Student Workbook CRM ADM 2020

CREW RESOURCE MANAGEMENT
AVIATION DECISION MAKING

CORRESPONDENCE COURSE 2020
CIVIL AVIATION ACADEMY AUSTRALASIA PTY LTD

Authority
This workbook has been produced by the Civil Aviation Academy
Australasia Pty Ltd (CAAA).
Revision Date
This Crew Resource Management (CRM) and Aircrew Decision
Making (ADM) - Non-Technical Skills Course Workbook was
updated in November 2017 (12th Edition).
Instructions to Candidate
This workbook contains a prompt at the completion of your reading to complete the Review Questions
(which have also been supplied with your workbook). It is strongly recommended that you first read through
your assessment (Review Questions) and then tag or note where information you read may assist with
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Your answers will then be assessed by our approved Facilitators. The minimum pass mark is 80%. Upon
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Within this document:
i. words denoting a gender or genders include each other gender; and
ii. words in the singular number include the plural and words in the plural number include the singular.
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CRM and ADM Course - Non-Technical Skills Training 2

© 2020 Civil Aviation Academy Australasia Pty Ltd
TABLE OF CONTENTS
MODULE ONE – INTRODUCTION
MODULE TWO – COMMUNICATION AND ASSERTIVENESS
MODULE THREE – COMMUNICATION AND ASSERTIVENESS
MODULE FOUR – SITUATIONAL AWARENESS
MODULE FIVE – DECISION MAKING
MODULE SIX – LEADERSHIP
MODULE SEVEN – TEAMWORK
MODULE EIGHT – UNDERSTANDING HUMAN ERROR
MODULE NINE – THREAT AND ERROR MANAGEMENT
MODULE TEN – NON FLIGHT CREW SPECIFIC

CONSIDERATIONS
MODULE 11 - AUTOMATION
CRM and ADM Course - Non-Technical Skills Training 3

MODULE ONE
INTRODUCTION
WHY ARE WE HERE?
As part of our understanding of CRM, think back to your most successful and rewarding team or
group experience. It may have been a:
 Sports Team;
 Volunteer Group;
 Crisis Experience; or
 Family Experience.
Think about your story and the characteristics of those experiences that made the team
successful and rewarding.
What does this mean to us and our workgroups?

How can we use this information in the future to assist us?
SO WHAT IS CREW RESOURCE MANAGEMENT?

Since its inception in the late 1970’s, Crew Resource Management (CRM) - the precursor to
Aircrew Decision Making (ADM) - has evolved to meet the aviation industry’s changing needs. It
has adapted to meet the continuing development of new knowledge and facilitation formats.
The current focus of Non-Technical Skills Training (NTST) is similar to that of the more
traditional CRM skills we have discussed for years but with a different emphasis and this is what
we will investigate in this course of study.
Teamwork
Communication
Consultation Leadership
Participation
Supervision
Behaviour
Decision Situational
Making Awareness
CRM ADM Course - Non-Technical Skills Training 4

It is the combination of the skills of decision making, communication, teamwork, leadership and
situation(al) awareness that results in effective and systemic consultation, participation,
supervision and behaviour.
Consultation
 Consultation is the mechanism through which issues are raised, communicated and
resolved participatively.
Participation
 Individuals become engaged in and committed to the process of sharing in the activities
of a group through participation.
Supervision
 Through supervision, information and instructions are conveyed to individuals and teams
to effectively carry out their roles, perform work tasks and adhere to instructions.
Behaviour
 Behaviour is an individual’s conformity to agreed safe work practices and reflects the
person’s commitment and participation.
An accepted definition (although fairly simplistic) is:

“CRM is the effective use of all resources, hardware, software and liveware to achieve a safe
and efficient flight operation.” Dr. John Lauber, 1984
And another:
The effective use of all available resources by an individual or crew to safely and
successfully accomplish a flight operation.
Then what is ADM?
Decision making is the cognitive process of selecting a course of action from among multiple
alternatives.
Decision making in an aeronautical environment involves any pertinent decision taken to

ensure the safe conduct of a flight.
As mentioned we have now progressed further to discuss CRM and Human Factors as Non-
Technical Skills Training (NTST). The Civil Aviation Safety Authority (CASA) defines NTST as:
"the mental, social, and personal-management abilities that complement the technical skills of
workers and contribute to safe and effective performance in complex work systems. They
include competencies such as decision-making, workload management, team communication,
situation awareness, and stress management."
To explain further let us consider the following scenario of two sisters and one orange.
There are two sisters in a kitchen, both of whom want an orange, but there is only
one left.
• What do you expect is the solution?
• How might they compromise?

The most common and perhaps simplest compromise could be that they cut the orange in half,
this way each will have half an orange.
That’s what they did. One sister went to the juicer and started to squeeze herself a rather too
small orange juice.
The other sister, with much difficulty, began to grate the rind off her half an orange to flavour a
cake.
Had they discussed needs rather than heading straight to solutions they could have both had a
whole orange.
Win – Win; We want what’s fair for all of us - how to achieve this in our workplaces formulates
this course.
Hawkins F (Human Factors in Flight) defines Human Factors: “It is about people in their working
and living environments. It is about their relationship with machines and equipment, with
procedures and with the environment about them. And it is also about their relationship with
other people”.
Human Factors incidents are not limited to mistakes and errors by pilots. In 1974 Turkish
Airlines Flight 981 was lost due to a failure to close a cargo door properly. It was also
discovered that the actual design of the cargo door was a major contributory factor to this error
being made. In August 1985 Japan Airlines Flight 123 suffered mechanical failure 12 minutes
after departure from Tokyo. Shortly after, it crashed killing 520 of the 524 people on board as a
result of the loss of the vertical stabiliser. The major causal factor was found to be a non-Boeing
approved repair conducted in 1978 after a tail strike which damaged the rear bulk head on the
aircraft.
Many would also successfully argue that Human Factor development started with man first
picking up a hand tool. In more modern times definitive inroads were made in the understanding
of Human Factors with the various time and motion studies of the late 1800’s and throughout
the World Wars of the early 1900’s. For example, 1937 saw the development and adoption for
wide use of the pilot checklist for the first time; now seen as a critical element in all aviation
roles.
World War II saw many improvements in the application of Human Factors in improving aviation
safety with the work of research conducted by people such as Paul Fitts and Aphonse
Chapanis.
Aphonse Chapanis, is widely considered one of the fathers of ergonomics and was a pioneer in
the field of industrial design. Ergonomics is the science of design taking into account human
characteristics. One of his major contributions was shape coding in the aircraft cockpit. After a
series of runway crashes of the Boeing B-17, Chapanis found that certain cockpit controls (due
partly to their proximity and similarity of shape) were confused with each other. Particularly, the
controls for flaps and landing gear were confused. Chapanis proposed attaching a wheel to the
end of the landing gear control and a triangle to the end of the flaps control, to enable them to
be easily distinguished by touch alone. This type of shape coding still occurs today.

TRADITIONAL CREW RESOURCE MANAGEMENT GENERATIONS
Traditionally, CRM is seen to have transitioned through five major generational changes. Each
generation encapsulates significant and contributory events to create an evolution of
understanding in CRM principles. Fifth Generation CRM looks to a strong emphasis on
Threat and Error Management (TEM). The focus here is
on techniques to avoid errors, trap errors and mitigate the
consequences. This generation acknowledges that
human error is unavoidable as humans are fallible. It
advocates a non-punitive policy regarding human error
but not violations.
The 1990’s saw the Fourth Generation, Crew Resource

Management Integration and Proceduralisation evolve.
This generation led to a reduction in standalone courses
and the integration of CRM with technical training.
The Third Generation Company Resource

Management (CRM training ‘in context’) of the early
1990’s was a systems approach. This generation
considered the broader operating environment and
various organisational structures of operators. The
training also extended to other groups such as cabin
crew, ATC and maintenance.
The Second Generation of Crew Resource

Management grew from the work being initiated with the
incorporation of CRM principles into the fabric of flight
training and flight operations. This was recognized as a
need by the working groups at the 1986 NASA Workshop.
Commencing in 1986, this generation looked more at
concepts such as situational awareness and stress
management.
This First Generation, Cockpit Resource Management

was derived from classical management and development
strategies with a strong focus on personality and
interpersonal skills. The emphasis was on trying to fix the
“wrong stuff” or what had happened.
The first generation commenced with the 1979 inaugural workshop sponsored by the National
Aeronautics and Space Administration (NASA). The workshop resulted from research into the
causes of air transport accidents. These accidents identified human error as a major causal
factor and subsequently the human element was the primary focus.
Cockpit Resource Management was first used by United Airlines in 1981. The training was
based upon work being undertaken to enhance managerial effectiveness in various corporate
areas. This United Airlines program was closely modeled on the training methods developed by
psychologists Robert Blake and Jane Mouton. This model of training was called the ‘Managerial
Grid’. As a result, the courses relied on psychological testing and involved games and exercises
which were not specific to the aviation environment. These courses were commonly criticised
for being personality manipulators and “charm schools”. However, on the positive side, training
was now commonly conducted on a recurrency basis and also presented outside the classroom
as Line Orientated Flight Training (LOFT). LOFT is not exclusively used for CRM training, but
does provide an excellent environment for CRM training in addition to other training for the
crews concerned.

Smaller operators may find the use of LOFT difficult as it relies on the use of a simulator for
flight specific scenarios. However other simulations can be completed in a classroom
environment or ground environment (e.g. hangar or your office) it just needs some imagination
and thought.
Benefits of LOFT include:

 Resources (aircraft) remain on-line.
 An effective assessment tool and training aid giving enhanced flexibility in the training
environment.
 Develops team skills.
 Improves operational standards and proficiency of crews.
 Training is conducted in a zero flight hazard environment.
 Training easily incorporates the technical and operational aspects of the operation.
 Excellent de-brief resource. Most LOFT exercises are videoed with a review undertaken
by the crew and facilitator in the de-briefing.
 Organisations can observe a multitude of crews in the same scenario enabling a review
of ‘on-line’ procedures and crew interaction in comparison to your organisation’s
Standard Operating Procedures.
 Demonstrates issues with crew interaction and organisational culture that might go
unnoticed ‘on line’.
 A source of behavioural markers for review and statistical analysis to ‘measure’ CRM
can be developed and reviewed.
 Designers/manufacturers can review design and ergonomic modifications.
 Improves operational safety.
 Flying non-normal scenarios indicate ‘clues’ to inappropriate actions or conflicting
information within the crew’s procedures and/or knowledge.
The Second Generation of Crew Resource Management was still specific to flight operations
at this time. However, due to the new emphasis on cockpit group dynamics the name was
changed to Crew Resource Management. This generation’s format is still commonly being used
today.
This development of an integrated CRM training approach was supported by several major
accidents. One of which, the British Midlands Airways B737-400 accident near Kegworth
(08/01/1989), again highlighted poor communication skills in the accident review. This accident
review also changed the rules for the wearing of seatbelts by passengers in airline operations.
Refer to the link for an interesting review of the British Midlands Accident.
https://www.youtube.com/watch?v=vZ_iripgXkQ
The Third Generation of Company Resource Management (CRM training ‘in context’) saw an
emphasis on team building, developing specific CRM skills and desired team behaviours. This
CRM training also introduced tools to enable participants to evaluate Human Factors. There is
however much belief, that this extension of the scope of training diluted the original focus of
human error reduction.

The 1990’s also saw the Fourth Generation, Crew Resource Management Integration and
Proceduralisation evolve. This generation led to a reduction in standalone courses and the
integration of CRM with technical training. It also provided for greater flexibility in CRM training
and enabled airlines to meet their regulatory requirements.
Significantly within this generation, specific behaviours were formally introduced into operational
checklists.
The final generation of CRM evolved quickly from its predecessor. Fifth Generation CRM looks
to a strong emphasis on Threat and Error Management (TEM).
A further aim of the 5th CRM generation was to make both the individual and organisation
aware of the threats affecting their working environments and how they occur. Therefore the
training included how to trap and mitigate threats as they affect flight safety. This is achieved
through the application of relevant Human Factors and threat management principles. Ideally,
CRM training of this evolution is designed to give information regarding the theory which
underlies human performance and the use of resources in order that crew performance and
flight safety is improved.
Currently the focus has moved to Aviation Decision Making (ADM).
AVIATION DECISION MAKING (ADM) TRAINING

ADM training is the operating philosophy based upon a comprehensive and detailed system for
improving crew performance. It has developed through the ‘generations’ to include all forms of
crew training and the entire crew complement. ADM training addresses the attitudes and
behaviours of crewmembers and their impact on the safety and effectiveness of operations. In
recent times, ADM training has focused on the crew as a group rather than the individual.
Contemporary ADM training however also provides individuals with the opportunity to examine
their behaviour and to make decisions on how that behaviour can be modified to further improve
teamwork.
The aim of ADM training is to:
Give you information regarding the theory, which underlies human performance and the
use of resources in order that crew performance and flight safety is improved. This is
achieved through the application of relevant NTST and ADM principles and techniques.
ADM is a tool that is used to minimise the element of human error. Although human error is
inevitable it is with the concepts of this course that we aim to minimise that risk.
Effective ADM training influences attitudes towards current and future operations in a positive
way to improve safety and efficiency. However, in order to remain effective and relevant it must
change with changing times. ADM training must also recognise that people as a society change,
as do our expectations and knowledge. With this in mind we have different expectations from
technology and its reliability.
The increasing demand for new technology to meet the demands of society brings with it
implications for ADM. With change we must ensure that ADM knowledge and application is
adapted to meet these new technologies.

None of this can be achieved without continued recognition of the ADM lessons of the past and
their application to the events of the future. This course will include reference to past accident
and incident scenarios to assist in our understanding of the application of what we learn here.
In the development of our Non-Technical Skills, an important issue to explore is how to acquire
knowledge and skills to work effectively in our teams and to, one day, lead those teams.
The three broad ways in which we develop our effectiveness is:

1. Formal education and training;
2. Challenging experiences;
3. Feedback.
The core characteristic of a good education is that the person ‘graduating’ has learnt how to
learn and to problem solve.
There has been extensive research into the nature of learning. As a

result there are many ways to examine the learning process. By
examining our own strengths and limitations in the learning process we
can work towards recognising this in our working teams and as
‘students’ in the mentor and training environment.
Over the next few pages we will examine our own learning styles and thus examine our natural
preference in the learning environment – something we do every day at work.
The ability to learn underpins the ability to be flexible, to be creative, to adapt to change and to
solve problems. This recognises that in our workplaces we operate in a complex, evolving
environment, the nature of the problems we face and the opportunities presented will tend to
change rather than remain fixed.
Our success depends on our ability to learn the true nature of new problems and their possible
solutions rather than depending upon our ability to apply specified solutions to predictable
problems.
Ever hear that phrase "It's just like riding a bike?" It

turns out riding a bike isn't actually all that easy. Take
this bike, for example. It looks like an ordinary bicycle
but with one tiny difference – can you spot the
difference in the photograph opposite? You may think
you can ride it, but I guarantee you're wrong.
Learning new skills is a little like riding this bike – we

think we don’t have to concentrate but we do!
‘Riding a Bike’:
http://viewpure.com/MFzDaBzBlL0?ref=bkmk

Kurt Lewin’s (1951) model of experimental learning has been extended and developed by
various learning theorists such a Kolb (1984) and the combined research of Honey and
Mumford (1995). Although many comments have been passed regarding their theories, it is well
accepted that in essence optimal learning requires an adequate allocation of effort to each of
the four components of the Action Learning Cycle. See below.
Reflection: on values,
objectives, strengths,
weaknesses,
opportunities and
problems. Questioning
your assumptions.
Immersion: in Conceptualisation:
experience through formulation of theories
the collection of into concrete goals and
extensive, unbiased plans before assessing
feedback. Exploring their suitability, their
what you can learn cost/benefit and
from it. potential obstacles.
Implementation:
building motivation
and confidence before
implementing plans to
enhance effectiveness,
capitalise on
opportunities and
solve problems.
Before moving on complete the Learning Style Assessment at Appendix 1 of

this workbook.

Descriptions of each stage of the cycle are:
1. Reflection
This involves the pondering of events to understand why they occurred and their implication in
light of your objectives.
You will tend to look at problems and opportunities from various

perspectives in order to increase your insights and appreciate
other points of view. This is vital in learning from your
experiences. Little learning will occur unless you devote time to
reflection. You will need to be clear about exactly what you are
trying to achieve.
Millions saw the apple fall, but Newton was the one who asked
why. Bernard Baruch
2. Conceptualisation
This refers to the contemplation of how you apply your theoretical knowledge in order to achieve
your objectives.
This will only become apparent when reflecting. This stage of the learning cycle is important as
there is nothing more important than a good theory. The best options are most likely to come
from generating a large number of alternatives. Another key aspect of conceptualisation is
thinking through the likely implications of the possible actions. Important in good situational
awareness.
The beginning of most great ideas tends to be the systematic search for better alternatives.
3. Implementation
Implementation in the learning process entails trying to influence people (and

yourself) and change situations.
You need the confidence to take the risks to test your theories and plans. It
is obviously a vital component of the learning cycle and one that we tend to
spend most time on where at times we should perhaps allow ourselves time
for contemplation and reflection?
4. Immersion
This involves the experiencing of outcomes implementing your plans.
We collect and collate the factual and emotional information with regard to what we expected to
happen and what actually happened. A clear sense of how well your plans have turned out is
crucial in exploring your approach to the task such that it can be more effective in the future.
Again we do not tend to spend the time required on this part of the learning cycle.

Your learning style is how you distribute your time across these activities.
Learning development and problem solving requires devoting an adequate proportion of energy
to each of the four sections. The concentration on any one section of the learning cycle will tend
to reduce the overall efficiency and effectiveness of your learning.
The optimal time we spend learning a task should depend on the nature of the task. It is often
claimed that technical professions, including pilots/engineers etc., concentrate too much on the
reflection and conceptualisation phases. However, the strengths of this are good planning and
the generation of robust solutions.
However, over-emphasis may lead to limited follow through with under-emphasis potentially
leading to limited innovation and strategic rationality resulting from insufficient awareness of the
broader issues.
THE MORAL FUNCTION OF ETHICS IN THE WORKPLACE

Values define appropriate standards of behaviour. Values are our convictions, they determine
what we consider to be most important, worthwhile and appropriate and influence our view
about how we should act – they help us to determine what is morally right and wrong.
These standards are what people use to decide what is right to wrong, fair or unfair, proper and
improper.
Organisations also attempt to define standards of conduct for their employees via documents
such as “Codes of Conduct”.
Ethically difficult situations arise frequently and may be extremely difficult to resolve. For
Example:
1. How would you respond to a small theft on the part of your supervisor?
2. How would your answer to the previous question be influenced if you were relying on
your supervisor to recommend you for a promotion that you had been striving to
achieve?
3. You suspect that your organisation has sent an invoice to a client for work that was done
for another customer. What would you do?
4. To what extent would you help your best friend obtain a job with your organisation if you
knew there were other more experienced and qualified candidates?
Values influence what we prefer and what we care about. We are more likely to set goals and
strive to achieve things that we value, rather than that which we consider to be of minimal

importance. The emotional consequences of successes and failures also depend upon the
value we place on a particular activity or outcome.
Classic work by Rokeach (1973) defined two types of value sets.
Instrumental Terminal
Values Values
Standards of conduct or methods

Specify the ultimate objectives
for achieving our objectives i.e.
we seek i.e. personal (self
morality (honesty) or competence
esteem) or social (equity).
(rationality).
What is important to remember is that our values are not always that of our work colleagues.
This is not wrong, we are just different people and must never impose our own priorities on to
others. We can do this without intent so just keep this in mind.
How would you deal with the following situation? Perhaps discuss with others to determine
different ideas. How realistic is this scenario?
SCENARIO
You are a fairly new employee, but you have come to the organisation with considerable
experience. In your present position, you must work with a more seasoned employee of the
company, whose behaviour is less than friendly. You are anxious to do a good job and realise
that your co-worker has a great deal of knowledge and experience, yet is unwilling to share that
information. When something goes wrong, your co-worker places the blame on you. You,
however, believe you are not at fault because your co-worker withheld valuable information that
would have prevented the mistake. In order to learn your job, you need to develop and maintain
a good relationship with your co-worker. You sense that this person is competitive and territorial
and believe that he/she is deliberately doing things to keep you from being successful.
Discussion:
What are three various approaches you might take to deal with this
situation?
What are the potential outcomes of each approach?
After considering the various approaches, which do you think would be

more effective? Why?

MODULE TWO
HUMAN FACTORS
Human Factors’ may be defined as:
The study of any factor that can influence

human activity.
It evolved from the disciplines of:

 Engineering and Ergonomics;
 Psychology;
 Physiology; and
 Sociology.
As aviation by its nature has always been at the forefront of development in the fields of
engineering and ergonomics, there has been a natural progression of the human factors
disciplines that go hand in hand with practical application of the technical issues. Accordingly, a
unique and defined area of study known as Aviation Human Factors emerged early in the 20th
century and has continued to lead the way over all other studies in human factors.
As with all current methods of analysis of aviation events, the human factors approach adopts
the proposition that human error is not only possible but is inevitable across all ranges of human
activity. The aim of analysing an event therefore is not to find errors and then try to recommend
ways to prevent the human from making them, but to note the error and then make
recommendations that will control the error.
The ultimate aim is to design equipment, ancillaries, software for human use so that error is
controlled by both:
 minimising the chances of error; and
 minimising the consequences of any errors that do occur.
Capt van Zanten (the KLM Capt involved in the Tenerife Accident between his aircraft and
another B747 – the other from PanAm) was lined up, checks complete and ready to go. When
the tower controller issued airborne instructions, which included the phrase ‘take-off’ (but not the
clearance) his high level of expectation engrossed him to the extent that he was adamant he
was cleared for take-off. A review of the cockpit voice recording showed clearly that he mis-
interpreted the message. This contrasted clearly with the queries and comments of the less
experienced first officer and flight engineer who felt they had not been issued with a take-off
clearance but felt too intimidated to assert themselves.
This was a classic case of greater experience, less safe versus lesser experience, more safe.
The Human Factor played a major contributing element to this accident. Let us look at the
contributing factors of being human further.

HUMAN NEEDS
Any team leader should always be aware of the fact that we are all human and as human’s we
have specific needs in order to function to our highest capabilities.
In 1938 psychologist Henry Murray published a catalogue of human needs. These were
described as either:
 primary (biologically innate); or
 secondary (learned or acquired).
Murray also identified needs for achievement, affiliation, power, dependence and succor (the
need to be taken care of).
Abraham Harold Maslow (April 1, 1908 – June 8, 1970) was a psychologist who studied positive
human qualities and the lives of exemplary people. In 1954 he expressed his theories in his
book, Motivation and Personality.
Maslow re-organised the human needs of Murray into levels of importance. Originally called a
Hierarchy of Human Motives they are now more commonly referred to as the Hierarchy of
Human Needs.

Once a need is satisfied it no longer provides motivation and the individual strives to satisfy the
needs of the next higher level.
Physiological Needs
Individuals are first concerned with their need for food, rest and exercise etc.
Until these needs are satisfied a person cannot concentrate on learning, self-expression or any
other task.
Although it is individual’s responsibility to be fit and healthy, it is the role of the team leader to
ensure the physical needs of the team are met i.e. they have eaten, they are suitably rested and
generally healthy.
We all know the difficulty in undertaking any task when we are tired, thirsty or hungry.
Safety and Security Needs
Security needs such as danger, threat and deprivation are considered to be the second priority
of human needs.
Especially relevant in aviation, safety is a constant concern for the team and can affect their
ability to focus on a task and to work as a successful team. We must always ensure we keep
ourselves and our team safe. In many cases maintaining situational awareness will fall to us as
the team focuses on the task at hand – this will vary with the task required and experience of
the team. This experience not only refers to those of the individual members but also of the
team working together as one unit.
Knowledge will ensure a feeling of safety and knowing “who will do what” (Role Clarity) should a
real emergency occur will provide this safety assurance. This is where good pre-task briefings
are essential. Never ‘assume’ everyone is on the same page even if the task is a repetitive one
or if the team has commonly worked together.
Social – Love and Belongingness Needs
This refers to the need for association with other people, to belong, to give and receive
friendship and love etc.
We are normally out of our normal social group when working (particularly if the team members
change often or are new to the organisation). It is therefore the role of the leader to ensure that
everyone feels at ease and as much a part of the group environment as is possible.
Self-Esteem Needs
This priority of the human pyramid is most closely associated with the leader/team relationship
in our workplace but also applies to daily working teams.
Our egotistical needs fall into two types:

 those relating to self esteem – the need for confidence, achievement, competence and
knowledge; and
 those relating to reputation – status, recognition, appreciation and deserved respect.

