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 role-plays are designed to allow upgrade candidates to use the decisionmaking tools. The candidates will conduct their own debrief.1 Threat and Error Management       Nature of human performance & error A model of human error Threat and error defined Latent threats Defenses Managing error 2.4 CRM Recurrent Training Jade Cargo International pilots receive a recurrent CRM component as part of the recurrent training package approved by the (CAAC).5 CRM Upgrade Training Jade Cargo International requires all candidates for Command training to receive an intensive CRM course. and a series of role-plays. leadership and team management.6 CRM Transition CRM Jade Cargo International includes a CRM component in all type transition courses.Page: 5 CRM Manual Date: January 2008 1. and team management skills. 1. This has proven to be a powerful tool to reinforce the learning process.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.3 Automation   Impact of automation Appropriate use of automation Flight Crew Training Centre . 1. They will be conducted in a cockpit environment and videotaped where appropriate for debriefing purposes. 2 Modules Content 2.2.2. This will be delivered during the ground school phase. The content of this CRM component is designed by the Head of Training in co-ordination with the CRM Instructor. The course consists of a review of decisionmaking. assisted by the facilitator.2.

Page: 6 CRM Manual Date: January 2008  Reference accidents with automation 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 2.4 Leadership.6 Problem-Solving & Decision Making     Problem identification Time management Company decision-making tool Reference accidents with decision-making issues 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 . Followership & Team Dynamics     Command authority Leadership styles Team effectiveness Reference accidents with leadership issues 2.8 Stress & Alertness Management    Types and sources of stress Fatigue & sleep management Jade Cargo International policy and procedures 2.

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

Errors are defined as unintentional deviations from required behavior and are to be expected in everyday life with unavoidable regularity.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. with aviation focus (Crew RM) 3rd Generation attempt at integration with technical training. 1990.5 Human Error Reason (Reason. 3. Violations refer to intentional noncompliance. Current CRM thinking focuses on training knowledge and skills. 3. In particular this means designing for error.Page: 8 CRM Manual Date: January 2008 It is now recognized that attitudes are difficult to change. Reason is the acknowledged expert on human error. but avoiding the trap of undue emphasis on attitudes. Most of these errors are small. 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. encompassing the best of previous generations. which cannot be tolerated in the aviation industry.4 Evolution of CRM      1st Generation concentrated on attitudes and personal management style (Cockpit RM) 2nd Generation introduction of modular training. 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. especially on a long. Not only is this more predictable and measurable.term basis in the presence of contradictory influences. Flight Crew Training Centre . and humans have good error-correcting mechanisms to mitigate the effects of these errors. Human Error) has developed a model of human error that classifies these according to the circumstances under which they occur. 3. but pilots are predisposed to accept knowledge and tools with which to improve performance.

A simple example of a latent threat is a mousetrap. but when the mouse tries to take the bait. The holes in the cheese are the flaws that exist in each individual layer of defense. Reason has likened the multiple layers of defenses to slices of cheese. the accident does not occur. Rather. In isolation it is insignificant. the last line of defense. of which the operating crew are the last link. Occasionally. Some were latent failures. In order to illustrate better the concept of latent threats. Flight Crew Training Centre . the holes will line up. Reason used Swiss cheese. There are similar events unfolding all around us in aviation. but placed together they form a robust wall. 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. It was but it is not an isolated case. The crew was the last chance of avoiding this accident. For example. Accident investigation has therefore become much more complex with additional factors to consider. the British Midland 737-400 that crashed in 1989 was a classic example of an error chain. Each layer in itself is a rather flimsy defense. it snaps.Page: 9 CRM Manual Date: January 2008 3. These are what Reason call “latent threats”. occurring years ago on the drawing board. If they can break the chain. 3. Others were management failures. leaving an opening in the defensive wall and allowing an accident to happen. possibly as early as the design stage of a product.8 Swiss Cheese In the example above it might appear that this was one very unlucky scenario. The accident is caused by the completion of a chain of events – the “error chain”. a combined layer of defenses that can act as an effective shield. This does not mean that accidents can no longer occur. 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. Without assigning a principle cause.7 The Error Chain The introduction of automated systems has made it virtually impossible for a frontline operator to cause an accident in isolation. existing conditions that might remain dormant for years.

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

nine common factors existed. research has shown that flight-crew error led directly to an undesired aircraft state. 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. However in all cases. 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. and correct them Mitigate Identify errors that have occurred and limit the damage Flight Crew Training Centre . presence of several of these warning flags should alert us to the possibility of danger.12 Avoid. the crew failed to see the threats and usually compounded them by making additional errors. Trap.Page: 11 CRM Manual Date: January 2008 Over 20% of the time though. However. The purpose of the NTSB review was to enable flight-crews to recognize that when multiple warning flags exist. great care should be taken to avoid compounding the problem by making additional errors. We have already determined that we cannot expect to work in a risk-free industry. These have been termed warning flags. 3.11 Warning Flags Aircraft accidents tend to have many similarities. such as an unstabilized approach. The NTSB identified in 1994 that of 37 commercial aviation accidents reviewed. 3.

