CREW RESOURCE MANAGEMENT

Disclaimer CRM THEORY 2 / 94

This Multi-Crew Cooperation Course is conducted on a modern

fly-by-wire simulator based on the Airbus A320 family.

General information in the training material will be relevant for all

jet aircraft, but technical details, procedures and handling
practices are only applicable to the A320 type.

Last change in this presentation: 29 / 04 / 2020

The human element
The SHELL model CRM THEORY 4 / 94

A conceptual model to clarify and understand human factors in the

aviation system and relationships between the components of the model.
The name is derived from the initial letters of the components:

▪ Software H
▪ Hardware
▪ Environment S L E
▪ Liveware
▪ Liveware
L

The meeting of any two components of the model is called an interface.

SHELL model definitions CRM THEORY 5 / 94

S – Software
The aircraft computer system, but also
includes checklists, manuals, charts etc.

H – Hardware
Anything that has a physical existence
such as the controls and switches
on the flight deck.
SHELL model definitions CRM THEORY 6 / 94

E – Environment
The surroundings in which the crew operates
(including the flight deck and outside of it).

L – Liveware
You as well as any other person whom you
interact with in the course of your duties
including your crew members and others.
L/H – Liveware-Hardware interface CRM THEORY 7 / 94

This is the relationship between man and H

machine – known as ergonomics.
S L E
In a well-designed cockpit there should be little
room for confusion when selecting a lever or L
switch. Examples of good ergonomics:

▪ Distinctive size, shape and colour of controls

▪ Labeling
▪ Easy operation of controls (mode and force)
▪ Often used controls are close to the operator
L/H – Liveware-Hardware mismatches CRM THEORY 8 / 94

Examples of bad ergonomics:

▪ Important (eg. avionics) switch next to a less important (eg. lights) switch
▪ Similar shape and size of levers, switches
▪ Scattered controls for the same systems

Fun fact: the standby compass in the MD-80

is behind the pilots and it can be checked
through two mirrors.
Newer aircraft or cockpit updates are designed
now so that the pilots have as much comfort
and ergonomics as possible.
L/S – Liveware-Software interface CRM THEORY 9 / 94

The interface where all crew interactions with the

software (systems) of the aircraft take place: H

S L E
▪ Checklists
▪ Performance manuals L
▪ Quick Reference Handbooks (QRH)
▪ Speed/Thrust tables
▪ Airway charts
▪ SID & STAR charts
▪ Approach plates
▪ FMS usage
L/S – Liveware-Software mismatches CRM THEORY 10 / 94

Examples of wrong interactions:

▪ Incorrect interpretation of
performance criteria
▪ Misreading approach plates
▪ FMS programming errors
▪ Checklist mismanagement
▪ Misinterpretation of the QRH
L/E – Liveware-Environment interface CRM THEORY 11 / 94

This is the interaction of the pilots with their H

surroundings. It not only includes the physical
surroundings but the overall working environment: S L E

▪ Duty time L
▪ Fatigue
▪ Operational factors
▪ Weather
▪ Illness
▪ Stress
L/E – Liveware-Environment mismatches CRM THEORY 12 / 94

Examples of negative environmental results:

▪ Poor decision making

▪ Sub-standard flying performance
▪ Loss of situation awareness
▪ Focusing on a single task
▪ Inattention to detail
▪ Sloppy procedures
▪ Failing to make standard callouts
▪ Reduced alertness
▪ Greater likelihood of disorientation
L/L – Liveware-Liveware interface CRM THEORY 13 / 94

This interface is effectively the subject of the Multi Crew

H
Cooperation course.
If you consider yourself the central „L” in the SHELL S L E
model, the other „L” is not just your co-pilot or the Cabin
Crew members but also:
L

▪ Air Traffic Control

▪ Ground Handling
▪ Ground Engineers
▪ Operations Staff
▪ Passengers
Communication
Importance CRM THEORY 15 / 94

Research into CRM issues by NASA shows that the two most significant
factors in the promotion of good CRM and MCC principles are:

▪ The Pilot Flying giving a thorough briefing;

▪ The Pilot Monitoring making enquiries and advocating his/her position.

The importance of effective communication in the multi crew environment

cannot be overstated!
Definition and methods CRM THEORY 16 / 94

Communication is the process by which an effective interchange of thoughts,

opinions, feelings or information is achieved. It can be:

▪ Verbal
Spoken or written words and the way of their expression.