Self Actualisation (Self Fulfillment)
The apex of the human need pyramid is self-fulfillment. This includes the realisation of your
personal potential for continued development and being creative.
Self-fulfillment provides the greatest challenge for the team leader but also provides the greatest
reward when it is accomplished. Remember you are attempting to make each task/experience
one in which the team has a positive experience and learn good practices/behaviours that they
are likely to repeat. A team environment is not an opportunity for the leader to prove how much
they know or how well they can complete a task. Your ability as a good leader will be proven in
the abilities of your team members in the long term.
Team leaders should strive to help their team satisfy their human needs in a manner that will
create a positive and healthy working environment. Individuals are less frustrated and can
therefore concentrate more on their work when this is achieved.
Everyone is motivated by the ultimate goal of fulfilling egotistical and self-fulfillment needs, the
team leader’s role is to help satisfy these needs. The leader should recognise that without the
basic needs being fulfilled individuals of the team will be much less motivated to perform at their
peak.
The following points suggest ways in which the team leader can help individuals fulfill their
needs:
 Keep team members motivated and interested in the task at hand by providing positive
guidance, opportunities to self govern and the opportunity to ask for assistance when
required. Positive feedback is a great motivator. Remember you are not the team cheer
squad though! Insincere praise or over enthusiastic praise can have as much a negative
impact as would bullying or aggressive behaviour from you as the leader.
 Show team members the benefit and purpose of a task and how it contributes to the
team goal. This is of particular importance in training and when new to the team. This
also applies more when a task seems mundane or repetitive. If we understand the
purpose of the task in the larger scheme of things we will be more likely to give it the
attention it requires.
 Keep team members informed. Not every detail is important, but any significant
changes, updates or relevant information should be passed as directly from the leader
as possible. (We will discuss more on team situational awareness later.)
 Inform the team what is expected and what to expect. Also keep them informed as to
their progress.
 Approach team members as individuals – remember our Learning Activity earlier – no-
one will have the same results. Each person works differently, reacts to stress and
fatigue differently and has a different level of knowledge and experience. Use these
differences to your advantage. The only way to do this however is to know the strengths
and weaknesses of your team and not to make assumptions.
 Give credit when credit is due and as immediate as is possible. Provide assistance and
negative feedback as required but do not critique an individual performance in front of
the group.
 Praise for a team member provides an incentive to do better and also gives a feeling of
fulfillment. However, we must be ever conscious that praise given too freely or without
sincerity is valueless.

MEMORY
Our ability to remember processes and procedures, predict likely outcomes and work to solve
problems, is key to our team performance. In order to use our memory to its greatest benefit we
need to understand how it works.
SHORT TERM MEMORY
Short Term Memory (STM), or Working Memory is good for between 10 and 20 seconds after
which it’s lost through interference with more in-coming information. Its capacity limit is about 7
items – hence the difficulty trying to remember say, a phone number or an airways clearance
without writing it down.
The information is retained using a process of rehearsal – hence acoustic information is easier
to remember than visual. Also STM is improved by clustering or ‘chunking’ – e.g. a familiar
postcode 2600, or a frequency 121.7 is remembered as one chunk.
LONG TERM MEMORY
Long Term Memory – is classified as one of two types: Semantic Memory (SM) or Episodic
Memory (EM).
Semantic Memory involves knowledge associated with data, skills, knowledge and things we
are able to do for a purpose, e.g. understanding a word, knowing a checklist item. It’s our
memory for meaning. It is generally thought that once information has properly entered your SM
it is never lost. It may occasionally be not locatable (i.e. can’t remember) but never lost. Some
remarkable abilities of memory even back to childhood are achievable when the subject is
placed under hypnosis. This can also be demonstrated by viewing a photograph or a friend
reminding you of an event you may not have thought of for 20 years and one small photo or
comment can bring a huge amount of memory 'flooding back' and in great detail.
Episodic Memory is our memory of specific events, e.g. a flight, or an incident during the flight.
Unfortunately EM is not static, but is influenced by what we feel should have happened, hence
embellishment in ‘war stories’. It’s also influenced by our expectations of the world in a similar
way to our initial perceptions. It can be problematic therefore when interviewing witnesses,
particularly expert witnesses who have pre-formed ‘expectations’.
An interesting fact is that amnesia affects Episodic Memory but not Semantic Memory, e.g.
many survivors may have little or no recollection of an accident but can still drive a car or fly an
aircraft.
MOTOR MEMORY
Motor Memory relates to our ability to accomplish tasks using motor programs and responses
that through practice have become automatic. They do not require conscious attention. The
process that leads to responses becoming automatic may be gradual or rapid and is heavily
dependent on experience, expectation and practice. It is important to realise though, there is a
relationship here. When experience, expectation or practice is low, responses will not be
automatic but will be considered and deliberate. Conversely, when experience is high, the

relevant responses will be highly automatic. For the most part of course this is a advantageous,
and is the key to humans being as accomplished as they are. However there is a dark and
dangerous flip-side. Automatic processing is definitely prone to a number of hazards.
Motor programs and responses do not require conscious control but they do require conscious
monitoring (checking the feedback loop from time-to-time). Why? Otherwise we make slips,
such as putting salt instead of sugar into a cup of tea, or picking up the telephone and saying
‘Come in’. Also, since many of these actions are performed without conscious awareness and
subsequent monitoring, an unplanned behaviour/outcome may not be detected for some time.
You can well imagine the implications of this in aviation!
The decision to exercise a skill, e.g. lowering the landing gear, is normally made consciously.
The pilot should then monitor his/her own behaviour to ensure the skill is carried through
correctly to conclusion. However, if for example we are preoccupied, the correct decision may
be made but the wrong skill may inadvertently be exercised. Further we may not monitor the
activity and so remain completely unaware of the error; e.g. raise flaps instead of the
undercarriage after takeoff and not check as we assume we were correct.
Another type of error is known as ‘environmental capture’. This occurs where a skill that is
frequently used in the one environment (same time/place/circumstances, i.e. becomes a habit),
may be elicited by that environment even though there has been no decision to utilise that skill.
For example:
1. Stopping at a set of traffic lights which are displaying ‘green’;

2. Finding yourself driving as if on the way to work when the intention was to drive to the
shop; or
3. Calling ‘three greens’ on finals regardless of the indication because being on finals is
enough to prompt the pilot to make this call despite any conscious intention to do so.
Be aware that environmental capture errors are more likely when you are preoccupied, tired, or
when excessively relaxed due to benign conditions. Also, motor memory or skill errors rarely
happen to novices because they have to think about what they’re doing. Conversely, they occur
far more frequently to those with experience.
Lastly, skills tend to be stored in the form of ‘non-declarative knowledge’. The possessor of the
skill may well not be able to articulate what the components of the skill are. Even worse, if there
is a desire to modify a well-honed skill then thinking about it may well spoil the execution of the
skill. For example - try and talk about what you are doing as you make a coffee or change gears
- your actions will be far ahead of the words and you will quickly become confused and may
makes errors as you try and get actions and words to match - one of the most complicated
things to learn when you become an instructor is the have actions and words match!
RESPONSE TIMES
Response Time (RT) is the time between the onset of a given signal and the production of a
response. A simple example is having a finger on a button waiting for a light to go on – RT in
this case is about 1/5th of a second. A more complex example may involve two buttons and two
lights (left and right) – the RT will be longer than for the simple case.

There are times, particularly in our working lives, when a rapid response is required. Then there
is also the need to trade-off between speed and accuracy. The following factors are relevant:
 Occasionally a response has to be made without sufficient information since any delay
might have catastrophic consequences.
 Conditions which increase our arousal level will lead to faster but less accurate
responding.
 As auditory stimuli are more likely to attract our attention than visual stimuli, there will be
a greater incidence of responding to them first and thus errors in response to them will
be greater.
 When we expect a stimulus, we have a prepared response ready to go. This is fine if the
expected stimulus occurs. But if a different stimulus occurs and we’re under pressure we
may very well make the prepared response i.e. make an error of commission.
 An increase in age between 20 and 60 years tends to be associated with slower but
more accurate responding.
TYPES OF ATTENTION
There are two potentially limiting stages to the processing of information. One is the limit to the
number of items which can be maintained in our working memory and the other limitation
concerns the rate at which information can pass through the system – the ‘channel capacity’.
Our channel capacity limit means that we are not able to devote conscious thought or ‘attend’ to
all of the stimuli that we receive. Thus some mechanism is required at an early stage in the
process to allow us to select the stimuli we wish to use as the basis for thought and decisions.
Two types of attention are sometimes described - Selective Attention and Divided Attention.
Selective Attention takes place when inputs are sampled to ensure that only information
relevant to the task at hand receives detailed processing. Fortunately the process is not this
rigid – there is a degree of spare capacity, e.g. allows us to hear our name or call-sign even
though presented on a non-attended input channel. This is referred to as the ‘cocktail party’
effect, we may not be listening to a conversation away from us but if we hear our name
mentioned we can suddenly 'hear' what is being said across a room.
It shows that information entering on a non-attended channel of which we have no conscious

awareness is still subjected to a good deal of analysis. It’s more forcefully activated in the
cockpit by using attention grabbing stimuli such as loud noises or flashing red lights.
We also possess a characteristic known as Divided Attention. It is generally not feasible to

concentrate on one task exclusively. Flying down finals is an example – attention is divided
between looking ahead outside and looking inside at the airspeed.
A benefit of this is that a task being performed using a motor program (i.e. automatically), will
still get occasional checking. Indeed serious errors can result in us becoming so consumed with
the main task that the progress of a concurrent motor program proceeds along unchecked – e.g.
while talking on a mobile phone turning up a one way street the wrong way.
Also impacting our ability to perform well in all of these situations is the additions of
stress and fatigue.

STRESS
AROUSAL (OR STRESS) LEVEL
Arousal is the term used to describe the body’s physiological responses to stress. We may often
be in a state of low stress and therefore low arousal. This occurs equally while relaxing at home
on a quiet Sunday afternoon, during the cruise phase of flight, or sitting on 110kph on an
interstate highway. In these situations the whole work rate slows down and consequently the
chance of noting a problem reduces. Moderate levels of arousal produce interest in external
events and in performing tasks. Accordingly, optimal arousal understandably corresponds to
optimal performance. It is the most desirable area in which to function.
In periods of high stress/arousal – e.g. emergency on a night approach in poor weather – our
sampling rate increases but the sampling range reduces due to our attention being restricted to
the primary task – termed ‘narrowing of attention’. This can result in the pilot missing vital
incoming information due to a narrow focus on the source of the problem.
This relationship between performance and stress/arousal can be depicted graphically.
Yerkes-Dodson Curve
Low Medium Arousal, Optimum
Arousal Performance High Arousal
Performance
Stress/Arousal
Human beings actually need a certain level of stress or arousal to function at their peak. When
the arousal level is too low, performance degrades. Likewise at high arousal levels performance
takes a nose dive. The Yerkes-Dodson Curve demonstrates diagramatically the relationship
between performance and stress/arousal.
Clearly human performance is optimal somewhere between the low and high stress/arousal
states. Best performance is obtained when a certain degree of stress/arousal exists.
MENTAL WORKLOAD
Aircraft designers in WWII were the first to encounter on a large scale the 'craziness' of
expecting the human ‘machine’ to process large and complex arrays of information. Our ability
to process information and hence our level of performance have their limits.

Errors made in the low arousal state generally are indicative of a loss of interest in the task.
They take the form of missed information due to lack of samples of the input from the
environment around us, e.g. the aircraft instruments. In the high arousal state errors tend to be
associated with important information being missed due to the narrowing or focusing of attention
onto only one aspect of the task.
This is where our human information-processing model is useful. Comparing it and the task can
help us determine the source of an overload for example. It may be that the task is too difficult,
i.e. the amount of information to be perceived in order for a decision to be made is beyond the
attentional capacity of the person (called qualitative overload). Alternatively there may be too
many responses to be made within the time available (called quantitative overload).
The human stress response is vital to our survival and adaptation to everyday threats and
demands. The physiological stress response affects us in many ways, physically and
psychologically. Individual stressors combine with each other and accumulate over time to
further reduce our capacity to perform.
Our psychological state can vary between high and low arousal but whether this is experienced
as stress depends on our interpretation of the experience e.g. aerobatic flight would result in an
increased state of arousal in most people, but some would then be over stimulated and
experience anxiety (and fear) and for others, simply a thrill.
A low state of arousal could be comfortable or uncomfortable depending on whether rest or

excitement is required.
Training, preparation, familiarity and confidence will extend the point at which the same
demands cause excessive arousal e.g. a trainee may show symptoms of over arousal in a
circumstance where an experienced person will remain composed.
An acute stress reaction is the response to a serious, often life threatening event i.e. aircraft
emergency.

The response is characterised as a "fight or flight".
Our basic survival actions are instigated by a biologically programmed adrenaline rush. The
"fear" can also result in a "freezing" and we are unable to make a decision or initiate a motor
action.
Chronic stress reaction is a succession of demanding events which may prevent us from
properly recovering our normal level of resistance. An excess of stress from different sources
will eventually take its toll and could possibly result in severe symptoms or illness.
Stressful life events pre-load the individual and lower our tolerance to external work related
stresses. Personal problems and concerns should ideally be dealt with so that their effects are
not taken into the airborne environment.
If personal matters cannot be resolved and the crew member's performance is inhibited, it is up
to the individual to acknowledge this to himself or others in the work place and seek to resolve
the matter before continuing.
High stress situations and/or events can also result in Remembered Stress. For example:
some months after a hijack by terrorists that culminated in a violent assault to recapture the
aircraft, a member of the crew immediately threw himself on the ground upon hearing a loud car
horn. His memory of past stimulus (machine gun firing) distorted his perception of the audible
stimulus (the car horn). He said, "It was as if the assault was happening all over again".
EFFECTS OF STRESS ON MENTAL ACTIVITY
The most common effects of stress on mental activity are:

 loss of concentration: omissions, simple mistakes.
 poor recall: “mental blocks”.
 poor control of attention.
 slowed reaction times, confusion.
 easily overloaded or over-taken by events.
 indecision, hesitation.
SYMPTOMS OF STRESS
Although symptoms may vary person to person the following are considered the most common
symptoms of stress on us humans:
Physiological Cardiovascular, Gastrointestinal, Respiratory, Sleep

disturbance, Migraines, Muscular tension, Low-grade
infections…
Psychological Anxiety, Uneven temper, Loss of interest, Poor self-
esteem, Feelings of loss of control…
Mental Difficulties in concentrating, Omissions, Errors,

Slowness, Poor judgement, Poor memory, Reduced
vigilance and attention…
Behavioural Loss of motivation, Tendency to skip items and look for
short cuts, Easily distracted, Slowness or
hyperactivity…

MANAGING STRESS
Once we have become aware of stress, we generally use one of two strategies: defence or
coping. Defence strategies involve alleviation of the symptom (i.e. taking medication) or to deny
that there is a problem. Coping with stress involves dealing with the source of the stress not just
the symptoms (e.g. delegating to reduce workload, prioritising).
Stress Management techniques include:

 Relaxation techniques, commonly the use of yoga and mindfulness techniques;
 Careful regulation of sleep and diet;
 A regime of regular physical exercise; and
 Counseling - ranging from talking to a supportive friend or colleague to seeking
professional advice.
There is no magic formula to cure stress and anxiety, merely common sense and practical
advice. Managing stress in flight operations can be assisted by:
 Prepare flights thoroughly - anticipate threats and unlikely situations.
 Plan and manage your workload to avoid time pressures.
 When time pressured, buy some time e.g. hold, delegate, slow down, delay your
departure;
 Use Crew Resource Management – team support strategies.
As soon as the flight is over, eliminate the secondary effects of stress appropriate to your
personality, for example, by physical or artistic activities. A good de-brief is also vital to alleviate
stress and to ensure a good recall of the correct procedures/responses next time that ‘event’
occurs.
Most forms of exercise are also good ways of restoring equilibrium.
FATIGUE
Greg Roach of the Centre for Sleep Research, University of South Australia, defines fatigue as:
‘the decreased capability to perform mental or physical work, or the subjective state in which
one can no longer perform a task, produced as a function of inadequate sleep, circadian
disruption, or time on task’.
Fatigue is often used interchangeably with the term sleepiness because they are closely linked,
but the two are separate concepts: an individual can be fatigued without actually being sleepy.
The best example of this is probably the shiftworker who, upon arriving home after an evening
shift, cannot immediately fall asleep despite feeling exhausted, but instead must wind down for
one or two hours.
There are two elements of fatigue:
1. Physiological fatigue refers to our body’s need to replenish and restore itself, especially
after activities such as physical activity and alcohol consumption. You can overcome
physiological fatigue by getting rest and sleep.

2. Subjective fatigue is an individual’s perception on how fatigued they feel, this can also be
related to motivation.
Fatigue is typically caused by delayed sleep, sleep loss, interruption of normal circadian
rhythms and concentrated periods of physical or mental stress and/or exertion. In the
workplace, working long hours, working during normal sleep hours and working on rotating
shifts all produce fatigue to some extent.
Fatigue is also referred to as either Acute or Chronic.
Acute Fatigue is tiredness or exhaustion experienced intensely and in the short term. Acute
Fatigue typically occurs at the end of a demanding flight or workday.
Chronic Fatigue is accumulated fatigue similar in most respects to acute fatigue but builds up
over time. Chronic Fatigue can be caused by extended periods of inadequate sleep, exercise or
a long haul flight.
SYMPTOMS OF FATIGUE
Physical
 increased reaction times.
 skill deterioration and difficulty making fine movements.
 lowering of own standards or accepting lower standards from others.
 losing concentration, forgetfulness.
 difficulty focusing.
 slowing of thought processes.
 tiredness/lethargy/falling asleep.
 irritability/loss of sense of humour.
 appetite loss.
 inaccurate performance.
Physiological
 decreased body temperature.
 decrease in muscular strength.
 poor co-ordination.
 heaviness in limbs.
 increase in heartbeat.
 mood changes.
 visual and aural alterations.
FATIGUE DUE TO SLEEP DEPRIVATION
Whilst the physiological mechanisms by which sleep restores alertness and cognitive
performance are not known, it is clear that the duration of sleep determines its recuperative
value. The relationship between sleep duration and recuperation is not necessarily linear, but
performance and alertness during wakefulness are generally enhanced as sleep duration
increases. Interestingly though, oversleeping may actually be detrimental to performance.

Under normal conditions (i.e. awake during the daytime, asleep during the night-time)
performance speed on simple, repetitive tasks (e.g. vigilance, simple addition, simple reaction
time, card dealing, serial searching) follows a daily rhythm such that it is slowest in the early
morning, increases over much of the waking day, and is fastest in the early evening. In contrast,
performance on more complex tasks that involve short-term memory processes (e.g. short-term
retention of prose, digit span performance, logical and verbal reasoning) tends to peak earlier
then decline over the waking day.
One method of determining the function of a process is to reduce or eliminate it and observe the
effects. This approach has been applied to the function of sleep through the study of sleep
deprivation (SD).
Typically, total SD results in increased sleepiness and impaired psychomotor performance.

However, the effects of SD are not uniform and may be mediated by the influences of both
incentive/motivation and task complexity. In studies where incentive/motivation has been raised
by providing feedback about results, giving monetary rewards, or fostering competition between
participants, the effects of SD are less profound than when incentive/motivation is low. In
addition, laboratory and simulator studies indicate that complex tasks are more affected by SD
than simple tasks.
FATIGUE AS AN ACCIDENT CAUSAL FACTOR
In terms of accident investigation, fatigue can be difficult to identify as a causal factor. This is
due to:
 The non-survival of crew.
 Fatigue being unreported resulting from a lack of awareness of indicators.
 A lack of historical, tangible and statistical data for comparison/analysis (no identifiable
benchmarks). However the introduction of mandatory/voluntary Fatigue Management
Systems into organisations will improve this over time e.g. FAID: Fatigue Audit
InterDyne.
 Hesitation by the investigator to include fatigue in the investigation as it may be
considered a personal failing of those involved in the accident.
 A lack of inclusion in the investigation process resulting from investigator knowledge
deficiency of this causal factor.
 Common errors in underestimating the level of fatigue. As such it remains unreported.
This results from unreliable estimators, the link to performance is not recognised,
reluctance to admit shortcomings and fatigue is seen as an unacceptable excuse within
the organisational or professional culture.
 Fatigue being considered as the ‘norm’ for operations and therefore not a distinguishable
factor.
 A lack of education throughout the industry relating to fatigue at this juncture.
 The interpretation of fatigue levels relying in part on the opinions/suspicions of
individuals.
 It not being a piece of physical evidence.
 It being difficult to assess in most cases as also affected by outside factors to the
workplace.

NAPPING
Napping improves mental performance. A 20 minute nap can give 2 hours of good alertness
level.
When napping, it is important to avoid Sleep Inertia. Sleep Inertia is a short term mental
confusion that occurs in the transition between napping and being awake – it can cause
confusion on wakening. Sleep Inertia can last 5 to 15 minutes. It is best therefore upon waking
from a nap to allow yourself this time to become fully awake before making any decisions. Sleep
Inertia has been known to last many hours dependent on the amount of sleep deprivation you
are suffering at the time.
Choosing the time to take a nap is also important. For example, a late afternoon nap can
influence your next sleep pattern resulting in a possible delay in the onset of sleep whereas a
morning nap does not normally have any impact on your next normal sleep pattern.
Most individuals need approximately eight hours sleep in a 24 hour period, although some may
need more or less than this to be fully refreshed. People can usually perform adequately with
less than eight hours sleep for a few days, building up a temporary sleep ‘deficit’.
However, any sleep deficit will need to be made up; otherwise performance will start to decline.
HOW TO NAP EFFECTIVELY
For years the "nap" has gotten a bad rap, but lately has developed a new respect thanks to
scientific evidence that dozing between midday and early afternoon has both mental and overall
health benefits. We humans have consolidated our sleep into one long period, however most
mammals sleep for short periods throughout the day and are programmed for two periods of
intense sleep; one between approx 2am and 4am and the other between 1pm and 3pm. There
is now considerable scientific data to show that the early afternoon drowsiness experienced by
most of us is not due to heat or a poor lunchtime diet but is simply our physiology telling us to
rest and if we do not do so our reaction times, memory, coordination, mood and alertness all
diminish significantly.

To understand how to nap effectively we must understand the various stages of sleep and our
brain activity during sleep.
A short afternoon 'cat nap' of 20 minutes gives us mostly stage 2 sleep. This will result in
enhanced alertness and concentration and also improves our mood and motor skills.
A nap of up to 45 minutes may include some REM sleep (or dreaming sleep) which enhances
creative thinking and boosts are sensory processing. This is the ideal length if you need to
spring into action when you wake. Anything longer could result in slow-wave sleep from which it
is difficult to wake without feeling groggy and disorientated. This feeling can last up to an hour
after waking.
Most of us need an hour and a half more sleep than we tend to obtain overnight. Therefore a
nap of between 90 minutes and 2 hours during the day can assist with this sleep deficit. This
length of nap will normally include all stages of the above sleep pattern. This will help to clear
the mind, improve memory recall and reduce any sleep deficit.
Once you have decided on the length of your nap you will also need to make sure you optimise
the benefits with the following tips:
 find a safe, comfortable place where you can ideally lie down (it takes 50% longer to fall
asleep if you are seated upright);
 if possible have a light blanket so you can be warm, but nothing too heavy as excess
warmth can make you oversleep;
 set an alarm;

 darken the room or wear eyeshades;
 if noise will be an issue wear ear plugs or put on some 'white noise';
 calm your body by breathing slowly and deeply whilst concentrating on relaxing one
muscle group at a time; and
 quieten your mind by repeating a mantra, taking a relaxing mental walk along a quiet
beach or laneway or bush area or "count sheep".
Naps make you smarter, healthier and safer. They reduce stress, lower the risk of heart attack
and stroke, diabetes and excessive weight gain. So if you want to be at your best all day (and
night if needed) take a nap.
AM I FIT - THE HUMAN PREFLIGHT

Normally we pre-flight our aircraft, check our equipment or vehicles thoroughly before we are
about to start. In most cases this is a routine procedure
mandated by our organisations.
But how about you?
Did you take a good look at yourself beforehand and are

you able to do the intended task or tasks?
Self assessment is very important to make sure you are safe!
You must assess yourself to check if you are suffering from any illness, medication use is
appropriate or if you are, for example, under the influence of a party from the night before and
haven't had enough sleep to be fully rested and capable of undertaking your duties.
The "I'm Safe Checklist" and "PAVE Checklist" are especially designed for you to be able to
'pre-flight' yourself and in the case of the PAVE Checklist - your resources, external influences
and environment too.

Many versions of these checklists are available and in use with various organisations. A more
detailed version of the PAVE Checklist is included below.

MODULE THREE
COMMUNICATION & ASSERTIVENESS
COMMUNICATION
Now that we have developed an understanding of what
ADM can mean to us we need to review more closely how
improved practices can be achieved. Effective
communication (and listening) with the right type of
assertiveness for the situation is one such way.
Communication is the means by which operations are

directed, analysed, planned and rehearsed, crew
resources are managed, team relationships are
established and emergencies identified. Communication
is also the basis of providing technical information in the
form of manuals, bulletins and checklists.
Communication skills are the foundations of both the support process and crew Situational
Awareness.
Communication is sharing information between individuals and is important for information

gathering, issuing instructions or making decisions. It needs to be clear, timely, relevant and use
standard language.
The basic elements in the communication processes are:
1. The Source
A sender, speaker, writer, transmitter.
The effectiveness of the source depends on three basic factors:

i. the ability to select meaningful symbols.
ii. the ability to portray positive attitudes, they must be confident and believe their
message is important.
iii. the ideas and feelings being transmitted must be meaningful (e.g. not too technical).
2. The Symbols
The alphabet translated into words, common gestures and facial expressions are simple oral
and visual symbols. However, these symbols by themselves are meaningless. Ideas are only
communicated when symbols are combined into meaningful wholes (sentences, paragraphs
etc.)
The source must select the symbols, ideas and also the medium by which they will best convey
the desired message.

