crm

Manual No.: JCI-13

Jade Cargo International Co. Ltd.

Crew Resource ManagementMANUAL

(January 2008)

Revision Status: Original

Approved By Flight Crew Training Section

Acknowledgement and credit for most of the content of this manual is hereby given to Emirates and SAA

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CRM Manual Date: January 2008

Table of Contents

1 CRM Training ................................................................................................... 4 1.1 Introduction ............................................................................................. 4 1.2 Courses ................................................................................................... 4

1.2.1 CRM Introduction Course .............................................................. 4 1.2.2 CRM Indoctrination Course ........................................................... 4 1.2.3 CRM Update Course ..................................................................... 4 1.2.4 CRM Recurrent Training ................................................................ 5 1.2.5 CRM Upgrade Training .................................................................. 5 1.2.6 CRM Transition CRM .................................................................... 5

2 Modules Content .............................................................................................. 5 2.1 Threat and Error Management ............................................................... 5 2.2 Culture .................................................................................................... 5 2.3 Automation .............................................................................................. 5 2.4 Leadership, Followership & Team Dynamics ......................................... 6 2.5 Communication (Communication Styles & Conflict Resolution) ............. 6 2.6 Problem-Solving & Decision Making ....................................................... 6 2.7 Cognition ................................................................................................. 6 2.8 Stress & Alertness Management ............................................................ 6 2.9 Situational Awareness ............................................................................ 6

3 Threat and Error Management ......................................................................... 7 3.1 Introduction ............................................................................................. 7 3.2 CRM Training in Aviation ........................................................................ 7 3.3 Human Performance ............................................................................... 7 3.4 Evolution of CRM .................................................................................... 8 3.5 Human Error ........................................................................................... 8 3.6 Human Factors In Design ....................................................................... 8 3.7 The Error Chain ...................................................................................... 9 3.8 Swiss Cheese ......................................................................................... 9 3.9 Threat and Error Management ............................................................. 10 3.10 Threat and Error .................................................................................. 10 3.11 Warning Flags ..................................................................................... 11 3.12 Avoid, Trap, Mitigate ........................................................................... 11

4 Culture ............................................................................................................ 12 4.1 Introduction ........................................................................................... 12 4.2 National Culture .................................................................................... 12 4.3 Individualism/Collectivism (IDV) ........................................................... 12 4.4 Effects on Crew Behaviors ................................................................... 12 4.5 Uncertainty Avoidance (UA) ................................................................. 13 4.6 Power Distance (PDI) ........................................................................... 13 4.7 Organizational and Professional Culture .............................................. 14

5 Automation ..................................................................................................... 14 5.1 Introduction ........................................................................................... 14 5.2 Flight Deck Automation ......................................................................... 14 5.3 What to Automate ................................................................................. 15 5.4 Fitts’ List ................................................................................................ 16 5.5 The Automation Pyramid ...................................................................... 17 5.6 The Irony of Automation ....................................................................... 18

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5.7 The Automation Issue ........................................................................... 18 5.8 Interfaces .............................................................................................. 18 5.9 Feedback .............................................................................................. 19 5.10 From an Aircraft Manufacturer ............................................................ 19 5.11 Ergonomic Design Principles .............................................................. 19 5.12 Conclusion .......................................................................................... 20

6 Leadership and Team Dynamics ................................................................... 20 6.1 Introduction ........................................................................................... 20 6.2 Leadership ............................................................................................ 20 6.3 Leadership Theory ................................................................................ 21 6.4 Action-Centred Leadership ................................................................... 21 6.5 Task ...................................................................................................... 22 6.6 Team Building and Maintenance .......................................................... 22 6.7 Individual Development and Satisfaction .............................................. 22 6.8 The Role of Leader ............................................................................... 22

6.8.1 Regulating Information Flow ........................................................ 22 6.8.2 Directing and Coordinating Crew Activities ................................. 23 6.8.3 Motivating Crew Members ........................................................... 23 6.8.4 Leadership Styles ........................................................................ 23

6.9 Cockpit Authority Gradient .................................................................... 25 6.10 Followership ........................................................................................ 25 6.11 Team Dynamics .................................................................................. 26