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

and on the philosophical and religious level by a belief in absolute Truth. uncertainty accepting cultures. but defined from below. 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 not expected by their environment to express emotions. Unstructured situations are novel. “there can only be one Truth and we have it”. “I know better than the people who wrote the books” style of operation.   4. “A rule for every situation” approach to flying and a marked reluctance to deviate from SOPs even if the situation demands it.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. People within these cultures are more phlegmatic and contemplative.Page: 13 CRM Manual Date: January 2008 4. Medium UA is optimum for the flight deck. of course. Uncertainty avoiding cultures try to minimize the possibility of such situations by strict laws and rules. Power and inequality. 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. unknown. Low UA Disregard for SOPs and procedures. Uncertainty avoidance is the extent to which members of a culture feel threatened by the uncertain or unknown. and different from usual. are more tolerant of opinions different from what they are used to. Power distance can be related to cockpit gradient. they try to have as few rules as possible. as much as by the leaders endorse a society’s level of inequality. People in uncertainty avoiding countries are also more emotional. It suggests that the followers. surprising. The opposite type. It indicates to what extent a culture programs its members to feel either uncomfortable or comfortable in unstructured situations. not from above. but some are more unequal than others. and on the philosophical and religious level they are relativist and allow many currents to flow side by side. safety and security measures. This represents inequality (more versus less). it ultimately refers to man's search for Truth. Effects on crew behaviors:  High UA Rigid adherence to procedures and SOPs.

Improvements in technology (automation) have resulted in only the two pilots remaining as required crew. this may or may not conflict with a Company’s management style. (Norbert Wiener) 5.2 Flight Deck Automation Early jet transport aircraft had a crew of five or six on the flight deck. This is endorsed by an open-reporting policy for safety and human factors issues. Flight Crew Training Centre . In particular. It is not the policies themselves that are a potential problem. against a conflicting trend. such as pilots. The aircraft manages and self-monitors many of the functions that were previously in the domain of the other crewmembers. though the Air Safety Report and Confidential Human Factors Reporting schemes. not what we thought we told them to do. or an organizational culture can prevail. 5 Automation The problem with computers is that they do what they are actually told to do. 5.1 Introduction Automation is defined as the replacement of a human function. and also provide some guidance for the management of automation issues. Furthermore. This chapter investigates the benefits and the traps associated with automation. Although there are numerous examples of the introduction of automated systems on the flight deck.Page: 14 CRM Manual Date: January 2008  Low PDI – decisions arrived at by consensus with all crew having equal Input 4. An “On time departure” policy or a “Minimum Fuel” policy might lead to unnecessary pressure to compromise. but the pilots’ perceptions of the Company’s intent. either physical or cognitive. The reason that this has been acceptable is that the residual workload has remained at a manageable level. there can be anomalies where a professional group. including radio operators.7 Organizational and Professional Culture Although national culture tends to dominate in most circumstances. navigators and flight engineers. promotion of a safety culture might be encouraged for the pilot group to resist a perceived weakness in any national characteristic. by a machine function. In Jade Cargo International we have a structure that emphasizes “Safe and efficient”. it is those automatic functions relating to flight path control and navigation with which we are primarily concerned.

Flight Crew Training Centre .3 What to Automate Prior to deciding on what to automate.” This may be the intention but the statement doesn’t provide the whole story. In particular.Page: 15 CRM Manual Date: January 2008 Why automate? “Automation brings increased safety. There are (system) performance issues associated with the introduction of automation. accuracy and reduced costs. 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. it is that humans are still required for the part of the task that cannot be automated. The latter will not be discussed here. engineers automate what they are able to automate and the rest is left for the human operator to manage. roles of humans change Creates more cognitive work. 5. same system (substitution) Reduction in workload Focuses user attention Less knowledge required Reduces error Reality Transforms practice. it is the understanding of the automation that causes concern. not to mention the human (social) effects. it would be a good idea to determine the comparative advantages of humans and machines. “Dekker and Woods” highlighted the apparent benefits of automation against the real effect: Table 1: Benefit of Automation: Intended Benefit Better Results. The issue of automation is not whether a machine is capable of doing the job. In practice this does not always happen. The problem with automation is therefore how man and machine interact – the interface.

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

it is possible to differentiate seven distinct levels. 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. – This is a high workload situation. so the overall workload is drastically reduced. Manual flight with flight director: the pilot now has a reduced cognitive load as he no longer has to interpret closing information. in practical aviation terms we have identified four levels of automation. In its current mode the aircraft will intercept the inbound course. Monitoring or supervising is the principle role left to the pilot. this refers to how far removed the pilot is from the actual job of flying the aircraft. There is a reduced cognitive load. vigilance and complacency may become issues. resulting in further reduced workload.    The potential problem that we face is that if we operate for too long in the fully automated regime. It also becomes more difficult to revert to more basic modes with reduced automation. Note that the pilot is still actively involved in the task and through FCU/MCP manipulation retains situational awareness of the flights progress. an area of weakness in interface design. but the pilot is relieved of the task of manual flight. Autopilot with fully managed modes (LNAV/VNAV): The pilot no longer has to calculate closing rate information or fly the aircraft. Pilots will dynamically move between levels. including when to turn it off! Flight Crew Training Centre . with different cognitive skills required. but the system must be programmed to give the correct guidance. such as nuclear power-plant control rooms. The principle pilot skill on modern generation automated aircraft knows which mode of automation is most appropriate to the task. Overall result is reduced workload.5 The Automation Pyramid Research literature on automation talks about levels of “supervisory control”. Autopilot with basic/selected modes: The cognitive demand is as above. although “fly-by-wire” will still be assisting. This refers to the level of monitoring and decision-making required by the operator. 5. according to any change in tactical goal. Although in some systems. The automation on the other hand may need to be re-programmed for last minute changes.Page: 17 CRM Manual Date: January 2008 suited. In the aviation scenario.