3. The Receiver
Communication can only be said to have taken place when the receiver reacts with
understanding and changes their behaviour accordingly.
There are three basic characteristics of receivers:

i. their abilities to question and comprehend.
ii. their attitudes, willingness, resistance etc.
iii. their experience, education etc.
The use of feedback in two-way communication helps prevent misunderstandings. The sender
and receiver also need to be prepared to question or challenge to ensure an accurate
understanding has resulted from the process.
Individuals also need to check to make sure the message has been heard accurately this can
be done by, for example, questions or paraphrasing.
Inquiry is to gain information by asking questions. For this critical component of communication
to be successful:
 Good situational awareness is needed such that you can fully understand the
implications of your operating environment and the task to be undertaken. The impact of
this operating environment needs to be considered and may need questions asked or
clarification from or for team members.
 Seek further information until you are satisfied that you have sufficient information to
undertake the task as required.
If you are unsure of an instruction given, for reasons of not understanding or not hearing the
instruction clearly, then ask again. “Please repeat” or “say again” are phrases that can be used.
It is best to make this clarification at the start and not undertake a task incorrectly.
Paraphrasing is a great tool. Paraphrasing means "repeating or restating what another person
says”. The objective of paraphrasing is to make the other person understand that you have
completely comprehended the matter. Paraphrasing is used effectively in teaching and learning
to clarify a lot of concepts and principles. As a leader this tool can be used to ensure the team is
all on the ‘same page’. As a team tool paraphrasing is widely underused.
Poor communication can also result from team members not ‘feeling’ as if they can speak up.
It is the responsibility of the entire crew to communicate effectively. It is important that our
communication is clear and to the point.
Ultimately inadequate communication and lack of “role clarity” can cause team
underperformance.
An example of poor role clarity can be shown in the following incident Poor
Role Clarity Example (ATSB Report)
http://www.atsb.gov.au/publications/investigation_reports/2004/aair/aair200404
285.aspx

We communicate in many different ways:
 Verbally – with speech and sounds.
 Facial expressions e.g. a smile or frown.
 Sign language e.g. thumbs up to say ‘yes I agree’.
 Body language e.g. a nod of your head to say ‘yes’.
None of these will however be effective unless we all understand their meaning and that that
meaning is consistent across the team.
Verbal communication may be face to face, or via radio or intercom. It is the primary mode of
communication within and to or from an aircraft. It is very important to use correct terminology to
prevent any confusion or
conflicts.
Non-verbal communication such

as body and facial expressions
can be used in noisy
environments.
In the case of either verbal or

nonverbal communication it is
important to receive feedback
from the recipient; this will let you
know they have received your
message correctly.
It is important to pay attention to the speaker, so that we know what is happening or about to
happen.
In order to listen more effectively:

 Actively attend to the speaker. DO NOT undertake other tasks whilst someone is
talking to you e.g. typing on computers (this particularly occurs whilst on the phone) and
walking (stop and look at the person) are two such examples of poor attention to the
speaker.
 Do not ignore what you do not want to hear. You may not agree with their comments
or suggestions, however they may still have a worthwhile contribution to make and may
raise ideas/concepts that you had not considered. Also, if you are not able to
concentrate at this time ask them to see you at another time or wait until you can give
them your attention.
 Avoid thinking about what you will say next whilst the other person is speaking.
This means you are not really focussing on what is being said NOW.
 Ask questions if unsure of the information.
 Restate the message if necessary. This is called ‘paraphrasing’ which we have
discussed earlier. It may seem time consuming at the time but has a huge long term
benefit in making sure the right message was received the first time.
 Acknowledge verbally or by action what the speaker has said.
Another layer to the communication process is “Assertiveness”.

It is important to be able to demonstrate assertiveness appropriate to the crew member's
individual role and the current situation. In order to effectively do this we must first, understand
the differences between submissive, aggressive, supportive and assertive behaviour.
Communication is sometimes needed to alert people to situations or issues that they are not
aware of or are trying to avoid. For example, sometimes you must speak up when a situation is
not safe, even when a more senior person has not noticed or does not agree. As a team leader
we may also be in situations where a member of the team may have more experience in the
task or with the organisational SOPs and this may deter us from intervening – assertive
communication will assist in this situation.
SUBMISSIVE BEHAVIOUR
If we demonstrate this type of behaviour we tend to allow others to dominate us and impose
their will upon us. This is being submissive.
Submission is characterised by:

 Lack of eye contact.
 Shifting of weight and slumped body.
 Use of non-assertive words: “whatever you think….you’re the boss.”
 Silence, resignation, inaction.
Submissive behaviour is often defensive. We concentrate on pleasing others and deny our own
knowledge, needs and driving force.
An Example
A crew member who sees mistakes being made by a more senior crew member and doesn't
speak up is guilty of submissive behaviour.
This style is inappropriate in the aviation environment and may ultimately result in other crew
members dismissing your views and information in an emergency.
AGGRESSIVE BEHAVIOUR
Aggression is a fact of life. Aggressive styles of communication do occur regularly but usually
have a negative result on teamwork.
Aggression is characterised by:

 Anger.
 Frustration.
 Aggressive postures e.g. leaning forward, glaring eyes, hands on hips, wide leg stance,
entering inside other’s personal space, finger pointing.
 A raised voice.
 Silence!
This style is also inappropriate in the aviation environment.

SUPPORTIVE BEHAVIOUR
Supportive communication primarily demonstrates concern for others whilst not denigrating your
own worth/values/opinions and thoughts.
Supportive behaviour is characterised by:

 A comfortable stance, often leaning forwards showing interest.
 Eye contact.
 A steady tone of voice.
 A ready smile.
 Palms and wrists are visible.
 Asking questions, agreeing and nodding.
ASSERTIVE BEHAVIOUR
This style enables us to say what we want in a way that does not abuse or dominate other
people. Assertive communicators know when and where to speak up. This is the ideal form
of communication for an effective team leader. This form of behaviour improves self esteem.
Through practice and experience, aggressive behaviour and feelings can be converted to
assertive behaviour. An assertive person is aware of feelings and deals with them and
demonstrates an approach where they can stand up for themselves both independently and
inter-dependently.
Assertive behaviour is based upon an acceptance of the

right to:
 Have and express ideas.
 Be listened to and taken seriously.
 Ask for what you want.
 Be treated with respect.
 Ask information of others.
Assertive word choices include the use of:

 “I” statements rather than “you” statements. “You” statements can be seen as
aggressive so try “my thoughts are......” or “in my opinion.......”.
 Factual descriptions instead of judgment or exaggeration.
 Expressions of thoughts, feelings and opinions reflecting ownership.
 Clear and direct requests.
For example:
“Let us....”
“How shall we do this?”
“I think........What do you think?”
“I would like......”
The appropriate body language includes:

 Standing or sitting straight.
 Appearing composed.
 Smiling.
 Maintaining eye contact.

Many adverse outcomes in the workplace are a result of absent or incomplete
communication. Strong verbal communication skills are key in coordinating teams and
optimising the flow of information between colleagues.
Problems can arise for a number of reasons, but one common occurrence is failure of ‘junior’
team members to question leaders about their actions. This can be especially problematic in the
event of an emergency or intense team task.
As a result of his personal experience, Martin Bromiley founded the Clinical Human Factors
Group in 2007. This group brings together experts, clinicians and enthusiasts who have an
interest in placing the understanding of human factors at the heart of improving patient safety.
Martin Bromiley is also an airline pilot with a wealth of human factors experience.
In “Just A Routine Operation” Martin Bromiley talks about his experience of losing his wife
during an apparently routine procedure and his hopes for making a change to practice in
healthcare.
This film was produced by thinkpublic for the NHS Institute for Innovation and Improvement.
Irrespective of its healthcare focus, the lessons for us are the same.
Use the link to access the Elaine Bromiley - Assertiveness Example.
https://www.youtube.com/watch?v=JzlvgtPIof4
The Guidance Phase of assertive communication enhances communication and the flow of
information.
Statement examples at this phase are:

 Relay information or observation. "There is…" "It is…"
 Inquiry Statement. "Will you…" "Do you…" "Have you…"
 The "I" statement. "I am concerned that……" "I think that…" (This enables expression
of direct concern).
Statements at this phase are designed to:

i. Give information to others. For example: SIC to PIC of giving of information; “There
seems to be an unexpected build up of cloud on our current track.” An appropriate
response would be a recognition from the PIC of the cloud and a correct operational
decision. If no response then move onto the next level of questioning.
ii. Question their Situational Awareness. For example: Questioning the PIC to make
them think about their options; “Do you agree that we may have to manoeuvre to avoid
the cloud?” You would expect an appropriate answer to this query which indicated that
the PIC did in fact recognise the cloud and the necessity to take action. If no response or
you are still concerned as to their level of Situational Awareness move onto the next
level of the Guidance Phase.
iii. Express your concern that they are not ‘situationally aware’. For example: informing
the PIC of your concerns with the current situation; “I am concerned that we will not
maintain Visual Meteorological Conditions (VMC) if we remain on this heading.”

Emergency Phase of Assertive Communication
This phase is used when all attempts at communication have failed to arouse a team member
from a possible loss of situational awareness.
It is the last attempt to either rouse the crew member's Situational Awareness to that of the rest
of the crew or for that crew member to explain their actions. e.g. "Captain, you must act now,
turn back".
Ideally this stage should be rarely used. To abuse or over use this stage will result in its
effectiveness being diminished and could jeopardise flight safety.
Failure of the crew member to respond to the Emergency Statement should be considered as
some form of incapacitation and positive takeover of control is mandatory. “Captain, I have
control”.
The guidance and emergency phase form part of an operational formal support process.
A similar process but shorter acronym to remember is the PAICE principle as is detailed below.
Probing Probing for better understanding (asking

questions).
Alerting Alerting others to what you see - this may include
your concern if action is not taken or detailing a
possible action to take.
Intent Here is why I think that is what we should do.
Challenging Challenging the suitability of the present strategy -
this may take the form of "if we do not xxxxx then
we will find ourselves xxxxxx".
Emergency Emergency warning of critical and immediate
dangers. At this stage you may need to take control
of the situation.

MODULE FOUR
SITUATIONAL AWARENESS
Situational Awareness is one of the cornerstones to successful understanding and
implementation of ADM principles and concepts.
Situational Awareness is the process of gathering information, deciding what it means and
anticipating what might happen in the future. This requires concentration and attention. We
need to create a mental model of interactions between our work process, equipment, the
environment and other workers to interpret what is happening now. The interpretation of this
information is enhanced by past experience and knowledge. Our ability to assess risk utilises
this skill, as it requires us to think ahead. Fatigue and stress will affect our memory and memory
recall. Organisational factors, including perceived organisational priorities (e.g. contract
requirements, timely departures) may lead to managers and workers applying a poor mental
model to various situations.
There are four main elements to Situational Awareness:
1. Information
• What information is available?
• How is it available?
• Can it be easily understood?
• Is it updated rapidly enough to provide timely and accurate information?
2. Environment
• Does the environment encourage alertness?
• How many distractions and disturbances are there?
• What prompts are in place to avoid inattentional blindness?
3. People
• Is fatigue an issue?
• How many different languages (professional as well as cultural) are used?
• How much experience do they have?
• How is assertiveness encouraged?
• How is variety in skills and backgrounds ensured?
4. Organisation
• Are there adequate resources?
• Do you have a variety of points of view and approaches available?
• Does your workplace value people having different points of view?
• Do you function under time or production pressures?
Having good Situational Awareness is being able to answer relevant questions at all times.
Questions can be both verbal and silent as in the case of aircraft systems and your own mind.
One way of defining Situational Awareness is “the ability or skill for a group or an individual
to recognise an undesirable chain of events and take early action in order to break the
chain of events”.

Having complete and accurate Situational Awareness is essential in any complex environment
in which human decision making is a key required tool. Situational Awareness applies to and
has been studied, in a variety of complex and dynamic systems including emergency response,
military applications, the off-shore industry, nuclear power plant management and of course
aviation flight operations, engineering and air traffic control.
Controlled Flight Into Terrain (CFIT) is the ultimate example of an accident resulting from a loss
of Situational Awareness.
Although not widely adopted by Human Factors specialists until the early 1990s, the term
Situational Awareness was in use during and after the wars in Korea and Vietnam by the US Air
Force fighter crews. Good Situational Awareness was seen as the decisive factor in air to air
combat and was referred to as the ‘Ace Factor’ (Spick, 1988). To survive a dog fight the fighter
crew had to observe the situation and anticipate the move of their rival before they could
determine their own next move. This ability to observe and orientate became part of the OODA
Loop (Observe-Orientate-Decide-Act) or ‘Boyd Cycle’ named after the war theorist Col. John
Boyd. To win you needed to get ‘inside’ your opponent’s OODA Loop and this required good
decision making and having better Situational Awareness than your opponent. If you were ‘out
of the loop’; you had lost your own Situational Awareness and this could have fatal
consequences in a dog fight situation.
More recently the military has used the terms Situational Awareness and Situational
Understanding. Where Situational Awareness is applied to knowing about the physical elements
in the environment (perception) and situational understanding (also known as ‘sense making’)
refers to the last two levels of understanding and projection. We will now discuss the areas of
perception, understanding and projection further.
Dr. Mica Endsley (1988) quoted Situational Awareness as;
“… the perception of elements in the environment within a volume of time and space, the
comprehension of their meaning and the projection of their status in the future".
This is perhaps the most widely accepted and established definition of Situational Awareness.
Of course many alternative definitions also exist; from the simple “what you need to know not to
be surprised” (Jeannot, Kelly and Thompson, 2003) to the more detailed “the continuous
extraction of environmental information along with integration of this information with previous
knowledge to form a coherent mental picture, and the end use of that mental picture in directing
further perception and anticipating future need” (Domingues, Vidulich, Vogel and McMillan,
1994).
Every pilot learns the concept of Situational Awareness during their initial training. However,
good situational awareness goes beyond just the flight deck. It is vital that all members of our
team maintain good Situational Awareness for example: crewman, ATC and ground handlers.
Using awareness and experience to recognise threats and assess risks is vital. Endsley’s above
definition can be broken into three (3) distinctive levels of Situational Awareness:
1. Perception: The ability to ‘see’ what is happening around you. It is the most basic level
of Situational Awareness and involves the processes of monitoring and recognition
which leads to an awareness of various elements e.g. objects, people, systems and
environmental factors and their current states e.g. modes, actions, locations and
conditions;

2. Comprehension: The ability to understand what you ‘see’ and its impact on the task at
hand. At this level the often disjointed information collected in the previous level is
integrated to understand how it will impact on our goals and objectives. This level
requires a comprehensive picture of the ‘situation’ to be developed; and
3. Projection: The ability to project this information into the future, a safe future. Not only
must we understand the task and comprehend the elements of the first level of
Situational Awareness and how they make up the situation in which we find ourselves,
we must now interpret that information and predict how it will affect the future state of our
operating environment. In successfully doing so we achieve Situational Awareness.
Mental representations when flying is not a full picture of reality. You cannot and indeed, do not
need to maintain a full accurate mental picture of all factors at all times – it is in fact impossible
to do so. We therefore filter ‘reality’ and sketch it into what is essential regarding our objectives.
The mental picture is therefore somewhat distorted, schematic, sometimes illogical, routine
based but resource saving and efficient.
We have to therefore ask “How reliable is our mental picture?”.
Our ability to rely on this mental picture depends on:

 Relevance: the mental representation of the situation must be appropriate for our goals.
For example as we approach cruise our mental picture should allow us to answer
questions such as “where are we?” “where are we going?” “what is our endurance?”
“what is the weather en-route and at our destination?”
 Conformity: the picture must be consistent with reality. For example if you should be
flying north then your mental picture should not show south. However it may occur that
you recognise as part of your mental picture a friend's house on the ground and this
‘tells’ you you are going in the correct direction but you may still be at an incorrect
altitude. The full picture does not conform with the required reality.
 Stability: control of a situation infers a reasonably stable mental representation. If new
inputs change your understanding every second, there will be no coherence, no
understanding of what is not updated, you will lose control sooner or later.
How to do better:
 Prepare for your flight and anticipate in order to control events.
 Know and respect your own limits.
 Manage your resources.
 Use and trust professional safety nets e.g. SOPs.
 Never stop training.
 Involve your team but respect their cognitive limits and also their abilities.
TEAM SITUATIONAL AWARENESS RELIES ON A TEAM

A team is a “distinguishable set of two or more people who interact dynamically,
interdependently and adaptively toward a common and valued goal/objective/mission, who have
each been assigned specific roles or functions to perform, and who have a limited life span of
membership”. (Salaas 1992)
Therefore a team is not just a group of people but a group with a specific purpose. Each
member of that team is working towards a common goal.

Team Situational Awareness is defined by Endsley
(1995) as “the degree to which every team member
possesses the Situational Awareness required for his
or her responsibilities”. The success or failure of the
team depends on the success or failure of each team
member to maintain Situational Awareness. Note:
commonly Dr. Mica Endsley refers to ‘Situation
Awareness’ and not the more commonly used term
‘Situational Awareness’.
Team Situational Awareness is contributed to by ALL

members of the crew (airborne and on the ground). It
is important to note that the loss of Situational
Awareness by one crew member may not be noticed
by other members of the crew (especially when not in
line of sight of crew members). It is therefore vital to
monitor each other and speak up if uncertain of the other’s Situational Awareness.
• Team Situational Awareness Devices: what devices are available to enable

information to be shared which includes direct communication (verbal and non-verbal),
shared displays (visual or audio displays or tactile devices) and a shared environment. In
the aviation industry we don’t always share the same environment i.e. flight crew to ATC
and therefore the reliance on verbal communication and technologies for sharing
displays of information becomes more necessary.
• Team Situational Awareness Mechanisms: these refer to the shared mental model of
the team. Good shared mental models enable the team to interpret information in the
same way and project each other’s actions with some degree of accuracy. Good shared
mental models can also aid in effective communication and coordination in team
settings.
• Team Situational Awareness Processes: this is the effective use of processes to

again share information throughout the team. This can include checking each other’s
work and perceptions, the coordinating of tasks, prioritising of tasks and planning for
contingencies.
Overall, ALL crew members contribute to Situational Awareness.
It is therefore vital to encourage safety related input from flight crew, air crewmen, cabin crew
and those external to the actual flight environment. Good communication is key to crew
success.

"RED FLAGS"
(or triggers that should generate a more cautious approach)
If you notice any of these “Red Flags” in yourself or a team member it can be
a sign of an approaching loss of Situational Awareness or in fact Situational
Awareness has already been lost. These "Red Flags" include:
 Ambiguity or unresolved discrepancy can lead to data and/or
information being interpreted in more than one way.
 Fixation/preoccupation results in the focusing on one item, tunnel
vision and/or distraction resulting in the exclusion of all else.
 Confusion generally resulting from stress and/or high workloads can
lead to anxiety and uncertainty. As a result the information will be
difficult to reconcile or process.
 Departure from SOPs whether unintentional or deliberate.
 Failure to meet targets i.e. ATC clearances, ETAs, speed restrictions.
 Failure to fly the aircraft or complete a task can be a sign of passive submission to
Situational Awareness.
 Failure to communicate e.g. unfinished sentences, ‘selective deafness’.
 Complacency is usually indicated by a lack of interest or arousal, boredom, fatigue, over
confidence in the system or yourself.
 A loss of leadership can result in a reduction in the ability to delegate tasks, initiate
actions, take the initiative or be proactive in the task(s) being undertaken.
WAYS TO GUARD AGAINST THE LOSS OF SITUATIONAL

AWARENESS
 Knowledge - Get the facts, the limits and the applicable rules, regulations and
procedures.
 Focus on the task(s) at hand by avoiding being both distracted and being complacent,
don't fixate.
 Stick to fundamentals by knowing what is safe and ensure these elements are always
protected.
 Delegate during high workloads.
 Solicit input from all of the ‘team’.
 Verbalise important situations and conditions.
 Use ‘gut’ feelings.
 Consider possible contingencies and project these ahead.
 Create visual and/or aural reminders if the task is interrupted.
 Always be aware of the “Red Flags” of Situational Awareness loss.

WHEN YOU HAVE LOST SITUATIONAL AWARENESS
 Revert to Basics – for example in a flight environment – get away from the ground and
FLY THE AIRCRAFT, in an office or workshop environment – STOP, THINK.
 Maintain control of the aircraft or situation at hand.
 Stabilise the aircraft.
 Buy time – create time and space. This minimises any errors by a safe and conservative
approach to the situation i.e. enter a holding pattern, climb, get back to SOPs, delay the
task or actions.
 Seek information by aural, visual and intuitive means.
 Resolve any uncertainty or ambiguity.
 Always then ask why Situational Awareness was lost
Good pre and post flight briefings are an essential tool in the prevention of a loss of situational
awareness and also a forum to discuss the loss of situational awareness that has occurred. The
STICC process below is an ideal starting point for any briefing delivery. By referring to this
process when giving a brief all elements will be covered in a logical and timely manner.
Situation Here is what I think we face

Task Here is what I think we should do
Intent Here is why I think that is what we should do
Concern Here is what we should keep our eye on because if that changes, we are
in a whole new situation.
The situation may change - watch out for that possibility.
Calibrate Now, talk to me. Tell me if:
 You do not understand
 You cannot do it
 You see something I do not

MODULE FIVE
DECISION MAKING
Decision making is judgement or choosing an option and is closely linked to situational
awareness, it involves assessing the situation, thinking of options, selecting and carrying out the
best option and evaluating the outcome.
Good decision making involves several mental qualities and skills. These include (but are not
limited to):
 personal attitudes;
 recognising and handling stress;
 risk assessment skills;
 recognising and being willing to change your behaviours; and
 the ability to evaluate these skills.
To most people these skills do not come naturally, at least not all of them. With study and
learning we can become better and even master them to our advantage. We can therefore
operate to a higher safety level. We can also learn to recognise negative traits in our own
characters and turn them around positively by self reflection or help from a mental coach.
There are two main factors that affect our decision making:
1. Social factors: Research and accidents have demonstrated that people will tend to ‘go
along’ with the group decision to avoid conflict. Individuals are frequently influenced by
the dominant opinions of a group or superior and will accept the decision even though
they do not believe it to be the correct one.
2. Situational factors: Such as stress, fatigue, time pressure. These factors reduce our
ability to make a decision and to make the correct decision. Not having the time to
assess the situation and not allowing sufficient time to process the information to come
up with suitable options can result in poor decisions. Time pressure will increase your
stress levels and therefore one poor decision will lead to more poor decisions.

OUR OWN PERSONAL RISK MANAGEMENT
Another aspect of decision making concerns the influence that risk has on the outcome. From
the time our awareness starts to develop in our early years we slowly build our own personal
system of risk management. Through trial and error and education we gradually expand our
experience of day-to-day life hazards, their likelihood and severity and how to deal with them.
Depending on our personality and circumstances we each possess a unique level of risk
acceptance and hence management. For example, skydiving to some is an acceptable risk
while to others the risks are grossly unacceptable.
While some responses are universally accepted as risky – not using a pedestrian crossing on a
busy four-lane highway for example – many others are seen as involving little or no risk. But are
the latter cases as harmless as they seem?
For example, if a ‘thirst’ stimulus exists then the simplest response is to go to a tap or bottle and
satisfy the need. So, are there risks associated with consuming the water, and if so what are
they and are they considered every time one has a glass of water? The answers of course
depend on the circumstances. A person would quite rightly assign vastly different levels of risk
when comparing having a glass of water in their own home with, as a tourist, accepting a non-
packaged vessel of water from a street vendor in a crowded, polluted third world city.
The constant process of assessing risk each time we decide on our response is our own
personal form of risk management. Virtually every response a person makes in their lifetime is
assessed for risk. This is undertaken either consciously or, as experience is gained, as an
automatic or learnt response. Poor risk management leads to errors and occasionally incidents
and accidents. Accordingly, the average, sensible person learns from their errors and will
gradually become more conservative with their risk acceptance as they age and gain
experience, still occasionally taking risks but requiring progressively greater motivation to do so
and with a greater amount of consideration or pre-planning.
EXPERIENCE VS SAFETY PARADOX

However, despite the usual progression to becoming more risk averse with advancing age and
experience, paradoxically sometimes major errors are made by the most experienced. Indeed
the person making the error(s) may be regarded as the pinnacle of safety and conservatism.
There is an endless supply of examples of this phenomenon. Why would this be so?
As we have seen already, the sub-processes of perception, long term memory and risk
management (which together are the main determinants of how decisions are made) are a
clean slate when we are born but become progressively more ‘programmed’ as we gain
experience. Though there are valuable up-sides of this phenomenon, there is a dramatic and
sometimes fatal downside. This is directly concerned with the conditioning and expectations that
arise irrevocably and almost uncontrollably as a result of our gaining of experience.
An early and well publicised accident where this phenomenon was a most significant factor was
the collision of two Boeing 747s during take-off at Tenerife in 1977. Among the many factors
which were of importance in this tragedy was the fact that KLM’s most senior and respected
captain was in charge of the aircraft which took off without a clearance.