7 Communication .............................................................................................. 27 7.1 Introduction ........................................................................................... 27 7.2 Principles of Communication ................................................................ 27 7.3 Communication Barriers ....................................................................... 27 7.4 Communication Styles .......................................................................... 28

7.4.1 Assertive Behavior [a1] ................................................................ 28 7.4.2 Aggressive Behavior [a2] ............................................................. 29 7.4.3 Supportive Behavior [s1] ............................................................. 29 7.4.4 Submissive Behavior [s2] ............................................................ 29

7.5 Dealing with Aggression ....................................................................... 30 7.6 Conflict Resolution ................................................................................ 31 7.7 Problem Solving .................................................................................... 31 7.8 Compromising ....................................................................................... 31

8 Problem Solving and Decision Making .......................................................... 32 8.1 Introduction ........................................................................................... 32 8.2 Structured Decision Making .................................................................. 32

8.2.1 The Model “Footprint” .................................................................. 33 8.2.2 Providing “Seamless Integration” ................................................ 33

8.3 A Problem-Solving Model ..................................................................... 34 8.4 Time Management ................................................................................ 35 8.5 The Jade Cargo International Decision-Making Model ......................... 36 8.6 Assess .................................................................................................. 37 8.7 Action .................................................................................................... 37 8.8 Manage ................................................................................................. 37

9 Cognition ........................................................................................................ 38 9.1 Introduction ........................................................................................... 38 9.2 Models .................................................................................................. 38

Flight Crew Training Centre

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9.3 A Model of the Cognitive Brain ............................................................. 38 9.4 Input functions ....................................................................................... 39

9.4.1 Senses ......................................................................................... 39 9.4.2 Attention ....................................................................................... 39 9.4.3 Divided Attention ......................................................................... 39

9.5 Perception ............................................................................................. 39 9.6 Processing Functions ........................................................................... 40

9.6.1 Memory ........................................................................................ 40 9.6.2 Sensory Memory ......................................................................... 40 9.6.3 Short-Term Memory .................................................................... 40 9.6.4 Long-Term Memory ..................................................................... 41 9.6.5 Flashbulb Memory ....................................................................... 41 9.6.6 Central Processor/Decision-Maker .............................................. 42 9.6.7 Problems with Decision Making ................................................... 42

9.7 Conclusion ............................................................................................ 43 10 Stress and Alertness .................................................................................... 43

10.1 Introduction ......................................................................................... 43 10.2 Stress .................................................................................................. 44 10.3 Types of Stress ................................................................................... 44

10.3.1 Acute Stress .............................................................................. 44 10.3.2 Episodic Acute Stress ................................................................ 45 10.3.3 Chronic Stress ........................................................................... 46 10.3.4 Sources of Stress ...................................................................... 46 10.3.5 Life Stress .................................................................................. 46 10.3.6 Environmental Stress ................................................................ 47 10.3.7 Cognitive Stress ........................................................................ 47

10.4 Alertness ............................................................................................. 48 10.5 Sleep Management ............................................................................. 48 10.6 Circadian Rhythms .............................................................................. 49 10.7 Stress and Alertness Management ..................................................... 50 10.8 Controlled Rest in the Flight Deck ...................................................... 50

11 Situational Awareness .................................................................................. 50 11.1 Introduction ......................................................................................... 50 11.2 Levels of Situation Awareness (SA) ................................................... 50 11.3 Loss of Situational Awareness ............................................................ 51 11.4 The Safety Window ............................................................................. 52 11.5 Situational Awareness and Error Management .................................. 53 11.6 Factors Affecting Situational Awareness ............................................ 53 11.7 Communication and Shared Situational Awareness .......................... 53 11.8 Techniques for Better Situational Awareness Management ............... 54

12 Reference Notes .......................................................................................... 55


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1 CRM Training1.1 Introduction

CRM training will be provided to all Jade Cargo International pilots in accordance with the policy contained within the Flight Operations Manual. CRM training provided to Jade Cargo International pilots is based on the requirements of the Chinese Civil Aviation Regulations (CAAC) and also meets the requirements of other regulatory bodies.

