and those where the human is better.4 Fitts’ List In the 1950s. detecting messages in noise. Poor program. 1986. Poor spoken material. accurate. inaccurate. The “Fitts” list’ is still valid today: Table 2: Fitts’ list3 Skill Speed Power Output Consistency Information Capacity Memory Machine Much superior Superior in level and consistency Ideal for repetitive activity Multi-channel. fast. Most notable of the differences from a flight-deck perspective is that humans are poor monitors and good at accepting revised plans. difficult to re. Poor at pattern assessment Wide energy ranges. J & George. Whiteside. User-derived impact analysis as a tool for usability engineering) 5. error correction Good at error correction Specialized. access restricted and formal Human Comparatively slow Comparatively weak Unreliable.Page: 16 CRM Manual Date: January 2008 “Engineering is not the process of building a perfect system with infinite resources. narrow range. some multi-function Sensing Perceiving Good at coping with Poor at coping with variation in variation in written & written & spoken material. slow communication Better for principles and strategies.” (Good. easy to re program. fast communication Ideal for literal reproduction. access versatile and innovative Reasoning Good deductive. Spine. Rather. slow. P. The principle task allocated to humans on the flight deck involves monitoring for which we are not ideally Flight Crew Training Centre . engineering is the process of economically building a working system that fulfils a need. M. T. subject to learning and fatigue Single-channel.

Overall result is reduced workload. The principle pilot skill on modern generation automated aircraft knows which mode of automation is most appropriate to the task. Although in some systems. so the overall workload is drastically reduced. Autopilot with fully managed modes (LNAV/VNAV): The pilot no longer has to calculate closing rate information or fly the aircraft.5 The Automation Pyramid Research literature on automation talks about levels of “supervisory control”. including when to turn it off! Flight Crew Training Centre . These four levels of automation are available to us to use as appropriate for the situation. Consider the case where an aircraft is on an intercept heading for an instrument approach:  Manual flight without flight director: requires the pilot to manually fly the aero plane and monitor the closing rate of the inbound track and adjust accordingly. Monitoring or supervising is the principle role left to the pilot. Pilots will dynamically move between levels.Page: 17 CRM Manual Date: January 2008 suited. it is possible to differentiate seven distinct levels. an area of weakness in interface design. according to any change in tactical goal. vigilance and complacency may become issues. – This is a high workload situation. This refers to the level of monitoring and decision-making required by the operator.    The potential problem that we face is that if we operate for too long in the fully automated regime. this refers to how far removed the pilot is from the actual job of flying the aircraft. although “fly-by-wire” will still be assisting. There is a reduced cognitive load. with different cognitive skills required. The automation on the other hand may need to be re-programmed for last minute changes. Note that the pilot is still actively involved in the task and through FCU/MCP manipulation retains situational awareness of the flights progress. such as nuclear power-plant control rooms. In its current mode the aircraft will intercept the inbound course. in practical aviation terms we have identified four levels of automation. resulting in further reduced workload. In the aviation scenario. but the pilot is relieved of the task of manual flight. Autopilot with basic/selected modes: The cognitive demand is as above. 5. but the system must be programmed to give the correct guidance. It also becomes more difficult to revert to more basic modes with reduced automation. Manual flight with flight director: the pilot now has a reduced cognitive load as he no longer has to interpret closing information.

Unfortunately. having been unable to completely replace the pilots with automation. communications and monitoring. It has already been noted that the introduction of automated features changes the role of the pilot. The report identified links between automation and situational awareness. If we do not fully understand the system we are not able to anticipate the system response or evaluate its performance. The FAA identified this weakness and commissioned a study that reported in 1996. the pilots still have to intervene at critical moments when the automation cannot cope. as routine automation takes away the opportunity to rehearse basic flying skills the skill and practice required by the pilots to manage these events is lacking. Studies have revealed that “mode” errors are among the most common on advanced aircraft. The major problem that has been identified with automation is due to a lack of understanding. Habsheim etc).8 Interfaces The blame for this lack of understanding is not necessarily with the pilot. Cali.6 The Irony of Automation The irony of automation is that. the FAA recommended that operators’ manuals should provide “clear and concise guidance” on conditions when the auto-pilot or auto-throttle will or will not engage. 5.Page: 18 CRM Manual Date: January 2008 5. 5. For this new knowledge and skills are required. In particular. The key issue is with the design of the interface: how the pilots and the automation communicate. The highest workload situations tend to be left un-automated. it is important to address the issues identified by accident reviews. Using automation requires us to:    Understand each mode before selection Anticipate how the aircraft will react to the mode change Evaluate whether the desired effect has been achieved Numerous accidents have resulted as a result of pilot inputs that were not appropriate for the correct completion of the desired task (Nagoya. will disengage or will revert to another mode.7 The Automation Issue Now that the benefits and drawbacks of automation have been identified. Flight Crew Training Centre .

Consequently. The Jade Cargo International procedure’s of calling FMA changes is designed to counter this threat. 5. Boeing and Airbus flight decks incorporate intuitive.9 Feedback “Norman” contests that the real issue with automation is due to poor or inappropriate feedback. These cues reinforce situational awareness and help keep the flight crew fully aware of changes occurring to the airplane’s status and flight path during all phases of automated and manual flight. feedback results in a reduction of situational awareness. Understandable error messages Error prevention These principles apply to computerized systems as much as day-to day items. Feedback is also required for monitoring normal system status change.11 Ergonomic Design Principles The following design principles have been identified as necessary for producing a usable interface:        Intuitive . A lack of.Page: 19 CRM Manual Date: January 2008 5.10 From an Aircraft Manufacturer Appropriate degree of automation. The failing of the man-machine system is because the pilot is no longer “in the loop”. the flight-crew member responsible for safe operation of the airplane. Boeing and Airbus flight decks are designed to provide automation to assist. or subtle. but not replace. Flight-crew errors typically occur when the crew does not perceive a problem and fails to correct the error in time to prevent the situation from deteriorating. 5.Logical layout of controls and displays Use of natural command language (Windows v Dos) Minimal user memory load (prompt keys) Consistency Feedback Clear. These systems support instrument displays with visual and tactile motion cues to minimize potential confusion about what functions are automated. easy-to-use systems. When was the last time you had to refer to a user manual for a chair or a tea-pot? …or a video cassette recorder…? Flight Crew Training Centre . Appropriate feedback makes the task of monitoring system failures or anomalies more effective.

Flight Crew Training Centre . We must guard against the threats posed by automation. In fact it has generated the potential for a different type of human error. There is a fundamental difference between leadership. the leader becomes a means of change and influence. the Captain is the designated “leader”. This chapter will identify some of the attributes necessary for effective leadership and identify how styles of leadership vary.12 Conclusion Automation is seen as the antidote to pilot error. either as an organization or as individuals to reduce the threat posed by a design that is less than perfect.1 Introduction There are various competing theories about what makes a leader and the definition of leadership. Aircraft accident and incident investigations have demonstrated that personality differences can influence the behavior and performance of crewmembers. 6 Leadership and Team Dynamics 6. 5. In the flight-deck environment. which is assigned. An individual's position as captain does not automatically assume that he or she is an effective leader. and an understanding of the goals and desires of the group.Page: 20 CRM Manual Date: January 2008 The advantage of retaining humans in the system is that they are adaptable and flexible. An optimal situation exists when leadership and authority are combined. Recognition of a poor design is part of the way towards eliminating the threat it poses. and authority. by knowledge of the appropriate levels of automation and understanding of the automated systems. Leadership is needed to effectively understand and cope with a variety of situations. 6. yet numerous accident and incident reports identify where the leader has failed in his role and remarkably has not exercised leadership. Appropriate feedback is vital to achieve and sustain the high levels of situational awareness required for safe operations. Through the use of example and persuasion.2 Leadership A leader is a person whose ideas and actions influence the thought and the behavior of others. Personality or attitude clashes within a crew complicate the task of a leader and can have an influence on both safety and efficiency. Humans are capable of devising strategies. which is acquired.