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. The highest workload situations tend to be left un-automated. In particular. 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. 5. Habsheim etc). Unfortunately. the pilots still have to intervene at critical moments when the automation cannot cope. 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.6 The Irony of Automation The irony of automation is that. The FAA identified this weakness and commissioned a study that reported in 1996.8 Interfaces The blame for this lack of understanding is not necessarily with the pilot. The key issue is with the design of the interface: how the pilots and the automation communicate. It has already been noted that the introduction of automated features changes the role of the pilot. communications and monitoring. If we do not fully understand the system we are not able to anticipate the system response or evaluate its performance.7 The Automation Issue Now that the benefits and drawbacks of automation have been identified. Studies have revealed that “mode” errors are among the most common on advanced aircraft. For this new knowledge and skills are required. it is important to address the issues identified by accident reviews. The major problem that has been identified with automation is due to a lack of understanding. having been unable to completely replace the pilots with automation.Page: 18 CRM Manual Date: January 2008 5. 5. Cali. Flight Crew Training Centre . The report identified links between automation and situational awareness. will disengage or will revert to another mode.

Feedback is also required for monitoring normal system status change. The Jade Cargo International procedure’s of calling FMA changes is designed to counter this threat. easy-to-use systems. Understandable error messages Error prevention These principles apply to computerized systems as much as day-to day items. but not replace.Page: 19 CRM Manual Date: January 2008 5. 5. The failing of the man-machine system is because the pilot is no longer “in the loop”. 5. Consequently. 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. feedback results in a reduction of situational awareness.10 From an Aircraft Manufacturer Appropriate degree of automation.11 Ergonomic Design Principles The following design principles have been identified as necessary for producing a usable interface:        Intuitive . These systems support instrument displays with visual and tactile motion cues to minimize potential confusion about what functions are automated. the flight-crew member responsible for safe operation of the airplane. Boeing and Airbus flight decks are designed to provide automation to assist. 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. or subtle. Appropriate feedback makes the task of monitoring system failures or anomalies more effective.9 Feedback “Norman” contests that the real issue with automation is due to poor or inappropriate feedback.Logical layout of controls and displays Use of natural command language (Windows v Dos) Minimal user memory load (prompt keys) Consistency Feedback Clear. A lack of. Boeing and Airbus flight decks incorporate intuitive. 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 .

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

Personal qualities required are those of courage. The leader must balance the demands of the task. This implies a certain amount of discretion in choice of action. and Manage Decision-Making Model.3 Leadership Theory Early research into leadership theory stems from the military. Some of this is relevant in the sphere of commercial aviation.4 Action-Centred Leadership Pilots tend to be naturally task-focused individuals. will power. The leader must have a thorough technical knowledge of the aircraft and appropriate supporting systems. Action. along with recognition of the appropriate source of assistance and the correct answer when provided. The importance of each sphere of responsibility will change dynamically according to the situation. the team and the individual.Page: 21 CRM Manual Date: January 2008 The Captain’s authority as leader is derived from the China Civil Aviation Regulations. with use of the Assess. 6. and a duty. An effective leader must have both technical and personal skills. to decide on a course of action. any limitations of this knowledge must be identified. initiative and integrity. An ability to communicate and self-motivation are also vital. from a practical view point the Captain has a right. Task Team Individuals Figure 1: Action Centred Leadership Flight Crew Training Centre . In addition. and be able to maintain team morale. however the leader also has other areas of responsibility. Jade Cargo International SOPs and technical training support this function of leadership. 6. As leader the Captain has both responsibility and accountability. In fact.

7 Individual Development and Satisfaction In the two-pilot flight deck.8. many of the considerations for the team also apply for managing an individual’s needs. suggestions Clarifying communication Providing feedback Regulating participation Flight Crew Training Centre . consider the following:      Planning Communication of intent Avoid over-involvement as it reduces the capacity to think ahead. With a wide variety of background. suggestions Giving opinions.6 Team Building and Maintenance Team work is vital for an effective solution to a task. Maintain situation awareness Monitor and evaluate the task’s progress 6.8 The Role of Leader The CRM Manual produced by Transport Canada identified the following four tasks that encompass the role of the leader: 6.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 6.5 Task To achieve the task. To enhance the sense of unity:     Use expertise within the team Briefing Co-ordination of effort Provide feedback 6.1 Regulating Information Flow The leader must regulate. ideas and suggestions within the crewmembers and outside sources       Communicating flight information Asking for opinions. manage and direct the flow of information.

there are differing degrees of participation such as democratic and participative.8.8. In between.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 6.2 Directing and Coordinating Crew Activities The leader must function as crew manager to provide orientation. It can range from the extreme of autocratic or dictatorial to “Laissez-faire”. Flight Crew Training Centre .4 Leadership Styles Having determined what is required of a leader.Page: 23 CRM Manual Date: January 2008 6. coordination and direction for group performance     Directing and coordinating crew activities Monitoring and assessing crew performance Providing planning and orientation Setting priorities 6. how is this delivered in practice? Leadership style refers to the degree of involvement between the leader and the team during decision-making.