▪ Non-verbal
Body language, eye-contact, posture, gesticulation, touch, silence etc.

▪ Image
An impression is created as a result of one’s appearance.
Achieving effective communication CRM THEORY 17 / 94

▪ Identification of the need to communicate

▪ Transmission of the message
▪ Reception of the message
▪ Feedback until the goal is reached

IDENTIFY FEEDBACK

TRANSMIT RECEIVE GOAL ACHIEVED

Vital aids to effective communication CRM THEORY 18 / 94

1. Information gathering
2. Advocacy / Assertiveness
3. Listening
4. Questions and conflict resolution
5. Overcoming the barriers to communication
Information gathering CRM THEORY 19 / 94

Seek information from every available source including:

▪ other flight crew members,

▪ cabin crew,
▪ ground personnel,
▪ maintenance personnel,
▪ operations staff,
▪ ATC.

Never be afraid of embarrassment when seeking information!

Advocacy CRM THEORY 20 / 94

▪ State your position and opinion clearly even if it is contrary to that of

other crew members.
▪ Do not be embarrassed to take an opposite point of view. Resolve
conflicts by advocacy.

In an emergency, some decisions must be made under extreme time pressure with
very little opportunity for the analytical decision-making process. The intuitive decision-
making process is based on gut reaction, experience and training.
A good leader will have the support of the team in critical situations, bearing in mind
that CRM principles still apply in the intuitive decision-making process.
Listening CRM THEORY 21 / 94

▪ Listening is an active and not a passive skill.

▪ Listening takes a conscious effort.

A listener may easily become bored because the brain has the capacity to listen at the rate of 900 words
per minute, yet we can only speak at a rate of about 125 words per minute.

▪ The speaker can make the task of listening simpler by:

▪ Paying attention to the rate of speech (we tend to speak faster when excited),
▪ Emphasising key words,
▪ Being aware of the tone of voice.
Listening CRM THEORY 22 / 94

THE POOR LISTENER THE GOOD LISTENER

▪ Interrupts ▪ Tries to understand the

▪ Is critical or judgemental other’s viewpoint
▪ Is argumentative ▪ Expresses interest
▪ Is passive ▪ Exhibits sensitivity
Questions and conflict resolution CRM THEORY 23 / 94

Open and closed questions

▪ Ask questions to check if your message has gotten through!

Conflict resolution
▪ If crew members are not communicating effectively, there will inevitably
be conflicts.
▪ Opposite opinions CAN be constructive when dealt with effectively!
▪ Synergy may be used to resolve conflict.

Remember: WHO IS RIGHT? WHAT IS RIGHT?

Handling the critique CRM THEORY 24 / 94

Critique
▪ Critique can significantly improve the performance of the crew.
▪ The time of giving it starts at the briefing stage and continues until the
de-briefing.
▪ The critique should consist of an objective viewpoint of how the mission is
going and all crew members should be actively encouraged to analyze it.
▪ Always take the critique as a constructive advice and not as a personal
offense.
▪ Give it in a proper way and receive it in a proper way.
▪ Check if you can profit of the critique you received and decide if you keep
it or not.
Overcoming communication barriers CRM THEORY 25 / 94

1. External or physical barriers

▪ Noise, poor radio reception, fatigue, workload, vibration, hearing loss etc.
▪ Some of these barriers may be possible to control by crew intervention.

2. Internal or psycho-social barriers

▪ Attitude, assumptions, prejudices, education, bias, cultural background,
eloquence, assertiveness, confidence etc.
▪ These are related to the culture and personality of the individual and are
therefore not directly controllable.
▪ The modern day multi-cultural crew is particularly susceptible to difficulty in
this area.
Quiz time! CRM THEORY 26 / 94

What contributes the most to effective general communication?

▪ Spoken words,
▪ Way of speaking (volume, pitch etc.), or
▪ Body language?
Quiz time! CRM THEORY 27 / 94

What contributes the most to effective general communication?

Words
7%

Body language Way of speaking

55% 38%

Applicable only when communicating feelings or attitude!

Read more: Albert Mehrabian
Ways of communication in the cockpit CRM THEORY 28 / 94

Compared to the structure of general communication,

effective communication in the cockpit is the opposite!

1. The main share is for spoken words (callouts, briefings etc.)

2. The second largest part is the way of speaking (tone, speed, content etc.)
3. The least important part is the body language.