will power. Personal qualities required are those of courage. along with recognition of the appropriate source of assistance and the correct answer when provided. Task Team Individuals Figure 1: Action Centred Leadership Flight Crew Training Centre . and Manage Decision-Making Model. In addition.3 Leadership Theory Early research into leadership theory stems from the military. This implies a certain amount of discretion in choice of action. to decide on a course of action. The leader must have a thorough technical knowledge of the aircraft and appropriate supporting systems. As leader the Captain has both responsibility and accountability. 6.4 Action-Centred Leadership Pilots tend to be naturally task-focused individuals. Action. The importance of each sphere of responsibility will change dynamically according to the situation. however the leader also has other areas of responsibility. and a duty. with use of the Assess.Page: 21 CRM Manual Date: January 2008 The Captain’s authority as leader is derived from the China Civil Aviation Regulations. Some of this is relevant in the sphere of commercial aviation. and be able to maintain team morale. Jade Cargo International SOPs and technical training support this function of leadership. The leader must balance the demands of the task. any limitations of this knowledge must be identified. 6. initiative and integrity. An effective leader must have both technical and personal skills. An ability to communicate and self-motivation are also vital. the team and the individual. from a practical view point the Captain has a right. In fact.

1 Regulating Information Flow The leader must regulate.Page: 22 CRM Manual Date: January 2008 6. experience and culture in Jade Cargo International the following techniques may also assist in promoting the individual’s needs:    Sensitivity to cultural needs Maintain an open environment by active listening Admission of errors and encourage Standard calls to identify deviations 6. With a wide variety of background.6 Team Building and Maintenance Team work is vital for an effective solution to a task. ideas and suggestions within the crewmembers and outside sources       Communicating flight information Asking for opinions. To enhance the sense of unity:     Use expertise within the team Briefing Co-ordination of effort Provide feedback 6. Maintain situation awareness Monitor and evaluate the task’s progress 6. suggestions Giving opinions. suggestions Clarifying communication Providing feedback Regulating participation Flight Crew Training Centre .8. many of the considerations for the team also apply for managing an individual’s needs. manage and direct the flow of information. consider the following:      Planning Communication of intent Avoid over-involvement as it reduces the capacity to think ahead.8 The Role of Leader The CRM Manual produced by Transport Canada identified the following four tasks that encompass the role of the leader: 6.7 Individual Development and Satisfaction In the two-pilot flight deck.5 Task To achieve the task.

coordination and direction for group performance     Directing and coordinating crew activities Monitoring and assessing crew performance Providing planning and orientation Setting priorities 6. It can range from the extreme of autocratic or dictatorial to “Laissez-faire”.4 Leadership Styles Having determined what is required of a leader. how is this delivered in practice? Leadership style refers to the degree of involvement between the leader and the team during decision-making. In between.8.Page: 23 CRM Manual Date: January 2008 6.2 Directing and Coordinating Crew Activities The leader must function as crew manager to provide orientation. Flight Crew Training Centre .8. there are differing degrees of participation such as democratic and participative.8.3 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 Maintain an "open" cockpit atmosphere Resolving/preventing angry conflict Maintain positive relations Providing non-punitive critique and feedback The leader is ultimately responsible for decisions      Assuming responsibility for decision making Gathering and evaluating information Formulating decisions Implementing decisions Providing feedback on action 6.

getting their ideas and suggestions without bringing them together as a group. collectively obtaining their ideas and suggestions. in this case the leader does not care whether the team performs well or not. using information available at that time. It may be acceptable to be “laissez-faire” when all goes well. For most effective leadership. Then makes the decision that may or may not reflect your subordinates' influence. These definitions below provide more detail to assist with understanding the concept.Page: 24 CRM Manual Date: January 2008 Laissez Faire Democratic/Participative Autocratic Figure 2: Authority Dynamic Range While “laissez-faire” (loosely translated as anything goes) might appear to be an appropriate attitude. “VROOM” has isolated five categories on the scale above. This differs from a “relaxed” attitude. Consensus Seeker [G2]: shares the problem with subordinates as a group. The definition used here is “laissez-faire”. Together. Consultative Autocrat 1 [A2]: obtains the necessary information from subordinates. Consultative Autocrat 3 [C2]: shares the problem with subordinates as a group. Consultative Autocrat 2 [C1]: shares the problem with relevant subordinates individually. Note that an individual need not always be associated with only one style.   Autocrat [A1]: solves the problem or makes the decision alone. The role played by subordinates in making the decision is clearly one of providing the necessary information. and then decides on the solution to the problem alone. regardless of performance – which is unacceptable on the flight deck. Then makes the decision that may or may not reflect the subordinates’ influence. generates and evaluates alternatives and attempts to Flight Crew Training Centre    . a different style is adopted according to the situation. but not if things are going wrong. while monitoring to assure necessary performance. Does not necessarily tell subordinates what the problem is while getting the information from them. rather than generating or evaluating alternative solutions.

which may differ between individuals and national cultures.Page: 25 CRM Manual Date: January 2008 reach agreement (consensus) on a solution. passive/critical. 6. the interaction between the flightdeck members will define the authority gradient between the two. supportive followers are as important as a leader. Ginnett. Of these classifications it is worth noting that the last. RE. predictability and an appropriate level of assertiveness. A two-dimensional model of follower behavior in Leadership: Enhancing the Lessons of Experience. R. The four combinations available are therefore passive/uncritical. Hughes. while respecting the Captain’s legal authority.9 Cockpit Authority Gradient In addition to the style adopted by the Captain. Flight Crew Training Centre . “Kelly’s” (Kelly. Jade Cargo International encourages a flat cockpit authority gradient. and followership is a skill in its own right. A steep gradient results in ineffective monitoring from the co-pilot. An effective follower requires qualities of flexibility and adaptability. levels of experience and different cultural backgrounds among the workforce in the company. avoids the Captains’ obligation and duty to make a decision and to accept responsibility. The role is much like that of a chairman. Nevertheless the duties and responsibilities of the pilot-in-command should in no way be affected by this need. since there are a number of nationalities. that of dependent/independent uncritical/critical thinking and active/passive involvement in the team’s performance. Redefining Airmanship) model of followership examines two dimensions. 1997. 1988. encourages an open atmosphere to monitor and challenge. 6. and a flat one reduces the Captains’ authority by constant (unnecessary) challenge.10 Followership Followership is often perceived as a short-term necessity on the way to a leadership position. R & Curphy. active/uncritical and active/critical. from the team perspective nothing could be further from the truth. G (Eds). While this might be an individual’s view. For successful team performance. A fifth group “Company men” is chameleons adopting any of the four other styles as appropriate.  Trying not to influence the group to adopt "own" solution and willing to adopt and implement any solution that has the support of the entire group. Followers are a vital part of a team. T. The optimum gradient. cited by Kern. G2. along with good communication skills.

Using the first minutes of meeting effectively is obviously very important. they are typified by mediocre performance and shift quadrants. Good communication skills have already been identified as critical for both leaders and followers. completing tasks in silence without adding to the team’s performance.Page: 26 CRM Manual Date: January 2008 Effective followers are essential to safe flight. They are also the foundation for teambuilding. Making a good first impression is vital. airlines form new teams for practically every duty. Flight Crew Training Centre . They inhibit crew decision-making and can encourage a feeling of invincibility to the pilot-in-command. to give the best possible impression during the crew brief and ensure that both pilots come across as open to communication from the crew. Team building is therefore a skill that needs to be emphasized if a “scratch” crew is to perform well. but through disillusionment and disenchantment are not prepared to speak up. not to foster an effective team but to avoid making waves. not afraid to speak up when necessary and challenge a flawed decision. unless identified and brought “back onside”. Sheep are akin to human automatons. They have the potential to destroy a team’s effectiveness. The crew briefing is probably the only opportunity to foster a vital link between the flight deck and the cabin. because they actively support without thinking. Alienated followers are those that have identified a problem with the operation. 6. A poor first impression could take as long as seven hours of continual contact to undo. Yes people can add an element of danger to the operation. A good first impression is vital for successful team bonding and should be accomplished in the first few minutes of team formation. The only way to ensure this is. Survivors are the Company men. An airline crew needs to be working together and communicating well from before the take-off roll.11 Team Dynamics Unlike military crews. Their motivation is political rather than task/team oriented. and actively supportive without being “yes men”.

