crm lessons learned from losa

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Human Factors Research Project CRM: Lessons Learned from CRM: Lessons Learned from LOSA LOSA James Klinect The University of Texas Human Factors Research Project CRM Conference 2000 – Southwest Airlines

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Page 1: CRM Lessons Learned From LOSA

Human Factors

Research Project

CRM: Lessons Learned from CRM: Lessons Learned from LOSALOSA

James KlinectThe University of Texas Human Factors Research Project

CRM Conference 2000 – Southwest Airlines

Page 2: CRM Lessons Learned From LOSA

The Many Generations of CRMThe Many Generations of CRM

• First Generation – Cockpit Resource Management• Strong focus on personality and interpersonal behavior

• Second Generation – Crew Resource Management• More team oriented and specific to flight operations

• Third Generation – CRM training in context• Considered the environment (e.g., org culture)• Extended CRM to other groups (e.g., Check airmen and flight attendants)

• Fourth Generation – CRM integration and proceduralization• Doing away with stand-alone CRM training• Full integration of CRM with technical training (e.g., AQP)

Page 3: CRM Lessons Learned From LOSA

Fifth Generation CRMFifth Generation CRM

• Criticisms of previous CRM generations1. CRM had lost it’s focus – What is CRM?

• Not just training that helps pilots work together as a team

2. CRM had become an end unto itself• Trained and evaluated CRM in independently of technical

performance

• Fifth generation CRM – Needed to make the original purpose of CRM more explicit and universal

• Purpose - Error management

Page 4: CRM Lessons Learned From LOSA

LOSA and CRMLOSA and CRM

• Problem – Little data supporting fifth generation CRM• How do flightcrews detect and manage error in normal operations? • What are effective and ineffective error management strategies?• What magnitude does CRM play in error management?

• LOSA - provides the needed data

• As a result of LOSA data, our perspective of CRM is starting to become more refined1. Expand the definition of fifth generation CRM2. Individual CRM skills play specific roles as “threat and error

countermeasures”

Page 5: CRM Lessons Learned From LOSA

An Expanded Definition of CRMAn Expanded Definition of CRM

CRM Skills

Error Management

Error Avoidance

Threat Management

Undesired Aircraft State Management

Fifth Generation CRM

Page 6: CRM Lessons Learned From LOSA

Threat and Error CountermeasuresThreat and Error Countermeasures

• After 4000 LOSA observations………….

• Behavioral markers as “threat and error countermeasures”

• As a result, four groupings of threat and error countermeasures have emerged1. Team building2. Planning3. Execution4. Review / Modify

Page 7: CRM Lessons Learned From LOSA

Team Building CountermeasuresTeam Building Countermeasures

• Two markers1. LEADERSHIP – In command, decisive, and encouraged

participation

2. COMMUNICATION ENVIRONMENT – Communication channels established and maintained

• Critical for all levels of performance:• Error avoidance• Threat management• Error management• Undesired aircraft state management

Page 8: CRM Lessons Learned From LOSA

Planning CountermeasuresPlanning Countermeasures

• Four markers1. BRIEFING – Quality of required briefings

2. PLANS STATED – Plans were communicated – “shared mental model”

3. WORKLOAD ASSIGNMENT – Roles and responsibilities were defined

4. CONTINGENCY MANAGEMENT – Strategies to anticipate and manage threats

• Most critical in:• Error avoidance• Threat management when the threat is expected (e.g., adverse weather)

Page 9: CRM Lessons Learned From LOSA

Execution CountermeasuresExecution Countermeasures

• Four markers1. MONITOR / CROSSCHECK – Crosschecking of systems and crew

members

2. WORKLOAD MANAGEMENT – Prioritization – “staying ahead of the curve”

3. VIGILANCE – Remained alert of the environment and aircraft position

4. AUTOMATION MANAGEMENT – Proper balance of automation and workload

• Most critical in: • Error management

Page 10: CRM Lessons Learned From LOSA

Review / Modify CountermeasuresReview / Modify Countermeasures

• Three markers1. EVALUATION OF PLANS – Reviewed and modified plans when

necessary

2. INQUIRY – Asked questions to clarify – “nothing taken for granted”

3. ASSERTIVENESS – Stated critical information with appropriate persistence

• Most critical in:• Undesired aircraft state management• Threat management when the threat is unexpected (e.g., A/C

malfunction)

Page 11: CRM Lessons Learned From LOSA

Fifth Generation CRM: Sixth Fifth Generation CRM: Sixth Generation?Generation?

• Restating the purpose with validation from data• Error avoidance• Threat management• Error management• Undesired aircraft state management

• CRM as threat and error countermeasures

• Team building – Leadership and Communication Environment

• Planning – Briefing, Plans Stated, Workload Assignment, and Contingency

Planning

• Execution – Monitor/Crosscheck, Vigilance, Workload, and Automation

Management

• Review/Modify – Evaluation of Plans, Inquiry, and Assertiveness

Page 12: CRM Lessons Learned From LOSA

University of Texas

Human Factors

Research Project

www.psy.utexas.edu/psy/helmreich/nasaut.htm