Body language is not used as much because the hands and eyes of the
pilots are occupied (for flying and instrument scanning). Furthermore, there
may be darkness, smoke etc. in the cockpit.
Tips for communication in the cockpit CRM THEORY 29 / 94

1. Spoken words:
Talk consciously, try to be clear and short.

2. Way of speaking:
Use a consistent tone, try not to show emotions.

3. Body language:
Point out only necessary things.
Do not gesticulate, especially when hand flying.
Misconceptions regarding communication CRM THEORY 30 / 94

ASSUMPTION REALITY

Message received is identical to what was sent. Messages sent and received are rarely the same.

You only communicate when you plan to do so. Communication is a continual process.

Communication ceases after reception. Communication continues until response to the feedback occurs.

The meaning of a word is determined by the sender. The meaning of a word is determined by the receiver.

Communication breakdown is the fault of the receiver. Communication breakdown is often the fault of the sender.
Decision making
Objective CRM THEORY 32 / 94

To understand the importance of decision making processes and the steps

to be followed.
Under a stressful situation when the human nature tends to rush and jump
from one thing to another without logical way of thinking, it is essential and
proven to be very helpful to have a guide line which shows us the correct
way of actions and thinking. This requires from us:

▪ A relaxed, structurized manner,

▪ Rational decisions,
▪ Continuous monitoring of things happening around us,
▪ Review of the actions we did.
DODAR CRM THEORY 33 / 94

Sometimes decisions must be made very quickly due to the nature of

the situation. Such sudden decisions may be based on "gut reaction" or
experience and training. These situations are quite rare, and the leader
should still have the support of the team members whenever possible.

But if there is time, we need to follow these steps of decision making:

DODAR
DODAR CRM THEORY 34 / 94

Diagnose Diagnose the problem using all available resources.

Gather all the information possible from all available sources to assess the options
Options
available.

Decide Make a decision based on the information.

Action Implement the decision: assign tasks and priorities.

Review Evaluate the impact of the decision and revise it accordingly.

Decision making loop CRM THEORY 35 / 94

COMMUNICATE
(gather information & identify the problem)

RECOGNISE & ACCEPT DECIDE ACTION AND

THE PROBLEM COMMUNICATE THE DECISION

MONITOR IMPLEMENT
The first rule CRM THEORY 36 / 94

FLY THE GODDAMN AIRCRAFT!

▪ Confirm which pilot flies the aircraft (PF)

▪ Ensure that there is 100% understanding about who is doing what
▪ Identify and confirm the problem
▪ Reduce the workload (Automation)
Why do we get it wrong? CRM THEORY 37 / 94

A few examples:

▪ Overconfidence
▪ Poor communication
▪ Loss of situation awareness
▪ Conflicting personalities
▪ „Get-there / home-itis”
Useful advices for Diagnosing and Information gathering CRM THEORY 38 / 94

▪ Silence all warning systems, but do not extinguish warning/caution lights

automatically!

▪ Call out the title of the failure or the indications

It is very easy to make the wrong actions during high stress and workload situations.

▪ Carefully identify where the indication is, and then identify the location of
the failed system
There have been many examples of the crew shutting down a good engine or isolating a
serviceable system through hasty action and lack of monitoring.
Useful advices for Diagnosing and Information gathering CRM THEORY 39 / 94

▪ Crosscheck other sources of information such as the instruments and local

fault lights.
Reading the name as it appears on the light or panel will help as the same terminology
will be used in the Abnormal or Emergency checklists.

▪ It may help to adjust the panel light illumination for better visibility of any
printed information next to the gauges and lamps intended to help identify
which engine or system it affects.
Useful advices for Diagnosing and Information gathering CRM THEORY 40 / 94

▪ Listen to your cockpit crew members.

▪ Other team members such as Cabin Crew, Air Traffic Control, Ground
personnel may also have valuable information that will help the decision-
making process.

▪ Once the problem is identified, gather all information that will assist in
identifying the available options.
Situational awareness
What is situational awareness? CRM THEORY 42 / 94

Situational awareness (SA) is knowing the status of the aircraft in relation to

the real world.

It includes:
▪ position and terrain information,
▪ flight parameters (airspeed, altitude, attitude etc.),
▪ any technical or operational deficiencies which might affect the flight.