HAZARDOUS ATTITUDES TO GOOD DECISION
There are also five (5) recognised Hazardous Attitudes which can and will affect how we make
decisions. Understanding how they apply in our working lives in important. These attitudes are:
1. Anti-Authority: "Don't tell me!" - when people have this attitude they may resent having
someone tell them what to do or they think of rules and regulations as silly and
unneeded.
2. Impulsive: "Do something quickly!" - this is what people do when they feel the need to do
something, anything and now. Usually they do the first thing that pops up in the thought
process.
3. Invulnerability: "It won't happen to me!" - accidents happen only to other people.
Thinking this may lead to taking more serious unnecessary risks.
4. Macho: "I can do it!" - these guys we know all too well. Trying to prove they are better
than anyone else and taking more risks. Both sexes are susceptible to this attitude.
5. Resignation: "What's the use?" - these people think that they do not make a great deal of
difference in what happens. When things are going well they think: "good luck". And
when things are not going so well, they seem to think that someone is out to get them.
In most people there is a mix of these attitudes. Some are more prominent than others. It makes
us interesting people to work with!
In some cases these attitudes can be seen as a benefit but in an intense form they can be very
detrimental to good decisions, teamwork and ultimately safe operations. There are antidotes for
extreme versions of these attitudes, some of which include:
1. Anti-Authority: Follow the rules, they are usually right and in place for a reason. If you do
not understand the reason - ask. Do not let your independence or haste allow you to
bend the rules to get it done 'your way', as this will backfire.
2. Impulsive: Not so fast - think first. Most workplace situations do not require a snap
decision to be made. Use the time you have to evaluate the situation, obtain more
information if possible and then make a decision/choose an action. As the saying goes
"sit on your hands" for just a moment and think.
3. Invulnerability: It can happen to you!! Just because it hasn't happened yet does not
mean it won't happen in the future. No-one gets up in the morning planning to have an
accident but they happen every day. By thinking you are not going to have one will only
give you a false sense of security and may actually increase the likelihood of something
going wrong.
4. Macho: Taking chances is foolish and may not only endanger yourself but others as well.
Although a certain amount of confidence is a good thing you must balance this with the
level of skill and knowledge you have in that task. As skills and knowledge increase so
will your ability to perform various tasks. It is important to keep a realistic view at all
times.
5. Resignation: I'm not helpless, I can make a difference and my point of view is
valued/important. Our organisations do not pay us out of sympathy - they have
employed us based on our skills and abilities. If not sure ask, but also make decisions

that you should without unnecessary deferment. This will give you confidence and next
time you will be more likely to consider this option. A good mentor will always be
available for you to discuss these decisions with and highlight any other factors for you
to take into account next time thus continuously improving your decision making.
No-one is perfect and therefore a perfect balance of these characteristics is unlikely to exist. We
must therefore train ourselves to reflect and self critique. After the event revisit your decisions of
the day and consider how well they were made and if the decision could have been improved or
how good that decision actually was. Discuss your ideas with others - in this way we can all
benefit and learn from the experience of others. De-brief are the most effective way to achieve
this.
Some decisions are well practised and have a very low risk of making an error i.e. turning onto
base leg, as this is a procedure you do more often and have practiced. However, many
decisions are non-routine, i.e. an angry passenger, unexpected weather conditions.
Decision making requires individuals to search their memory to recognise cues then identify and
apply the right set of rules. Technical expertise, experience and familiarity with the situation
influence decision making, as do fatigue, stress, noise and other distractions.
Our work environment is a series of events requiring us to make continuous decisions. One
decision after another and the previous one often influences the next. These kinds of decisions
are also made throughout our entire lives.
Basic airmanship and common sense are important in a good decision and these two traits
cannot be emphasised enough.
There are 4 main types of Decision Making all of which have advantages and disadvantages.

Recognition Primed Decision Rule Based Decision Making
Making
Involves identifying the situation and
Relies on remembering an effective remembering or looking up in a manual the
response to previous situations of a rule or procedure that applies.
similar type.
Advantages: Advantages:
- very fast - good for novices
- requires little conscious thought - can be a rapid decision if the rule is
already known or learnt
- can provide satisfactory workable
option(s) - easy to justify i.e. followed the procedure
- useful in routine situations
Disadvantages:
- time consuming if the manual has to be
Disadvantages: consulted
- requires the decision maker to be - it is not always easy to recall or locate
experienced relevant procedures
- may be difficult to justify after the - the rule may be out of date or inaccurate
event and therefore may not give the best result
- process does not develop a higher level
understanding and/or skills
Choice Through Comparison Creative Decision Making

of Options Requires devising a novel course of action
for an unfamiliar course of action - rarely
Involves identifying options, weighing up their used in high time-pressure environments
relevant features in terms of a match to the unless there are no alternatives.
requirements of the situation.
Advantages:
Advantages: - produces solutions to unfamiliar
- useful in contingency planning problems
- fully compares alternative courses of - new solutions may be invented
actions which have wider application
- can be justified
- more likley to produce the optimal solution Disadvantages:
- time consuming
- untested solutions
Disadvantages: - difficult under noisy and distracting
- requires time environments
- not suited for a noisy, distracting - difficult under stress
environment - may be difficult to justify
- can be affected by your stress levels
- can in fact produce a cognitive overload
and 'stall' the decision-maker

DECISION MAKING
What is the difference between problem solving and decision making?
 Problem solving involves a unique situation that is not common and for which there are
no decision rules.
 Decision making has many alternatives and is the process of selecting the most
appropriate alternative given the available information.
What is ‘escalation of commitment’ and how can it be reduced?
This refers to persistence when a course of action is no longer a ‘good’ decision. It can be
reduced by the development and implementation of good teams, ensuring good information that
is regularly updated, regular meetings/discussions and the obtaining of an objective review of
the project.
The interrelating events that impact good decision making are people, the aircraft or machinery
we operate, the environment in which we operate and these occur all the time. We can divide
them into five (5) parts:
1. Person: the person involved makes continuous decisions about his own competence
and general feeling (health, fatigue, stress);
2. Aircraft/Machine: the state of the aircraft/machinery is a huge source of information on
which we will base our decisions;
3. Environment: environment is where we operate. Think of the weather, other traffic,
noise, distractions etc.;
4. Operation: this is the interaction of the previous three items - is everything going as
planned? What is our plan?;
5. Situation: this is knowing what is going on around you so is therefore the sum of the
previous four items. These are brought together as the situational awareness of the
people involved. The higher the situational awareness, the safer the operation and the
better the decision making process.
FOUR COMPONENTS OF SUCCESSFUL DECISION MAKING

1. Decision Framing: This involves first determining and structuring the question which
must be decided, and then developing preliminary criteria for selecting one option over
another.
2. Information Gathering: This involves determining relevant facts and making reasonable
estimates of unknowables. In this process it is important to avoid being overly confident
in our current beliefs and seeking information that confirms our biases.
3. Coming to Conclusions: This involves systematic rules to consider all the available
information relevant to making decisions.
4. Learning from Experience: This comprises making predictions, gathering and recording
information to determine whether the predications were accurate, regularly evaluating
the effectiveness with which decisions were made, and using this learning to make
similar decisions more effectively in the future.

10 DECISION MAKING TRAPS
1. Plunging in occurs when you begin to gather information and reach conclusions without
first taking a few minutes to thing about the ‘actual issue’ or think through the decision
that needs to be made.
2. Frame blindness occurs when you set out to solve the wrong problem because the
mental framework you created caused you to overlook better options. You have lost
sight of your objectives.
3. Lack of frame control occurs when the problem is only looked at or defined in one way –
you failed to ‘find an alternate possible way to solve the issue/problem’.
4. Failing to collect factual information often occurs because of your overconfidence in your
own judgement. Often in this situation you only seek information that only confirms your
belief/idea/solution.
5. Relying inappropriately on ‘rules of thumb’ can result in a decision made by relying on
easily available or remembered information.
6. Winging it rather than following a systematic procedure when making the decision or
choice.
7. Group failure comes from assuming that good choices will follow automatically because
you have smart people involved and therefore do not manage the group decision main
process.
8. Fooling yourself about feedback – this happens when you fail to accurately and honestly
interpret the evidence from past experiences.
9. Not keeping track by using systematic records to track your decision making process
and assumptions and results.
10. Failing to create and audit of your decision processes will only make you constantly
exposed to the above mistakes.
However the following points highlight the key factors in effective crew decision-making and
performance (the shared mental representation): (study of pilots in a simulated emergency
situation)
 High levels of problem solving related discussions and were planful in making decisions.
 Greater situational awareness, obtaining information in time to use it and adopt a
resource conserving strategy while they acquired the information needed.
 Crews were engaged in contingency planning were more effective in making decisions
when emergencies were encountered.
 Talk was task relevant, more commands and suggestions from all crew members, more
statements of intent, more information exchanges, acknowledgements and
disagreements.
 More explicit in defining the problem, articulating plans, explaining rationale and co-
ordinating responsibilities among the crew.

MODULE SIX
LEADERSHIP
One person can live on a desert island without leadership. Two people, if they’re totally
compatible, could probably get along and even progress. If there are three or more, someone
has to take the lead. Today we have a more nuanced view of leadership. We no longer think in
terms of the Lone Ranger or the Great Man. But no matter how collaborative our organisations,
someone still needs to choreograph the players and make final decisions. Leadership might
rotate among the three inhabitants on a desert island, but leadership is needed nonetheless. So
let’s admit it: in a nation, in a world, in an organisation as complex and fluid as ours, we cannot
function without leaders.
A single brain sometimes cannot make decisions alone. In a team, every member contributes to
his level best to achieve the assigned task.
The team members must be compatible with each other to avoid unnecessary conflicts and
misunderstandings.
Every team should have a team leader who can hold their team together and extract the best
out of the team members. The team leader should be such that every individual draws
inspiration from them and seeks their advice and guidance whenever required. The leader
should be a role model for their team members.
A team leader plays an important role in guiding the team members and motivating them
to stay focused.
The workplace is one environment where effective leadership is incredibly important.
Effective leadership in the workplace is about much more than just management, assigning
tasks, setting work directions. It is a comprehensive responsibility which involves inspiring and
motivating, giving confidence and encouragement, while also providing authority and
constructive feedback, managing relationships – and of course, ensuring that all team members
understand and share the mission and goals.
Know thyself! One of the key steps to becoming an effective leader in the workplace is
reviewing your own leadership style and becoming more aware of your own strengths and
weaknesses.
Questions to ask yourself include:

 What leadership style do I have?
 Does my leadership style impact negatively on the team?
 Do the decisions I make benefit the whole team or only a few?
 Does what I say as a leader match up with what I ask my team members to do?
 Do I ask more of my team than I do of myself?
 Do I expect higher standards of my team than I do of myself?

THE TRANS-COCKPIT AUTHORITY GRADIENT (TAG)
Captain Co-Pilot
A well-balanced cockpit is unbalanced (but not too heavily) in favour of the Captain.
Initial CRM concepts discussed the Captain's constant objective being to find a subtle
compromise that maintains this authority gradient without losing the support of other crew
members. In order to further understand and develop this theory we must look into the main
leadership styles.
THERE ARE 4 MAIN LEADERSHIP STYLES

Autocratic
This style relies upon authority and obedience. The leader's main concern is for task completion
and is combined with a minimum concern for people i.e. dictating to others.
Laisses-faire
This leader has a minimum concern for both production and people. This leader will put forward
the least effort required to remain in the organisation.
Self Centred
This type of leader shows mainly concern for self where a flight crew would consist of two
individuals, but no crew. The leader shows no interest in what other crew members are doing,
all the while believing that others know their responsibilities.
Synergistic
The leader makes the decisions but with the help and active participation of other crew
members. A strong two-way communication is established with all information reaching the
leader. The leader is able to delegate.

Leading by example is one of the most important factors in becoming an effective workplace
leader. How you conduct yourself as a leader will send out constant messages to your team –
for example, if you come to work only to sit around, shut away from your team by a closed door
and/or a closed mind, then your team will be getting the message that you can’t be bothered
about them or their concerns.
Conversely, if you are familiar with your team member’s daily responsibilities and concerns and
show that you recognise that each of them play an important part in the overall functioning of
the organisation, then this sends out the message that everyone on the team is valued.
Effective leaders share several attributes in common which ensure that they are successful in
their leadership roles. Different attributes may be more important in different situations and with
different teams but a core group of traits and characteristics is seen again and again in effective
leaders:
• Team-building skills – recognition and acknowledgement are two of the most powerful
motivators in human behaviour; a leader who gives credit where it is due, shares it
around the team and rewards individuals for their contribution will build a more cohesive
and successful team.
• Flexible leadership style – an effective leader is one who can adapt their leadership
style to suit different scenarios and different teams of people.
• Courage and determination – effective leaders have the confidence to stand behind
what they believe in and the drive to inspire their team to overcome challenges.
• Open Mind – effective leaders take risks; they are not afraid of innovative ideas which
challenge the status quo and welcome these from their team.
• Integrity – leadership cannot succeed without trust and respect and these two can only
be given when a leader shows great integrity and ethics.
• Good communication skills – probably the most important trait of all, as without the
ability to communicate well, all the other traits might well be useless. An effective leader
will not only express himself clearly and persuasively but will also be a good listener.

Within any team there must be a
leader e.g. the Pilot in Command,
Managing Director, CEO. This leader
may be a Designated Leader (through
a hierarchy or company structure) or a
Situational Leader who takes the lead
for a particular task or skill that is
required (e.g. this person may have
worked in this environment or at this
location before). It is important that if
Situational Leadership is going to be
used the Designated Leader
communicates this change to all team
members. In most situations the
Designated Leader will still hold the
overall responsibility and authority.
Being a good leader is hard and we can fall into some typical 'leadership traps', which
includes:
 you are "the company";
 an inability to delegate;
 refusal to accept criticism and input from
others;
 fear of competent subordinates;
 showing favouritism to some team
members;
 still doing what worked even long after it
doesn't;
 not knowing when to let go.
Being aware of these traps is the first step. Then recognizing them in yourself and making the
step to make the changes. Good leaders makes mistakes and move on learning from each one.
THE LEADER AS A CRITIC

No skill is more important to a leader than the ability to analyse, appraise and judge team
performance.
The team naturally looks to a leader for guidance, analysis, and appraisal as well as
suggestions for improvement and encouragement.
This feedback is called a critique.
A critique may be oral, or written and should come straight after a team performance. This
ensures details of the performance are easy to recall.
A critique may be performed in front of the team or in private. If an individual is critiqued in front
of a group this has the advantage of benefiting the group however, as the leader you must
ensure you avoid any embarrassment for the individual.

Two common misconceptions with critiques:
1. A critique is not a step in the grading process. It is a step in the learning process.
2. A critique is not necessarily negative in its content. A critique can, and should, be as
varied in content as the performance being critiqued.
The team must understand the purpose of the critique; otherwise they will be unlikely to accept
the criticism offered and little improvement in their team performance will result.
The leader must adjust the tone, technique and content of the critique to the occasion as well as
the team members.
CHARACTERISTICS OF AN EFFECTIVE CRITIQUE
Objective
 Focused on individual/team performance.
 Not reflect personal opinions, likes, dislikes and biases.
 Too much sympathy or over-identification is not of any benefit.
 Honest.
 Based on the performance as it actually occurred not as it may have been desired.
Acceptable
 The team must have confidence in the leader’s abilities, qualifications, sincerity,
competence and authority.
 If the critique is presented fairly, with authority, conviction and from a position of
recognisable competence it is more likely to be accepted by the student.
Comprehensive
 Not necessarily a long critique.
 The leader must decide if the greater benefit will come from discussion of the major
items rather than the entire exercise.
 Covers strengths and weaknesses
Constructive
 A critique is useless unless the team/individual benefits from it.
 Praise for praise sake is of no value.
 Praise can be well used to inspire the team's ongoing performance and that of
individuals.
 Do not just identify the weaknesses – give positive guidance
Organised
 Valuable comments will lose their impact unless they are organised into a logical
sequence.
 The sequence of the performance itself is the most commonly used and logical.
 Be flexible to ensure the team understands the critique.
Thoughtful
 A critique reflects the leader’s thoughtfulness towards the team’s need for self-esteem,
recognition and approval from others.

 Ridicule, anger or fun at the expense of the team or individual member have no place in
a critique.
Specific
 Specifics rather than generalities should always be used.
 The team must be able to focus on something concrete.
 The leader should ensure they have a clear, well founded and supportable idea in mind,
it should be expressed with firmness and authority in terms that cannot be
misunderstood by the team.
 At the conclusion of a critique the team should be clear on what they did well and what
they did not, most importantly, how they can improve.
GROUND RULES FOR BRIEFING
There are a number of rules and techniques to keep in mind when conducting a brief.
The following apply regardless of the type of brief conducted:
1. Except in rare circumstances do not extend the brief beyond its scheduled time and into the
time allotted for other activities. A point of diminishing return can quickly be established.
2. Avoid trying to cover too much or everything. A few well made points will usually be more
beneficial than a large number of points that are not developed adequately.
3. Allow a time for a summary of the brief to re-emphasise the most important things to
remember.
4. Avoid dogmatic or absolute statements, remembering that most rules have exceptions.
5. Avoid controversies with the team and do not get into the delicate position of taking sides
with group factions.
6. Never allow yourself to be manoeuvred into the unpleasant position of defending criticism. If
the criticism is honest, objective, constructive and comprehensive, no defence should be
necessary.
7. If part of the brief is written, make certain that it is consistent with the oral portion.

MODULE SEVEN
TEAMWORK
A successful team results when the output of the team as a whole is greater than the sum of the
outputs of the individual team members. Each individual should be encouraged to contribute in
the most effective and productive way to ensure the overall team task can be achieved. This
process of interaction is known as Synergism. There is no point developing a football team that
has many individual outstanding players, if they do not work together as a team to get the ball
forward to enable a goal to be kicked then there is a lack of synergy and the 'team' will fail.
Within a team you will find many differences:

 Personalities;
 Age;
 Experience and training levels;
 Gender;
 Physical abilities etc.
This means that with many different team members you will need particular elements to make a
good team environment.
You need to Support one another, which can be achieved by:

 Delegating and sharing the work load;
 Accepting and understanding your role and that of others within the team;
 Being open to other team member ideas; and
 Maintaining good working relationships.
You must also be able to Solve Conflicts; at times there will be conflicts between team
members and it is best to solve them quickly when they occur:
 Be open-minded;
 Listen to your team members;
 Clarify misunderstandings before they escalate into something more serious;
 Understand your role; and
 Understand each team member’s role.
Remember:

Of course Good Communication is needed to ensure your information is received by the team
efficiently and effectively, if you are unsure then ask.
It is important to ensure that communication between team members is encouraged from the
outset, even if that information often turns out to be irrelevant or not important, team members
should not be afraid or embarrassed to speak up.
PRECONDITIONS FOR GOOD AVIATION TEAMWORK

 Effective and balanced leadership.
 Clear two-way communication.
 Clear role and task allocation.
 Shared understanding of roles.
 Clear operating procedures.
 Balanced participation.
 Effective feedback.
Most of these conditions can be established via a

clear and unambiguous briefing, normally
conducted by the leader and "sets the tone" for
the mission or flight. The leader needs to include within this brief "permission" for the other
crew members to speak and contribute to team performance and decision making where
appropriate.
Effective teamwork is also promoted via an appropriate organisational structure and culture.
The establishment of high quality and consistent:

 SOPs;
 Checklists
 Operations manuals;
 Training;
 Logistical support;
 An integrated philosophy of operations;
all promotes effective teamwork within a particular organisation.
What are some of the barriers that may exist for the effective working of a team?

Some of the ideas you may have come up with may include:
 poor communication or different language skills.
 different leadership and support styles.
 conflicting leadership and support styles.
 workload pressures.
 time pressures.
 stress.
 illness.
 fatigue.
 different levels of experience, age or positions within the team.
 conflicts.
 disagreements.
 personality conflicts.
What makes a good team? This can vary from team to team but generally the following are
seen as a good start:
 good leadership;
 good support;
 a common goal;
 skilled members of the team;
 good communication;
 good training – both of the individuals and the team as a whole;
 understanding the decision making processes within the team; and
 appreciation of different personality styles including leadership styles.

MODULE EIGHT
UNDERSTANDING HUMAN ERROR
The Concept of Safety (ICAO Doc 9859): Safety is the state in which the risk of harm to
persons or property damage is reduced to, and maintained at or below, an acceptable level
through a continuing process of hazard identification and risk management.
Human error contribution to accidents is considered to be 70% to 100% for most well defended
hazardous technologies. Simply put, a defended hazardous technology is a technology such as
aviation where there are defences in place for safety.
Human error is the by-product of the human condition. Therefore it is another factor to discuss,
understand and manage in the field of ADM.
ADM is the tool used to reduce the adverse effects of human error. As the saying goes - you
need to understand the enemy in order to defeat it.
It is also the ability to differentiate those errors in relation to their consequences and decide
which can be ignored as they have no serious consequence(s) or will be rectified in a future
process and those which are more serious and cannot be ignored.
It is argued by many industry experts that it is very difficult to think of an aviation accident that
does not have significant human contributions in its cause.
Air crew error is involved in many of these cases but human error can also be made by those in
the cabin, Air Traffic Control, maintenance, designers of our equipment and procedures,
meteorology reporters and loaders (to name but a few!). Company management and regulators
can also make human errors that may contribute to an accident in some way. Many accidents
have had causal errors made by not only the flight crew but were also contributed to by
decisions and policy from company management.
“To err is human” – what does this mean?
It refers to the undeniable quality of humans of being capable to make mistakes, errors in some
way shape and form every day.
Have you made a mistake today?
Perhaps forgotten to bring a necessary item to work, made a spelling mistake, spilt coffee in the
tea room?
Other than some possible inconvenience there is little negative impact from these
errors/mistakes. They are therefore of little consequence and quite often get forgotten in our
busy days.

For some this question may be hard to answer as there has been no consequence of those
actions however we may have sped on our way to work – no accident, no speeding fine, no
incident and we don’t think about it any further however not only did we drive at the wrong
speed we probably did so intentionally which is a violation of the rules.
However back to our spilt coffee on the tea room floor. Your co-worker comes in and does not
see it, slips on the liquid and falls resulting in a broken ankle. This result is a little different in its
consequences. We now have an injured co-worker who needs attention, will probably be off
work for a short period of time which requires a replacement to undertake their work, not to
mention their recovery time and expenses associated with possible compensation and medical
bills. A very different outcome as a result of one variable, your co-worker entering the room
before you cleaned up the spill or it had dried (if you didn’t bother to clean up!!). This is how
accidents happen. No-one plans to break their ankle and yet our doctors’ surgeries and
hospitals are filled with people with broken bones because accidents do happen and they are all
caused by something or someone not doing what was expected or anticipated.
So we must equip ourselves with as many skills as possible to reduce their number and the
level of their consequence should they not be entirely preventable. One of those skills is the
understanding of human error and how it works.
Two important considerations arise from error making:

1. Everyone is capable of making errors no matter how experienced or inexperienced in the
task; and
2. We must learn from our errors.
These considerations remind us that the most experienced can make a mistake or error. Being
human, we can also learn from these errors. The natural outcome of an error is an adaptation in
behaviour.
Simulators and simulated exercises are an excellent example of how we are able to learn from
our mistakes.
So therefore are we saying that we NEED errors in order to be safer?
An apparent contradiction? We all make errors. This is how we learn the most basic to most
complicated of skills. Intelligence is strongly linked to learning error.
James Reason once said:

WISDOM
“Error and wisdom are the
ERROR
flip side of the same coin”.
To learn from one’s errors in wisdom.

We can learn from errors and adapt our performance.
To manage one’s errors is professional.
We can detect and recover errors before they have serious consequences.