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

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

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

along with methods of eliminating them. It serves a complex and vital role in establishing and maintaining relationships Flight Crew Training Centre . the words used tend to be very important. This is the most relevant definition to the task of flying an aircraft. This can be verbal or non-verbal information.e. 7. The actual words used accounting for only about 10% The impact of body language is greatly reduced in a flight deck. as does the fact that many of our pilots do not use English as their native language. verbal communication is one of the oldest forms of human interaction. Body Language and tone of voice makes up for the majority of human communication. There are many barriers to communication within a cockpit. In the case of Jade Cargo International.2 Principles of Communication Human communication is the act of sharing information. While modern flight decks are well insulated. degrading language. rank could impinge on communication as well. 7.Page: 27 CRM Manual Date: January 2008 7 Communication 7.3 Communication Barriers The flight deck of an airliner is not an ideal place to have a conversation. So. noise is still a factor. Barriers to communication are also identified. culture plays a large part. in communication within a crew. the advantages of various communication styles and the requirement for conflict resolution. Between a Captain and a First Officer. as much as 90%. and very rarely are raised voices heard. This chapter describes the principles of communication. Communication breaks down barriers and promotes the exchange of important information.1 Introduction One of the key skills required for operating a multi-crew aircraft is the ability to communicate. This chapter is aimed at producing effective crew communication in the context of multi crew operations. The actual words used accounting for about 10%. However. insulting. 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.

It is stating our own needs and feeling without putting others down. Being Assertive:    Heightens self esteem Makes other people take notice Establishes authority Assertive behavior is a desirable form of communication. The SOPs contain standard phrases and occasions when exchanging information or verifying facts is required. assertive. This is especially in the flight deck from a person in a position of authority. the focus.4 Communication Styles To assist in analyzing effective communications. supportive and submissive. Flight Crew Training Centre . The principle means of communication is by the use of Standard Operating Procedures (SOPs). 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.4. two aspects of the message content will be considered.1 Assertive Behavior [a1] An assertive style enables one to speak in such a way that one does not abuse or dominate others. 7. whether on the needs of others or your own. a lively discussion in low workload phases usually goes a long way toward “setting the tone”. 7.Page: 28 CRM Manual Date: January 2008 between people. Establishing a cordial and efficient working relationship can be made easier by the use of some of the techniques covered in this chapter. whether unnecessary emotional language or “put-downs” are used. aggressive. By adhering to these “standard calls” the danger of miscommunication is greatly reduced. While a silent flight deck is desirable in some stages of flight.

it is clear that aggression comes about when an individual is focused on his own needs and uses put. 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. A2 behavior rarely occurs without precursors. Referring to the matrix. the key here is the use of “put downs” or abusive language. In a non-critical situation. are avoided at all times. Flight Crew Training Centre . They put themselves down. 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.4.downs. With a submissive style the individual focuses on others’ needs in a way that diminishes their own worth. 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.4.4.Page: 29 CRM Manual Date: January 2008 7. It is important that “put downs” or words or tone of voice that may be interpreted as such. However.2 Aggressive Behavior [a2] This is when someone is being aggressive. It is unlikely to motivate the team. However this may change depending on circumstances. This is a “no-go” area for us at work. The key to identifying aggression is the use of “put downs”. When aggressive feelings burst forth we tend to regret it afterwards because serious negative consequences usually occur as a result of aggression. such as during training or non-normal situations. 7. Therefore. 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. not recommended but part of life. Aggressive behavior will have a negative impact on a team. Being focused on one’s own needs is very human. 7.4 Submissive Behavior [s2] The simplest definition of submissive behavior is the acceptance of “put downs”. and will likely isolate the aggressor.

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

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

Page: 32 CRM Manual Date: January 2008 Provided these concepts are borne in mind. it is possible for diverse personality types from widely disparate cultures to work together harmoniously and ensure safe flight. and reduces the risk of omissions and errors in the assessment phase of the problem.2 Structured Decision Making Research has identified numerous occasions where similar accidents nearly occurred. Conflict Resolution. Most of them are based on the original CRM loop of Inquiry. 8. Advocacy. either for routine or novel situations. It is not which model that is used that is important. Action and Critique.1 Introduction Problem-solving and decision-making are activities we conduct instinctively every day. This chapter introduces the Company decision-making model. which provides a structured approach to problem solving and decision-making. It is the end result that we are interested in. Using a structured approach for problem solving and decision making leads to a better outcome. 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. or good or bad outcomes. Flight Crew Training Centre . However. once in a while. This raises the question as to whether we should consider good or bad decisions. 8 Problem Solving and Decision Making 8. however it is the industry’s belief that a structured decision making process will reduce the risk of a poor outcome. a situation arises that is beyond our scope or experience. The importance of time management is also covered in this chapter. rather that a model is used. Using a structured approach is a form of SOP for decision making.

according to the manufacturers non-normal checklist and or company procedures. 8. 8. it was decided to call this the “Action Phase”. Flying skills and good management of the auto-flight systems is also applicable throughout the application of the RMM.2 Providing “Seamless Integration” To provide the required “seamless integration” as required by Advanced Qualification Program (AQP). 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. as well as the appropriate CRM principals. “The Situational Assessment Model focuses on factors that influence a flight crew’s assessment of a situation and the subsequent management of available resources”.2. Flight Crew Training Centre .1 The Model “Footprint” The model is based on the “Battelle” “Situational Assessment Model” that had been developed for the FAA.     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. This model was expanded to accommodate the following: Procedures to rectify / contain the problem Making a decision Implementing the decision However. indicating when manufacturer’s company procedures should be applied. During each of the phases specific guidance is provided. further modification to the RMM was required.2. Because this additional phase consists mainly of corrective actions. The RMM is based on the assumption that the crew is fully proficient with the following.Page: 33 CRM Manual Date: January 2008 The Jade Cargo International. Risk Management Model (RMM) is for the two man crew cockpit.