During basic training, position awareness might simply be achieved by good

chart reading.
Reality vs. Interpretation CRM THEORY 43 / 94

The human mind creates an image, a model of the reality. The quality of this
model (how true it is compared to the real world) depends on many factors:

▪ Available information
▪ Human perception
▪ Experience
▪ Biases

The resulting interpretation is what we think is going on

(„what the situation is”).
Reality vs. Interpretation CRM THEORY 44 / 94

You have made up your mind. Would you change it?

Probably YES, if:

▪ Your stress level is low
▪ You are able to accept feedback
▪ You are able to enquire

Probably NO, if:

▪ You are complacent („I’ve done it this way before and it worked”)
▪ You are in a crisis or under high stress
▪ You believe a change of mind would destroy your self-esteem
Factors influencing situational awareness CRM THEORY 45 / 94

▪ Orientation
▪ Technical Knowledge
▪ Flying Skills
▪ Experience
▪ Human Factors
▪ Briefings
▪ Communications
▪ Teamwork
Multi-crew situational awareness CRM THEORY 46 / 94

In a multi crew environment, each pilot will have his own level of awareness
about the situation.

The total situational awareness will not be the sum of all the individual's
situational awareness, but that of the person who will make the decision
(normally the Captain)!

How to raise situational awareness (SA) in the cockpit?

1. Raise the Captain’s SA (by informing him/her)
2. Delegate the decision to the crew member with the highest level of SA
Multi-crew situational awareness CRM THEORY 47 / 94

Why is it important?
In the 1977 Tenerife accident, two Boeing 747s collided on the ground. One crew (PanAm) had good
situational awareness and knew that the other aircraft (KLM) was taking off towards them.
At least one of the crew of the KLM aircraft also realised the situation but was unable to persuade the
Captain to wait with the take-off, so that the situational awareness level in the KLM aircraft remained at
the level of the Captain.
583 people lost their lives. This accident is (and hopefully will stay) the deadliest in aviation history.
Loss of situational awareness CRM THEORY 48 / 94

Loss of situational awareness is more likely to occur during abnormal or

emergency situations, when the normal monitoring is interrupted and workload has
increased. If situational awareness is lost, it is vital to regain it as soon as possible.

Typical situations where SA can be lost or degraded:

▪ Deviation from Standard Operating Procedures (SOPs)
▪ Non-standard phraseology
▪ Breaches of the “sterile cockpit”
▪ Failure to monitor the flight path of the aircraft
▪ Poor or non-existent briefings
▪ Communications breakdown
▪ Very high or very low stress levels
Loss of situational awareness CRM THEORY 49 / 94

▪ Deviation from Standard Operating Procedures (SOPs)

If the aircraft is operated contrary to normal published procedures, the
expected sequence of events will not occur, making a loss of crew or
individual situational awareness almost inevitable.

▪ Failure to monitor the flight path of the aircraft

An aircraft crashed because all three flight deck members were trying to
solve an unsafe landing gear indication (preoccupation/fixation). Whilst the
crew were investigating the possibilities, no one noticed that the autopilot
altitude hold had disengaged, and that the aircraft was descending into the
ground.
Loss of situational awareness CRM THEORY 50 / 94

▪ Very high stress levels

In this situation we need to process information at a very high rate and
information overload may occur which will also lead to a loss of our
situational awareness.

▪ Very low stress levels

In this situation the information flow is at a low rate (e.g. on a long-haul
flight) and our lack of arousal may lead to a late recognition of our situation
and the consequential loss of situational awareness.
Teamwork, Leadership, Followership
The importance of teamwork CRM THEORY 52 / 94

A team can be described as a group of people gathered to perform a task.

▪ In a commercial aircraft operation, the task is to operate the aircraft with

the maximum safety and greatest efficiency.
▪ To achieve these goals the whole task is broken down into many smaller
tasks, each of which may vary in detail as circumstances change, and each
of which will demand a different response from the team.
▪ For the task to be completed successfully, it is important that each member
of the team is fully aware of what role they are supposed to be filling.
▪ It is equally important that each team member should be aware of what
roles are supposed to be played by the other team members.
Who makes up the team? CRM THEORY 53 / 94

The commercial success of an airline operation demands the activities of a

very large team covering all aspects or activities, including:

▪ Marketing and sales ▪ Flight operations

▪ Passengers ▪ Cabin Crew
▪ Freight ▪ Flight deck crew
▪ Maintenance ▪ etc.
▪ Ground handlers

Whilst not forgetting the overall picture, during this course we will concentrate
on the activities of the flight operations team and more specifically, on the
tasks and roles associated with the flight deck of a multi crew aircraft.
Leadership and Followership CRM THEORY 54 / 94

Effective leadership is in the center of multi crew co-operation.