2 Principles of Communication Human communication is the act of sharing information. as does the fact that many of our pilots do not use English as their native language. culture plays a large part. So. in communication within a crew. and very rarely are raised voices heard.Page: 27 CRM Manual Date: January 2008 7 Communication 7. 7.e. While modern flight decks are well insulated. verbal communication is one of the oldest forms of human interaction. Barriers to communication are also identified. In the case of Jade Cargo International. Body Language and tone of voice makes up for the majority of human communication. The actual words used accounting for about 10%.1 Introduction One of the key skills required for operating a multi-crew aircraft is the ability to communicate. 7. the advantages of various communication styles and the requirement for conflict resolution. This can be verbal or non-verbal information. the words used tend to be very important. It serves a complex and vital role in establishing and maintaining relationships Flight Crew Training Centre . degrading language. insulting. as much as 90%. Communication breaks down barriers and promotes the exchange of important information. There are many barriers to communication within a cockpit.3 Communication Barriers The flight deck of an airliner is not an ideal place to have a conversation. noise is still a factor. This chapter is aimed at producing effective crew communication in the context of multi crew operations. This is the most relevant definition to the task of flying an aircraft. However. Communication on the flight deck can be affected primarily by:    Tone of voice Focusing on own/others’ needs The use of emotional language or “put-downs” i. rank could impinge on communication as well. The actual words used accounting for only about 10% The impact of body language is greatly reduced in a flight deck. along with methods of eliminating them. This chapter describes the principles of communication. Between a Captain and a First Officer.

Flight Crew Training Centre . 7. It is stating our own needs and feeling without putting others down. By adhering to these “standard calls” the danger of miscommunication is greatly reduced. whether on the needs of others or your own. aggressive. a lively discussion in low workload phases usually goes a long way toward “setting the tone”.Page: 28 CRM Manual Date: January 2008 between people. From these two aspects the following model can be constructed: Table 1: Communication Styles “No put-downs” (1) Focus on own needs A Focus on needs of others S Assertive A1 Supportive S1 “Put-downs” (2) Aggressive A2 Submissive S2 Four communication styles can be determined from this model. and the manner. 7.4 Communication Styles To assist in analyzing effective communications. Establishing a cordial and efficient working relationship can be made easier by the use of some of the techniques covered in this chapter. Being Assertive:    Heightens self esteem Makes other people take notice Establishes authority Assertive behavior is a desirable form of communication. While a silent flight deck is desirable in some stages of flight. supportive and submissive. two aspects of the message content will be considered. whether unnecessary emotional language or “put-downs” are used. the focus.4. The SOPs contain standard phrases and occasions when exchanging information or verifying facts is required.1 Assertive Behavior [a1] An assertive style enables one to speak in such a way that one does not abuse or dominate others. assertive. The principle means of communication is by the use of Standard Operating Procedures (SOPs). This is especially in the flight deck from a person in a position of authority.

downs. it is clear that aggression comes about when an individual is focused on his own needs and uses put. When aggressive feelings burst forth we tend to regret it afterwards because serious negative consequences usually occur as a result of aggression. Therefore. The key to identifying aggression is the use of “put downs”.4. Referring to the matrix. the key here is the use of “put downs” or abusive language. However. In a non-critical situation.4. A person using a submissive style of communication allows himself to be dominated.3 Supportive Behavior [s1] A supportive style focuses on others needs in a way that does not downgrade themselves. Flight Crew Training Centre . A person being supportive will:    Show concern Not diminish their own or others’ worth Be willing to help and listen In a typical crew the PNF should adopt a supportive role.4 Submissive Behavior [s2] The simplest definition of submissive behavior is the acceptance of “put downs”. not recommended but part of life. However this may change depending on circumstances. They put themselves down. 7. With a submissive style the individual focuses on others’ needs in a way that diminishes their own worth.4. 7. is it better to be submissive in order to defuse a situation? Sometimes it may be preferable to “let it go” in order to preserve harmony. such as during training or non-normal situations.Page: 29 CRM Manual Date: January 2008 7. A2 behavior rarely occurs without precursors. and will likely isolate the aggressor. are avoided at all times. It is unlikely to motivate the team. Being focused on one’s own needs is very human. This is a “no-go” area for us at work. Aggressive behavior will have a negative impact on a team. It is important that “put downs” or words or tone of voice that may be interpreted as such. Defining a “put down” is not easy and it is incumbent on all parties (particularly in a multi-cultural environment such as Jade Cargo International) that great care is taken to avoid anything that can be construed to be one.2 Aggressive Behavior [a2] This is when someone is being aggressive.

This brings the focus back to the task at hand and reduces conflict. be supportive.5 Dealing with Aggression If aggression is met with aggressive behavior. their needs will be overlooked. In fact submissive behavior often comes about as a result of aggressive behavior on the part of another person. focusing on this usually helps in restoring harmony. the assumption might be that they have nothing to contribute. It may be necessary to vary the style of communication according to the situation. but leads to good understanding when accomplished. Dealing with aggression is not easy. The use of the communication styles model identifies boundaries between own/others needs and the use of “put-downs”. Establishing the position of the lines can be difficult. Each individual and in fact every team. and perhaps discount their views even in a crisis 7. If the other person is submissive. will find a style that works well for them. If someone is submissive. These boundaries are not necessarily static or evenly divided. The best response is to focus on the other person’s needs (where this does not compromise safety) and ignore the perceived put-downs. Some of the factors that affect the position of these lines are:      Race Culture Nationality Age Seniority / Rank It must be emphasized that the lines move all the time. Since the safety of the flight is of paramount importance and is a common need between all parties. Assertive and supportive behavior styles are those that promote the most efficient communication. Being aware of this and expecting it from yourself and others goes a long way toward fostering good communication. provided that the intent is to stop the use of put-downs. An assertive response might also be effective. In other words. Flight Crew Training Centre . it is likely communication that will break down completely.Page: 30 CRM Manual Date: January 2008 Sometimes a person will prefer not to say anything for fear of being laughed or shouted at.

There is more than one way to do anything. When sides are chosen. Animosities can develop. Conflict is usually present because of:     Differences in needs. Conflict becomes unhealthy when it is avoided or approached on a win/ lose basis.6 Conflict Resolution Any time two or more people are brought to work together. The two key learning points in resolving a conflict are: 7. Unwillingness to work through issues. which will lead to better results. the results may be positive or negative. Conflict is not a necessary component of human behavior. Flight Crew Training Centre . You must give to get. What is important when conflict does occur is that the issue is resolved and that safety is not compromised. No one makes major concessions. Conflict resolution can be achieved on a win/win basis and this produces the best results. When conflict is dealt with constructively. actions and situations. test their position and beliefs. It is possible to cooperate with conflict arising. and stretch their imagination. Conflict should not be taken as another word for not working together.Page: 31 CRM Manual Date: January 2008 7. depending on how those involved choose to approach it. but unfortunately does occur a great deal. Conflict is healthy when it causes the parties to explore new ideas. High respect for mutual support. Differing expectations of outcomes . Resolving conflict requires an analysis of the root cause of the conflict. Assertive and cooperative. 7.favorable versus unfavorable.7 Problem Solving     Needs of both parties are legitimate and important. productivity will diminish or stop. the stage is set for potential conflict.8 Compromising     Important all parties achieve basic goals and maintain good relationship. If conflict does occur. objectives and values. Differences in perceiving motives. trust and support will deteriorate. collaborate or compromise. Reference to the Action-Centred Leadership model1 can assist in probing sources of differences. No one person or idea is perfect. and the damage is usually difficult to repair. communications may breakdown. people can be stimulated to greater creativity. words.