1.2 Courses

1.2.1 CRM Introduction Course

The Jade Cargo International CRM Introduction Course is a “CAAC” approved course conducted by Jade Cargo International staff. The course is not assessable.

The Initial Course will be applied to all new pilots upon entry to Jade Cargo International. It is designed to introduce pilots who have received prior Human Performance training with other airlines to the concepts in use at Jade Cargo International. The required time is prior to transition training. It is designed to be complementary to the Transition Course (see below). The duration of the course is one day.

1.2.2 CRM Indoctrination Course

The Jade Cargo International CRM Indoctrination Course is a “CAAC” approved course conducted by Jade Cargo International staff. The course is not assessable.

Most pilots joining Jade Cargo International will have completed Human Performance training as part of their license requirements; however CRM is viewed as specific to the airline. Therefore, the purpose of this course is to deliver Jade Cargo International perspective on CRM, expanding on the introductory course that has already been completed. The duration of the course is two days and is designed to be applied in isolation. The award of a Certificate of Completion and registration with Crew Records signifies successful completion of a course.

1.2.3 CRM Update Course

Jade Cargo International designates a three-year training cycle for CRM. This cycle is deemed to begin when a pilot completes his transition training with Jade Cargo International. To revalidate a pilot’s CRM training at the end of the cycle, a one day update course is conducted.


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1.2.4 CRM Recurrent Training

Jade Cargo International pilots receive a recurrent CRM component as part of the recurrent training package approved by the (CAAC). The content of this CRM component is designed by the Head of Training in co-ordination with the CRM Instructor.

1.2.5 CRM Upgrade Training

Jade Cargo International requires all candidates for Command training to receive an intensive CRM course. The course consists of a review of decision-making, leadership and team management, and a series of role-plays. The role-plays are designed to allow upgrade candidates to use the decision-making tools, and team management skills. They will be conducted in a cockpit environment and videotaped where appropriate for debriefing purposes.

The candidates will conduct their own debrief, assisted by the facilitator. This has proven to be a powerful tool to reinforce the learning process.

1.2.6 CRM Transition CRM

Jade Cargo International includes a CRM component in all type transition courses. This will be delivered during the ground school phase. The course is tailored to suit the specific requirements of each aircraft type.

2 Modules Content2.1 Threat and Error Management

Nature of human performance & error A model of human error Threat and error defined Latent threats Defenses Managing error

2.2 Culture The characteristics of National culture Influence of Professional & Organizational culture Defenses against multi-cultural threats Safety culture within Jade Cargo International

2.3 Automation Impact of automation Appropriate use of automation


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Reference accidents with automation issues

2.4 Leadership, Followership & Team Dynamics Command authority Leadership styles Team effectiveness Reference accidents with leadership issues

2.5 Communication (Communication Styles & Conflict Resolution)

Model for effective communication Source of Conflict Communication role-play Reference accidents with communication issues

2.6 Problem-Solving & Decision Making Problem identification Time management Company decision-making tool Reference accidents with decision-making issues

2.7 Cognition Overview of cognitive functions Perception Senses Memory Limitations

2.8 Stress & Alertness Management Types and sources of stress Fatigue & sleep management Jade Cargo International policy and procedures

2.9 Situational Awareness Types of situational awareness Skills affecting individual situational awareness Loss of situational awareness Reference accidents with situational awareness issues


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3 Threat and Error Management3.1 Introduction

Investigation of commercial airline accidents has identified that a significant proportion of these are due in some way to a human element. Despite improvements in technology, design and engine reliability, Human Factors still have a critical influence on the accident rate.

Regulators and industry have sought to reduce the human effect by the introduction of non-technical training to address the human issues. Regulators require knowledge of Human Performance and Limitations (HPL) for license issue, completion of a Multi-Crew Co-ordination (MCC) course prior to airline employment and for an airline to run an approved Crew Resource Management (CRM) program for all phases of training.

Threat and error management is at the core of current CRM practice. This is due, in part, because it encompasses all other areas of the discipline. The safe and efficient management of an aircraft requires a balance of both technical knowledge and skills, with an understanding of the limitations of the human operator.