▪ It is not solely the Captain of the aircraft who is the leader. Each member
of the crew must recognize that they have a leadership role that
enhances the performance of the crew as a whole.
▪ Therefore all members of the crew must have effective leadership skills
and use these at the appropriate stages of the flight.

Leadership works most effectively when there is active followership.

▪ Followership is not a passive role but an active one which enhances the
process of leadership. Leaders direct their followers and followers can
carry out the task and provide feedback.
Leadership CRM THEORY 55 / 94

Acquired leadership
▪ The captain is not necessarily the leader all the time.
▪ The captain has the ultimate authority which is an assigned function, however if
the First Officer is the pilot flying (PF), he/she acquires the leadership function
whilst fulfilling that role.
▪ Leadership skills can be learned and improved throughout a crew member’s life.

Effective leadership
▪ The leader is the key person whose strategies and actions enhance the
performance of the team. This is accomplished by utilizing good communication
skills to clearly define the task, assign roles and accept any feedback.
▪ The leader should be able to inspire the group to want to achieve a successful
outcome to the task. The success of the task depends to a large extent on the
quality of the leadership.
NOTEC - Non Technical Skills CRM THEORY 56 / 94

▪ Co-operation: Skill in which a pilot is able to work and communicate actively

among group members and create a mutual environment.

▪ Leadership and Managerial: It focuses on pilots' ability to coordinate and

manage a task, problem or direct an entire group. This exercise is usually in
put in the views of a 'Pilot in Command'.
▪ Situation Awareness: A pilot's perception of the elements in the
surrounding, including the aircraft systems, external environment, time and
the "projection of their status in the future".
▪ Decision making: the ability to recognize a problem, evaluatepossible
options and choose the final outcome.
Leadership skills – Information processing CRM THEORY 56 / 94

The leader must handle the flow of

information from all available sources
both inside and outside the aircraft.
This includes:

▪ Processing operational information

▪ Receiving ideas and suggestions
▪ Giving ideas and suggestions
▪ Clarifying information
▪ Handling feedback
Leadership skills – Managing crew action CRM THEORY 57 / 94

The leader must act as the crew manager to co-ordinate crew performance.
This includes:

▪ Managing crew activities

▪ Assessing and prioritizing crew performance
▪ Stipulating the plan and orientation
▪ Assigning goals and tasks
Leadership skills – Inspiration and Motivation CRM THEORY 58 / 94

The leader should create an environment which encourages crew

co-operation and full participation.
This includes:

▪ Creating a good team culture

▪ Encouraging full participation
▪ Resolving conflicts
▪ Maintaining effective relationships
▪ Welcoming critique and feedback
Leadership skills – Decision making CRM THEORY 59 / 94

The leader is responsible for the decision.

This includes:

▪ Collecting and assessing the information flow

▪ Making the decision
▪ Assigning tasks and goals
▪ Prioritising tasks
Leadership loop CRM THEORY 60 / 94

Ask questions, collect and

update all available information

Inquiry

State your opinion and express any

concerns and actively seek ideas or
Feedback Advocacy advice from other crew members.
Be assertive, do not have an
aggressive attitude

This is the analysis of the plan: it A difference of opinion should be seen as a

could be either self-analysis or Conflict positive rather than a negative influence of
feedback from the crew. This is part of Critique leadership. The conflict should be resolved
resolution
the overall feedback process and may by the leader using the principle of what is
result in a change of the decision right, not who is right
Decision
making

Once a decision is made, execute it but be prepared

to revise it in the light of feedback from the crew if
the desired result has not been achieved
Leadership styles CRM THEORY 61 / 94

▪ There is a direct relationship between leadership style and the

participation level and hence the performance of the team.
▪ Different styles of leadership might be appropriate to deal with different
circumstances (Situations S1 or S4)
Personality, attitude and behaviour CRM THEORY 62 / 94

We all have both a behavioral style and a personality.

An enhanced awareness of these qualities in ourselves and in others will

give us a better understanding of our reactions to people and situations.