Action and Critique. Conflict Resolution. and reduces the risk of omissions and errors in the assessment phase of the problem.1 Introduction Problem-solving and decision-making are activities we conduct instinctively every day. GOOD OUTCOMES ARE GENERALLY ENSURED BY THE USE OF     Briefings Sharing the workload Planning for change Using aircraft equipment to your best advantage POOR OUTCOMES ARE CAUSED IN PART BY:      Attitudes Failures of judgment Deviation from SOPs Lack of briefings leading to misunderstandings and omissions Emotions overcoming good judgment Various structured models are in use in airlines around the world.Page: 32 CRM Manual Date: January 2008 Provided these concepts are borne in mind. Flight Crew Training Centre . Using a structured approach is a form of SOP for decision making. rather that a model is used. a situation arises that is beyond our scope or experience. However. The importance of time management is also covered in this chapter. Advocacy. however it is the industry’s belief that a structured decision making process will reduce the risk of a poor outcome. or good or bad outcomes. 8. Using a structured approach for problem solving and decision making leads to a better outcome. Most of them are based on the original CRM loop of Inquiry. it is possible for diverse personality types from widely disparate cultures to work together harmoniously and ensure safe flight. This chapter introduces the Company decision-making model. which provides a structured approach to problem solving and decision-making. It is not which model that is used that is important. either for routine or novel situations. This raises the question as to whether we should consider good or bad decisions. It is the end result that we are interested in.2 Structured Decision Making Research has identified numerous occasions where similar accidents nearly occurred. 8 Problem Solving and Decision Making 8. once in a while.

Page: 33 CRM Manual Date: January 2008 The Jade Cargo International. 8. “The Situational Assessment Model focuses on factors that influence a flight crew’s assessment of a situation and the subsequent management of available resources”. Because this additional phase consists mainly of corrective actions. Flying skills and good management of the auto-flight systems is also applicable throughout the application of the RMM. During each of the phases specific guidance is provided.2 Providing “Seamless Integration” To provide the required “seamless integration” as required by Advanced Qualification Program (AQP). indicating when manufacturer’s company procedures should be applied. as well as the appropriate CRM principals.     Handling skills (manual and auto-flight) Technical knowledge (Type specific) Procedures (Manufacturer and Company) Basic Knowledge in Human Factors Principles It must be emphasized at the outset that the RMM and CRM is intended to provide an extra dimension to the Pilot’s management skills and not to make up for a lack of knowledge or skills in any of the above mentioned documents. it was decided to call this the “Action Phase”.2. according to the manufacturers non-normal checklist and or company procedures. Flight Crew Training Centre . 8. The RMM is based on the assumption that the crew is fully proficient with the following. it is felt that the process to “Rectify / contain the problem” had very specific needs that could only be accommodated by allocating it to a phase of its own. Risk Management Model (RMM) is for the two man crew cockpit.2.1 The Model “Footprint” The model is based on the “Battelle” “Situational Assessment Model” that had been developed for the FAA. further modification to the RMM was required. This model was expanded to accommodate the following: Procedures to rectify / contain the problem Making a decision Implementing the decision However.

Men in general and particularly pilots tend to go straight to a solution. the problem and the solution. Using these classifications we can use a model to identify the appropriate type of communication to best assist with resolving the situation. it is essential to accurately determine what the exact nature of the problem is. Jade Cargo International uses a problem-solving model to focus on the problem until these questions are answered. The situation can be considered in two separate domains. there are two typical responses. By staying below the line as much as possible. Whenever a problem is encountered at work. Flight Crew Training Centre . Any communication relating to this issue can also be considered as either information about the problem/solution or an enquiry. immediately come up with a solution or stay with the problem by further defining it. Jade Cargo International uses the catch phrase “stay below the line” to help crews focus on the issues related to the problem before taking action.3 A Problem-Solving Model Prior to deciding on a course of action. a better understanding of the problem itself can be gained. The line in question determines whether the discussion is centred on the problem (below the line) or on solutions to the problem (above the line). seeking more information about it. questions Problem Information [PI] – Analysis Information SI PI SE PE Sometimes it is more appropriate to spend time in gathering information before developing a solution.Page: 34 CRM Manual Date: January 2008 8. This does not always produce the best solution. Enquiry Solution Problem Examples of each category are:     Solution Enquiry [SE] – Suggestion Solution Information [SI] – Instruction Problem Enquiry [PE] . to make sure we fully understand the implications. its implications and how much time is available. A key factor in making this decision depends on how much time is available.Information seeking.

is a valuable problem. Consider the likely responses to these two questions:   Where do you think we should divert to? Or Do you think we should divert to Munich? The first question is an open question [PE?]. In all cases. The use of open questions can assist in staying below the line. Time Available: Cautions require a timely response. this limits the opportunity for assessment. It is for this very reason that moving above the line should be done with caution. using a traffic light system. In the latter case. immediate action is required. Assessment of how much time we have is essential in problemsolving. On the other hand. others may be less time dependent. Time can be considered as. it is possible to prioritize accordingly. The effective use of time is very important in problem solving. Once a time frame has been established. Warnings and Time-Critical Warnings are coded red on EFIS displays. losing vital feedback. might compound Flight Crew Training Centre . A fast decision may not always be the correct one. They may be associated with immediate action drills (such as GPWS). recall actions (Engine Fire) or a checklist (Fire Wheel Well). 8.Page: 35 CRM Manual Date: January 2008 The key of “staying below the line” allows us to fully assess the problem within the available time. taking too much time to collect information and make a decision.4 Time Management Some situations require an immediate response. available and required. In many cases it assists with our assessment of time. Time Required: Other levels of alert may or may not necessarily be identified with color coding on EFIS. critical. However there will be some occasions where it may be necessary to slow down or enter into a holding pattern. Moving above the line is significant because it involves a suggestion or an instruction.   The key to these different types of time is that EICAS/ECAM will assist with our assessment of time. EFIS architecture. whereas the second is almost a suggestion [SE]. both in Boeing (EICAS) or Airbus (ECAM). Time spent “below the line” is kept to a minimum. A solution in the form of a question however. but will probably be accepted.solving resource. may at best get a query in response. all conversation tends to stop and the decision is implemented. Caution level alerts are amber on EFIS.  Time Critical situations require immediate action. time is available to consider the problem and when is appropriate to take action. Open questions allow more options. when there is little available.

test understanding. Achieving the best solution demands good teamwork. prioritize. test understanding propose. delegation] Remember that in complex situations. build] EVENT STATUS Making the Decision Consider: TASK NEEDS Aircraft performance EROPS AWOPS ATC DDM/MEL GROUP NEEDS crew company passengers INDIVIDUAL NEEDS control stress individual crew members passenger  Options(Itemize best option. keep partner in the loop] PROCEDURE TO RECTIFY / RECALL ITEMS / USE EICAS. seek information.Page: 36 CRM Manual Date: January 2008 difficulties. test understanding. the Captain must manage. NAVIGATE. An early calculation of the time situation will assist with decisionmaking. GROUP AND INDIVUDUAL needs  MONITOR PROGRESS – continually check for poor judgment (PJ) [Participation. Good teamwork needs good communication. summarize] CHECK CB’s AND SWITCHES ● IDENTIFY DIAGNOSE: What is wrong? • VERIFY How to RECTIFY • Identify procedure ACTION PHASE [Monitor. Flight Crew Training Centre . 8. COMMUNICATE CONTINUOUSLY [Use Autopilot if available] ASSESSMENT PHASE [Seek information. This means that the F/O is best assigned the task of flying. QRH If needed: “stop the checklist” MANAGEMENT PHASE [summarize.5 The Jade Cargo International Decision-Making Model RISK MANAGEMENT MODEL AVIATE. propose. Open Participation)  Brainstorm options and check for poor judgment  Summaries  DECIDE[selling if required IMPLEMENTING THE DECISION  Satisfy TASK. prioritize.