3.2 CRM Training in Aviation

The relationship between Human Factors, HPL, MCC and CRM is most easily described as one of specialization.

Human Factors or ergonomics is the broad science that covers human interaction in the workplace, environment, home, and with other humans. This includes everything from the design of a tool, to the brightness required of an electronic display, to the design of a checklist, to the amount of air recirculation that is required in a pressurized aircraft.

Human Performance and Limitations refers to those aspects that relate to human involvement in aircraft operations. This is a general overview and broadly theoretical. MCC starts to cover the practicalities of multi-crew operations, whereas CRM is focused at the level of the individual airline and is normally a customized program.

3.3 Human Performance

Human performance can be considered as falling into three categories; knowledge, skill and attitude. Traditionally the focus of CRM has been on attitude, which has typically resulted in only temporary changes in behavior and is not universally accepted by the pilot population. Every airline has the anecdotal CRM immune Captain, who complains that it is all a waste of time and does not apply to him.


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It is now recognized that attitudes are difficult to change, especially on a long- term basis in the presence of contradictory influences.

Current CRM thinking focuses on training knowledge and skills. Not only is this more predictable and measurable, but pilots are predisposed to accept knowledge and tools with which to improve performance.

3.4 Evolution of CRM 1st Generation concentrated on attitudes and personal management style

(Cockpit RM)

2nd Generation introduction of modular training, with aviation focus (Crew RM)

3rd Generation attempt at integration with technical training, focus on specific skills

4th Fourth Generation developed alongside the introduction of Advanced Qualification Program (AQP) and LOFT

5th Fifth Generation introduced the concept of error management

This has now evolved into “threat and error” management, encompassing the best of previous generations, but avoiding the trap of undue emphasis on attitudes.

3.5 Human Error

Reason (Reason, J, 1990, Human Error) has developed a model of human error that classifies these according to the circumstances under which they occur. Reason is the acknowledged expert on human error.

Errors are defined as unintentional deviations from required behavior and are to be expected in everyday life with unavoidable regularity. Most of these errors are small, and humans have good error-correcting mechanisms to mitigate the effects of these errors. Violations refer to intentional noncompliance, which cannot be tolerated in the aviation industry.

3.6 Human Factors In Design

The principle need for Human Factors in design is to account for individual differences and to produce a system that is better matched to real human performance. In particular this means designing for error.

Error cannot be avoided so the design must ensure that the most serious mistakes are prevented by trapping mechanisms and clearly forewarned by use of appropriate and timely feedback.


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3.7 The Error Chain

The introduction of automated systems has made it virtually impossible for a frontline operator to cause an accident in isolation. This does not mean that accidents can no longer occur. Rather, that the causes of most recent accidents have been found to be omissions or errors that occurred remotely from the operator who suffered the loss. These are what Reason call “latent threats”, existing conditions that might remain dormant for years, possibly as early as the design stage of a product. A simple example of a latent threat is a mousetrap. In isolation it is insignificant, but when the mouse tries to take the bait, it snaps.

Accident investigation has therefore become much more complex with additional factors to consider. The accident is caused by the completion of a chain of events – the “error chain”, of which the operating crew are the last link. If they can break the chain, the accident does not occur.For example, the British Midland 737-400 that crashed in 1989 was a classic example of an error chain. Without assigning a principle cause, some of the factors were as follows:

Lengthened 737-400 entered service requiring increased thrust Existing engines approved for higher thrust without flight-test Type certification granted Operator differences training approved Fleet operated with mix of different style engine instruments Significance of other operator’s engine defects not identified Engine malfunction during accident flight Incorrect identification of engine malfunction

All of these factors were required for the accident to take place. Some were latent failures, occurring years ago on the drawing board. Others were management failures. The crew was the last chance of avoiding this accident, the last line of defense.

3.8 Swiss Cheese

In the example above it might appear that this was one very unlucky scenario. It was but it is not an isolated case. There are similar events unfolding all around us in aviation.