The way that we act also affects the whole team. This reaction can either
be advantageous or dangerous in the flight environment.
Personality CRM THEORY 63 / 94

▪ For most of us our personality is

determined by the age of about
seven years, and then cannot be
changed.
▪ Most airline pilots fall into the middle
of the Extrovert / Introvert and
Stable / Unstable line. Many airlines
now use psychometric testing as part
of their interviewing and selection
process to ensure that the correct
personality types are recruited.
▪ Extreme behavioral of any kind is not
welcome in the cockpit, we must be
able to adapt ourselves to the
situation.
Hazardous attitudes CRM THEORY 64 / 94

▪ Anti-Authority: found in individuals who do not like being given orders

They don’t like being told what to do and rather do everything their own way

▪ Insensitivity: Someone who does not analyze methodically the best

solution to a problem
They make rushed intuitive decisions without the normal inquiry, advocacy and
decision-making processes which are inherent in good MCC

▪ Invulnerability: The “It will never happen to me” syndrome

Some people consider themselves totally invincible or completely immune from
accidents
Hazardous attitudes CRM THEORY 65 / 94

▪ Macho: Individuals who are out to prove something to both themselves

and to others
To appear powerful and brave, they may disregard involved risks in a decision

▪ Resignation: People who have this attitude are defeatists who believe
that no matter what course of action they adopt, it will not affect the
outcome
They may feel that the result is pre-determined so any intervention will be ineffective
Behavioural styles CRM THEORY 66 / 94

Unlike our personality, it is possible to modify our behavior. The way we

behave or how our behavior is perceived has a fundamental effect on the
performance of the crew.

The following behavior patterns exist:

▪ People Oriented
▪ Task Oriented
▪ Both or none
Behavioural styles CRM THEORY 67 / 94

▪ People Oriented
Those who consider the feelings of others first when making a decision. A person who exhibits a
high people orientation and low task orientation can be considered a caring person.

▪ Task Oriented
Consideration is first given to the task or goal in the decision-making process. Personal
effects are disregarded. A person who exhibits high task orientation and low people
orientation is considered to have an aggressive style of behaviour.

▪ Both or none
A person who has low people and task orientation is considered autonomous or a loner.
A person who has high people and task orientation is considered to be assertive. This is
the ideal behavioral style to obtain the best performance from the team.
Behavioural styles CRM THEORY 68 / 94
Assertive behaviour CRM THEORY 69 / 94

An assertive person believes that he/she has the following rights:

▪ To openly express their feelings

▪ To be taken seriously
▪ To achieve goals
▪ To be respected and to give respect
▪ To be given information
▪ To make errors
▪ To allow others to be assertive

Aggressive behaviour does not consider the feelings of others and must be
strictly differentiated from assertive behaviour.
Assertive behaviour CRM THEORY 70 / 94

Elements of assertive behaviour:

▪ Defending your opinion

▪ Honest behaviour
▪ Confident manner
▪ Respect for others
▪ Meaningful interaction
▪ Clearly indicating agreement or disagreement
▪ Using “I” in the discussion

Assertive behaviour in a multi crew environment is not a threat to authority, but

ensures that the clarity of the situation eases decision making, increases synergy
and is vital to the overall safety of the flight.
Assertive behaviour CRM THEORY 71 / 94

The advantages for assertive behaviour:

▪ Enhances decision making

▪ Encourages reciprocal assertive behaviour
▪ Increases synergy
▪ Boosts self esteem
▪ Has the respect from others
▪ Creates active responses
▪ Facilitates problem solving
Enhancing assertiveness CRM THEORY 72 / 94

Non-assertive individuals sometimes feel that they must defer to another's

opinion to avoid a conflict.

▪ They must learn that a difference of opinion is often a healthy and

necessary stage in the decision-making process
▪ They must learn that assertion rather than aggression is perfectly
acceptable
Enhancing assertiveness CRM THEORY 73 / 94

Aggressive individuals must discover how to express themselves without

hostility to others. They often feel that unless an aggressive stance is taken
then they will be seen as non-assertive.

▪ An aggressive person often has difficulty in applying the "what is right not
who is right'' principle
▪ An aggressive person need not become passive, but needs to learn to
use the positive aspects of aggression in a less hostile manner
Cultural differences CRM THEORY 74 / 94

There are some cultures which believe that a junior crew member should
never question the actions or decisions of the captain or the more senior CM.

A training module on assertiveness would probably not be well received by

them, they have the norm to refrain from questioning the decisions and
actions of a superior. But this is the opposite of what is desirable!

