CRM, Threat and Error Management, and LOFT

What does this chapter cover?

The big picture

Four branches: CRM, the SHEL model, threat and error management, and LOFT. Tap + to open.

• Crew performance CRM, SHEL, TEM, LOFT How crews meet the human performance training rule: CRM; the SHEL model of human factors; TEM, short for threat and error management; and LOFT, line oriented flight training.
  • CRM use of all resources Crew Resource Management: making good use of every resource you have to keep flying safe and efficient, so there are fewer errors, less stress and better teamwork.
    • Effective use of all resources To keep flying safe and efficient and to manage human error, in multi-crew and single-pilot flying, and for ATC and engineers too.
    • Thinking and people skills not stick-and-rudder handling Cognitive skills (awareness, problem solving, decisions) and interpersonal skills (communication, teamwork).
    • Tenerife disaster, 1977 the catalyst One of the worst crashes ever. It turned CRM from an idea few people practised into a full training programme.
    • 4 training aims CRM training builds four skills: avoiding errors, handling threats, managing errors, and recovering from an aircraft state nobody wanted.
      • Error avoidance Thinking ahead to predict and avoid errors before they happen; the first of the four CRM training aims.
      • Threat management Spotting and handling threats: things the crew did not cause but still have to deal with.
      • Error management Using defences that stop errors happening, catch them when they do, and limit the damage.
      • Undesired aircraft state management Handling the outcome of unmanaged errors, such as incorrect configuration, unstable approaches, or vertical, lateral or speed deviations.
    • 15 core skills in six groups CRM training covers 15 skills and competencies; here they are grouped into six clusters.
      • Leadership and team Cluster of three skills: leadership/command, team building and the trans-cockpit authority gradient.
        • Leadership / command Using appropriate authority to keep focus on the task and on crew members' concerns, and supporting others in completing tasks.
        • Team building Setting task priorities, using crew resources to achieve objectives, and improving crew interpersonal relations.
        • Authority gradient How authority sits between captain and first officer. Too steep: a bossy captain. Too flat: two captains. Best: clear authority with a good working relationship.
      • Cognitive vigilance Cluster of two skills: situation awareness and vigilance.
        • Situation awareness Understanding present system and environmental conditions and anticipating changes as the flight progresses.
        • Vigilance Consciously avoiding complacency, watching system and environment changes, and telling other crew of potential threats and errors.
      • Operational control Cluster of three skills: decision making, workload management and automation management.
        • Decision making Detecting a deviation, assessing the problem, generating options, identifying risks and choosing the best course, then reviewing it to learn.
        • Workload management Prioritising and delegating to keep focus on primary tasks, keeping everyone in the loop, and monitoring the flight's progress.
        • Automation management Using automation to help manage the flight, especially at high workload, while tracking mode changes and keeping ahead of the curve.
      • Communication Cluster of three skills: communication, assertiveness and briefings.
        • Communication Speaking clearly and listening to feedback; saying the plan out loud and clearing up anything unclear, especially in briefings and debriefings that involve everyone.
        • Assertiveness Querying others in ambiguous situations to clarify actions, and constructively asserting views for team effectiveness.
        • Briefings Open, interactive briefings that check others' understanding by inviting questions and focus on operational issues.
      • Safety governance Cluster of three skills: setting bottom lines, contingency management and evaluation of plans.
        • Setting bottom lines Keeping an eye on what the crew is doing, especially near the limits, and speaking up when the risk of error is growing.
        • Contingency management Constant awareness of changes in the flight's progress, assessing threats and planning contingent actions for constraints that may develop.
        • Evaluation of plans Looking back at what was done, and asking the rest of the crew how threats and errors were handled and what could be done better.
      • Human performance Cluster of one skill: human performance awareness.
        • Human performance awareness Awareness of personal and human limitations, recognising stress loads, and being assertive when approaching those limits.
  • SHEL model Edwards, 1972 A conceptual model of human factors named from Software, Hardware, Environment and Liveware, first developed by Edwards in 1972.
    • S: Software procedures, checklists, symbology Procedures, manuals, checklist layouts, documents, symbology, computer programmes, maps and charts.
    • H: Hardware flight deck, displays, controls The machine: flight deck design, aircraft structure, instrument presentation, position and operating sense of controls, machinery and equipment.
    • E: Environment conditions inside and outside The surroundings, inside the workplace and outside it.
    • L: Liveware, the hub four groups of influence The person: the most important, valuable and flexible part. Everything else has to be shaped to fit the person.
      • Physical size, strength, senses Body measurements, strength, and the limits of sight and hearing.
      • Physiological health and body Body factors: nutrition, health, lifestyle, fatigue, duty, sleep, drugs, alcohol, incapacitation, decompression and illusions. Their effect, with psychosocial factors, is more pronounced.
        • Nutrition and health food intake, dehydration Check what you ate in the last 24 hours, and watch for dehydration.
        • Fatigue and sleep duty hours, circadian dysrhythmia Acute and chronic fatigue, duty hours and flight duration, and sleep factors such as crew rest, sleep deficit and circadian dysrhythmia (jet lag).
        • Drugs, alcohol, carbon monoxide With a mild headache, take only medicine prescribed by an aviation specialist.
        • Illusions vestibular and visual Vestibular illusions such as somatogyral, somatogravic, the leans and coriolis, and visual illusions such as black hole, autokinesis and landing illusions.
      • Psychological mental state Mental factors: perception, reaction time, disorientation, attention, information processing, workload, experience, knowledge, training, planning, attitudes, expectations, confidence, emotional state and personality.
        • Perception and attention fixation, channelised attention High arousal overload narrows attention.
        • Information processing capacity, memory, saturation Mental capacity, delayed or poor decision making and judgment, memory capacity and forgetting, plus workload such as task saturation and underload.
        • Attitudes and personality complacent, macho, impulsive Attitudes such as complacency, macho, anti-authority and impulsive traits.
      • Psychosocial life pressures Conflict with others, personal loss, money or family pressure.
  • Threat and error management manage, not eliminate Thinking ahead to predict and avoid errors and threats and manage any that occur; TEM manages threats and errors rather than trying to eliminate them.
    • Threats 6 kinds, from outside the crew Things that happen outside the crew's control but that the crew must handle. They make the job more complex and make errors more likely.
      • Environmental weather, terrain, airport, traffic Bad weather, terrain, airport conditions, busy traffic or TCAS events, and airports you do not know.
      • ATC command errors, similar call signs Threats from air traffic control: command events or errors, language difficulties and similar call signs.
      • Aircraft malfunctions, automation events Threats from the aircraft itself: malfunctions and automation events.
      • Crew support dispatch, ground, maintenance errors Threats from support agencies: dispatch, ground and maintenance events or errors.
      • Operational time pressure, diversions Time pressure, irregular operations, flight diversions and missed approaches.
      • Cabin cabin crew, medical, passengers Cabin events such as flight attendant errors and passenger events.
    • Errors 5 kinds, crew action or inaction Something the crew did, or did not do, that took things away from what the crew or the company meant to happen. TEM sorts errors into five kinds.
      • Intentional non-compliance Knowingly breaking the rules or the operator's procedures.
      • Procedural Getting a rule or procedure wrong in the doing: you meant the right thing but did it wrong, or forgot a step.
      • Communication Messages misheard, misunderstood or never passed on, inside the crew or with people outside such as ATC.
      • Proficiency Lack of knowledge or psychomotor (stick and rudder) skills.
      • Operational decision A decision-making error, not standardised by regulations or procedures, that unnecessarily compromises safety, such as flying through known wind shear instead of going around.
    • Undesired aircraft state an error left unmanaged Needs immediate recovery or a go-around.
    • Threats and errors will happen so manage them TEM accepts that threats will turn up and errors will happen; it aims to manage them, not to wipe them out.
  • LOFT full-mission simulation Line-oriented Flight Training: non-jeopardy, facilitated full mission simulation of line operations, emphasising communications, management and leadership.
    • Non-jeopardy, facilitated real time, like the line LOFT is realistic, real-time, full mission training in situations representative of line operations, without jeopardy to the crew.
    • Validates programmes, not individuals LOFT is not a method of checking individual performance; it validates training programmes and operational procedures.
    • Retraining at once, without stigma An individual or crew needing more training after a LOFT session gets it immediately, with no stigma or recrimination.