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

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

Open Participation)  Brainstorm options and check for poor judgment  Summaries  DECIDE[selling if required IMPLEMENTING THE DECISION  Satisfy TASK. QRH If needed: “stop the checklist” MANAGEMENT PHASE [summarize. 8. test understanding propose. 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.5 The Jade Cargo International Decision-Making Model RISK MANAGEMENT MODEL AVIATE.Page: 36 CRM Manual Date: January 2008 difficulties. prioritize. propose. prioritize. Achieving the best solution demands good teamwork. the Captain must manage. COMMUNICATE CONTINUOUSLY [Use Autopilot if available] ASSESSMENT PHASE [Seek information. An early calculation of the time situation will assist with decisionmaking. test understanding. 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. delegation] Remember that in complex situations. GROUP AND INDIVUDUAL needs  MONITOR PROGRESS – continually check for poor judgment (PJ) [Participation. keep partner in the loop] PROCEDURE TO RECTIFY / RECALL ITEMS / USE EICAS. This means that the F/O is best assigned the task of flying. Flight Crew Training Centre . NAVIGATE. seek information. test understanding.

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

An awareness of these limitations and errors can reduce their impact on flight operations. these are known as “mental models”. This chapter looks in particular at some of the limitations of the human brain and the typical errors that can occur as a result. output functions and an internal processing function. Flight Crew Training Centre . 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. INPUT PROCESSING OUTPUT Figure 1: Basic Cognition Flow Very simply. Some characteristics of mental models are:     They are incomplete and constantly evolving They are usually not completely accurate. In the same way. Mental models are vital to users for controlling systems and problem-solving.Page: 38 CRM Manual Date: January 2008 9 Cognition 9.3 A Model of the Cognitive Brain As in most processing flows. The importance of the model is that it is effective in assisting understanding. A model may not be a very good literal representation of a system. do something with that information and then act on it.1 Introduction Cognition is all about how humans process information.2 Models Psychologists use models to produce a simple explanation of how something complex works. we receive information. individuals create internal representations of how systems work. Mental models are also a key component of situation awareness. 9. but functionally can be quite accurate. we will consider the brain in terms of input functions.

not all of them get through to the processing stage.4. Attention is directed by the processing function and can be thought of as a filter to the overload of sensations all around us. even though they do not have the loudest voice.4. Perception is incredibly powerful. 9. Sound on the other hand is omnidirectional. so much that. sound and touch. The “cocktail party” syndrome provides a useful example of this.3 Divided Attention Problems occur when we need to attend to more than one matter at a time. During a busy. The brain will filter the unwanted background noise. We are unable to effectively monitor our principle task. but only a limited signal can be conveyed. but it is not being ignored completely. smell and taste. are actually switching from one to the other. touch. Flight-deck design typically makes use only of the first three of these – sight. at some point they will lose part of one or other signal. Routine (status) information is therefore conveyed by visual cues. However the brain does have a mechanism for making sure that we do attend to matters that affect us. sound. Those who believe that they can monitor two channels simultaneously.Page: 39 CRM Manual Date: January 2008 9. 9. The advantage of sight is that quite complex information can be transferred to the user as long as they are looking at the signal. Attention is believed to be a single-channel function. as many of the signals are neither intended for us nor relevant to us. if we miss-perceive an event. it would become increasingly difficult to maintain the original conversation. If someone nearby were to mention a key topic of interest to you (such as your name). noisy social function it is quite possible to sustain a conversation with someone. warnings or “attention-getters” use audible alarms.2 Attention Our senses are constantly receiving and discarding signals. it is very difficult to subsequently identify it correctly and take the correct action to Flight Crew Training Centre .4.5 Perception Perception can also be thought of as another filter by the processing function. sight.4 Input functions 9.1 Senses We have five senses through which we receive information. as firstly you would detect this new signal and secondly try to monitor it as well as the initial conversation. This is quite normal. It is only possible to concentrate on one signal at a time. 9. This refers to a “pre-processing” stage where the brain interprets what it thinks it has seen before dealing with it.

unless it is consciously being dealt with. expect 150 by xxx. 9. Perception is considered to be the first stage of Situational Awareness.2 Sensory Memory Sensory memory refers to how long the senses maintain received data before it is consciously dealt with or lost.1 Memory Memory is the storage area of the brain.6.5 second to replay the stimulus before it is lost. Psychology text-books (and the internet) have numerous examples of such illusions. An example might be an R/T call that interrupts a conversation. In this case the “echoic” memory (of the auditory system) can retain the data for as long as 10 seconds.6.6. Sensory memory data is lost by decay. descend 180. We can increase the effectiveness of our short-term memory by “chunking” information. The string “28531018015011972” is clearly longer than seven digits. short-term and long-term. which really belongs with the input functions. for instance if you are looking in the general direction of the EICAS/ECAM and a message pops up and disappears. New information received on top of this will replace the current contents of working memory. speed 310. the original message has been replayed by the mind. Flight Crew Training Centre . Another type of memory is sensory memory. and retained by conscious attention. 9.72”.Page: 40 CRM Manual Date: January 2008 deal with the problem. It has a capacity of approximately seven bits of information. The mind can have difficulty perceiving something it has never seen before or that appears to be impossible. The processing function is considered to have two types of memory. and contact 119. you have as little as 0.3 Short-Term Memory Short-term or “Working” memory is extremely limited and slow in operation.6 Processing Functions 9. 9. However it becomes more manageable even with additional information in the form – “Heading 285. Iconic memory (for visual stimuli) is almost literally gone in a flash. typically with the response “…was that for us?” but by the time the question is asked.