In these situations, only persistent and regularly conducted trainings can

improve air safety and change behavioural patterns of this style.
Threat and Error Management (TEM)
What is TEM? CRM THEORY 76 / 94

Threat and Error Management is a safety management tool used

in the aviation industry by promoting „defensive flying for pilots”.

It maximizes safety margins through a proactive philosophy of

anticipation, recognition and recovery using techniques for
managing threats, errors and Undesired Aircraft States (UAS).
Threats CRM THEORY 77 / 94

Threats are events or conditions that „come at the crew”.

These events occur beyond the influence of the flight crew increasing the
operation complexity of a flight, by placing attention and management
demands on the crew, if safety margins are maintained.

The level of demand that these threats place on the crew range from
insignificant and discretely manageable, to complex sequences of
interactions with each other, requiring significant attention from the crew.
Threat categorization CRM THEORY 78 / 94

The TEM puts threats into two categories:

▪ Latent threats
These are not obvious to the flight crew and are generally hidden by the
system.

▪ Overt threats
These are present on a given day and are either anticipated or not by the
crew. They can be either Environmental or Organizational.
Latent threats - Examples CRM THEORY 79 / 94

Risk taking culture and macho attitudes

Professional Culture
(e.g. traditional pilots from the early barnstorming days of aviation)

Safety rules and operating procedures are not considered important

Organizational Culture
(e.g. rules are considered unnecessary as „nothing will hapen to me”)

Not questioning the person in authority.

National Culture
(e.g. the Captain is always right, even when he is wrong)

Not clearly describing what actions are required and when.

Vague Policies
(e.g. previous accidents caused through unclear ground de-icing policies)
Overt threats – Environmental – Examples CRM THEORY 80 / 94

Thunderstorms, turbulence, poor visibility, wind shear, icing conditions, IMC, extreme
Weather
temperatures

Tough-to-meet clearances and restrictions, re-routes, language difficulties and

ATC inconsistent terminology or units of measure (QFE/meters), traffic congestion,
controller errors, similar callsigns

Confusing or faint signs and markings, runway/taxiway closures, inoperative or complex

Airport
navigational aids, poor braking action, contaminated surfaces, birds, airport construction

Terrain High ground, slopes, lack of visual references (black hole effects and other visual illusions)
Overt threats – Organizational – Examples CRM THEORY 81 / 94

Operational On-time performance pressure, delays, late arriving aircraft or flight crew, poorly
Pressure matched crew (e.g. inexperience with route)
Aircraft system, engines, flight controls or automation anomalies or malfunctions,
Aircraft
MEL/CDL items with operational implications, other threats requiring crew attention

Cabin Cabin events, flight attendant errors, distractions, interruptions, door security

Aircraft repairs on the ground, maintenance log problems, maintenance events and
Maintenance
errors
Aircraft loading events, fueling errors, agent interruptions, improper ground support,
Ground/Ramp
de-icing

Dispatch Load sheet errors, crew scheduling events, late paperwork, changes or errors

Documentation Errors or missing information in manuals or charts, inadequate SOPs

Errors CRM THEORY 82 / 94

Errors are events or conditions that ”come from the crew”.

They are actions or inactions by the flight crew that lead to events that
were not what the organization or flight crew intended or expected.

Unmanaged or mismanaged errors can create or contribute to Undesired

Aircraft States which compromise flight safety and increase the probability
of adverse events.
Error categorization CRM THEORY 83 / 94

Errors are grouped under three categories:

▪ aircraft handling errors,
▪ procedural errors,
▪ communication errors.

This way of classifying errors is based on „Primary interaction” or what the

crew were doing when the error was committed.
(E.g. incorrect flap extension is noticed, the crew interact with the aircraft
controls so this is classified as an Aircraft handling error)
Aircraft handling errors – Examples CRM THEORY 84 / 94

Manual handling errors such as speed and position deviations, incorrect flaps,
Flight Control
speed brake, auto-brake, thrust reverser or power settings

Incorrect entries or mode selections

Automation
(e.g. settings for altitude, speed, heading, auto-throttle settings)

Systems / Radio / Incorrect packs, altimeter, fuel switch or radio frequency settings or incorrect
Instruments anti-icing techniques

Attempting to turn down wrong taxiway or runway, selection of incorrect taxiway,

Ground Navigation
runway or gate, taxi speed to fast and failure to hold correct position
Procedural errors – Examples CRM THEORY 85 / 94