Reason has likened the multiple layers of defenses to slices of cheese. Each layer in itself is a rather flimsy defense, but placed together they form a robust wall, a combined layer of defenses that can act as an effective shield.

In order to illustrate better the concept of latent threats, Reason used Swiss cheese. The holes in the cheese are the flaws that exist in each individual layer of defense. Occasionally, the holes will line up, leaving an opening in the defensive wall and allowing an accident to happen.


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We cannot have a foolproof layer of defense, at any level, but as long as the holes do not line up, the accident chain is broken. The last layer of defense is the flight-crew, and it is up to us to break the chain.

3.9 Threat and Error Management

Aviation is a hazardous industry but it is not a dangerous one. The latest statistics indicate that one accident occurs per million aircraft departures. The safety record in the airline industry is held in high regard, because despite the risks, safe operations are the norm. Threats and errors are unavoidable, but they are well managed within a system that has countless checks and balances.

3.10 Threat and Error

Threat is defined as an influence, external to the flight-deck that requires action to ensure safe operation. Errors made by the crew during normal and non-normal operations may require intervention to prevent an unsafe situation arising. (Errors made by other people ATC, Engineering, Management, Regulators etc are threats to the crew.)

Threats - External influencesErrors - Internal influences

Safe operation depends on management of those threats and errors that cannot be completely eliminated.

Some examples of common threats are:

Adverse weather Terrain Airport conditions Aircraft malfunctions Automation events.

There are four broad classifications of flight-crew errors:

Procedural – appropriate procedure followed but incorrect execution – i.e. wrong altitude selection on MCP

Communication – missing information or misinterpretation Decision – elective decision by crew that unnecessarily increases risk – i.e. flying to close to a thunderstorm Violations – intentional non-compliance – i.e. performing a checklist from

memory.

Most errors committed by the flight-crew are inconsequential. Line Operational Safety Audits (LOSA) observations have shown that over 70% errors are inconsequential, in fact almost half of all errors go totally undetected by the crew. A small percentage (8%) results in additional errors, the start of an accident chain.


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Over 20% of the time though, research has shown that flight-crew error led directly to an undesired aircraft state, such as an unstabilized approach.

3.11 Warning Flags

Aircraft accidents tend to have many similarities. The NTSB identified in 1994 that of 37 commercial aviation accidents reviewed, nine common factors existed. These have been termed warning flags. The purpose of the NTSB review was to enable flight-crews to recognize that when multiple warning flags exist, great care should be taken to avoid compounding the problem by making additional errors.We have already determined that we cannot expect to work in a risk-free industry. However, presence of several of these warning flags should alert us to the possibility of danger.

The flags can be loosely divided into threats and errors:

Those accidents described below and covered during Jade Cargo International CRM courses have many of these warning flags clearly identifiable. However in all cases, the crew failed to see the threats and usually compounded them by making additional errors.

3.12 Avoid, Trap, Mitigate

How we deal with these threats and errors depends on the phase of flight:

Avoid Identify potential threats/errors in advance and avoid them Trap Identify current threats/errors that are developing, and correct them Mitigate Identify errors that have occurred and limit the damage


Threats ErrorsCaptain flying

Experience gradient

First duty day

Time since awakeOperational stress

Procedural errorPoor tactical decision

Failure monitor/challenge

Improper checklist use

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4 Culture4.1 Introduction

Due to the diverse nature of the workforce, Jade Cargo International has identified that cultural issues represent a significant difference from a typical airline CRM program. This chapter identifies the key concepts that differentiate national cultures and also examines the influence that may occur as a result of particular sub-cultures, such as organizational, professional and safety culture.

4.2 National Culture

Most discussion about culture tends to centre on the effects of national culture. Hofstede carried out the principle research in this area1. He identified five dimensions where cultures differ. The five dimensions are Individualism/Collectivism, Uncertainty Avoidance, Power Distance, Long-term/ Short-term orientation and Masculinity/Femininity. The last two do not typically apply to pilot groups, (which are predominantly male). The remaining three dimensions are discussed below.