“When someone asks me how I can best describe my experience in nearly 40 years at
sea I merely say ‘uneventful’…of course there have been winter gales and fog and the
like but in all my experience I have never been in an accident worth speaking about. I
have seen but one vessel in distress in all my years at sea………
I never saw a wreck and I never have been wrecked. Nor was I ever in any predicament
that threatened to end in a disaster of any sort……..”(1907)
Captain EJ Smith became the captain of the Titanic 5 years after making the above statement.
Certainly a very experienced sea captain however he still made mistakes.
An important aspect of error awareness is the ability to differentiate errors in relation to their
consequences, determine those which can be ignored as inconsequential (or perhaps they will
be rectified in a future process) from those which are more serious that require action to prevent
the consequences arising.
Often we make mistakes in the simplest of tasks and as a result these go unnoticed.
Researchers have conducted many studies and reviews which differentiate the various types of
errors. We need only a fundamental understanding of the error types but we do need a good
understanding of the solutions. Solutions are three fold:
 Error reduction strategies intervene at the source of the error by reducing or eliminating
the contributing factors.
 Human-centred design, Ergonomic factors and Training.
 Error capturing strategies intervene once the error has already been made, capturing
the error before it generates adverse consequences.
 Checklists and Task cards/Flight strips.
 Error tolerance strategies intervene to increase the ability of a system to accept errors
without serious consequence.
 System redundancies.
It is important to acknowledge and make the distinction between errors that are unintentional
and a violation which is intentional.
Contributing Factors
eg culture, training,
procedures
Human
Error
Incidents
Accidents

ERROR VS VIOLATIONS
Error
A decision/action/inaction where the eventual result was not intended.
Violation
Knowingly and intentionally breaking or not following a rule or procedure.
The main difference between errors and violations is the intention of the outcome by the
individual. An error is not necessarily expected, planned for, or wanted. A violation generally
occurs due to the considered action of an individual; however the motivation for the violation
must be examined in order to determine the intent of the action. If a violation is motivated by a
desire to improve something – e.g. a violation of Standard Operating Procedures in order to
ensure on-time performance targets, this should be dealt with in a different way perhaps to an
individual action that was motivated by recklessness, when the end goal is easily anticipated
and desired (e.g. sabotage etc.).
The two most common types of error are (Reason, 1990):

 slips and memory lapses: Slips are errors in which the right intention or plan is
incorrectly carried out. For example you may miss an item on a checklist; and
 mistakes: Where the actions follow the plan but the plan deviates from some adequate
path to the desired goal. Mistakes involve a failure or deficiency in the judgment process.
For example you may call for the wrong checklist.
Mistakes can be further categorised into two groups:

 rule-based mistakes, in which you encounter some relatively familiar problem, but
apply the wrong pre-packaged solution (either the misapplication of a good rule, or the
application of a bad rule); and
 knowledge-based mistakes, in which you encounter a novel situation for which your
training has not provided some rule-based solution. The consequence is that you have
to use on-line reasoning based upon some (usually) incomplete or incorrect mental
model of the problem.
Errors can be further broken down into: (Hawkins, 1987).

 Random error is error that occurs without any kind of pattern e.g. a pilot landing at
various touchdown points.
 Systematic error is when an error occurs consistently e.g. an engineer constantly
carrying out an incorrect procedure due to inaccurate training.
 Sporadic error is when an individual who normally carries out an activity to a high level
of accuracy, commits an error e.g. an Air Traffic Controller who normally maintains
aircraft separation to a high standard and on one occasion fails to do so.
 Errors of omission occur when an individual forgets to do something e.g.
unintentionally skipping an item on a checklist or job card.
 An error of commission is when an action is carried out that shouldn’t be e.g. boarding
passengers when the flight has been delayed for an hour.
 An error of substitution, is when an action is carried out at the right time, but it is the
wrong action e.g. shutting down the wrong engine, or using an incorrect part of a
maintenance procedure.

The latest research from the NASA/University of Texas Crew Aerospace Research project
indicated that on average crews made two observable errors for every flight sector flown.
How many flight/operational hours do you have?

How many errors do you make per flight hour?
It would be a rare person who could honestly say none – we make mistakes and errors simply
driving to the local shop. Normally these would not have any significant consequences and thus
go unnoticed in the scheme of our day.
Statistically millions of crew errors are made before a major accident occurs. This results from
most errors having no significant consequence. However the same error can in a different
situation or circumstance have significant consequences i.e. lining up without a clearance when
there is no traffic will have no significant operational safety consequence however the same
mistake when the traffic pattern is full may have a very different consequence.
Here is a simple error which due to the actual situation proved to not only be embarrassing for
those concerned but also very expensive!
The aircraft was being taxied from a hanger toward the departure gate
for boarding when the crew lost directional control. The aircraft entered
a monsoon drainage ditch causing serious damage. There were no
serious injuries to the six crew on board.
The aircraft was being moved by maintenance crew who taxied by

using engines 1 and 4. They apparently did not realise that the
aircraft’s braking system was powered by engines 2 and 3.
THE ERROR CHAIN

Four out of every five accidents can be attributed to human error as a primary cause. However
these accidents and incidents are most often the result of a series or string of events.
The links in an error chain tend to occur sequentially; they may or may not be related to each
other and may not be readily apparent to the crew.
The central idea behind the error chain The Error Chain
is the understanding that any
investigation of an accident or incident
will reveal a chain of events that lead
to the actual event taking place.
Airport
Accident

Contributing factors may include:
 Training;
 Judgment;
 Fitness to work/fly;
 Errors by other personnel;
 Distraction;
 Inattention;
 Errors of omission;
 Non-adherence to SOPs; and
 Violations.
Errors can also lead to violations resulting in a spiral effect of errors and/or violations being
established. For example – you are just about the commence descent but become distracted
due to poor planning (an error has been made). You are then rushed and decide not to
undertake the top of descent checks as required by your SOPs (a violation has resulted). In this
case the relatively simple error of poor planning has led us to a violation that we would not
normally consider.
HUMANS CONTRIBUTE TO ERRORS IN TWO WAYS

1. PERSON Approach
This focuses on the errors and violations of the individuals. Any corrective action or training as a
result of any investigation is directed at the individual.
Blaming the individual can be emotionally satisfying and legally convenient but it does not
ultimately lead to a better understanding of the cause(s) or the prevention of further accidents.
You cannot change the human condition - mistakes will happen.
Particularly where safety is concerned we must differentiate between the error and the
consequences. The consequences often rely upon the error tolerance i.e. the error for safety
within the system in which we operate.
It is quite often said that it is the employee who has made the error and learnt from that error
who becomes one of the best employees to have around!
2. SYSTEM Approach
This traces the contributing factors back into the system as a whole and examines the
“system’s” contribution to the accident/incident. Any corrective or remedial action is directed at
the organisation and system.
This more global and long-term solution approach accepts that accidents result from
characteristics common to all operators and that they arise from a sequence of events (however
rare) where barriers, defences and established controls do not function as planned or designed.

Examples of Systemic Failures:
 Managers – unsafe strategy in place.
 Senior Staff – unsafe decision(s) made.
 Resources – facilities devoted to the operation can be affected by financial or
management decisions.
 Production – unsafe acts by the actual participants and is the ‘real-time’ layer.
 Defences – set up by all high risk industries in order to protect man and equipment
against adverse unseen events.
VIOLATIONS
Violations are deliberate breaches from the normal procedure or rules. For example you elect
not to conduct a checklist even though it is a SOP for your operation.
It is important to note that:

 Violations are deliberate and stretch the system’s defences.
 Violators will assume others are following the rules and procedures.
 Violations are forbidden, so violators do not tell anyone what they are doing or have
done.
 Violations take the system out to the edge of the safe operating envelope.
When looking at the subject of violations, we need to first understand why we have rules. Rules
or procedures are often in place to enhance safety or efficiency. Generally speaking these often
come about from past accidents or incidents, with regard to safety, and problems with
turnaround and work times, with regard to efficiency. Rules and procedures can also help
ensure the on-going transfer of knowledge to new staff or newly qualified personnel. They can
also help to promote consistency and predictability of the work environment.
One of the biggest reasons procedures are in place is because people can forget all of the
relevant and necessary steps in completing a certain task, and can’t always solve a problem
without a defined procedure to follow. This is especially true when it is a task someone is very
familiar with, but hasn’t completed in a long time. They have the confidence that they can do the
job without reference to the procedures, however there is a danger they will miss something
because they aren’t as current with the task as they think they are. Procedures also help to
identify steps in a task that would otherwise be missed, that is, not every step in a task is self-
evident.
A violation is defined as “knowingly and intentionally breaking or not following a rule or

procedure”. The problem with this definition is that personnel may not always know about the
procedure, but still manage to breach it.
So why do people violate? Well most of the time, it is rarely because they can see the outcome,
understand that it is probable and continue anyway. People violate for a number of individual
and work place motivational reasons.
 Expectation
That on a particular occasion the rules will have to be bent to get the job done.
 Powerfulness/Macho
That one has the ability to do the job without necessarily following the procedures.

 Opportunities/Creativity
Short cuts or way to do things “better”.
 Work Planning Problems
Inadequate planning leads to solving problems on the fly.
 Norms
Everyone does it this way.
 No peer influence
Lack of peer sanction increases the probability of a violation.
 Malicious Intent
For example: Sabotage.
Violation types also vary and these include:

 Situational – it is impossible to get the job done if you strictly follow the procedures.
 Routine – the procedure is regularly ignored and may even have become an 'unwritten
rule' or workplace procedure.
 Optimising – staff believe they know how to achieve the same outcome, but faster.
 Exceptional – special situations that the procedures hadn’t envisaged.
 Socio-pathic – individuals can be intent on not following normal social convention.
One of the most dangerous things about violating a rule or procedure is the lack of defence that
then exists. When someone commits an error, the system often has at least one safeguard to
catch this error. It was envisaged by someone that this error could occur and the system was
designed to cope with this eventuality. A violation, on the other hand, involves working outside
of the defined system by ignoring rules and procedures. As such, there are fewer, if any,
defences that will work to prevent an adverse outcome.
In investigating such an event, it is important to determine how and why the violation occurred.
Often the violation will have occurred due to a conflict between goals, such as the need to
complete a maintenance task fully but also ensure the aircraft leaves on time. If the timeframe is
inadequate for the task, then personnel may find a way to complete the task in less time,
thereby meeting the more important goal in their minds, the on time departure. As mentioned
above, it may also be possible that the employee was not aware of the procedure or rule and as
such, this was an inadvertent violation.
So what can be done about violations? Since it is impossible to change the human condition,
the only thing that is variable is the system and conditions under which the humans work.
Therefore, it may be possible to:
 (Re)identify Hazards, assess risks – part of the Safety Management System.
 Review and expand the defences.
 Act to reduce the frequency of errors.
 Design: limit the chance/consequence of an error and/or a violation – if it is impossible to
move outside the system, violations cannot occur.
 Act to increase compliance with rules and procedures – eradicate violations.
 Remove or re-write irrelevant procedures.
 Review or redesign job specifications.

CULPABILITY
The instinct to blame individuals for their actions is still a strong one in today’s society.
Examples include the mid-air accident in Brasil (blame the pilot – criminal proceedings initiated)
and Kerang train/truck collision in Victoria (blame the truck driver – criminal proceedings
initiated). But is it really fair to blame the last person who touched the controls, the equipment or
interacted with the system? Humans are fallible, and this is something that cannot be changed,
but as mentioned above, changing the conditions in which humans work can help improve the
outcome.
There are a number of problems with evaluating the actions of individuals. These are:
Outcome bias – if the outcome is good it is harder to discipline someone for doing the wrong
thing than if the outcome was bad.
Hindsight bias – knowledge of the end result leads you to believe this eventuality should have
been obvious to those involved.
Local Rationality – investigators must understand why people behaved as they did at that point
in time and explore why the organisation could not see the possible outcome.
Accountability – why shouldn’t pilots, engineers, air traffic controllers be held accountable for
their actions? This desire is often very strong when investigating an incident.
Blame or Absolution – or Regulation or Education? Which is the better outcome? Blaming

someone is easy and focuses on performance, absolution is a lot harder and works to identify
system deficiencies.
In determining culpability, the motivations, goals, and external pressures on the individual
should be considered.
THE REASON MODEL

This model is likened to the holes in slices of Swiss cheese. It is very unlikely that when placed
upon each other one continuous hole will appear – but it is still statistically possible – this is how
accidents happen – the holes in the cheese line up!
This model enables examination of both latent conditions and active failures thereby providing a
framework for analysing safety and investigating incidents and accidents in aviation (and other
industries).
The model enables managers to proactively apply its principles and accident investigators to
reactively use its principles.

James Reason (1991) defines organisational accidents as “situations in which latent conditions
(arising mainly from management decisions, workplace practices or cultural influences)
combined adversely with “local trigger events” (task or environment conditions – weather,
location, workplace, equipment failure) and with active failures (errors and/or procedural
violations) committed by individuals or teams at the sharp end of the organisation, to produce
the accident.”
Absent
Organisational Task and Individual & Failed
Factors Environmental & Team Defences
Conditions Actions
Source: Qantas Airways Limited
Reason also uses the medical metaphor of “resident pathogens” to describe latent conditions.
These conditions are usually initiated remote in time and location from the accident site and
often lay dormant within a system for various amounts of time until they become active as a
result of active failures and/or trigger events. They are more commonly committed by designers,
directors, managers, supervisors etc.
Active failures refer to errors and violations having an immediate impact on the system and are
committed by those at the “sharp end” of the participants i.e. flight crew, engineers, loaders etc.
Analysis of major accidents in technological systems has clearly indicated that the preconditions
to disasters can be traced back to identifiable organisational deficiencies. It is typical to find that
a number of undesirable events, all of which may contribute to an accident, lay dormant over an
“incubation period”, often for years, until a trigger event (e.g. an abnormal operating condition)
precipitates a disaster. Furthermore, accident prevention activities in systems recognise that
major safety problems do not belong exclusively to either the human or the technical
components; they emerge from interactions between people and technology. The environment
in which these interactions take place adds to the complexity.
Let us now break down the concepts of the Reason Model and further examine its role in
preventative and reactive safety management. The Reason Model is a key tool in the
investigation of incidents and accidents (reactive use) but can also be used if we predict a
possible incident or accident and use the same ‘slices of cheese’ to examine where a failure
could possibly occur. In this way we can attempt to fix the problem before an incident or
accident can happen (preventative use).

In this examination we will use the diagram below from ICAO.
Source: International Civil Aviation Organisation
Identify the Organisational Processes
The legal responsibility and duty of care for the safety of workers and their operations falls at the
feet of management. These roles are normally considered to be that of supervisors and senior
management of departments.
Questions should always be asked of the organisation and normally stem from questions on the
other four (4) areas of the Reason Model. Some examples are:
 Were written procedures available?
 Were safety rules communicated to and understood by all those concerned?
 Were safety procedures enforced?
 Was there adequate supervision?
 Were all workers appropriately trained?
 When did the last training take place?
 Had any Hazards previously been identified and treated or remained untreated?
 Were unsafe conditions corrected?
 Were regular safety inspections/audits carried out?
A review of documents may also assist with the development of this information. Samples would
include:
 Training records and notes.
 Medical details of the workers concerned.
 Work history records.
 Procedural and Operational Manuals.
 Previous incident reports and accident details.
 Organisational policies and procedures.

Organisational Factors to be considered can also include:
 Poor Documentation.
 Poor Contractor or Supplier Management.
 Inadequate Monitoring and Measurement.
 Inadequate Specialisation.
 Poor Training.
 Poor Risk Management.
 Poor Authority and Responsibility.
 Lack of Management Commitment.
 Inadequate Safety Management Systems.
 Incompatible Goals between management, contracts, workers etc.
 Inadequate Communication.
 Inadequate Resource Management.
 Inadequate Design.
 Unsuitable Materials.
 Poor Management of Change.
 Inadequate Provision of Resources.
A change in organisational procedures is a common result of an accident or incident as

invariably better or updated procedures are developed.
Latent conditions/failures are loopholes in the system’s defences, barriers and safeguards
whose potential existed for some time prior to the onset of an incident or accident sequence,
although, until the time of the accident there were no bad outcomes. On some occasions,
however, these weaknesses combine with both active failures and local triggers (or both) to
create a trajectory of accident opportunity (sometimes only momentary) through some or all of
the system’s various protective layers. Notable international examples include the Herald of
Free Enterprise ferry disaster, Chernobyl nuclear reactor, Dryden, Erebus, space shuttle
Challenger etc.… closer to home the Monarch, Seaview and Lockhart River accidents all
pointed to latent failures contributing toward the adverse outcome.
Latent conditions can include:

 Hazard identification.
 Risk management processes and procedures.
 Policies and procedures.
 Organisational Culture.
(see also the 16 organisational factors above for further links to possible latent factors)
Most latent failures are only revealed ‘after the event’. Although, it is very important to note that
the potential for a system to develop latent failures may be assessed proactively. This is critical
to improving an organisation’s ‘safety health’, and is a central reason for introducing proactive
safety management practices into organisations.
Identify the Absent or Failed Defences
Failure in this area results from inadequate or absent defences that failed to protect the system
or detect any inadequacy in the system. They failed to protect the system technically and/or its
human error component.

Defences are barriers or safeguards put into place to protect a system from both active and
latent failures. Defences are important safeguards in maintaining an acceptable level of system
safety. The identification of inadequate defences simply puts the responsibility of safety back on
the structure of the organisation. For example, if an inadequate defence is a lack of staff
knowledge about the use of fire extinguishers, this automatically points to a need to evaluate the
company policy on recurrent emergency training. Regularly evaluating defences provides a
tangible means by which latent organisational factors can be identified. It is important that an
organisation regularly identifies what defences are currently in place to contain recognised
safety Hazards.
Identify the Workplace Conditions (Task/Environmental Conditions)
Task/Environmental conditions are task, situational and human conditions that directly influence
performance in the workplace. Deficiencies in these conditions can promote the occurrence of
errors and violations.
These conditions can be categorised in two groups:
1. Error Enforcing Conditions:

 Task Unfamiliarity: The environment provided a task which is not familiar.
 Time Shortage: The environment provided a task for which there was insufficient time in
which a reasonably skilled person could perform the task.
 Noise Work Environment: The environment provides a complex and distracting array of
stimuli and as a result we are unable to determine the required information accurately.
 Poor Human/System Interface: The design of equipment leads to the wrong use of or
selection of the wrong item.
 Designer/User Mismatch: The designer had intended the person to meet a goal that was
not directly in line with how others routinely used it.
 Training Mismatch: The training received to perform a task is not correct. The employee
was therefore unable to apply the correct knowledge or skills.
 Hostile Environment: This occurs where the employees find themselves in an
environment that degrades the performance of their work e.g. heat, untidy workplace,
rain etc.
 Poor Instructions or Procedures: The written procedures or instructions given are not the
most appropriate for the situation.
 Information/Task Overload: The employee is unable to process all the information
available or too many tasks are competing for their attention and time.
 Fatigue: The employee was unusually fatigued.
 Lack of Confidence: Where the employee fails to act in accordance with his training due
to a lack of confidence.
 Inexperience (Not Lack of Training): The employee lacked sufficient experience to detect
that this behaviour would produce a poor performance.
2. Violation Enforcing Conditions

 Lack of Safety Culture: The local environment lacks an adequate level of safety culture.
 Management/Staff Conflict: Conflict at the task environment level leads to violation
promoting conditions.
 Poor Morale: Poor morale contributing to violation promoting conditions.
 Poor Supervision and Checking: The employee responsible for checking another's work
failed to do so adequately.

 Group Violation Condoning Attitude: This situation occurs when there is evidence of a
group belief that violations of this type are acceptable and common practice.
 Hazard Misperception: Where the employee does not belive a Hazard exists.
 Lack of Management Care and Concern: Lack of care and concern at the managerial
level leads to the employee feeling that the task performed is not crucial or important.
 Lack of Pride in Work: The employee has no pride in the task being performed.
 Risk Taking Culture Encouraged: The employee demonstrates a risk taking approach by
their everyday behaviours and actions.
 Complacency (It Can't Happen): The employee belief that a given error, event or
occurrence will not happen to them.
 Learned Helplessness: The employee has learned that whatever they do is not likely to
influence the outcomes.
 Perceived Licence To Bend The Rules: The employee believes that the rules need not
apply in this situation (or to them!)
Also consider the condition of the equipment i.e. is it new or second hand, modifications,
fractures, design flaws, incorrect or insufficient labelling or confusing marks.
Samples of equipment clarification questions are:

 Was the equipment appropriate for the task(s) being undertaken?
 Was there an equipment failure?
 What is the correct equipment for the task?
 What caused the equipment to fail?
 Were hazardous or dangerous substances in use?
 Was (or should) personal protective equipment being used?
 Was the equipment readily available?
 Was the equipment clearly marked with instructions and markings, if applicable?
Factors to consider when assessing the equipment associated with an incident or accident:
 Design.
 Construction.
 Testing.
 Inspection.
 Maintenance.
 Modification.
 Appropriate to task.
Identify the Active Failures
Human active failures are errors or violations committed by those at the sharp end of the
system. Usually, the consequences of these active failures are caught by the system defences
or by the people themselves, and have no ill effects. On some occasions, they may occur in
conjunction with a breach in the defences and cause an incident or accident. The less defended
the system, the more likely it is that active failures will have immediate adverse outcomes. On
other occasions, active failures may themselves create instant gaps in the defences.
Previous studies into effective and ineffective flight crew safety behaviour (Helreich, Klinect and
Wilhelm, 1999) have established that individual and team actions can be classified into five (5)
error types based on intended and unintended actions.

1. Communications Error
An error that results from information that is improperly or incompletely communicated, withheld
or misunderstood. For example, flight crew misunderstanding an ATC clearance or crewman
failing to inform the pilot of an unusual noise on take-off.
2. Proficiency Error
An error where tasks are improperly executed because of a lack of skill or knowledge. For
example, a flight crew member failing to maintain an approach speed retention due to a lack of
recency.
3. Operational Decision Error

A decision-making error, involving situations not covered by procedures or regulations, that
unnecessarily compromises safety. For example, a flight crew member deciding not to conduct
a go-around in marginal weather conditions.
4. Procedural Error
An error in the execution of formal written procedures. The equipment operator may have good
intentions to follow procedures but executes them incorrectly. For example, making an incorrect
entry into a GPS.
5. Intentional Non-Compliance/Violation
A deliberate or wilful deviation from established regulations and/or Company procedures. Such
deviations reflect unsafe work practices and possibly even complacency. Violations range from
taking simple shortcuts; e.g. not bothering to stow passenger carry-on-baggage; to one-off
breaches of regulations, seemingly dictated by unusual circumstances; e.g. breaking of a rule to
avoid loss of life.
THE SHEL(L) MODEL

Many methodologies exist for the further understanding of how the aviation (and other)
environments work. Similar to the application of the Reason Model, the SHEL(L) Model can be
used in both a predictive sense in hazard identification and risk assessment and as a reactive
investigative model after an incident or accident has occurred.
The SHEL Model is named for its elements:

1. Software (S) (procedures, training, regulations, etc.);
2. Hardware (H) (machines and equipment);
3. Environment (E) (the operating circumstances in which the other elements interact);
4. Liveware (L) (humans in the workplace) – this is both ourselves and others in the
workplace and hence appears twice. The central Liveware show the relationship of
ourselves to all other elements in the Model.

SOFTWARE HARDWARE
Liveware
(us)
ENVIRONMENT LIVEWARE
The SHEL Model is relatively unknown compared to some and is a methodology used to
analyse the highly complex relationships between people, technical systems, machines,
organisations and the environment. As with all working models of analysis is has its advantages
and disadvantages. These we will discuss a bit later.
We (liveware) are adaptable but are also subject to variations in performance and are not
‘standardised’ to the same degree as hardware for example. The edges of the ‘blocks’ are
therefore always shown as irregular shapes as we do not interface perfectly with the various
components of the world in which we work.
Many models are varied over time as they are developed and reworked by those in the field of
analysis. The original SHEL concept was developed by Eric Edwards (1972) – Man and
Machine for Safety. It was then further developed into the commonly seen ‘building block’ as
first used by Frank Hawkins in 1984.
The model can also be referred to as the SHELL or SHEL(L) Model which also highlights the
element of liveware that is central to the diagram.
The SHEL(L) Model is used to help visualise the interrelationships among the components of, in
our case, the aviation system. It places emphasis on the human being and the human's
interfaces with the other components of the system.
Liveware
In the centre of the SHEL(L) Model are those persons (liveware) at the front line of operations
and is the most critical and adaptive element of the model.
The other components of the system must be carefully matched to us if stresses or weaknesses
in the system are to be captured or avoided.
Several different factors contribute to the irregular shapes on the liveware block edges and
include:
 Physical factors: This refers to our physical capabilities to perform the required tasks,
e.g. our strength, height, reach, vision and hearing. Physical factors also include our
need for food, water, oxygen etc. Differences in physical factors occur within any team. It
is also true of ethnic groups, age specific and male/female groups. In any early design

planning within the workplace or the designing of equipment, consideration must be
given to anthropometry (human body measurements) and biomechanics to ensure a
smooth interface between the central liveware and the other elements of the model. For
example, how far can a person easily reach when strapped into the aircraft seat?
 Physiological factors: These factors affect our internal physical processes, which can
compromise our physical and cognitive (thought processing) performance and include
our general health and fitness, illness, drug or alcohol use, personal stress and fatigue
as common examples.
 Psychological factors: These factors impact our psychological ability to address all the
circumstances that may occur in the workplace e.g. training, knowledge, experience and
workload. It can also include motivation and judgment, risk adverseness, confidence and
stress. Human Information Processing (HIP) is also a factor here. Remember from
previous reading that the HIP involves our sensory system and our ability to collect and
interpret this information. Unfortunately our senses are subject to degradation for a
variety of reasons which also relies on our memory, motivation and stress levels.
 Psycho-social factors: These include the external factors in the social system of our
workplace and how we interact as individuals. These factors bring pressure in the
working and non-work environments e.g. an argument, a death or illness in the family or
personal financial problems.
All of these factors influence how we interact with the other elements of the model.
Liveware-Hardware (L-H). The interface between us and the machine (ergonomics) is the
combination most commonly considered. It determines how we interface with the physical work
environment e.g. the design of seats to fit the sitting characteristics of our human body, displays
to match the sensory and information processing characteristics of how we as the user would
interpret this information (e.g. red for warnings and green for safe), and proper movement,
coding and location of controls for us to be able to use them effectively (e.g. seats that adjust
forward and back and in height to enable us to effectively reach the controls). Unfortunately not
all mismatches are discovered, as a characteristic of us humans is our ability to compensate
and adapt thereby masking a poor interface with sometimes catastrophic consequences e.g. we
use cushions to raise our position in the seat rather than get the seat fixed – what if the cushion
moved just after take-off or landing? Poor interface with the element of hardware can also result
in short cuts or non-standard procedures. How many of us have asked someone else to check
our fuel as we are too short to climb up and look for ourselves and can’t find or be bothered to
get the step ladder?
Liveware-Software (L-S). The L-S interface is the relationship between us and the supporting
systems (software) e.g. procedures and regulations, manuals, checklists and computer
software. It includes such "user friendliness" issues as currency, accuracy, format and
presentation, vocabulary, clarity and symbology. An example of a hazard related to this
interface is the misinterpretation of a checklist. This interface is often difficult to observe and
hence is also difficult to resolve after an incident e.g. misinterpreting a checklist is difficult
evidence to ‘discover’ after an accident and often difficult to predict. Another issue to consider is
that our procedures, checklists etc. are normally written by those who already understand the
system and may not be written for those who have never seen the equipment before. ‘Flat Pack’
instructions are a classic example – usually tiny little diagrams and very brief instructions as to
what goes where and which screw to use!