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 …. Retrieval of information is fast and effortless and parallel processing is available. 9.4 Long-Term Memory Information transfers to the long-term or permanent memory by rehearsal and repetition. Data in the long-term memory can be in the form of single bits of data or in the form of learned routines. but becomes irretrievable due to interference.6. episodic memory gives an autobiographical view of events. It is believed to be unlimited in capacity and lasts forever. 9.5 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. and Mitigate). even if the correct data has never been learned. Flight Crew Training Centre . This enables the brain to come up with a “sensible wrong answer”. Data is stored in one of two methods by the long-term memory.Page: 41 CRM Manual Date: January 2008 Chunking has reduced this sequence to just five bits of information. Short-term memory data is lost by displacement and retained by rehearsal. patterns or mini theories. if you were told that Lexus have developed a new luxury car. This enables this “knowledgebase” to handle recurrent routines. whereas semantic memory stores similar data in a form of hierarchical tree. manageable by most. For example. such as ATM (Avoid.6. One technique to assist with retrieval is the use of mnemonics.. but with inability to retrieve or access the information. Usually the event and what you were doing at the time are inextricably linked as one memory. However the problem is not with forgetting. using “motor actions” without recourse to the conscious workspace. some secret? Long-term memory data is not lost. For this reason it is normally possible to date these events quite accurately. long after the event. but it is top secret. Trap.

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

The term arousal will be used as the generic term for both. Performance varies with a number of factors. In this respect. stress and fatigue produce similar results. 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. sleeps loss and disruption on the body and discusses techniques to manage stress and alertness. This chapter covers the effects of stress.Page: 43 CRM Manual Date: January 2008 towards a landing with significant issues not resolved. Our interest is human performance. your brain knows how to deal with them… 10 Stress and Alertness 10.7 Conclusion The brain is exceptionally powerful but typically limited to dealing consciously with one issue at a time. including workload and circadian rhythms.1 Introduction Stress may be defined as the demands that act on the human body. Optimum Stimulation Creativity Rationality Problem Solving Progress Under Stimulation Boredom Frustration Dissatisfaction Over Stimulation Overload Confusion Distress Flight Crew Training Centre . This chapter highlights some of the issues now that they have been identified. 9. others mental strains. some a combination of both. Some of these place physical strains on the body. It is easily overloaded and can also produce biased results.

1 Acute Stress Acute stress is the most common form of stress. performance actually peaks. Too much stress decreases a person’s ability to function. Acute stress is thrilling and exciting in small doses. Stress is also a factor in achieving peak performance due to the release of adrenalin. for example. The right side shows over stimulation. require the crew to be at optimal performance.stimulation. from being somewhat dormant. largely impossible. acute and chronic. Sustained operation in the shaded area is however. consider that arousal refers to stress. Flight Crew Training Centre . These prepare the body to react when presented with danger.3. Initially. As stress increases further. and other symptoms. within easy reach of peak performance if new demands arise. Optimum human performance takes place in the shaded area at the top of the curve. The wellknown “fight or flight” or “adrenalin rush” syndromes are as a result of stress. The body needs an optimum level of stress to operate. but the time spent in these phases is relatively short. A fast run down a challenging ski slope. such as take-off and landing.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. 10. performance improves. Too little stress causes complacency. which differs according to individuals and within individuals. performance declines below optimum or satisfactory performance and enters a rapid decline thereafter. overdoing on short-term stress can lead to psychological distress.3 Types of Stress Stress can be divided into two types. into the optimum performance range (shaded). That same ski run late in the day is taxing and wearing. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. The American Psychological Association explains these as follows: 10.2 Stress Stress is not necessarily a bad thing. tension headaches. upset stomach. 10. but too much is exhausting. is exhilarating early in the day. After a certain point. Performance tends to degrade very rapidly if an attempt is made to remain at optimum for a long period. A small amount of stress acts as a stimulus and results in improved performance. The left side of the curve shows a person in a state of under. Stress has been necessary for the evolutionary survival of the human. Critical phases of flight. By the same token. as stress increases. In the diagram above. It is preferable to remain on the left hand side of the curve. Skiing beyond your limits can lead to falls and broken bones. and then falls away.