Takeaway: CRM uses every resource, SHEL matches the system to the human, TEM manages threats and errors, and LOFT trains it all without jeopardy.

How did cockpit culture change?

Then and now

The old flight deck against the CRM flight deck. Read each pair.

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What makes CRM work?

What makes CRM work

Foundations, programme, aims and the rule behind it. Tap + to open each.

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What is a steep or shallow authority gradient?

Authority gradient

Column height is authority between captain and first officer. The dashed line is the gradient.

Memory hook: Steep: one voice. Shallow: no leader. Desired: a leader who listens.

Takeaway: Steep is a domineering captain over an unassertive first officer; shallow is two captains with no clear leader. Aim for the middle.

Where does the human fit in the SHEL model?

SHEL model

You are the L in the middle. Each dashed line is an interface, with a typical mismatch.

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What goes wrong at each SHEL interface?

SHEL edge by edge

You are the hub. Tap each number for what fails there.

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What affects the individual (Liveware)?

Inside the human

Four kinds of factor, with the book's examples. Tap + to open each.

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Which SHEL interface does a problem belong to?

Which interface

Think of the problem, then answer from the top. The first yes names the interface.

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Where do threats and errors come from, and who speaks up?

TEM at a glance

Four views: the TEM stages, six threats, five errors and the authority gradient.

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Can you name the type of crew error?

Error type

Read each case and press the stamp that applies.

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Numbers to know

Numbers

Counts and dates the exam likes.

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Pairs that catch students out

Don't mix up

Read each pair, then the rule that tells them apart.

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Test yourself

Ten questions from this chapter.

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