Liveware-Environment (L-E). This interface involves the relationship between us and our
internal and external environments. This was the earliest recognised interface. Initially we
worked to change the human to the environment e.g. oxygen masks and helmets whereas we
now work with the environment to meet the human needs e.g. soundproofing, pressurisation
etc. The internal workplace environment includes temperature, ambient light, noise, vibration
and air quality. The external environment includes visibility, turbulence and terrain. The
environmental considerations also go further to include the political and economic environment
both on a large scale and within a particular organisation or industry group. For example the
recent GFC has caused many organisations to curtail spending on areas which in more
profitable climates we would not consider reducing e.g. training and new equipment. We now
tend to ‘make do’ for longer. This puts greater stress on the interface and our interactions can
be less safe and efficient as a result.
Liveware-Liveware (L-L). The L-L interface is the relationship between ourselves and others in
the workplace. Flight crews, engineers, ground staff and other operational personnel function as
groups. The relationships of these groups to each other play an important role in how we work
as an effective team. This interface is concerned with training, proficiency, leadership,
cooperation, teamwork and personality interactions. The advent of Crew Resource Management
has resulted in considerable focus on this interface. As individuals we may be proficient but as a
team our level of proficiency may deteriorate as we do not work well together and of course vice
versa, we may achieve more as a cohesive team. Also included in this interface are corporate
culture, corporate climate and company operating pressures, which can all significantly affect
human performance.
Advantages of the SHEL(L) Model as an analytical tool:
 Hazard identification is a difficult task in complex systems and elements can be missed.
The SHEL(L) Model provides a methodology for examination of the human (liveware)
interaction with the elements of hardware, software, the environment and other liveware.
 The Model can be used as both a predictive (e.g. hazard identification) and reactive tool
(e.g. accident and incident investigation model).
 The Model enables us to visualise the processes and relationships which aids with
understanding. The elements can be built up block by block to develop an awareness of
the relationships.
 The Model is relatively simple in its application and principles and is relatively well
known for example being recommended by the ICAO as a tool in aviation accident and
incident investigation.
 In the Model’s use of the ‘Human Factor’ as the central element it enables a review of
the ‘person’ and their relationships and not just the engineering point of view which can
be a particular issue in the design of new equipment; for example an instrument may
appear in isolation as being more ergonomic but when placed into the working
environment may be difficult for us to include it in our visual instrument scan process.
Disadvantages of the SHEL(L) Model as an analytical tool:
 Due to the ‘Human Factor’ being the central element to which the interface of all other
elements are based this can leave out other important interactions e.g. machine to
environment, machine to machine, software to machine etc. It does not consider those
relationships which are not related to a Human Factor interface.

 The Model is simple but does not ‘stand alone’ as an all encompassing model to suit all
purposes. It therefore needs to be used in association with other models or principles to
give a full and clear picture of an event e.g. the Reason Model.
 The Model demonstrates failures between the ‘Human Factor’ and the other elements
i.e. when there is a mismatch. This process however assumes that the other elements of
hardware, software and other liveware are functioning correctly and that the environment
is conducive to the task. This is not always the case but is not highlighted in the
application of the Model.
 Due to the emphasis of the Model on the ‘Human Factor’ this can lead to a focus or ‘over
emphasis’ of this factor in the event of an accident if this Model is used as the primary or
sole tool.
CULTURAL RELATIVISM AND INCIDENTS/ACCIDENTS

Our belief systems and our own cultural awareness also impact safety. Specifically the concept
of cultural relativism highlights how the most appropriate or ‘right way’ for a group of people to
live together and survive in the world is relative to their culture.
Different cultures differ widely in their views of:

 Personality: Is it more virtuous to be group reliant or independent? Gregarious or
reserved? Expressive or controlled?
 Family: Are extended, nuclear or single parent families preferred?
 Social Structure: Should relationships between people be formal or informal?
Interdependent or independent? Hierarchical or egalitarian?
 Time: Are you late for a meeting if you are 20 secs after the start time? 2 minutes? 20
minutes? Is the wisdom of age of the vigour of youth most valued?
 Ingroup/Outgroup: Is it best to make a distinction between members of your ingroup
(family, friends, organisation) and outgroup (those outside of the ingroup), or should this
distinction be minimised?
 Material Possessions: Are they valued intrinsically or as a means towards a fairer
society?
 Nature: To be exploited or live in harmony with?
 Socialisation: Is a supportive or restrictive process of initiation into a culture most
appropriate? Should this be a harsh or lenient process?
Ethnocentrism refers to the tendency

to regard your own culture as superior
to others. This tendency tends to be
universal, in that members of virtually
all cultures feel this way. The mixing of
cultures can also cause ‘problems’. For
example, workers in a Puerto Rico
factory left the company when it
introduced participative management
practice. They left to work for a
company that had ‘more competent
managers’ “....if they have to ask the
workers how to run the plant, they
can’t be that good!”

ORGANISATIONAL CULTURE
As an organisation develops its cultural identity is developed.
As the company moves forwards to a maintenance phase it is critical to continuously assess

and monitor to maintain a positive safety culture.
Organisational culture recognises and identifies the behaviour and values of particular
organisations (e.g. the behaviour of members of one company versus that of another company,
or government versus private sector behaviour). Organisations provide a shell for national and
professional cultures. In an airline, for example, pilots may come from different professional
backgrounds (e.g. military versus civilian experience, and bush or commuter operations versus
development within a large carrier). They may also come from different organisational cultures
due to corporate mergers or layoffs.
ICAO Safety Management Manual, 2006
Your organisational culture is the framework upon which your organisation operates in all
aspects of its operations.
The organisational level is the level at which “the greatest leverage can be exerted to create and
nourish a safety culture”.
Helmreich 1999
It has been defined as "the specific collection of values and norms that are shared by people
and groups in an organisation and that control the way they interact with each other and with
stakeholders outside the organisation”.
This definition continues to explain organisational values as "beliefs and ideas about what kinds
of goals members of an organisation should pursue and ideas about the appropriate kinds or
standards of behaviour organisational members should use to achieve these goals. From
organisational values develop organisational norms, guidelines or expectations that prescribe

appropriate kinds of behaviour by employees in particular situations and control the behaviour of
organisational members towards one another.“
Charles W. L. Hill, and Gareth R. Jones, (2001) Strategic Management.
Strong Organisational Cultures are said to exist

where staff respond well because of their
alignment to company values. In such
environments, companies operate like well-oiled
machines, cruising along with outstanding
execution and perhaps occasional minor
amendments to existing procedures. Where
Organisational Culture is strong, people do things
because they believe it is the right thing to do.
Conversely, there is weak Organisational Culture
where there is little alignment with company values
and control is exercised through extensive
procedures and bureaucracy.
You have probably experienced various Organisational Cultures from working in a number of
different companies, even though you are doing the same job, the way this is done in each
company will be different.
Each organisation will demonstrate a number of aspects that indicate their current level of
‘safety culture’. James Reason describes a number of these aspects:
 an effective reporting system;
 openness to safety communication and ideas; and
 a demonstrated commitment to safety at all levels.
It is important to note that these factors are not just the responsibility of senior management.
This table looks at the three main types or organisational cultures that exist. Review this table
with your current organisation in mind.
TYPE A TYPE B TYPE C

Information is hidden Information may be Ignored Information is actively
sought
Messengers are “shot” Messengers are tolerated Messengers are trained
Responsibilities are shirked Responsibility is Responsibilities are shared
compartmented
Bridging is discouraged Bridging is allowed but Bridging is rewarded
discouraged
Failure is covered up Organisation is just and Failure causes inquiry
merciful
New ideas are crushed New ideas create problems New ideas are welcome
Note: Bridging refers to the sharing of ideas and ‘cross communication’ between departments
within your organisation.
Westrum 1995

It is important to remember that no organisation sits exactly within one type but may exhibit
some attributes of all three and may also vary its ‘type’ over a period of time and situation.
“Aviation organisations require information as much as aircraft require fuel.” Westrum
In our working environments we must learn to acknowledge and work with

all forms of cultural influence and understand that we are all different.
These differences bring with them advantages and disadvantages that
must be worked with.
PROFESSIONAL CULTURE
Professional Culture refers to your profession: pilot, engineer, cabin crew, accountant,
receptionist.
Professional culture recognises and identifies the behaviour and characteristics of particular
professional groups (e.g. the typical behaviour of pilots versus that of ATCs or AMEs). Through
personnel selection, education and training, on-the-job experience, etc., professionals (e.g.
doctors, lawyers, pilots and ATCs) tend to adopt the value system of, and develop behaviour
patterns consistent with, their peers; they learn to "walk and talk" alike. They generally share a
pride in their profession and are motivated to excel in it. On the other hand, they frequently have
a sense of personal invulnerability, e.g. they feel that their performance is not affected by
personal problems and that they do not make errors in situations of high stress.
ICAO Safety Management Manual, 2006
Members who have a strong professional culture generally have a greater value for their work
and therefore will do a better job than a member with less value for their work. By enjoying and
appreciating what you do for a living, you will also be more willing to teach and help the new
recruits into the company.
Professional Culture can also have an impact on how we view others. For example, how many
lawyer and accountant jokes do you know? This is part of our ‘thinking’ towards these
Professional Cultures. We have a perception of the person and their abilities based on their
profession and this can influence how we treat and mix in a team environment. There has
always been a ‘professional rivalry’ for example between military and civil pilots, pilots and
engineers – we even have ‘slang’ terminology for some groups – pilots and the public may view
cabin attendants as “trolley dollies” whereas cabin crew may view pilots as “intensive care
passengers”. How we respond to these perceptions and work together as a team will determine
the influence of this particular culture within our working environment. Every profession has its
role to play.
The involvement of other professional cultures into ADM training and not just the flight crew
continues to be introduced across the aviation industry with great success. In most situations a
form of role play is used. For example Qantas used a role play of a flight from Sydney over the
Pacific Ocean which was forced to ditch into the sea as part of their ADM training. The aircraft
has to be evacuated (including passeng ers played by crew members) into inflated rafts. This
was simulated in a swimming pool complete with cold water from hoses for the rain and reduced
lighting! The raft occupants were required to erect the raft’s roof. The cabin crew had been

trained in this but not the flight crew. This required a large degree of interaction and a ‘re-think’
of the traditional flight crew / cabin crew gradient was required for the successful completion of
the roof.
In our working environments we must learn to acknowledge and work with all forms of
cultural influence and understand that we are all different. These differences bring with
them advantages and disadvantages that must be worked with.
THE EVOLUTION OF SAFETY CULTURE

Safety culture within an organisation develops from a pathological (concerns more about being
caught than being safe) through to a reactive and then calculative (mechanically following the
required steps) culture and then through a proactive response to a generative stage where safe
behaviours and practices are fully integrated into the organisation’s polices and practices.
Organisations will pass through these stages of safety culture development regardless of where
they start.
When reviewing the SMS implementation plan, the current stage of a safety culture needs to be
determined in order to understand its current form and to work through the ongoing stages
successfully.
The evolutionary stages of safety culture development are:

1. Pathological: The organisation is not yet interested in safety. More focus is placed on
the importance of not getting caught rather than a focus on safety.
2. Reactive: Safety issues are now recognised as having some importance. This interest
however is driven as a result of incidents or an accident. Safety values may start to be
developed but practices are still very basic in their application. In many cases
management still believe that incidents and accidents are the result of inattention,
violations and mistakes. This is often not just the beliefs of management but can exist
throughout a majority of the organisation. Safety is a reactive process where systems
are put in place after the fact.
3. Calculative: This stage reflects the organisation’s shift to a recognition that safety needs
to be taken seriously. Safety is calculated i.e. risk assessments are being conducted and
often a cost-benefit analysis is also part of the organisational planning. Quantitative
assessments are normally used to justify safety and measure mitigators. A poor safety
record is seen as having an impact on the organisational ability to be competitive in the
market and incidents and accidents cost money. At this stage safety is still not a core
belief or value within the organisation. This is often reflected in the safety procedures
being a standalone element of the organisation.
4. Proactive: This is the first stage where safety is recognised as valuable in its own right
and not an ‘add on’. At this stage of development, safety is starting to form the way
business is done – however it is not totally there yet. The organisation is now putting into
place systems and procedures to prevent the incident and accident and responds more
to hazards in a preventative and proactive manner.
5. Generative: Safety has become more the way business is done. Safety is treated as a
key element of the organisation and is integrated throughout the organisation. The
system is still not perfect, no system is, but at all levels within the organisation safety is
seen as a key priority and its benefits are understood.

GENERATIVE
Safety is how we do
business around here
INCREASING
INFORMEDNESS PROACTIVE
We work on the problems
that we still find
CALCULATIVE
We have systems in place
to manage hazards
REACTIVE
Safety is important; we do a lot
every time we have an accident INCREASING
TRUST
PATHOLOGICAL
Who cares as long as we
are not caught!
The Evolution of Safety Culture – Patrick Hudson
In the implementation of any positive safety program and associated culture within your
organisation you will be aiming to move towards the following:
FROM TO
Fragmented → Integrated
Negative → Positive
Reactive → Proactive
Ad hoc → Continuous
Historical looking → Forward looking
Cost based → Value based
Narrowly focused → Broadly focused
Functionally → Process driven

driven
Enterprise-wide Risk Management; Standards Australia HB 250-2000

EVOLUTION OF SYSTEM SAFETY THINKING
In the aviation regulatory environment, historically aviation safety focused on compliance
against standards. Over the years these regulatory standards have become increasingly
complex. Some say that regulations have been ‘written in blood’, because after an accident
occurred an immediately obvious solution to reduce similar accidents in the future was to write a
regulation to fix the problem.
This approach worked relatively well during the early years of aviation, but during the 1970’s
accidents continued to occur with regularity in spite of all the rules and regulations. This was
highlighted in 1977 when two Boeing 747 aircraft collided on the runway at Tenerife, causing the
world’s worst air accident. In fact, (Hollnagel 1993) revealed that the estimated involvement of
human error in accidents within high risk technology industries (such as aviation) increased
fourfold between the 1960s and 1990s, from a minimum of 20% to a maximum of 80%.
These high numbers are hardly surprising since nearly all technological systems are not only
operated by human beings, they are also designed, constructed, organised, managed,
maintained and regulated by them.
During the early years, aviation safety efforts were directed towards improving the technology,
with the main focus on operational and engineering methods for combating hazards. Admirable
success was achieved in sustaining a reduced accident rate. However it soon became apparent
that human error was capable of (and often did) circumventing even the most advanced safety
devices. Efforts were then directed to the human element in the system.
The 70s and 80s will be remembered for the prevailing enthusiasm regarding aviation Human
Factors. Cockpit (and then Crew) Resource Management (CRM), Line-Oriented Flight Training
(LOFT), Human Factors training programs, attitude development programs, etc. and a
campaign to increase the awareness of the pervasiveness of human error in aviation safety had
been initiated. Human error, however, continues to be at the forefront of accident statistics.
Statistics can be misleading in understanding the nature of accidents and they fail to reveal
accidents as processes, with multiple interacting chains. Human failures are not restricted to the
“sharp end” of a particular operation, nor can we take account of only those unsafe acts that
were proximal causes of an accident. The interacting chains often go back over considerable
periods of time and involve many different components of the over-all system.
The investigation of major catastrophes in large-scale, high-technology systems has revealed

accidents to have been caused by a combination of many factors, whose origins could be found
in the lack of Human Factors considerations during the design and operating stages of the
system rather than in operational personnel error. Examples of such catastrophes include the
accidents at the Three Mile Island (1979) and Chernobyl (1986) nuclear power plants, the
Challenger space shuttle (1986), the double B-747 disaster at Tenerife (1977) and the Bophal
(1984) chemical plant.
Large-scale, high-tech systems such as nuclear power generation and aviation have been
called sociotechnical systems, in reference to the complex interactions between their human
and technological components. Management factors and organisational accidents are key
concepts in sociotechnical system’s safety. The terms system accident and organisational
accident reflect the fact that certain inherent characteristics of sociotechnical systems, such as

their complexity and the unexpected interaction of multiple failures, will inevitably result in an
accident.
The accident sequence begins with the negative consequences of organisational processes, i.e.
decisions concerning planning, scheduling, forecasting, designing, specifying, communicating,
regulating, and maintaining etc. These decisions are themselves the products of influences and
constraints created by the financial, economic and political context in which the organisation
functions. Remedial action based on safety findings goes beyond those who had the last
opportunity to prevent the accident, i.e. the operational personnel, to include the influence of the
designers and managers, as well as the structure of the system. In this systems approach the
objective is to find what, rather than who, is wrong.
Some may be concerned with the systems approach in exploring the relationship between
Human Factors, management and organisation – and how it influences aviation safety and
effectiveness, and the loss of individual accountability. Others may feel this could be a subtle
way of “passing the buck” for safety entirely to management. In fact, the idea of organisational
accidents represents a broadened view of system safety, which does not intend to shift
responsibility or blame; it is recognised that individuals do not operate in isolation, but are “links
of the chain” within a system. Keep in mind that the analogy of ‘accident chains’ is limited in its
scope when attempting to explain the complex interactions within a systems explanation of
accident causation.
So what is a complex system? The field is still very new and there is no agreement about terms
and terminology but the following quotes start to give an idea:
…a system that is complex, in the sense that a great many independent agents are interacting
with each other in a great many ways. (Waldrop 1993)
…to understand the behaviour of a complex system we must understand not only the behaviour
of the parts but how they act together to form the whole. (Bar-Yam, 1997)
...complex adaptive systems consist of a number of components, or agents, that interact with
each other according to sets of rules that require them to examine and respond to each other’s
behaviour in order to improve their behaviour and thus the behaviour of the system they
comprise. (Stacey: 1996:10)
In the early days of complex systems theory, the emphasis was on large networks of simple
agents with simple interactions. More recently there has been a realisation that smaller
networks of complex agents can show the same kinds of behaviour and can be equally comple
Complex systems have a number of properties, some of which are listed below:
Emergence
What distinguishes a complex system from a merely complicated one is that some
behaviours and patterns emerge in complex systems as a result of the patterns of
relationship between the elements. Emergence is perhaps the key property of complex
systems and a lot of work is being done to try to understand more about its nature and
the conditions which will help it to occur.

Relationships are short-range
Typically, the relationships between elements in a complex system are short-range, that
is information is normally received from near neighbours. The richness of the
connections means that communications will pass across the system but will probably
be modified on the way.
Relationships are non-linear

There are rarely simple cause and effect relationships between elements. A small
stimulus may cause a large effect or no effect at all. Relationships contain feedback
loops. Both negative (damping) and positive (amplifying) feedback are key ingredients of
complex systems. The effects of an agent’s actions are fed back to the agent and this, in
turn, affects the way the agent behaves in the future. This set of constantly adapting
nonlinear relationships lie at the heart of what makes a complex system special.
Complex systems are open

Complex systems are open systems—that is, energy and information are constantly
being imported and exported across system boundaries. Because of this, complex
systems are usually far from equilibrium: even though there is constant change, there is
also the appearance of stability.
The parts cannot contain the whole

There is a sense in which elements in a complex system cannot ‘know’ what is
happening in the system as a whole. If they could, all the complexity would have to be
present in that element. Yet since the complexity is created by the relationships between
elements, that is simply impossible. A corollary of this is that no element in the system
could hope to control the system.
Complex systems have a history

The history of a complex system is important and cannot be ignored. Even a small
change in circumstances can lead to large deviations in the future.
Complex systems are nested

Another key aspect of complex adaptive systems is that the components of the system—
usually referred to as agents—are themselves complex adaptive systems. So an
economy is made up of organisations which are made up of people which are made up
of brains, which are made up of cells—all of which are complex adaptive systems.
Boundaries are difficult to determine

It is usually difficult to determine the boundaries of a complex system. The decision is
usually based on the observer’s needs and prejudices rather than any intrinsic property
of the system itself. We often hear of groups having ‘strong’ or ‘weak’ boundaries but
without any clear sense of the meaning. It is possible to gain some clarity by considering
connectivity. It is hypothesised that an individual agent can only have a certain number
of connections to other agents. We can then think of the strength of a group’s
boundaries as the proportion of connections which are made within the group—the
greater the proportion, the stronger the group boundaries. If all connections are made
within the group it forms a closed system.

The Management Dilemma
Often senior management are faced with a dilemma, the desire for a profitable business versus
the safest possible way of achieving an outcome – production (or profit) versus safety. It can
often be hard for management to see the need for a Safety Management System (SMS) when
there is a perception that the organisation is “already safe”.
The ICAO SMS Manual states: “The management teams of operators and service providers
bear a special responsibility for safety management. In a major study of airlines around the
world, it was found that the safest airlines had a clear safety mission, starting at the top of the
organisation and guiding actions right down to the operational level”.
An organisation’s Safety Management System works with good CRM/ADM practices to enhance
and build upon safe work practices and culture. A Safety Management Systems is an integrated
set of work practices, beliefs and procedures for monitoring and improving the safety and
health of all aspects of an operation. It recognises the potential for errors and establishes robust
defences to ensure that errors do not result in incidents or accidents.
A successful SMS involves:

 Goal setting;
 Planning;
 Allocation of resources and time;
 Documentation; and
 Measuring of performance against goals.
SMS at a Glance
Safety
Safety Policy Safety Risk

and Objectives Management
Safety Management Safety

Assurance Commitment Promotion
Effectiveness Efficiency
Aviation
Community
Stakeholders

MODULE NINE
THREAT AND ERROR MANAGEMENT
The principles of Threat and Error Management logically follow the topic of Understanding
Human Error in that we now discuss strategies and techniques in order to manage the threats
we experience and errors we may make.
Threat and Error Management (TEM) is an overarching safety concept regarding aviation
operations and human performance. TEM is not a revolutionary concept, but has evolved
gradually, as a consequence of the constant drive to improve the margins of safety in aviation
operations through the practical integration of Human Factors knowledge.
“The easiest way to understand Threat and Error Management (TEM) is to liken it to defensive
driving for a motorist. The purpose of defensive driving is not to teach people how to drive a
vehicle (e.g. how to shift a manual transmission) but to emphasise driving techniques that
people can use to minimise safety risks (e.g. techniques to control rear-wheel skids). Similarly,
TEM does not teach pilots how to technically fly an airplane; instead, it promotes a proactive
philosophy and provides techniques for maximising safety margins despite the complexity of
one’s flying environment. In this sense, TEM training can be framed as defensive flying for
pilots.
TEM proposes that threats (such as adverse weather), errors (such as a pilot selecting a wrong
automation mode), and undesired aircraft states (such as an altitude deviation) are every day
events that flight crews must manage to maintain safety. Therefore, flight crews that
successfully manage these events regardless of occurrence are assumed to increase their
potential for maintaining adequate safety margins. It is this notion that provides the overarching
objective of TEM—to provide the best possible support for flight crews in managing threats,
errors, and undesired aircraft states.”
Ashleigh Merritt, Ph.D. & James Klinect, Ph.D.
Threat and Error Management in its initial development assisted observers to analyse cockpit
activity. The origin of TEM is tied to the commencement of ‘Line Orientated Safety Audits’
(LOSA) and began with the simplest of questions “Do the concepts taught in training transfer to
normal everyday flying operations?”. These initial observations were designed to evaluate Crew
Resource Management (CRM) behaviours. The analysis of the error being committed lead to
further detailed observations of:
 Who caused the error?

 The responses to the error.
 The outcome of the error.
Just analysing the error did not give a complete picture. The conditions under which the error(s)
was made also needed to be researched. The concepts of Threat and Error Management were
then included in order to capture the full operational complexity of a flight.