stomach. diarrhea. they describe themselves as having "a lot of nervous energy. acute stress doesn't have enough time to do the extensive damage associated with long-term stress. and can't organize the slew of self-inflicted demands and pressures clamoring for their attention. irritable. back pain. The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent tension headaches. and so on. who suffer acute stress frequently. acid stomach.Page: 45 CRM Manual Date: January 2008 Fortunately. anxiety. shortness of breath. migraine headaches. and sometimes their irritability comes across as hostility. flatulence. They seem perpetually in the clutches of acute stress. 10.3. and it is highly treatable and manageable. have too many irons in the fire. Interpersonal relationships deteriorate rapidly when others respond with real hostility. however. and depression. If something can go wrong. migraines. Often. but always late. Treating episodic acute stress requires intervention on a number of levels. and chest pain.2 Episodic Acute Stress There are those. It is common for people with acute stress reactions to be over aroused. They take on too much. their child's occasional problems at school. they tend to be abrupt. and heart disease. sweaty palms. The work becomes a very stressful place for them. transient over arousal leads to elevation in blood pressure. muscular problems including tension headache. Because it is short term." Always in a hurry. shorttempered. whose lives are so disordered that they are studies in chaos and crisis. hypertension. It's a laundry list of what has gone awry in their lives: the auto accident that crumpled the car fender. generally requiring professional help. most people recognize acute stress symptoms themselves. The most common symptoms are:    emotional distress--some combination of anger or irritability. They're always in a rush. a deadline they're rushing to meet. and the muscular tensions that lead to pulled muscles and tendon and ligament problems. the loss of an important contract. dizziness. cold hands or feet. and tense. gut and bowel problems such as heartburn. heart palpitations. constipation. chest pain. and irritable bowel syndrome. it does.    Acute stress can crop up in anyone's life. anxious. rapid heartbeat. Flight Crew Training Centre . the three stress emotions. jaw pain.

which exhibits as either a physical response e. Chronic stress destroys bodies. Frequently. promotion to Captain). It's the stress of unrelenting demands and pressures for seemingly interminable periods of time. perhaps. Some examples are: marriage or divorce. they ignore chronic stress because it is old. and.Page: 46 CRM Manual Date: January 2008 Often. hyperventilation. or a mental response such as irritability. heart attack. Chronic stress comes when a person never sees a way out of a miserable situation. of dysfunctional families.4 Sources of Stress A stressor is the term used to define the cause of stress.. This is the grinding stress that wears people away day after day. minds and lives. It's the stress of poverty. Generally. stroke. People are immediately aware of acute stress because it is new.3. the symptoms of chronic stress are difficult to treat and may require extended medical as well as behavioral treatment and stress management. There are three broad sources of stressor: life. More precisely. their patterns of interacting with others. They blame their woes on other people and external events. chronic stress is not. People wear down to a final. of being trapped in an unhappy marriage or in a despised job or career. sweating. even cancer. a change in lifestyle is a source for this type of stress. They forget it's there. year after year. Chronic stress kills through suicide. violence. lifestyle and personality issues are so ingrained and habitual with these individuals that they see nothing wrong with the way they conduct their lives. 10.e. change in job or responsibilities (i.g. environmental and cognitive.5 Life Stress Life stress typically results from a person’s particular lifestyle. familiar. they see their lifestyle. the illness or death of a close relative or friend. and their ways of perceiving the world as part and parcel of who and what they are. tremors. the individual gives up searching for solutions.3 Chronic Stress While acute stress can be thrilling and exciting. heart arrhythmia. The worst aspect of chronic stress is that people get used to it. fatal breakdown. It wreaks havoc through long-term attrition. 10. With no hope.3. This could come in many different forms. and sometimes. Flight Crew Training Centre . Because physical and mental resources are depleted through long-term attrition. stress is accepted as the human response to these stressors.3. 10. almost comfortable.

10. or the selecting SPD instead of HDG. Temperatures in the cockpits rise rapidly on the ground during summer. Two common examples could be heat and noise. Sleep disturbance is also a source of environmental stress.3. who collided with a ground vehicle whilst landing. 10. most pilots will experience some degree of hearing loss. Suffice to say that life stress is almost definitely a threat to aircraft safety. His accident statement directly attributed the incident to his state of mind. humans tend to become victims of “intentional selectivity”. The original research was carried out by US Navy psychologists during the Vietnam era and has been expanded since. Noise is an unavoidable factor with aircraft operation. This is referred to as “tunnel vision”.deck. Another not uncommon consequence of high workload is the tendency to trade accuracy for speed. This is caused by the limited ability of humans to process information. The most quoted example is that of a pilot experiencing marital difficulties. Heat causes a subtle and unseen form of incapacitation. When workload is high. In the long-term. These occur when a pilot follows a “motor-action” response and selects a control very similar to the desired one. Examples are the auto-brake selector instead of brake fans. The effect is that pilots will become focused on a task. Pilots using noise attenuating headsets report less fatigue over long sectors. This is again caused by the brain trying to manage large chunks of information in short periods. and mismanage priorities. but with a dissimilar function. Noise arouses the individual.7 Cognitive Stress Cognitive stress refers to the mental workload imposed on a person. especially when it involves an operating pilot.6 Environmental Stress Environmental stress results from the physical environment surrounding an individual. However. as it is a mental “picture” it is extremely difficult to establish any direct causal link between life stress and an aircraft accident.3. either on the apron. this will be covered later in the chapter. or in the flight. The effects of cognitive stress overload are most often experienced in high workload situations.Page: 47 CRM Manual Date: January 2008 Research carried out by various organizations suggests a strong link between life stress events and aircraft accidents. High workload causes a skilled pilot to commit what are termed “action slips”. Noise is generated internally (radios) and externally (airflow and engine). In trying to complete a task and move to Flight Crew Training Centre . but exposure for extended periods also causes a drop in performance. as their brains try to accept large and unmanageable chunks of information.