Deviation from standard operating procedures, PF/PM duty mistakes

Deviation from (e.g. intentional or unintentional failure to cross-verify automation inputs, PF makes
SOPs own automation changes, PM doing PF duties, PF doing PM duties, deviations from
government regulations, flight manual requirements)

Omitted briefings or items missed

Briefings
(e.g. omitted departure, take-off, approach or handover briefing)

Incorrect challenges or responses, items missed, performed from memory,

Checklists
checklist performed late or at the wrong time

Callouts Omitted or incorrect take-off, descent or approach callouts

Incorrect weight and balance, fuel information, ATIS, clearance recorded or

Documentation misinterpretation of paperwork items i.e. metric imperial data, incorrect logbook
entries or incorrect application MEL procedures
Communication errors – Examples CRM THEORY 86 / 94

Misinterpreted instructions, missed calls, incorrect read-backs, wrong clearances

Crew to External
communicated
(ATC)
(e.g. for a taxiway, gate or runway)

Miscommunication or misinterpretation between crew

Pilot to Pilot
(e.g. handover instructions)
Undesired Aircraft States CRM THEORY 87 / 94

Undesired aircraft states are conditions caused by the crew that could reduce
normal margins for safety. These are often the result of poor Threat and Error
Management by the crew and require some form of action. Examples:

▪ Aircraft Handling
▪ Vertical, lateral or speed deviations
▪ Unnecessary weather penetration or unauthorized airspace penetration
▪ Unstable approach or long, floated, firm or off-centerline landings
▪ Operation outside aircraft limitations
▪ Ground navigation
▪ Runway or taxiway incursions
▪ Wrong taxiway, ramp, gate or hold spot
▪ Taxi above speed limit
▪ Incorrect Aircraft configuration
▪ Incorrect system configuration
▪ Incorrect engine configuration
▪ Incorrect weight and balance configuration
TEM model CRM THEORY 88 / 94

▪ Threat management strategies and countermeasures intervene between

the threats and the tasks
▪ Possible threats are continuously monitored and eliminated before they
create UAS.
▪ They are best described as the safety tools which exist within the system.
▪ Countermeasures are divided into categories based on their source:
▪ „Hard” resources are provided by the aviation system
▪ „Soft” resources referring to crew contribution at the human level
Hard resources CRM THEORY 89 / 94

▪ Legislative controls (ICAO, CAA, FAA)

▪ Aircraft System Design: Collision Avoidance Systems (TCAS/ACAS)
▪ Operating procedures and practices (SOPs, checklists, briefings)
▪ Training (maintain and develop expertise, improve crew coordination)
Soft resources – Planning countermeasures CRM THEORY 90 / 94

Interactive and operationally thorough briefing that meets SOP

SOP Briefing
requirements in establishing points where actions are required

Operational plans and decisions adequately discussed to provide the crew

Plans Stated
with a shared understanding

Roles and responsibilities defined and understood for normal and non-
Workload assignment
normal situations

Development of effective strategies to manage threats including

Contingency
anticipating their nature and consequences as well as allocation of
Management
resources to manage them
Soft resources – Executing countermeasures CRM THEORY 91 / 94

Monitor and
Crew actively monitor and cross-check systems and each other
cross-check

Operational tasks are given correct priority to ensure primary flight duties are
Workload
adequately managed, task fixation is avoided and workload capacities are not
Management
exceeded

Adequate use of automation is applied to balance workload and situational

Automation
requirements. The crew communicates and maintains shared awareness of
Management
automated conditions and executes recovery techniques when anomalies occur
Soft resources – Reviewing countermeasures CRM THEORY 92 / 94

Evaluation and Crew decisions are collectively analyzed to verify the existing plan is the best
Modification of Plans option

Crew openly question and clarify current plans adopting an attitude where
Inquiry
nothing is assumed correct or knowledge is complete and unchallengeable

Assertiveness Critical information and solutions are posited assertively and without hesitation
Home exam CRM THEORY 93 / 94

Now go to the „My Exams” page in Evionica,

and please take your CRM Progress check!
You have 60 minutes to complete the test after starting it. Should you need
to retake it or you want to achieve a better score, choose the Retake option.

When finished, continue with the MCC Presentation.

 CRM THEORY 94 / 94

See you later

in the simulator!