The first TEM based LOSA was conducted by Continental Airlines in 1996. Based upon the
results a one day training course was developed and attended by all pilots. Findings from the
LOSA were addressed during the training and included, for example, correct application and
use of checklists and the lack of clear guidance on when to conduct a missed approach. A
further LOSA was conducted in 2000. To quote Captain Don Gunther, Senior Director of Safety
Regulation and Regulatory Compliance at Continental Airlines:
“The 2000 LOSA, when compared to the results of 1996, showed the pilots had not only
accepted the principles of error management but incorporated them into everyday operations.
LOSA 2000 showed a sizeable improvement in the areas of checklist usage, a 70 percent
reduction in non-conforming approaches (i.e. those not meeting stabilised approach criteria),
and an increase in overall crew performance. It could be said that Continental had taken a turn
in the right direction.”
Based on the success with Continental Airlines, the International Civil Aviation Organisation
(ICAO) made LOSA a central focus of its Flight Safety and Human Factors Program.
Since its early days TEM has evolved to become an organisational tool used in training, incident
reporting and accident and incident analysis.
Threat and Error Management By Phase Of Flight
Phase of % of Threats Errors Mismanaged

Flight Accidents Experienced Errors
Load, Taxi and 5.0% 23% 25% 18%
Unload
Take Off 12.8%
Initial Climb 7.8% 28% 22% 16%
Climb 6.5%
Cruise 5.8% 10% 13% 17%
Descent 6.4%
Initial 6.6%
Approach 39% 40% 35%
Final 19.8%
Approach
Landing 29.3%
In 1999, 66% of worldwide fatal and non-fatal accidents occurred in the descent/approach and
landing phase of flight.
It is important to note that in the above table the threat and error observations of the last three
columns refer to those observations during normal operations not necessarily resulting in any
accident.
Also note the large number of threats and errors observed during load, taxi and unload
compared to the actual accident that occur. These are therefore inconsequential errors for
example.

THE THREAT AND ERROR MANAGEMENT (TEM) MODEL
The Threat and Error Management (TEM) Model is a conceptual framework that assists in
understanding, from an operational perspective, the inter-relationship between safety and
human performance in dynamic and challenging operational contexts. Below is an operational
model of threat and error which was developed by the research of Professor Bob Helmreich and
his team (University of Texas).
THREATS ERRORS
Threat Error
Management Management
Inconsequential
Undesired State
Undesired State Management

The TEM Model can be used in several ways. As a safety analysis tool, the model can focus on
a single event, as is the case with an accident/incident analysis; or it can be used to understand
systemic patterns within a large set of events, as is the case with operational audits. The TEM
Model can be used as a tool to help clarify human performance needs, strengths and
vulnerabilities. The TEM model can also be used as a training tool, helping an organisation
improve the effectiveness of its training, and consequently of its organisational safeguards.
Originally developed for flight deck operations, the TEM Model can nonetheless be used at
different levels and sectors within an organisation, and across different organisations within the
aviation industry. It is therefore important, when applying TEM, to keep the user’s perspective in
the forefront. Depending on "who" is using TEM (front-line personnel, intermediate
management, senior management, flight operations, maintenance, air traffic control) slight
adjustments to related definitions may be required.

There are three basic components in the TEM model, from the perspective of flight crews:
threats, errors and undesired aircraft states. The model proposes that threats and errors are
part of everyday aviation operations that must be managed by flight crews, since both threats
and errors carry the potential to generate Undesired Aircraft States (UAS). Flight crews must
also manage undesired aircraft states, since they carry the potential for unsafe outcomes.
Undesired aircraft state management largely represents the last opportunity to avoid an unsafe
outcome and thus maintain safety margins in flight operations.
THREATS
Threats originate outside our influence and require active management in order to prevent them
becoming of consequence to the safe operation of the aircraft i.e. threats:
 occur outside the influence of the crew i.e. not caused by the crew;
 increase the operational complexity of a flight; and
 require the crew attention and management if safety margins are to be maintained.
Operational threats include weather, terrain, aircraft serviceability, external errors (ATC, other
crew members) and also include latent threats such as national and organisational culture and
policies, regulations etc.
Professor Helmreich and his team undertook a review (through the use of the concepts of
LOSA) of major airlines and found that on 79% of observed flights there was at least one threat,
with an average of two threats per flight.
Threats can sometimes be managed discreetly and at other times require a more complicated
management plan as they interact together.
During typical flight operations, crews have to manage various complexities for example,
dealing with adverse meteorological conditions, airports surrounded by high mountains,
congested airspace, aircraft malfunctions, errors committed by other people outside of the
actual aircraft crew, such as air traffic controllers, regulators or maintenance workers etc. The
TEM Model considers these complexities as threats because they all have the potential to
negatively affect operations by reducing margins of safety.
Some threats can be anticipated, since they are expected or known to the flight crew. For
example, flight crews can anticipate the consequences of a thunderstorm by briefing their
response in advance, or prepare for a congested airport by making sure they keep a watchful
eye for other aircraft as they execute the approach.
Some threats can occur unexpectedly, such as an in-flight aircraft malfunction that happens
suddenly and without warning. In this case, flight crews must apply skills and knowledge
acquired through training and operational experience.
Lastly, some threats may not be directly obvious to, or observable by, flight crews who are
otherwise occupied, and may need to be uncovered by safety analyses. These are considered
latent threats. Examples of latent threats include equipment design issues, optical illusions, or
shortened turn-around schedules.

Threats can be further divided into:
1. Environmental Threats: these are outside of the organisation’s control. For example:
 Adverse Weather: turbulence, thunderstorms, poor visibility, wind shear and icing.
 Airport: poor or confusing signage, faint markings, runway/taxiway closures,
unserviceable navigational aids, poor breaking action, contaminated
runways/taxiways.
 Air Traffic Control: difficult to meet clearances or restrictions, diversions, holdings,
language difficulties, controller errors.
 Environmental Operations Pressures: terrain, traffic, radio congestion.
2. Organisational Threats: these originate within flight operations. For example:
 Aircraft: systems, engines, flight controls, automation malfunctions, Mandatory
Equipment List (MEL) operational implications.
 Operational Pressure: on-time performance pressures, delays, late arrivals of crews
or aircraft.
 Cabin: cabin events, flight attendant/crew errors, distractions, interruptions.
 Dispatch and Paperwork: load sheet errors, schedules, changes or errors on the
paperwork, illegible paperwork.
 Ground/Ramp: aircraft loading, fuelling errors, interruptions from ground agents,
improper ground support, errors in ground support or loading, de-icing errors and
delays.
 Manuals and Charts: missing information, outdated information.
Threat Management can be defined as how the flight crew anticipate and/or respond to threats.
Mismanaged threats are then linked to or induce flight crew error. Common techniques and
tools used to manage threats and prevent crew errors include:
 Weather radar;
 Weather forecasts and advisories;
 Correct use of procedures and checklists;
 Crew briefings.
Threat management provides a proactive means to maintain margins of safety in flight

operations, by voiding safety-compromising situations at their roots. As threat managers, flight
crews are the last line of defence to keep threats from impacting flight operations.
ERRORS
Error is defined as a crew action or inaction that:
 leads to a deviation from crew or organisational intentions or expectations i.e. errors
come “from” the crew whereas threats come “at” the crew;
 reduces safety margins; and
 increases the probability of adverse operational events on the ground or during the flight.
Errors can result from a slip or lapse but can also induce a threat – whether expected or not.
Errors can also be deliberate – noncompliance errors. Unmanaged and/or mismanaged errors
frequently lead to undesired aircraft states. Errors in the operational context therefore tend to
reduce the margins of safety and increase the probability of adverse events.

During the same LOSA study discussed earlier, Professor Helmreich and his team found that on
68% of flights observed there was at least one error and again the average per flight was two
errors.
Interestingly:
 Automation errors were 31% of total errors observed; and
 Checklist errors were 21% of total errors observed.
85% of all errors are inconsequential whilst 15% are consequential. However, of the 15% of
consequential errors 3% produce an additional error (leading to the ‘Error Chain’ concept as
discussed earlier) while 12% produced an undesired aircraft state.
The TEM Model classifies errors based upon the primary interaction of the crew at the moment
the error is committed. Therefore, for example:
 In order to be classified as an aircraft handling error, the pilot or flight crew must be
interacting with the aircraft (e.g. through its controls, automation or systems).
▪ Automation: incorrect altitude, speed, heading, auto throttle settings, mode
execution or entries;
▪ Flight Control: incorrect flap, sleep brake, auto brake, thrust reverser or power
settings;
▪ Ground navigation: attempting to turn down the wrong taxiway or runway, missed
taxiway/runway/gate;
▪ Manual Flying: hand flying vertical, lateral or speed deviations, missed
runway/taxiway, failure to hold short or taxi above the taxi speed limit; and
▪ Systems/Radio/Instruments: incorrect altimeter, fuel switch or radio frequency
settings.
 In order to be classified as a procedural error, the pilot or flight crew must be interacting
with a procedure (e.g. checklists; SOPs; etc).
▪ Briefings: missed items in the brief, omitted departure, takeoff, approach or
handover briefing;
▪ Callouts: committed takeoff, descent or approach call outs;
▪ Checklist: performed checklist or omitted the checklist, missed items, wrong
challenge and response, performed wrong or performed late;
▪ Documentation: wrong weight and balance, fuel information, ATIS or clearance
recorded incorrectly, misinterpreted items on the flight paperwork;
▪ Pilot Flying (PF)/Pilot Not Flying (PNF): PNF doing all PF duties, PF doing PNF
duties;
▪ SOP Cross-Verification: intentional and unintentional failure to cross-verify
automation inputs;
▪ Other Procedural: other deviations from government regulations, flight manual
requirements or standard operating procedures.
 In order to be classified as a communication error, the pilot or flight crew must be
interacting with people (ATC; ground crew; other crewmembers, etc).
▪ Crew to External: missed calls, misinterpretation of instructions or incorrect read-
backs to ATC, wrong clearance, taxiway, gate or runway communicated.
▪ Pilot to Pilot: within the crew communication or misinterpretation.

Regardless of the type of error, an error’s effect on safety depends on whether the flight crew
detects and responds to the error before it leads to an undesired aircraft state and to a potential
unsafe outcome. This is why one of the objectives of TEM is to understand error management
(i.e. detection and response), rather than solely focusing on error causality (i.e. causation).
From the safety perspective, operational errors that are timely detected and promptly responded
to (i.e. properly managed) and/or errors that do not lead to undesired aircraft states, do not
reduce margins of safety in flight operations, and thus become operationally inconsequential. In
addition to its safety value, proper error management represents an example of successful
human performance, presenting both learning and training value.
Error Management is an inevitable part of learning, adaptation and skill maintenance. Therefore
a critical element of TEM is to understand what types of errors are made, under what
circumstances and how flight crews respond in those situations. Of interest is that 45% of the
observed errors in the LOSA Archive went undetected or were not responded to by the flight
crew which emphasises a main point in TEM – an error that is not detected cannot be managed.
UNDESIRED AIRCRAFT STATES

Unfortunately not all errors are well managed. Sometimes they lead to another error or safety-
comprising event called an Undesired Aircraft State (UAS).
An Undesired Aircraft State (UAS) is defined as a position, speed, attitude or configuration of an

aircraft that:
1. results from flight crew error, actions or inaction; and
2. clearly reduces safety margins.
Undesired Aircraft States can occur as a result of a multitude of factors and can include:
 Incorrect Aircraft Handling: vertical, lateral or speed deviations, unnecessary weather
penetration;
 Poor Ground Navigation: runway/taxiway incursions, wrong taxiway, ramp, gate or hold
position, taxi above speed limit; and
 Incorrect Aircraft Configuration: automation, engine, flight control, systems or weight and
balance events.
Undesired aircraft states can be managed effectively (returning the aircraft to safe flight) or
mismanaged leading to an additional error, a further undesired aircraft state or worse an
incident or accident.
An important learning and training point for flight crews is the timely switching from error
management to undesired aircraft state management. An example would be as follows: a flight
crew selects a wrong approach in the Flight Management Computer (FMC). The flight crew
subsequently identifies the error during a crosscheck prior to the Final Approach Fix (FAF).
However, instead of using a basic mode (e.g. heading) or manually flying the desired track, both
flight crew become involved in attempting to reprogram the correct approach prior to reaching
the FAF. As a result, the aircraft passes through the localiser, descends late, and goes into an
unstable approach. This would be an example of the flight crew getting "locked in" to error
management, rather than switching to undesired aircraft state management. The use of the
TEM Model assists in educating flight crews that, when the aircraft is in an undesired state, the
basic task of the flight crew is undesired aircraft state management instead of error
management. It also illustrates how easy it is to get locked into the error management phase.

Also from a learning and training perspective, it is important to establish a clear differentiation
between undesired aircraft states and outcomes. Undesired aircraft states are transitional states
between a normal operational state (i.e. a stabilised approach) and an outcome. Outcomes, on
the other hand, are end states, most notably, reportable occurrences (i.e. incidents and
accidents). An example would be as follows: a stabilised approach (normal operational state)
turns into an unstablised approach (undesired aircraft state) that results in a runway excursion
(outcome).
The training and remedial implications of this differentiation are of significance. While at the
undesired aircraft state stage, the flight crew has the possibility, through appropriate TEM, of
recovering the situation, returning to a normal operational state, thus restoring margins of
safety. Once the undesired aircraft state becomes an outcome, recovery of the situation, return
to a normal operational state, and restoration of margins of safety is not possible.
THREAT AND ERROR MANAGEMENT TOOLS

Since the first flight of Orville and Wilbur Wright in 1903 threat and error management tools
have been practiced. As technology and aviation has changed, various tools have been
developed to manage threats, errors and undesired aircraft states.
Regardless of the tools, they will only work if the flight crew uses them. Therefore TEM tools
work best when pilots adopt TEM techniques. Effective crew co-ordination and Crew Resource
Management skills are therefore effective TEM countermeasures. These include:
1. Anticipation/Planning Countermeasures
 SOP Briefing: the required briefing was interactive and operationally thorough. It was
concise and not rushed meeting SOP requirements. Bottoms lines were established.
 Plan Stated: operational plans and decisions were communicated and acknowledged
with a shared understanding regarding those plans i.e. everyone was on the “same
page”.
 Work Assignment: roles and responsibilities were defined for normal and non-normal
situations. These were both communicated and acknowledged.
 Contingency Management: crew members developed effective strategies to manage
threats to safety. Threats and their consequences were anticipated with the use of all
available resources to manage those threats.
2. Recognition/Execution Countermeasures
 Monitor/Cross Check: crew members actively monitored and cross-checked systems
and other crew members. Aircraft position, settings and crew actions were verified.
 Workload Management: operational tasks were prioritised and properly managed to
handle primary flight duties. This avoided task fixation and did not allow work
overload to occur.
 Automation Management: automation was properly managed to balance situational
and/or workload requirements by briefing the automation setup to other members of
the crew and agreed and known effective recovery techniques from automation
anomalies were understood by the crew.

3. Recover/Review Countermeasures
 Evaluation/Modification of Plans: existing plans were reviewed and modified when
necessary. Crew decisions and actions were openly analysed to ensure the existing
plan was still the best plan.
 Inquiry: crew members asked questions to investigate and/or clarify current plans of
action. Crew members were not afraid to express a lack of knowledge as there was
an existing ‘nothing taken for granted’ attitude.
 Assertiveness: Crew members stated critical information and/or solutions with
appropriate persistence i.e. crew members spoke up without hesitation.
Tools can be either “hard” or “soft” safeguards.

1. “Hard” Safeguards: are associated with aircraft design e.g. automated systems,
instrument displays and aircraft warnings (TCAS).
2. “Soft” Safeguards: e.g. regulations, standard operating procedures, licensing standards,
training and checklists.
Initial research in the LOSA Archive has supported links between TEM and CRM. Flight Crews
that develop contingency management plans, such as proactively discussing strategies for
anticipated threats, tend to have fewer mismanaged threats; flight crews that exhibit good
monitoring and cross-checking usually commit fewer errors and have fewer mismanaged errors
and finally flight crews that exhibit strong leadership, inquiry and workload management are
typically observed to have fewer mismanaged errors and undesired aircraft states than other
flight crew combinations.

MODULE TEN
NON-FLIGHT CREW SPECIFIC
CONSIDERATIONS
Although all of the principles discussed in this course apply to all participants in the aviation
industry it is imperative that we discuss those members of our team who are not flight crew and
the specifics of their working environment and its impact on CRM. Here we discuss a few issues
pertinent to some of these team members.
CABIN CREW
A number of specific issues of CRM and related Human Factors are involved in the cabin of the
aircraft. With modern times, the aircraft cabin has progressively become more luxurious and
user friendly. It is also expected that more forms of aircraft accidents are survivable and hence
the need for procedures such that our crews and passengers are safely evacuated and do not
suffer from secondary injuries becomes a priority in the event of an incident or accident
becomes more apparent.
AIR RAGE AND VIOLENCE
It is now more commonplace for our aircraft to fly higher and faster. As such most of our cabin
environments are air conditioned and pressurised. Although more comfortable for the majority of
us this environment can lead to aero-medical concerns in relation to breathing difficulties and if
combined with alcohol, the pressurised cabin can trigger behavioural problems that must be
effectively dealt with in a confined and constrained environment. In-flight violence is becoming
an increasingly reported occurrence.
Unruly passenger behaviour generally falls into five categories:

1. alcohol related incidents;
2. use of prohibited electronic devices;
3. smoking in lavatories;
4. drug or medication related incidents; and
5. bomb or hijack threats.
Reasons for unruly passengers' behavior are varied. Disruptive passengers are members of
every socio-economic group. They are male and female, young and old, first class, business,
and economy travelers. Reasons for unruly behavior can include but are not limited to:
 free flowing alcohol;
 more people flying;
 oversold flights;
 crowded planes;
 small seats;
 excessive and oversized carry-on bags;
 frequent delays and cancellations;
 conflicting carrier policies etc.

According to a study by NASA/ASRS presented in March 2000, unruly passengers whose
behaviour disrupts pilots can cause serious flying errors. In 40 percent of the 152 cases
NASA/ASRS analysts studied, pilots either left the cockpit to quell a disturbance or were
interrupted from their routine by flight attendants seeking help. In a quarter of those cases, the
pilots said they committed errors such as flying too fast, going to the wrong altitude, or taxiing
across runways reserved for other aircraft as a result of their involvement in a cabin situation.
Air rage incidents have also resulted in emergency landings, cockpit break-ins, physical injury to
crew and passengers and emotional trauma for everyone onboard.
Flight attendants experience the brunt of passenger misconduct. In the confined environment of
a crowded aircraft at 30,000 feet, cabin crew simply cannot walk away or call for help in
threatening or violent situations. The nearest police force might be hours of flying time away.
Since 1999, United Kingdom (UK) Airlines have reported disruptive behaviour on board to the
UK Civil Aviation Authority (CAA) on a common reporting basis. The CAA classifies an incident
of air rage as either serious (where the safety of an individual or the aircraft was compromised
and include those which resulted in an aircraft diversion) and significant (those of concern but
did not constitute a major threat to safety). The reports ranged from smoking on the aircraft, not
being seated when required to do so to violence or threats of violence against crew and/or
passengers. The majority of ‘air rage’ incidents do not in fact involve any angry disputes e.g.
using a lap top at the incorrect time or the use of a mobile phone.
2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

Number of reported incidents 1,486 1,359 2,219 2,702 3,529
(total)
Serious 53 56 58 31 44
Significant 1,433 1,303 2,161 2,671 3,485
Context
Number of flights per serious 17,000 16,000 18,000 35,000 24,000
incident
Millions of passengers carried 2.1 2.0 2.1 4.0 2.8
per serious incident
Incident Details
Violence involved 183 (12%) 142 (10%) 172 (8%) 197 (7%) 240 (7%)
Violence towards crew 79 64 58 99 106
Contributory factors
Alcohol involved 530 (36%) 479 (35%) 746 (34%)
1,041 1,315
(39%) (37%)
Alcohol – pre-boarding 151 118 172 232 310
Alcohol – airline 95 90 124 134 115
Alcohol – own 154 171 215 282 391
Smoking involved 562 (38%) 546 (40%) 563 (25%) 643 (24%) 746 (21%)
Smoking in toilet 430 455 459 564 705
Caution must be taken when comparing years as reporting levels and methods have changed
over time.
Adapted from “Disruptive Behaviour On Board UK Aircraft 2008/2009”

Possible solutions to the Air Rage issue include:
1. Zero Tolerance, Mandatory Training and Victim Support: Organisations must adopt and
enforce written policies on disruptive passengers that spell out the steps to be taken
when an incident occurs. The airline must also provide comprehensive, realistic training
on handling disruptive passengers to all employees. Support, such as legal advice and
time off for court appearances should also be provided for victims of air rage.
2. Mandatory Incident Reports: Aviation regulatory bodies must require all organisations to
report all incidents of air rage. Industry and regularity bodies cannot continue to treat
crew interference as a rare, isolated problem. Mandatory reporting is the only way to
truly track the scope and penalties of air rage.
3. Responsible Alcohol Policies: Organisations must establish more responsible alcohol

service policies. No alcoholic drinks should be served before takeoff. Only one drink
should be served at a time. The organisations should train flight attendants to recognise
drunken behaviour and how to effectively cut off passengers who have had too much.
Free drinks should never be used as compensation for delays or cancellations. In
addition, organisations should remind gate agents to enforce the law and deny boarding
to intoxicated passengers. Gate agents must also be properly trained to recognise the
signs of inebriation, to prevent a potentially dangerous situation on the aircraft.
4. Law Enforcement Cooperation: For example in 2000, the U.S. Congress passed a law to
deputize law enforcement officials to arrest or detain passengers suspected of
crewmember interference. But the implementation of this important program has been
spotty. There is still confusion over jurisdictional issues on international flights, which
allows some perpetrators to walk free.
5. More Passenger Education: Educational materials explaining laws governing

interference with crew members and the possible consequences must be provided to
passengers. Warnings should be placed on safety cards in airline seat pockets, on ticket
jackets or boarding passes. An announcement warning passengers about the
consequences of air rage should be included in the pre-flight passenger safety briefing.

MAINTENANCE
The “Dirty Dozen” are error inducing factors introduced by Gordon Dupont whilst with
Transport Canada and were precursors to the “Magnificent Seven”. (The Magnificent Seven, in
contrast, are elements which can improve performance and assist in the elimination of error.)
Gordon Dupont developed the ‘Dirty Dozen’ in his work on “Human Performance in
Maintenance” and then in 1994 as a series of twelve posters which are still widely used today.
Errors by Maintenance Personnel were recognised as one of the causal factors by investigators
of the accident in Dryden, Ontario on 10th March 1989. Shortly thereafter Gordon Dupont was
employed by Transport Canada as they worked to mitigate these factors in future
incidents/accidents.
Dirty Dozen Explanation

Lack of Verbal/written or a combination of both.
Communication
Complacency An insidious cause leading/contributing to judgment errors.
Lack of Changing technology requires us to remain current at all times.
Knowledge
Distraction Leaving of a task physically and/or mentally resulting in errors e.g.
omission. Distraction is responsible for 15% of all maintenance
errors – Appendix H of JAR 145.
Lack of Essential as a multitude of workers are involved in maintenance.
Teamwork
Fatigue Sufferer is usually unaware as chronic fatigue accumulates its
harmful influence. Acute fatigue causes event based errors.
Lack of Safety relies upon availability e.g. training, supervision, supplies.
Resources
Pressure Recognition of excessive/unrealistic pressure from individuals, a
superior or organisation (perceived or realistic) is critical.
Lack of Depends upon our personality and working environment e.g. refusal
Assertiveness to compromise on standards.
Stress Critical is recognition of excessive stress (acute or chronic) and its
effective management.
Lack of Causes a failure to recognise consequences and relies on factors
Awareness other than printed manuals/procedures i.e. commonsense and lateral
thinking.
Norms Behaviours within our ‘group’ include acceptance by peers and
dictates our behaviour/response to others regardless of what we
consider as individually appropriate behaviour.

The “Magnificent Seven”, in contrast, are elements which can improve performance and assist
in the elimination of error. The Magnificent Seven posters are described in the following
paragraphs.
1. Safety is not a game because the price of losing is too high.

When safety, quality, and customer service are company priorities, history has shown that these
companies are able to withstand the competition and economic pressures. Avoid falling into the
trap of "If you do not have time to do things right the first time around, you always have time the
second time around, if you get the chance."
2. Our Signature is our word and more precious than gold.

Once the work has been completed, the documentation has been done indicating everything
has been accomplished to meet the airworthiness requirements, we know the work has been
completed to the best of our capabilities.
3. We all do our part to prevent Murphy from hitting the jackpot.

When we consider Reason's Model of Error Analysis and look at everyone's role in preventing
errors, we can see that when a company has an incident, there is a chain of events established
identifying the contributing factors and the causes of the incident. We find that there were latent
failures in the regulations, management, policies, and company culture. Then, there are active
failures from direct supervision, scheduling, use of resources, time management, and
communication. And then, there are other active failures, like the Dirty Dozen, that influenced
the judgment of the technician, which lead to an error.
4. We always work with a Safety Net.

Safety nets are the precautions or counter measures we take in our day to day lives to prevent
the latent errors and human factors from effecting our judgment. The safety nets are the
precautions we take to bring us back to reality when we become overly emotional during the last
task we just completed. Safety nets we all use include dual inspections, using checksheets,
taking pride in our signature, making notes as to where we left off, staying fit and vigilant, using
the manual, and the list goes on and on. We all have our own countermeasures. Continue to
use and review your safety nets to make them even better. We need to make sure we have a
tight net protecting us, with no holes in it.
5. We are all part of the team.