Once the Group is informed and placated. a good commander will then address the passengers and crew and explain to them the steps taken. it diminishes in importance and the group need comes to the fore. Both the assessment and time factor may be provided by EICAS/ ECAM indications. An important point here is that you do not rush. It is a circular or iterative process. The specific action and or checklist required may be dictated by the type of situation. Action centered leadership is based on the principle that during a normal flight. individual needs (a cup of coffee or a visit to the restroom perhaps) can be attended to. if there were any elements of confusion during the initial assess phase. Individual type procedures will determine what other action may be required.8 Manage Once the action has been completed. Once this is under control. Use Action-Centered leadership to meet the needs of the task. “Did the action solve the problem?” “Are you sure?” These are good questions to ask of oneself. obstacles and weather. It is only when you have to make decisions in somewhat abnormal situations that the weighting of the circles change.7 Action During this phase the emphasis is placed on procedural/technical knowledge combined with good communication and monitoring techniques. the task need is paramount. Undue haste has led to more accidents than most people realize. all the circles are the same size. For example in the first stages of a diversion. we must come back to summarizing our actions and again reflect and analyze our actions. 8. the first priority is to maintain control of the aircraft. When the process is complete.6 Assess The assessment phase is characterized by problem-solving and time assessment. With the aircraft descending and flying in the desired direction. including the navigation away from terrain. Information may come from SOPs or other sources such as QRH or other manuals and will need to be clearly defined.Page: 37 CRM Manual Date: January 2008 8. 8. Once the problem is clearly defined and summarized should we then move above the line. Flight Crew Training Centre . the team and the individual. it is time to manage. However.

but functionally can be quite accurate. INPUT PROCESSING OUTPUT Figure 1: Basic Cognition Flow Very simply. Mental models are also a key component of situation awareness. these are known as “mental models”. Flight Crew Training Centre .3 A Model of the Cognitive Brain As in most processing flows. we receive information.2 Models Psychologists use models to produce a simple explanation of how something complex works.Page: 38 CRM Manual Date: January 2008 9 Cognition 9. In the same way. they typically contain errors and contradictions They provide simplified explanations of complex phenomena They can be represented by sets of condition-action rules (If… then…) 9. 9. The importance of the model is that it is effective in assisting understanding. An awareness of these limitations and errors can reduce their impact on flight operations. This chapter looks in particular at some of the limitations of the human brain and the typical errors that can occur as a result. individuals create internal representations of how systems work. A model may not be a very good literal representation of a system. output functions and an internal processing function. Some characteristics of mental models are:     They are incomplete and constantly evolving They are usually not completely accurate. we will consider the brain in terms of input functions.1 Introduction Cognition is all about how humans process information. Mental models are vital to users for controlling systems and problem-solving. do something with that information and then act on it.

4.3 Divided Attention Problems occur when we need to attend to more than one matter at a time. This is quite normal. sound. If someone nearby were to mention a key topic of interest to you (such as your name). We are unable to effectively monitor our principle task. The “cocktail party” syndrome provides a useful example of this. 9. Sound on the other hand is omnidirectional. The brain will filter the unwanted background noise. sound and touch. Flight-deck design typically makes use only of the first three of these – sight. but it is not being ignored completely. at some point they will lose part of one or other signal. This refers to a “pre-processing” stage where the brain interprets what it thinks it has seen before dealing with it. It is only possible to concentrate on one signal at a time.4.2 Attention Our senses are constantly receiving and discarding signals. warnings or “attention-getters” use audible alarms. smell and taste.1 Senses We have five senses through which we receive information. Perception is incredibly powerful.Page: 39 CRM Manual Date: January 2008 9. 9. if we miss-perceive an event. even though they do not have the loudest voice. but only a limited signal can be conveyed. it is very difficult to subsequently identify it correctly and take the correct action to Flight Crew Training Centre . touch. noisy social function it is quite possible to sustain a conversation with someone. it would become increasingly difficult to maintain the original conversation. Attention is directed by the processing function and can be thought of as a filter to the overload of sensations all around us. so much that.5 Perception Perception can also be thought of as another filter by the processing function. Attention is believed to be a single-channel function. are actually switching from one to the other. Those who believe that they can monitor two channels simultaneously. The advantage of sight is that quite complex information can be transferred to the user as long as they are looking at the signal. During a busy. sight.4 Input functions 9. However the brain does have a mechanism for making sure that we do attend to matters that affect us.4. as many of the signals are neither intended for us nor relevant to us. 9. as firstly you would detect this new signal and secondly try to monitor it as well as the initial conversation. not all of them get through to the processing stage. Routine (status) information is therefore conveyed by visual cues.

Perception is considered to be the first stage of Situational Awareness. which really belongs with the input functions. 9. An example might be an R/T call that interrupts a conversation. you have as little as 0.6 Processing Functions 9. It has a capacity of approximately seven bits of information. short-term and long-term. Psychology text-books (and the internet) have numerous examples of such illusions. and contact 119. The string “28531018015011972” is clearly longer than seven digits. typically with the response “…was that for us?” but by the time the question is asked.6. New information received on top of this will replace the current contents of working memory.Page: 40 CRM Manual Date: January 2008 deal with the problem.2 Sensory Memory Sensory memory refers to how long the senses maintain received data before it is consciously dealt with or lost. However it becomes more manageable even with additional information in the form – “Heading 285. the original message has been replayed by the mind.1 Memory Memory is the storage area of the brain. descend 180. The processing function is considered to have two types of memory.72”. The mind can have difficulty perceiving something it has never seen before or that appears to be impossible. 9.6. In this case the “echoic” memory (of the auditory system) can retain the data for as long as 10 seconds.5 second to replay the stimulus before it is lost. Iconic memory (for visual stimuli) is almost literally gone in a flash. Sensory memory data is lost by decay. expect 150 by xxx. Another type of memory is sensory memory. and retained by conscious attention.3 Short-Term Memory Short-term or “Working” memory is extremely limited and slow in operation. unless it is consciously being dealt with.6. We can increase the effectiveness of our short-term memory by “chunking” information. for instance if you are looking in the general direction of the EICAS/ECAM and a message pops up and disappears. 9. Flight Crew Training Centre . speed 310.

One technique to assist with retrieval is the use of mnemonics.5 Flashbulb Memory This is a phenomenon which describes what happens when an event so incredible occurs that the information is immediately placed in long-term storage. you would be able to state with a fair degree of confidence that:     It has four wheels It has leather seats It has an amazing stereo It will be available in black and silver …. This enables this “knowledgebase” to handle recurrent routines. even if the correct data has never been learned. Data in the long-term memory can be in the form of single bits of data or in the form of learned routines. long after the event. Flight Crew Training Centre . episodic memory gives an autobiographical view of events. such as ATM (Avoid. but with inability to retrieve or access the information. For example. 9. using “motor actions” without recourse to the conscious workspace. and Mitigate).Page: 41 CRM Manual Date: January 2008 Chunking has reduced this sequence to just five bits of information. Usually the event and what you were doing at the time are inextricably linked as one memory. manageable by most. It is believed to be unlimited in capacity and lasts forever. if you were told that Lexus have developed a new luxury car.4 Long-Term Memory Information transfers to the long-term or permanent memory by rehearsal and repetition. some secret? Long-term memory data is not lost.6. This enables the brain to come up with a “sensible wrong answer”.. Retrieval of information is fast and effortless and parallel processing is available.6. patterns or mini theories. Data is stored in one of two methods by the long-term memory. However the problem is not with forgetting. 9. but becomes irretrievable due to interference. For this reason it is normally possible to date these events quite accurately. but it is top secret. Short-term memory data is lost by displacement and retained by rehearsal. Trap. whereas semantic memory stores similar data in a form of hierarchical tree.