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

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

The use of alcohol is not recommended as a form of stress relief. providing awareness and in need of management. The use of card and board games has historically been a popular form of stress relief.8 Controlled Rest in the Flight Deck The FOM also provides for controlled sleep during low workload situations. The duration of rest is limited to prevent sleep inertia. when conducted in a structured fashion. This practice is based on extensive research done by NASA among others. In the modern world. In accidents involving human error. is the duty of every crewmember. Exercise is often used as a form of stress relief. a staggering 88% have been identified as involving a loss of situational awareness.Page: 50 CRM Manual Date: January 2008 Circadian Rhythms As with the other threats that we face. 10. However it is often quoted without really being explained. Others prefer mental stimulation. this is a potentially dangerous practice. 11.7 Stress and Alertness Management The FOM requires pilots to be in good physical and mental health – fit for duty. It is another warning flag. who has it and the skills necessary for maintaining and sharing situational awareness.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. computer games appear to be increasingly filling this role. As any medical practitioner will verify.1 Introduction Situational awareness is frequently stated as a factor in accidents and incidents. Managing stress and sleep effectively. It has proven that controlled rest is a very effective tool for combating fatigue and maintaining alertness. the Flight Crew Training Centre . 10. This acts as an effective fatigue prevention tool and allows a satisfactory level of alertness to be maintained. 11 Situational Awareness 11. In extreme cases this can take the form of dangerous sports. This chapter will explain what it is. circadian disrhythmia is not sufficient cause to cease operations. with dire consequences in the aviation industry.

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

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

identified by the PM: PM: “Looks like a 15 knot tailwind on approach” This is shared perception – they have noticed the problem PF: “OK.6 Factors Affecting Situational Awareness Studies have revealed a ten-fold difference in SA between pilots within the same airline.” This identifies shared comprehension – the PF understands. task management and prioritization. potential problems that are identified early allow the opportunity to avoid. indicating that the crew is thinking ahead [Level 3 SA].7 Communication Awareness and Shared Situational For a crew to be most effective they must share the same high SA. It has also been observed that crews flying non-glass aircraft have better SA than those with the latest technology. then the crew is only noticing problems [Level 1 SA]. Skills relating to spatial ability.” Flight Crew Training Centre . perceptual speed and working memory capacity are inborn. we can make the link to identify at which level of SA we are operating at. unstabilized approach. Information can be shared at all three levels of SA. and use the speed brake if necessary. self-monitoring. Situational awareness can be trained to a certain extent. I’ll reduce speed xx miles earlier than briefed. Basic skills that high SA crews exhibit are. Human error is inevitable. If the crew is trapping a lot of errors. The best strategy is to “Mitigate” the problem by going-around. attention-sharing. this may indicate they are operating at understanding [Level 2 SA]. Consider the case of an unexpected tailwind on approach. otherwise crew SA tends to fall to that of the weaker crewmember. Should such a state occur. if mitigation seems to be the key factor.e. Advanced skills include pre-flight planning. there is very little time left to correct it. communications. PM: “They might change runways if the surface wind picks up. 11. Finally. By analyzing how we deal with the problem. The Mitigate phase commences at the start of the Safety Window (2000’ AGL). scan patterns and checklist use. 11. However. too high.Page: 53 CRM Manual Date: January 2008 In the final stages of the approach. so that we can take action to improve it. too fast etc) must be avoided.5 Situational Awareness and Error Management Using “Threat and Error” management principles. an undesired aircraft state (i. psychomotor skills and pattern matching are trainable. contingency planning. 11.

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

L. A. Colombus. W.. R.. Paper presented at the IXth International Symposium on Aviation Psychology. Indonesia. 8-12.C.. Ooi. Ohio. what is it? (Error. Merritt. Paper presented at the SAS Flight Academy Training Conference..S. (1996). University of Texas: Aerospace Crew Research Project.C. Paper presented at the Training and Safety Symposium.. R. & Helmreich.L. Paper presented at the IXth International Symposium on Aviation Psychology. November 20-24. R.C. R. (1996. (1995). Paper presented at the ICAO Global Human Factors Seminar. P. 1991. P. Merritt. A. A. & Merritt. Flight management attitudes questionnaire 2. Creating and sustaining a Safety Culture. In proceedings of the VIIIth International Symposium on Aviation Psychology. April-May. Merritt. CRM: I hate it. 1996. (1997).. CRM Advocate.C. The Aerospace Crew Research Project Line-LOSChecklist: Assessing system safety and crew performance. April. Flight Crew Training Centre . 1997. Cultural influences on flight operations. Columbus: Ohio State University. May 1995. New Zealand.R.L. Colombus. & Merritt. Merritt. & Helmreich. April 23-25. 1997.0 (International) & 2...C. (1997). Merritt. 1996.. CRM in 1995: Where to from here? In Proceedings of the Third Australian Aviation Psychology Symposium. and culture) Paper presented at the Orient Airlines Association Air Safety Seminar.. April). R. stress..C. & Helmreich. R. Wilhelm. April-May. (1991)..C. Helmreich.C. A. (1996). A.A. A. 1. Local solutions for global problems: The need for specificity in addressing human factors issues. Helmreich. Replicating Hofstede: a study of pilots in eighteen countries.. Guangzhou.L. Ohio.L. & Sherman. Sydney.L. Auckland. (1995). (1995). Cultural issues in crew resource management.1 (USA/Anglo) (Technical Report 96-4).Page: 55 CRM Manual Date: January 2008 12 Reference Notes Helmreich. A. T. (1996). Jakarta. Designing culturally sensitive CRM training: CRM in China. Merritt. J. A..J..R. Taggart. November 26-28.C. 1995.

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