We are part of a team. Maintenance do their job every night to maintain the aircraft to provide
the reliability expected by dispatch, flight crews, cargo department, management, and
customers.
6. We work to accentuate the positive and eliminate the negative.

We all hate to see errors take place for the obvious reason. But, if we have an error take place
without learning from it, then it will most likely happen again in the future.
7. Just for today - Zero Error

When we look at error prevention and at the big picture, it can be quite overwhelming. Break
error prevention into little steps and we can make giant strides in reducing errors. Like anything
else worthwhile, if we take the steps necessary to prevent errors one day at a time, it will not be
an insurmountable challenge.
Extracted from Aircraft maintenance technology – Article by By Richard Komarniski

MODULE ELEVEN
AUTOMATION
Automation is a system or part of a system performing a predetermined action (or sequence of
actions) with complete autonomy when activated.
Under standard conditions, pilots have no control over automations except in most cases, a
deactivation switch.
The flight decks of many aircraft (e.g. Airbus A319/A320/A330 and the Boeing 777) bear little
resemblance to the aircraft being built in the 1970’s or even earlier.
Benefits include:
 technical reliability.
 advances in engine technology.
 reduced workload.
 less knowledge required.
 same system but improved performance.
 focuses the operator on the right answer.
Although in many ways automation has radically changed flying an aircraft by simplifying tasks
and removing the need for some crewmembers e.g. navigators and fight engineers, it has also
introduced new considerations and problems to the flight deck which will be discussed in this
module.
The introduction of automation was with the goal of enhancing safety and improving efficiency.
There were those, however, who saw the overuse of automation as potentially dangerous. Dr.
Roger Green (a leading expert in aviation Human Factors from the UK) pointed out that the
trend in automation was for humans to play a monitoring role and the automation to undertake
problem solving. Computers, he believed, were more conducive to the monitoring role as they
did not get bored, suffer from losses in concentration or get tired. He saw the new automation
as a reverse of skills and strengths which would ultimately lead to the ‘de-skilling’ of pilots. He
was concerned that one day an aircraft would not be able to solve the problem and hand back
the problem solving to the flight crew who were by this stage significantly deskilled in this
process.
With increasing automation and reliance on computers this creates an environment in which the
ability of crewmembers understanding of the systems they operate decreases. This would also
apply to maintenance engineers and Air Traffic Controllers (ATC). For example the operation of
the Flight Management System (FMS) raises issues for both the flight crew and ATC. An Air
Traffic Controller may cancel a standard arrival route (STAR) for a straight-in approach thinking
that they have done the crew a favour. However, this will now require the re-programming of the
FMS resulting in an actual increase in workload in the cockpit.

As stated one of the primary benefits of the introduction of new technologies and automation is
improved safety. In some situations the increase in technology results in greater risk taking
elsewhere. For example the relatively recent introduction of Traffic Alert and Collision Avoidance
Systems (TCAS) into large aircraft was designed to enhance the existing levels of safety in the
event that ATC was not able to maintain traffic separation between aircraft. There are those that
believe that TCAS should be able to provide the ability to maintain this separation and not ATC.
The introduction of this new technology may therefore become the method of maintaining
separation rather than an additional feature of safety. Ultimately the safety of the system will not
then have been enhanced.
Accident Rate by Aircraft Generation

1st generation 2nd generation 3rd generation
B707 B727 MD80 A300-600/ A310 MD11
Hull Loss per million departures
DC8 B737-100/200 A319/A320/A321

10 B747 MD90 A330/A340
DC9 B737-300/400/500
9 DC10 B757/B767 B777
8 A300B4
7
6
5 1st generation
4
3
2 All aircraft
1 2nd generation
3rd generation
0
1959
1965
1971
1973
1979
1985
1987
1993
1961
1963
1969
1975
1977
1989
1991
1995
1967
1981
1983
The above graph indicates many aspects of the impact of automation on accident statistics. As
a new aircraft enters usage the accident rate is relatively high as the crews need time to
understand the new technology. For example the introduction of the A320 saw 3 accidents in a
very short period of time. The most famous being the accident which occurred at the Habsheim
Airshow on the 26th June 1988. A detailed account of this accident can be found in Air Disaster,
Volume 3 written by Macarthur Job. As experience increases and the aircraft designs improve
the accident rate declines. We must also consider that the older aircraft are also aging and
create more maintenance issues and they also tend to be purchased by smaller and start-up
companies with all staff under training. New aircraft also benefit from a modern environment of
radar coverage and aircraft instrumentation.
We continue to learn from accidents and as such the ‘fly-by-wire’ (FBW) technology introduced
to civilian flying in the A320 has improved and so too has the associated crew training in this
new technology. The Airbus 319 and 321 and the Boeing 777 all successfully use this form of
technology.
Additional challenges also result with the introduction of automation. These challenges can
include reliability and the prevalence of nuisance or false warnings.

False Warnings: alert sounds/signals which occur for no valid reason.
Nuisance Warnings: alert sounds/signals which occur for a valid reason but at an inappropriate
time. ATSB Report R19980002 issued 13/01/98 in part reports the GPS arrival procedure for
Wynyard (Tasmania) requires aircraft to track directly over Table Cape. This can result in
nuisance GPWS warnings that either distract crews from their duties at a time of high workload
or result in crews ignoring these warnings altogether. The safety value of GPWS is dependent
upon the reaction of crew to any warning from the system. The standard response to a GPWS
warning requires the crew to immediately initiate a climb. The existence of nuisance warnings
will diminish the effectiveness of GPWS as it may result in crews ignoring warnings.
The most significant effect of these types of warnings is the mental acceptance of the ‘cry wolf’
phenomenon. This causes us to ignore the warnings as we see them so often that they no
longer trigger in us a suitable and correct response. Other effects include:
 Time is lost (often at critical moments) proving a warning as fake, nuisance or true.
 Distraction of the crew, again at critical moments.
 Warnings that occur at busy/noisy times can be missed particularly if they occur at other
times as either false or nuisance warnings. Critical warnings that are correct may
therefore go unnoticed as we have ‘trained our brains’ not to accept the signal as a true
indictor even if it occurs at a valid time or for a valid reason.
 Tendency to ‘write off’ the warning as either false or misleading without justification.
In a different light the occurrence of these warnings does lead to amendments to procedures
and design to enhance safety. For example a Nuisance Warning can occur due to rigging or
wiring tolerances being too sensitive at critical times. This may result in an update of the wiring
system.
Another example of changes in technology resulting in advantages and disadvantages is the

use of Control Pilot Data Link Communications (CPDLC). CPDLC is a method by which air
traffic controllers can communicate with pilots over a datalink system. Some regarded the
introduction of CPDLC as advantageous in mitigating some human errors. Others believed the
errors introduced were too significant.
Human error reduction by use of CPDLC:

 Communication errors and misunderstandings are reduced by written communication
and messages/instructions being sent and read as and when possible by ATC or flight
crews.
 Written communication reduces omission errors (Errors of omission result from a failure
to undertake a task or action, in this case resulting from verbal communication
interruptions which require a response and associated task at that time and not a
convenient time to the crew or ATC) resulting when tasks were interrupted for verbal
communication (less distraction errors).
 Reduced stress and fatigue related errors as the workload (written communication
requiring less time to undertake) is reduced.
 Reduced workload enhances airspace management efficiency (some cockpit efficiency)
which reduces the error inducing environment.

Human error introduced/accentuated by CPDLC:
 Design induced error from mixed equipment usage for flight crew/ATC as systems are
retrofitted or introduced.
 Omission errors by flight crew:
 Increased scan to incorporate the CPDLC screen leading to a reduced full
instrument/surrounding airspace scan.
 Increased workload of the hands/eyes as data is no longer communicated by the
voice/ears.
 Operator Induced Error (interpretation and reading) by the Pilot Not Flying (PNF) reading
the data to the Pilot Flying (PF). Operator induced error relates to errors due to
inadequate performance on the part of an individual as a result of a deficient skill,
motivation or vision.
 Errors associated with decision making and Situational Awareness from high cockpit
workload pressures during busy/critical stages as the PNF must now verbalise all text
messages.
PILOT EXPERIENCES WITH AUTOMATION
The following quotes come from the US Aviation Safety Reporting System (ASRS) which is
administered by NASA and funded by the FAA:
“Being new in an automated cockpit, I find that pilots are spending too much time playing with
the computer at critical times rather than flying the aircraft. No one looks outside for traffic.”
“My first priority was data entry rather than Situational Awareness….”
“This is another case of learning to type 80 words a minute instead of flying the aircraft.”
OPERATIONAL CONSIDERATIONS WITH AUTOMATION

In order to take full benefit of automation the flight crew must:
 Have a proper understanding of automation including its advantages and disadvantages.
 Ensure the company has and you use the Standard Operating Procedures for the use of
Cockpit Automation.
 Proper training for the correct use of the systems.
 Motivation to learn – When flying multiple types familiarise yourself with the different
cockpit layouts and modes of Automation.
 Aviate, Navigate, and Communicate.
 One head up at all times – In a single Pilot environment Automation tasks should never
interfere with outside vigilance.
 Cross check accuracy – Verify flight plan amendments prior to ‘activating’, use of raw
data to verify position and maintain Situational Awareness.
 Know what mode your Flight Management System/Autopilot is in at all times – Both crew
should always be aware of changes made to an Automation system.
 When things don’t go as expected – TAKE OVER.
 Use the appropriate level of Automation for the task.
 Practice task sharing – back each other up.

NEVER FIGHT AUTOMATION.
If there is a problem, change the level of automation.
There is no argument in the fact that training is important but it is expensive. However it is
necessary to train flight crew to operate new and different aircraft both safely and efficiently.
Some issues that have been raised regarding training in advanced flight deck technology
aircraft are:
 Is the pilot a control operator, a systems manager or both?
 When should pilot’s take over and not rely on the automation systems?
 Who is in control, the pilot or the aircraft?
The duties of the flight crew still include monitoring, planning and making decisions in reference
to the operations, and the tasks that are traditionally performed which also includes
communicating, navigating and operating the aircraft. However the training should include
emphasis on the pilot’s decision making, knowledge of systems, monitoring and crew co-
operation and the balance between those and the use of automation within the cockpit.
Despite their high reliability, accurate flight path control, and flexible display of critical aircraft
related information, automated flight management systems can actually decrease pilot’s
situational awareness, place the pilot ‘out of the loop’ due to reliance on automation and can
result in poor human monitoring capabilities. In the end it is the flight crew’s ability to provide the
final defence against a situation that may occur.
As we continue to design better aircraft and more effective training for crews, we must always
allow for this most vital of all contributors to flight safety, but should never knowingly solely rely
upon it.
ELECTRONIC FLIGHT BAGS (EFB)

The Electronic Flight Bag (EFB) is another innovation being used in cockpits of modern aircraft.
Traditional EFBs are typically not permanently mounted in the aircraft and are considered
Portable Electronic Devices (PEDs).
Electronic Flight Bag (EFB) means a portable Information System for flight deck crew
members which allows storing, updating, delivering and/or computing digital data to support
flight operations or duties.
EFB system means the hardware, the operating

system, the loaded software and any antennae,
connections and power sources, used for the operation
of an EFB.
Portable Electronic Device (PED): A self contained

electronic device that is not permanently connected to
any aircraft system, although it may be connected
temporarily to an aircraft’s electrical power system,
externally mounted antenna, data bus or mounting
device. PED’s include numerous communications and
computing devices.

The earliest form of the EFB involved the use of personal laptops by individual pilots in the early
1990s. Commonly spreadsheets and word processing programs were used to perform weight
and balance calculations and form completion. The first broad application of the EFB was
undertaken by FedEx in 1991 with the introduction of their Airport Performance LapTop
Computer which was simply a commercially purchased laptop for crew use in aircraft
performance calculations. In the mid 1990s they also introduced Pilot Access Terminals on
aircraft which enabled access to power and data interfaces.
EFBs can electronically store and retrieve documents required for flight operations, such as
maps, charts, the Flight Crew Operations Manual, Minimum Equipment Lists (MEL) and other
control documents. In the past, some of these functions were traditionally accomplished using
paper references or were based on data provided to the flight crew by an airline’s “flight
dispatch” function. The scope of the EFB system functionality may also include various other
hosted databases and applications. Physical EFB displays may use various technologies,
formats and forms of communication.
CASA CAAP 233-1
As personal computing technology has become more compact and powerful, with extensive
storage capabilities, these devices became capable of storing all the aeronautical charts for the
entire world on a 1.5kg (approx) computer (compared to the approx 35kg of paper normally
required for worldwide paper charts).
The primary purpose of the EFB is the reduction, and in some cases replacement, of paper-
based reference material including the Flight Manual, Aircraft Operating Manuals and
Navigational Charts. The ability of the EFB to automatically calculate performance and weight
and balance calculations is also a major purpose behind its widespread use.
Benefits of the EFB use vary and usually depend on the size of the operation, type of
applications used, the existing content management and distribution system.
Benefits of EFB use may also include:

 weight savings by replacing the traditional flight bag;
 reduced medical claims from handling traditional flight bags;
 reduced cost in maintenance of documentation, planning times etc.;
 minimising the occurrence and effects of flight crew error;
 maximising the identification and resolution of errors;
 reduced time in flight planning and calculations;
 minimises paperwork in the cockpit;
 provides faster access to data required for operations and emergencies;
 reduces workload during stressful situations;
 increased efficiency by reducing or eliminating paper processing;
 increased safety; and
 reducing pilot workload.

As with all new sources of data there are considerations that require time and adjustment by
both operators and individuals. These include but are not limited to:
 time and effort is required by the crew in locating and orientating the display for use;
 inputting data can be time consuming and lead to long ‘head-down’ time;
 EFBs that have no designated location while they are in use, such as a cradle, may
obstruct access to other displays/controls. This problem will be especially pronounced if
the EFB is physically large enough, relative to the size of the flight deck, so as to be
difficult to be moved about quickly and easily. EFBs not in a cradle may fall or disrupt
systems use within the cockpit;
 unless the EFB is updated and ‘connected’ to the operator or aircraft systems there may
be inconsistencies in the information leading to confusion and increased errors;
 upgrades and customisation is an expectation of the manufacturer by the
customer/operator. The responsibility of performing the updates needs to be clearly
assigned by the manufacturer and also the operator;
 ambient lighting conditions vary greatly in the cockpit. The EFB display must be usable
under all lighting conditions. Ability to adjust the screen brightness, size of the text and
font style is therefore required. Individual viewing distance and off-angle viewing will also
affect text legibility. Screens or text that are not legible will cause pilot distraction (as the
pilot attempts to position the display for better legibility) and could potentially result in
harmful consequences if critical information is misread, or not read at all;
 graphical icons could be used to access commands or they may represent files and
other system objects. They are typically small and of limited graphical resolution, so the
actual object or command they represent may not be intuitively clear to untrained users.
It is important that users are trained on their interpretation and the actual graphical
image is not the sole means of representing an object or command. Text information
about that object or command should also be available;
 the EFB user interface should be consistent and intuitive within and across various EFB
applications. The interface design (including, but not limited to, data entry methods,
colour-coding philosophies, terminology, and symbology) should be consistent across
the EFB and various hosted applications;
 the successful implementation of any new system or procedure relies on good
procedures and training. The individual operator’s ability to undertake this greatly
impacts the effectiveness of the EFB in flight operations. This must include feedback
during and after the implementation phase;
 appropriate evaluation of EFB proficiency is key to ensuring that pilots achieve
proficiency during initial EFB training and maintain that proficiency during line operations
as evaluated through both line checks and recurrent or continuing qualification training.
EFB evaluation should be consistent with the carrier’s EFB policy and standard
operating procedures;
 there are many reasons why systems fail to operate as expected. For example, functions
that require external data may fail when that data is not received, producing a partial
failure. A total failure may occur if there is a hardware fault. The user should be aware of
the system status at all times. Without a clear indication of the EFB status, the user may
make decisions based on outdated, incorrect, or incomplete information;
 integrating the EFB with other flight deck systems could allow the electronic
documentation application to customise its information based upon current flight
conditions. Doing so can help to reduce crew workload by reducing the amount of
information the crew must consider. An unintended consequence can be complacency
where the crew relies on the decision aid to select information for review without
sufficient crew involvement.

Every operator is required to ensure that training is provided and that procedures and usage
policies are in place prior to the use of the EFB within the operator’s aircraft. Crews should
ensure they are fully conversant with all of these policies and procedures prior to using a
provided or their own EFB.
In summary:
 The EFB software design should minimise flight crew workload and head-down time.
 The positioning, use, and stowage of the EFB should not result in unacceptable flight
crew workload. Avoid complex, multi-step data entry tasks during takeoff, landing, and
other critical phases of flight. An evaluation of EFB intended functions should include a
qualitative assessment of incremental pilot workload, as well as pilot system interfaces
and their safety implications.
 If the intended function of an EFB includes use during critical phases of flight, such as
during takeoff, landing, or abnormal and emergency operations, its use should be
evaluated during simulated or actual aircraft operations under those conditions.

Appendix 1 LEARNING STYLE ASSESSMENT
To analyse your teaching style through your own style of learning, rate yourself on the following
questions.
Your answers should reflect the extent to which the statements describe your actual behaviours
and attitudes not your ideal or desired behaviours and attitudes. Be as honest as you can.
Perhaps by asking yourself how others may perceive or would rate you may be of assistance.
Indicate your response out of 7 on the answer sheet below.
RATING SCALE
1 2 3 4 5 6 7
To a minimal extent To a moderate extent To a large extent
1 I often spend time thinking about what I am really trying to achieve.

2 I concern myself with realistic plans based upon sound reasoning, rather than the
‘pie-in-the-sky’ ideals.
3 I am rarely paralysed by endless analysis.
4 I often seek new experiences.
5 Rushing to meet a deadline makes me uncomfortable.
6 Careful planning and forethought usually lead to better outcomes than reacting to
situations that arise and leaving things to the last minute.
7 My teaching approach is focused upon getting the job done.
8 I am often more interested in novel ideas more than those that are practical.
9 I prefer to stand back from a situation and consider all the perspectives.
10 I devote considerable time to assuring that my logic is correct.
11 Novel and creative ideas are often not practical.
12 Dealing with unexpected problems is exciting.
13 I tend to listen more than I talk.
14 I try hard to base my actions on relevant theory.
15 Achieving results is often my prime objective.
16 I seek feedback from those likely to be critical of my work.
17 Many drafts are often needed to produce a high quality report.
18 My approach to problem solving is relatively unemotional and objective.
19 I strive to always come straight to the point.
20 Living in the present is more important than pondering the past or pining for the
future.
21 When making decisions, I try to consider all the options.
22 I try to conduct meetings and lessons in a methodical manner.
23 Reports are most useful when not overly complicated by too many ‘ifs’ and ‘buts’.
24 Seeking to understand how others feel is something I often do.
25 In general, I find that sound analysis leads to better decisions than intuition.
26 It is not uncommon for me to detect inconsistencies in other people’s arguments.
27 Theories are fine, but practical results are what really count.
28 I thrive on tackling new and different challenges.
29 Time spent questioning my assumptions is time well spent.

30 Problems often stem from people failing to stick to their plans.
31 I rarely waste time speculating about what potentially might go wrong.
32 Dealing with crisis is a challenge that I enjoy.
33 Making rash decisions is something that I am careful not to do.
34 Linking theoretical insights to my actions is something that I often do.
35 The ideas that I tend to seek are those that are practical and realistic.
36 Implementing specific plans tends to cramp my style.
37 I tend to spend more time thinking than acting.
38 Over-reliance on feelings would cloud my logic and better judgement.
39 I evaluate the value of a theory by ease with which is can be put into practice.
40 I regularly devote time to seeking feedback on my projects.
Please complete your answers to the 40 questions in the table below.
ANSWERS
Column One Column Two Column Three Column Four
1. 2. 3. 4.
5. 6. 7. 8.
9. 10. 11. 12.
13. 14. 15. 16.
17. 18. 19. 20.
21. 22. 23. 24.
25. 26. 27. 28.
29. 30. 31. 32.
33. 34. 35. 36.
37. 38. 39. 40.
TOTAL TOTAL TOTAL TOTAL
Interpretation Guidelines
Add up your 10 responses in Column One. Write your total next to the word Reflection below.
Add up your 10 responses in Column Two. Write your total next to the word Conceptualisation
below.
Add up your 10 responses in Column Three. Write your total next to the word Implementation
below.
Add up your 10 responses in Column Four. Write your total next to the word Immersion below.
Aspect of the Learning Cycle Total

Reflection
Conceptualisation
Implementation
Immersion

Your learning style is how you distribute your time across these activities.
Learning development and problem solving requires devoting an adequate proportion of energy
to each of the four sections. The concentration on any one section of the learning cycle will tend
to reduce the overall efficiency and effectiveness of your learning.
The optimal time we spend learning a task should depend on the nature of the task. It is often
claimed that technical professions, including pilots/engineers etc., concentrate too much on the
reflection and conceptualisation phases. However, the strengths of this are good planning and
the generation of robust solutions
However over-emphasis may lead to limited follow through with under-emphasis potentially
leading to limited innovation and strategic rationality resulting from insufficient awareness of the
broader issues.
Using the data collected from the above questions plot your learning style on the graph below
and then join the four dots which indicate your score out of 70.

Questions:
1. How do you distribute your time and energy across the four central activities of the
learning cycle? To what extent do you agree with the profile of your learning styles?
2. Would your colleagues agree with the spread across the learning cycle components?
Would they say you are spending too much time in any one section and is this reflected
in the above diagram?

YOUR ASSESSMENT SHOULD NOW
BE ATTEMPTED
REFERENCE SHOULD BE MADE TO THIS DOCUMENT

AND YOUR OWN EXPERIENCES AND THOUGHTS
TO ANSWER THE REVIEW QUESTIONS.
PLEASE NOTE:
1. Your responses must be legible and in black/blue ink (pencil will not be accepted) or
typed.
2. Other than when asked for a definition all answers must be your own work, ‘cut and
pasted’ answers to questions will be marked incorrect.
3. Answers copied from other Review Question submissions will result in a fail
assessment on all associated Review Question submissions.


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CREW RESOURCE MANAGEMENT

AVIATION DECISION MAKING

CIVIL AVIATION ACADEMY AUSTRALASIA PTY LTD

© 2017 CIVIL AVIATION ACADEMY AUSTRALASIA PTY LTD

CRM and ADM Course - Non-Technical Skills Training 2

MODULE ONE – INTRODUCTION

MODULE TWO – COMMUNICATION AND ASSERTIVENESS

MODULE THREE – COMMUNICATION AND ASSERTIVENESS

MODULE FOUR – SITUATIONAL AWARENESS

MODULE FIVE – DECISION MAKING

MODULE SIX – LEADERSHIP

MODULE SEVEN – TEAMWORK

MODULE EIGHT – UNDERSTANDING HUMAN ERROR

MODULE NINE – THREAT AND ERROR MANAGEMENT

MODULE TEN – NON FLIGHT CREW SPECIFIC

CRM and ADM Course - Non-Technical Skills Training 3

What does this mean to us and our workgroups?

SO WHAT IS CREW RESOURCE MANAGEMENT?

CRM ADM Course - Non-Technical Skills Training 4

An accepted definition (although fairly simplistic) is:

Then what is ADM?

Decision making in an aeronautical environment involves any pertinent decision taken to

CRM ADM Course - Non-Technical Skills Training 5

CRM ADM Course - Non-Technical Skills Training 6

The 1990’s saw the Fourth Generation, Crew Resource

The Third Generation Company Resource

The Second Generation of Crew Resource

This First Generation, Cockpit Resource Management

CRM ADM Course - Non-Technical Skills Training 7

Benefits of LOFT include:

CRM ADM Course - Non-Technical Skills Training 8

Currently the focus has moved to Aviation Decision Making (ADM).

AVIATION DECISION MAKING (ADM) TRAINING

The aim of ADM training is to:

CRM ADM Course - Non-Technical Skills Training 9

The three broad ways in which we develop our effectiveness is:

There has been extensive research into the nature of learning. As a

Ever hear that phrase "It's just like riding a bike?" It

Learning new skills is a little like riding this bike – we

CRM ADM Course - Non-Technical Skills Training 10

Before moving on complete the Learning Style Assessment at Appendix 1 of

CRM ADM Course - Non-Technical Skills Training 11

You will tend to look at problems and opportunities from various

Implementation in the learning process entails trying to influence people (and

This involves the experiencing of outcomes implementing your plans.

CRM ADM Course - Non-Technical Skills Training 12

THE MORAL FUNCTION OF ETHICS IN THE WORKPLACE

CRM ADM Course - Non-Technical Skills Training 13

Classic work by Rokeach (1973) defined two types of value sets.

Standards of conduct or methods

What are the potential outcomes of each approach?

After considering the various approaches, which do you think would be

CRM ADM Course - Non-Technical Skills Training 14

The study of any factor that can influence

It evolved from the disciplines of:

CRM ADM Course - Non-Technical Skills Training 15

CRM ADM Course - Non-Technical Skills Training 16

Safety and Security Needs

Social – Love and Belongingness Needs

Our egotistical needs fall into two types:

CRM ADM Course - Non-Technical Skills Training 17

CRM ADM Course - Non-Technical Skills Training 18

SHORT TERM MEMORY

LONG TERM MEMORY