9. The process tends to be dominated by vision and can only work sequentially. the explosion of the Space Shuttle Challenger [January 1986]. or we press on Flight Crew Training Centre . GPWS and Wind-shear warnings fall into this category. It is the intention in pilot training to transfer emergency drills into over-learned routines. Overconfidence Sunk Cost – “throwing good money after bad” Wishful thinking Outguessing Randomness Plan Continuation Error – The most significant trap that we fall into as pilots is that we find it hard to discontinue a bad approach. this is when the action has become a learned routine. It can only deal with one issue at a time. There may be occasions where it appears to be doing several tasks. a response and is handled by the knowledge-base in the form of “motor-actions”. The events of September 11. the death of Princess Diana [August 1997] and the crash of Concorde [July 2000]. This prevents the cognitive functions from reaching overload and resulting inaction. however it is a single channel device.6. but in fact it is just switching quickly between them. 2001 are slightly different in this respect. human decisions have numerous sources of bias that may hinder optimal performance.Page: 42 CRM Manual Date: January 2008 Examples of events producing a “flash-bulb” effect are. Common psychological traps that humans may encounter include:        Confirmation bias – only accepting evidence that confirms our position and rejecting contradictory evidence.6 Central Processor/Decision-Maker The processor in the brain is exceptionally powerful. 9. the assassination of JFK [November 1963]. as they are referred to by the date itself. in particular responses to RTO. Availability – Solutions selected because they are available and simple to execute regardless of effectiveness. There are other occasions where humans can do more than one thing at a time.6.7 Problems with Decision Making As powerful as it is.

stress and fatigue produce similar results. Optimum Stimulation Creativity Rationality Problem Solving Progress Under Stimulation Boredom Frustration Dissatisfaction Over Stimulation Overload Confusion Distress Flight Crew Training Centre .1 Introduction Stress may be defined as the demands that act on the human body. Performance varies with a number of factors. The term arousal will be used as the generic term for both.Page: 43 CRM Manual Date: January 2008 towards a landing with significant issues not resolved. Our interest is human performance.7 Conclusion The brain is exceptionally powerful but typically limited to dealing consciously with one issue at a time. This chapter highlights some of the issues now that they have been identified. sleeps loss and disruption on the body and discusses techniques to manage stress and alertness. including workload and circadian rhythms. 9. some a combination of both. This chapter covers the effects of stress. Alertness is a term used to describe the state of the body as it reacts to stress and also to describe a state of awareness. It is easily overloaded and can also produce biased results. others mental strains. Some of these place physical strains on the body. your brain knows how to deal with them… 10 Stress and Alertness 10. In this respect.

As stress increases further. Critical phases of flight.Page: 44 CRM Manual Date: January 2008 The diagram above can be used to explain the effects of both stress and fatigue and these are covered below.1 Acute Stress Acute stress is the most common form of stress. The left side of the curve shows a person in a state of under. require the crew to be at optimal performance. Stress is also a factor in achieving peak performance due to the release of adrenalin. These prepare the body to react when presented with danger. The right side shows over stimulation. for example. Optimum human performance takes place in the shaded area at the top of the curve. overdoing on short-term stress can lead to psychological distress. acute and chronic. from being somewhat dormant. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. Sustained operation in the shaded area is however. Acute stress is thrilling and exciting in small doses. Skiing beyond your limits can lead to falls and broken bones. which differs according to individuals and within individuals. The body needs an optimum level of stress to operate. performance actually peaks. By the same token. Flight Crew Training Centre . 10. Stress has been necessary for the evolutionary survival of the human. tension headaches. Too little stress causes complacency. performance declines below optimum or satisfactory performance and enters a rapid decline thereafter. Performance tends to degrade very rapidly if an attempt is made to remain at optimum for a long period.3. The wellknown “fight or flight” or “adrenalin rush” syndromes are as a result of stress. In the diagram above. That same ski run late in the day is taxing and wearing. such as take-off and landing. After a certain point.3 Types of Stress Stress can be divided into two types.stimulation. upset stomach. and then falls away. but the time spent in these phases is relatively short. Initially. within easy reach of peak performance if new demands arise. and other symptoms. A small amount of stress acts as a stimulus and results in improved performance. 10. The American Psychological Association explains these as follows: 10. but too much is exhausting.2 Stress Stress is not necessarily a bad thing. into the optimum performance range (shaded). Too much stress decreases a person’s ability to function. performance improves. is exhilarating early in the day. largely impossible. consider that arousal refers to stress. A fast run down a challenging ski slope. It is preferable to remain on the left hand side of the curve. as stress increases.

Because it is short term. most people recognize acute stress symptoms themselves. The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent tension headaches. chest pain. a deadline they're rushing to meet. muscular problems including tension headache. migraines. 10. Treating episodic acute stress requires intervention on a number of levels. Flight Crew Training Centre . stomach. whose lives are so disordered that they are studies in chaos and crisis. transient over arousal leads to elevation in blood pressure. and tense. and it is highly treatable and manageable. their child's occasional problems at school. they tend to be abrupt. and heart disease. sweaty palms. cold hands or feet. anxious. It is common for people with acute stress reactions to be over aroused. They take on too much. it does. They're always in a rush. Often. shorttempered. heart palpitations. It's a laundry list of what has gone awry in their lives: the auto accident that crumpled the car fender. the loss of an important contract. acute stress doesn't have enough time to do the extensive damage associated with long-term stress. and sometimes their irritability comes across as hostility. and depression. who suffer acute stress frequently. shortness of breath. and can't organize the slew of self-inflicted demands and pressures clamoring for their attention. The most common symptoms are:    emotional distress--some combination of anger or irritability.2 Episodic Acute Stress There are those. They seem perpetually in the clutches of acute stress. acid stomach. hypertension. rapid heartbeat. gut and bowel problems such as heartburn. and chest pain. however. generally requiring professional help.    Acute stress can crop up in anyone's life. dizziness. flatulence. If something can go wrong.Page: 45 CRM Manual Date: January 2008 Fortunately. diarrhea. back pain." Always in a hurry. they describe themselves as having "a lot of nervous energy. and irritable bowel syndrome. irritable. jaw pain. and so on. migraine headaches. but always late. anxiety. have too many irons in the fire. and the muscular tensions that lead to pulled muscles and tendon and ligament problems. constipation.3. Interpersonal relationships deteriorate rapidly when others respond with real hostility. The work becomes a very stressful place for them. the three stress emotions.

10. even cancer. environmental and cognitive. fatal breakdown. year after year.Page: 46 CRM Manual Date: January 2008 Often. violence. and. the individual gives up searching for solutions. With no hope.3 Chronic Stress While acute stress can be thrilling and exciting. almost comfortable. This is the grinding stress that wears people away day after day. Flight Crew Training Centre . They forget it's there. and their ways of perceiving the world as part and parcel of who and what they are.3. They blame their woes on other people and external events. promotion to Captain). People are immediately aware of acute stress because it is new. hyperventilation. Some examples are: marriage or divorce. chronic stress is not.4 Sources of Stress A stressor is the term used to define the cause of stress.3.5 Life Stress Life stress typically results from a person’s particular lifestyle. 10.3. change in job or responsibilities (i. More precisely. the illness or death of a close relative or friend. There are three broad sources of stressor: life. Chronic stress kills through suicide. sweating. a change in lifestyle is a source for this type of stress. and sometimes. This could come in many different forms. tremors. Chronic stress comes when a person never sees a way out of a miserable situation. familiar. heart attack. Frequently. of being trapped in an unhappy marriage or in a despised job or career. minds and lives.e. their patterns of interacting with others. 10. It's the stress of poverty. stress is accepted as the human response to these stressors. stroke. heart arrhythmia. which exhibits as either a physical response e. the symptoms of chronic stress are difficult to treat and may require extended medical as well as behavioral treatment and stress management. or a mental response such as irritability. lifestyle and personality issues are so ingrained and habitual with these individuals that they see nothing wrong with the way they conduct their lives. It's the stress of unrelenting demands and pressures for seemingly interminable periods of time. Generally.g. Chronic stress destroys bodies. they see their lifestyle. perhaps. of dysfunctional families. they ignore chronic stress because it is old.. People wear down to a final. Because physical and mental resources are depleted through long-term attrition. It wreaks havoc through long-term attrition. The worst aspect of chronic stress is that people get used to it.