4.3 Individualism/Collectivism (IDV)

Individualism on the one side, versus its opposite, collectivism, is the degree to which individuals are integrated into groups. On the individualist side we find societies in which the ties between individuals are loose: everyone is expected to look after him/herself and his/her immediate family. On the collectivist side, we find societies in which people from birth onwards are integrated into strong, cohesive in-groups, often extended families (with uncles, aunts and grandparents) which continue protecting them in exchange for unquestioning loyalty. The word “collectivism” in this sense has no political meaning: it refers to the group, not to the state. Again, the issue addressed by this dimension is an extremely fundamental one, regarding all societies in the world.

Expatriates are typically of a more individualist nature, having left their country of domicile for economic advantage.

4.4 Effects on Crew Behaviors High IDV – Personal gain and protection of oneself are the main priorities.

“Look after number 1” regardless of the effect on the operation

Low IDV – Focus is on the gain for the collectivist whole regardless of personal inconvenience or benefit.

A compromise between the two extremes is what is desired for safe operation


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4.5 Uncertainty Avoidance (UA)

Uncertainty avoidance deals with a society's tolerance for uncertainty and ambiguity; it ultimately refers to man's search for Truth. It indicates to what extent a culture programs its members to feel either uncomfortable or comfortable in unstructured situations. Unstructured situations are novel, unknown, surprising, and different from usual. Uncertainty avoiding cultures try to minimize the possibility of such situations by strict laws and rules, safety and security measures, and on the philosophical and religious level by a belief in absolute Truth; “there can only be one Truth and we have it”. People in uncertainty avoiding countries are also more emotional, and motivated by inner nervous energy. The opposite type, uncertainty accepting cultures, are more tolerant of opinions different from what they are used to; they try to have as few rules as possible, and on the philosophical and religious level they are relativist and allow many currents to flow side by side. People within these cultures are more phlegmatic and contemplative, and not expected by their environment to express emotions.

Uncertainty avoidance is the extent to which members of a culture feel threatened by the uncertain or unknown.

Effects on crew behaviors: High UA Rigid adherence to procedures and SOPs. “A rule for every

situation” approach to flying and a marked reluctance to deviate from SOPs even if the situation demands it.

Low UA Disregard for SOPs and procedures. “I know better than the people who wrote the books” style of operation.

Medium UA is optimum for the flight deck.

4.6 Power Distance (PDI)

Power-Distance is the extent to which the less powerful members of organizations and institutions (like the family) accept and expect that power is distributed unequally. This represents inequality (more versus less), but defined from below, not from above. It suggests that the followers, as much as by the leaders endorse a society’s level of inequality. Power and inequality, of course, are extremely fundamental facts of any society and anybody with some international experience will be aware that all societies are unequal, but some are more unequal than others.Power distance can be related to cockpit gradient.

Effects on crew behaviors: High PDI – can lead to an autocratic leadership style by the Captain – a

steep cockpit gradient

Medium PDI – a consultative style where input is sought but the final decision is made by the Captain


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Low PDI – decisions arrived at by consensus with all crew having equal Input

4.7 Organizational and Professional Culture

Although national culture tends to dominate in most circumstances, there can be anomalies where a professional group, such as pilots, or an organizational culture can prevail, against a conflicting trend.

In particular, promotion of a safety culture might be encouraged for the pilot group to resist a perceived weakness in any national characteristic.Furthermore, this may or may not conflict with a Company’s management style. An “On time departure” policy or a “Minimum Fuel” policy might lead to unnecessary pressure to compromise. It is not the policies themselves that are a potential problem, but the pilots’ perceptions of the Company’s intent.

In Jade Cargo International we have a structure that emphasizes “Safe and efficient”. This is endorsed by an open-reporting policy for safety and human factors issues, though the Air Safety Report and Confidential Human Factors Reporting schemes.

5 AutomationThe problem with computers is that they do what they are actually told to do, not what we thought we told them to do. (Norbert Wiener)

5.1 Introduction

Automation is defined as the replacement of a human function, either physical or cognitive, by a machine function. Although there are numerous examples of the introduction of automated systems on the flight deck, it is those automatic functions relating to flight path control and navigation with which we are primarily concerned.

