crm lessons learned from losa
TRANSCRIPT
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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
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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)
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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
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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”
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An Expanded Definition of CRMAn Expanded Definition of CRM
CRM Skills
Error Management
Error Avoidance
Threat Management
Undesired Aircraft State Management
Fifth Generation CRM
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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
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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
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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)
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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
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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)
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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
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University of Texas
Human Factors
Research Project
www.psy.utexas.edu/psy/helmreich/nasaut.htm