10. most pilots will experience some degree of hearing loss.3.6 Environmental Stress Environmental stress results from the physical environment surrounding an individual.Page: 47 CRM Manual Date: January 2008 Research carried out by various organizations suggests a strong link between life stress events and aircraft accidents. who collided with a ground vehicle whilst landing. These occur when a pilot follows a “motor-action” response and selects a control very similar to the desired one.deck. humans tend to become victims of “intentional selectivity”. This is caused by the limited ability of humans to process information. 10. The effect is that pilots will become focused on a task. as it is a mental “picture” it is extremely difficult to establish any direct causal link between life stress and an aircraft accident. This is referred to as “tunnel vision”.7 Cognitive Stress Cognitive stress refers to the mental workload imposed on a person. Noise is generated internally (radios) and externally (airflow and engine). Noise arouses the individual. either on the apron. and mismanage priorities. This is again caused by the brain trying to manage large chunks of information in short periods. Pilots using noise attenuating headsets report less fatigue over long sectors. Sleep disturbance is also a source of environmental stress. Suffice to say that life stress is almost definitely a threat to aircraft safety. but with a dissimilar function. this will be covered later in the chapter. Noise is an unavoidable factor with aircraft operation. Examples are the auto-brake selector instead of brake fans. Temperatures in the cockpits rise rapidly on the ground during summer. The effects of cognitive stress overload are most often experienced in high workload situations.3. However. Two common examples could be heat and noise. The most quoted example is that of a pilot experiencing marital difficulties. or in the flight. The original research was carried out by US Navy psychologists during the Vietnam era and has been expanded since. Another not uncommon consequence of high workload is the tendency to trade accuracy for speed. When workload is high. Heat causes a subtle and unseen form of incapacitation. In trying to complete a task and move to Flight Crew Training Centre . as their brains try to accept large and unmanageable chunks of information. especially when it involves an operating pilot. In the long-term. but exposure for extended periods also causes a drop in performance. High workload causes a skilled pilot to commit what are termed “action slips”. His accident statement directly attributed the incident to his state of mind. or the selecting SPD instead of HDG.

Although this can be an effective strategy.Page: 48 CRM Manual Date: January 2008 the next. they may become bogged down in processing the data. with an inability to sleep further. after reaching a peak. However. Again this is caused by the inability to manage large amounts of information. Where pilots have actually assigned priorities to other tasks. Immediately after awakening. The consequences of sleepiness are:  Decreased physical and mental performance Flight Crew Training Centre . Sleep achieved as the body temperature starts to rise can be disrupted by mid-morning. workload (physical exertion).5 Sleep Management Sleep is a vital physiological function. this occurs during pre-flight where the workload is high with pre-assigned priorities. Sleep quality is also affected by our body clock. The inevitable result is a slowdown in completing the task. this continues to improve performance until. Better quality sleep is achieved during our natural night. thereby inducing further errors. Response time. if we do not achieve enough sleep at the right time. Other factors affecting alertness might be the quality and/or quantity of the previous sleep (sleep debt). Managing alertness is an essential skill for long-haul flying. For example. Depending on the individual. This might be due to time since awake. Techniques for maintaining vigilance in such a situation are similar to those for combating fatigue.discipline must be exercised to ensure a review is completed checking the suitability of actions performed. the range of optimal performance is reached. lack of stimulus (stress) or circadian rhythms. humans will trade off speed against accuracy. or experiencing difficulty in responding to another task is another possible symptom. self. when workload is at an absolute minimum. It cannot be stored. Typically. On a night flight. the mind and body are still in a state of drowsiness. or state of awake ness. leading to withdrawal effects and further disrupted sleep. inactivity and a lack of interaction in a low-light environment can result in insufficient stimulation and loss of vigilance. A loss of sleep leads to suppressed Rapid Eye Movement (REM). The tendency is to accept a less than optimum solution to a problem.4 Alertness Consider that arousal now refers to alertness. a F/O may experience difficulty in calculating the take-off speeds because he feels the need to check the ATIS for the latest temperature. After some time of being awake. this can have a negative effect during the cruise. Getting eight hours of disrupted sleep can have effects similar to too little sleep. 10. it starts to decline as fatigue or weariness sets in. 10. but conversely a sleep debt can build up. As in the case of stress. Jade Cargo International aircraft have advanced automation features that manage most routine tasks. it may take some time before performance reaches an acceptable level.

External refers to the body being “out of sync” with the environment. This is known as jet-lag. this can leave the pilot somewhat disoriented for several days after a trip involving several time-zone changes. on the wrong time zone. Knowing how to combat the ill-effects caused by these factors is an acquired skill that needs to be practiced actively by the modern airline crewmember. Stress and fatigue combine to pose a significant challenge to airline operations. It is kept synchronized on a daily basis by exposure to bright light and regular social interaction. The typical biological clock works on a 25-hour cycle. Longer term effects include depression and chronic fatigue. 10. Jet-lag can be described as external or internal. the nature of long-haul operations means that pilots are more often than not. which include:       Disturbed sleep (inability to fall asleep or stay asleep) Increased waking (work-time) sleepiness Decreased physical or mental performance Increased reports of fatigue More negative mood Gastrointestinal problems Flight Crew Training Centre . rather than eastbound which compresses the day. However. which extend the operating day. The longer body-day also makes it easier to adjust to time zone changes on westbound routings. An individual with a significant “sleep-debt” (accumulated sleep disruption) is often irritable. not all body functions resynchronize at the same rate. Internal refers to the different body functions being “out of sync” with each other. sleep is deeper rather than longer. neither well rested nor within their circadian rhythms. Shift-work has similar effects to jet-lag. will have little problem achieving optimal performance at short notice should it become necessary.Page: 49 CRM Manual Date: January 2008    Decreased positive and increased negative mood Increased vulnerability to performance decrements Following sleep loss. Following the disturbance of a time-zone change. inattentive and has an increased reaction time.6 Circadian Rhythms A well-rested individual operating within their normal circadian rhythms.

who has it and the skills necessary for maintaining and sharing situational awareness. In accidents involving human error. 11 Situational Awareness 11. computer games appear to be increasingly filling this role.7 Stress and Alertness Management The FOM requires pilots to be in good physical and mental health – fit for duty. As any medical practitioner will verify. This practice is based on extensive research done by NASA among others. It is another warning flag.1 Introduction Situational awareness is frequently stated as a factor in accidents and incidents. when conducted in a structured fashion. is the duty of every crewmember. This chapter will explain what it is. This acts as an effective fatigue prevention tool and allows a satisfactory level of alertness to be maintained. Exercise is often used as a form of stress relief.8 Controlled Rest in the Flight Deck The FOM also provides for controlled sleep during low workload situations. providing awareness and in need of management. 11. 10. In extreme cases this can take the form of dangerous sports. circadian disrhythmia is not sufficient cause to cease operations. However it is often quoted without really being explained.2 Levels of Situation Awareness (SA) “Endsley” has produced the commonly accepted definition of situation awareness as: “The perception of the elements within a volume of time and space. The duration of rest is limited to prevent sleep inertia. It has proven that controlled rest is a very effective tool for combating fatigue and maintaining alertness. In the modern world. The use of card and board games has historically been a popular form of stress relief. a staggering 88% have been identified as involving a loss of situational awareness. this is a potentially dangerous practice.Page: 50 CRM Manual Date: January 2008 Circadian Rhythms As with the other threats that we face. the Flight Crew Training Centre . Managing stress and sleep effectively. The use of alcohol is not recommended as a form of stress relief. 10. Others prefer mental stimulation. with dire consequences in the aviation industry.