This chapter investigates the benefits and the traps associated with automation, and also provide some guidance for the management of automation issues.

5.2 Flight Deck Automation

Early jet transport aircraft had a crew of five or six on the flight deck, including radio operators, navigators and flight engineers. Improvements in technology (automation) have resulted in only the two pilots remaining as required crew.

The reason that this has been acceptable is that the residual workload has remained at a manageable level. The aircraft manages and self-monitors many of the functions that were previously in the domain of the other crewmembers.


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Why automate? “Automation brings increased safety, accuracy and reduced costs.” This may be the intention but the statement doesn’t provide the whole story. There are (system) performance issues associated with the introduction of automation, not to mention the human (social) effects. The latter will not be discussed here.

The issue of automation is not whether a machine is capable of doing the job; it is that humans are still required for the part of the task that cannot be automated.

The problem with automation is therefore how man and machine interact – the interface. In particular, it is the understanding of the automation that causes concern.

“Dekker and Woods” highlighted the apparent benefits of automation against the real effect:

Table 1: Benefit of Automation:

The table above illustrates how the intended benefits of automation will not be achieved without additional effort.

5.3 What to Automate

Prior to deciding on what to automate, it would be a good idea to determine the comparative advantages of humans and machines. In practice this does not always happen; engineers automate what they are able to automate and the rest is left for the human operator to manage.


Intended Benefit RealityBetter Results, same

system(substitution)

Reduction in workload

Focuses user attention

Less knowledge required

Reduces error

Transforms practice, roles ofhumans change

Creates more cognitive work, often at the wrong time

Difficulties with SituationAwareness

New knowledge and skills required

New error associated with communication

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“Engineering is not the process of building a perfect system with infinite resources. Rather, engineering is the process of economically building a working system that fulfils a need.” (Good, M, Spine, T, Whiteside, J & George, P, 1986, User-derived impact analysis as a tool for usability engineering)

5.4 Fitts’ List

In the 1950s, Fitts identified those skills where machines exceeded and those where the human is better. The “Fitts” list’ is still valid today:

Table 2: Fitts’ list3

Most notable of the differences from a flight-deck perspective is that humans are poor monitors and good at accepting revised plans. The principle task allocated to humans on the flight deck involves monitoring for which we are not ideally


Skill Machine HumanSpeed

Power Output

Consistency

InformationCapacity

Memory

Reasoning

Sensing

Perceiving

Much superior

Superior in level and consistency

Ideal for repetitive activity

Multi-channel, fastcommunication

Ideal for literal reproduction, access restricted and formal

Good deductive, difficult to re- program, fast, accurate. Poor

error correction

Specialized, narrow range, Good quantitative assessment.

Poor at pattern assessment

Poor at coping with variation in written & spoken material. Poor at detecting messages in noise.

Comparatively slow

Comparatively weak

Unreliable, subject to learning and fatigue

Single-channel, slowcommunication

Better for principles and strategies, access

versatile and innovative

Good inductive, easy to re program, slow, inaccurate. Good at error correction

Wide energy ranges, some multi-function

Good at coping with variation in written &

spoken material. Poor at detecting messages in

noise.

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suited. The automation on the other hand may need to be re-programmed for last minute changes, an area of weakness in interface design.

5.5 The Automation Pyramid

Research literature on automation talks about levels of “supervisory control”. This refers to the level of monitoring and decision-making required by the operator. In the aviation scenario, this refers to how far removed the pilot is from the actual job of flying the aircraft.Although in some systems, such as nuclear power-plant control rooms, it is possible to differentiate seven distinct levels, in practical aviation terms we have identified four levels of automation.

These four levels of automation are available to us to use as appropriate for the situation. Pilots will dynamically move between levels, according to any change in tactical goal.

Consider the case where an aircraft is on an intercept heading for an instrument approach:

Manual flight without flight director: requires the pilot to manually fly the aero plane and monitor the closing rate of the inbound track and adjust accordingly. – This is a high workload situation, although “fly-by-wire” will still be assisting.

Manual flight with flight director: the pilot now has a reduced cognitive load as he no longer has to interpret closing information, but the system must be programmed to give the correct guidance. Overall result is reduced workload, with different cognitive skills required.