In a well-known phrase: Aviate. The pilot must monitor the aircraft (flight-path. crew.” This is quite complex. one must understand and think ahead. The problems with SA in accident cases have mostly revolved around pilots failing to notice! Figure 1: Levels of Situational Awareness The key to situational awareness knows what comes next. It is not just enough to notice a situation. systems.3 Loss of Situational Awareness Individuals have differing levels of situational awareness. Navigate. then our decisions will be well founded and good performance will follow. 11. Flight Crew Training Centre . there are different domains that must be monitored by the pilot. The Importance of Situational Awareness Now that we know what SA is. the environment (terrain and weather) and the people (ATC. fuel and time). Situational Awareness + Decision-Making = Performance SA is our current “mental mode” and not only directs attention where required. but what it means is that there are three levels of situational awareness. passengers and company). those with normally high SA tend to recognize when they are losing SA. which mitigates part of the problem. If we are aware of all the relevant factors (good SA). but it guides our selection of goals by providing understanding and projection. and Communicate.Page: 51 CRM Manual Date: January 2008 comprehension of their meaning and the projection of their status in the near future. why is it so important? Situational awareness is considered to be the driving force behind good decisions. In addition to three levels of SA. automation modes.

clear briefings and good communication should take place to achieve this.uncertainty about a situation (often accompanied by anxiety or uneasiness) Failure to fly the plane: everyone is focused on non-flying activities Failure to look outside: everyone heads down Failure to meet expected checkpoint on flight plan or profile-ETA. etc Failure to adhere to standard operating procedures Failure to comply with limitations. Mitigate” is one solution to the problem. Results from observations at several different airlines. The trapping phase begins at top-of. Additional errors should be guarded against as these could lead to an error-chain forming. fixation and confusion. there is much to be concerned about here. Most accidents involving human error include at least four of the following:           Ambiguity . if potential problems can be identified in time. When below 2000’ AGL (approximately 7nm from the airport) there is limited time to troubleshoot an unresolved problem. After descent initiation. Trap.descent and leads up to the approach. regulations etc Failure to resolve discrepancies . Avoiding error is the initial course of action. Jade Cargo International uses the concept of the “Safety Window”.contradictory data or personal conflicts Failure to communicate fully and effectively .information from two or more sources that doesn't agree Fixation .Page: 52 CRM Manual Date: January 2008 Clues that indicate a possible loss of SA are ambiguity. In fact most are within seven miles of the airport.focusing on any one thing to the exclusion of everything else Confusion .vague or incomplete statements 11. Flight Crew Training Centre . less time is available for noticing and avoiding. Prior to descent. fixation and confusion exist. so the emphasis should switch to trapping any errors that do occur. The philosophy is to stay out or get out of the safety window where ambiguity. fuel burn. minimums.4 The Safety Window Reviews of accident trend data continue to indicate that most accidents occur close to the ground. during the take-off and landing phases. identified that most of the consequential and additional errors occurred during the descent and landing phase. Since historically over 70% of accidents have occurred in this phase. These may indicate that an error chain is in progress. A three-stage model “Avoid.

there is very little time left to correct it. Human error is inevitable. Finally. so that we can take action to improve it. 11. if mitigation seems to be the key factor. attention-sharing. It has also been observed that crews flying non-glass aircraft have better SA than those with the latest technology. Should such a state occur. Basic skills that high SA crews exhibit are. PM: “They might change runways if the surface wind picks up. we can make the link to identify at which level of SA we are operating at. self-monitoring.5 Situational Awareness and Error Management Using “Threat and Error” management principles. too fast etc) must be avoided. 11.6 Factors Affecting Situational Awareness Studies have revealed a ten-fold difference in SA between pilots within the same airline.Page: 53 CRM Manual Date: January 2008 In the final stages of the approach. identified by the PM: PM: “Looks like a 15 knot tailwind on approach” This is shared perception – they have noticed the problem PF: “OK. this may indicate they are operating at understanding [Level 2 SA]. an undesired aircraft state (i. potential problems that are identified early allow the opportunity to avoid.” Flight Crew Training Centre . Advanced skills include pre-flight planning. then the crew is only noticing problems [Level 1 SA]. If the crew is trapping a lot of errors. unstabilized approach. psychomotor skills and pattern matching are trainable.7 Communication Awareness and Shared Situational For a crew to be most effective they must share the same high SA. scan patterns and checklist use.e. perceptual speed and working memory capacity are inborn. Consider the case of an unexpected tailwind on approach. The best strategy is to “Mitigate” the problem by going-around. contingency planning. By analyzing how we deal with the problem. too high. The Mitigate phase commences at the start of the Safety Window (2000’ AGL). and use the speed brake if necessary. communications. Skills relating to spatial ability. indicating that the crew is thinking ahead [Level 3 SA].” This identifies shared comprehension – the PF understands. However. Information can be shared at all three levels of SA. I’ll reduce speed xx miles earlier than briefed. task management and prioritization. Situational awareness can be trained to a certain extent. 11. otherwise crew SA tends to fall to that of the weaker crewmember.

The response “Ok” is no guarantee that the other pilot has even noticed – he may just be acknowledging that you have stopped speaking! 11. Monitor and evaluate current status relative to your plan. Develop a plan and assign responsibilities for handling problems and distractions.8 Techniques for Better Situational Awareness Management           Predetermine crew roles for high-workload phases of flight. Solicit input from all crew-members including cabin. dispatch. Create visual and/or aural reminders of interrupted tasks Watch for clues of degraded SA. Flight Crew Training Centre . Project ahead and consider contingencies. Rotate attention from plane to path to people . ATC. etc. Speak up when you see SA breaking down. maintenance. Typically crews are comfortable with “perception” level communication. but for various reasons feel inhibited in offering more processed information for fear of offending the other pilot.don't fixate. It is essential to confirm a level of understanding when communicating at the perception level. Focus on the details and scan the big picture.Page: 54 CRM Manual Date: January 2008 This is shared projection – they are thinking ahead.

The Aerospace Crew Research Project Line-LOSChecklist: Assessing system safety and crew performance. P. Replicating Hofstede: a study of pilots in eighteen countries.C. 1991. (1995). R.0 (International) & 2..L. Paper presented at the IXth International Symposium on Aviation Psychology. May 1995. Taggart.L.. (1997).L. A. Sydney. Helmreich. CRM: I hate it. Guangzhou. R.A.. R. Designing culturally sensitive CRM training: CRM in China.L.C. Auckland. (1996).C. Columbus: Ohio State University. & Merritt. R. Merritt.L. Ohio. April. Local solutions for global problems: The need for specificity in addressing human factors issues.L. & Helmreich. and culture) Paper presented at the Orient Airlines Association Air Safety Seminar. 1996. Paper presented at the IXth International Symposium on Aviation Psychology.1 (USA/Anglo) (Technical Report 96-4). Paper presented at the Training and Safety Symposium. (1997). & Sherman. Colombus. 8-12.. Jakarta.. Merritt. 1996. CRM Advocate. J. Ohio. Creating and sustaining a Safety Culture. 1995. April 23-25. R. (1995). April-May. 1. P.Page: 55 CRM Manual Date: January 2008 12 Reference Notes Helmreich. Merritt. 1997. (1996).R.C. November 26-28. A. Indonesia. Merritt..C. & Merritt. & Helmreich. Cultural influences on flight operations. Merritt. Colombus.C. W. University of Texas: Aerospace Crew Research Project.C. A.R. A. Ooi..S. A. & Helmreich. R. In proceedings of the VIIIth International Symposium on Aviation Psychology. what is it? (Error. stress. New Zealand. A. CRM in 1995: Where to from here? In Proceedings of the Third Australian Aviation Psychology Symposium... Paper presented at the ICAO Global Human Factors Seminar. Flight Crew Training Centre ..C. April). November 20-24. (1996.J.. (1995).. Paper presented at the SAS Flight Academy Training Conference.C. Helmreich. Flight management attitudes questionnaire 2. Wilhelm. A.. (1996). Cultural issues in crew resource management. A... Merritt. T. April-May. 1997. (1991).

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