Autopilot with basic/selected modes: The cognitive demand is as above, but the pilot is relieved of the task of manual flight, resulting in further reduced workload. Note that the pilot is still actively involved in the task and through FCU/MCP manipulation retains situational awareness of the flights progress.

Autopilot with fully managed modes (LNAV/VNAV): The pilot no longer has to calculate closing rate information or fly the aircraft. In its current mode the aircraft will intercept the inbound course. There is a reduced cognitive load, so the overall workload is drastically reduced. Monitoring or supervising is the principle role left to the pilot.

The potential problem that we face is that if we operate for too long in the fully automated regime, vigilance and complacency may become issues. It also becomes more difficult to revert to more basic modes with reduced automation.

The principle pilot skill on modern generation automated aircraft knows which mode of automation is most appropriate to the task, including when to turn it off!


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5.6 The Irony of Automation

The irony of automation is that, having been unable to completely replace the pilots with automation; the pilots still have to intervene at critical moments when the automation cannot cope.

The highest workload situations tend to be left un-automated. Unfortunately, as routine automation takes away the opportunity to rehearse basic flying skills the skill and practice required by the pilots to manage these events is lacking.

5.7 The Automation Issue

Now that the benefits and drawbacks of automation have been identified, it is important to address the issues identified by accident reviews. It has already been noted that the introduction of automated features changes the role of the pilot. For this new knowledge and skills are required.

The major problem that has been identified with automation is due to a lack of understanding. If we do not fully understand the system we are not able to anticipate the system response or evaluate its performance.Using automation requires us to:

Understand each mode before selection

Anticipate how the aircraft will react to the mode change

Evaluate whether the desired effect has been achieved

Numerous accidents have resulted as a result of pilot inputs that were not appropriate for the correct completion of the desired task (Nagoya, Cali, Habsheim etc). Studies have revealed that “mode” errors are among the most common on advanced aircraft.

5.8 Interfaces

The blame for this lack of understanding is not necessarily with the pilot. The key issue is with the design of the interface: how the pilots and the automation communicate. The FAA identified this weakness and commissioned a study that reported in 1996. The report identified links between automation and situational awareness, communications and monitoring.

In particular, the FAA recommended that operators’ manuals should provide “clear and concise guidance” on conditions when the auto-pilot or auto-throttle will or will not engage, will disengage or will revert to another mode.


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5.9 Feedback

“Norman” contests that the real issue with automation is due to poor or inappropriate feedback. The failing of the man-machine system is because the pilot is no longer “in the loop”.Appropriate feedback makes the task of monitoring system failures or anomalies more effective. Feedback is also required for monitoring normal system status change. A lack of, or subtle, feedback results in a reduction of situational awareness.

The Jade Cargo International procedure’s of calling FMA changes is designed to counter this threat.

5.10 From an Aircraft Manufacturer

Appropriate degree of automation.Boeing and Airbus flight decks are designed to provide automation to assist, but not replace, the flight-crew member responsible for safe operation of the airplane. Flight-crew errors typically occur when the crew does not perceive a problem and fails to correct the error in time to prevent the situation from deteriorating. Consequently, Boeing and Airbus flight decks incorporate intuitive, easy-to-use systems. These systems support instrument displays with visual and tactile motion cues to minimize potential confusion about what functions are automated. These cues reinforce situational awareness and help keep the flight crew fully aware of changes occurring to the airplane’s status and flight path during all phases of automated and manual flight.

5.11 Ergonomic Design Principles

The following design principles have been identified as necessary for producing a usable interface:

Intuitive - Logical layout of controls and displays

Use of natural command language (Windows v Dos)

Minimal user memory load (prompt keys)

Consistency

Feedback

Clear, Understandable error messages

Error prevention

These principles apply to computerized systems as much as day-to day items. When was the last time you had to refer to a user manual for a chair or a tea-pot? …or a video cassette recorder…?


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The advantage of retaining humans in the system is that they are adaptable and flexible. Humans are capable of devising strategies, either as an organization or as individuals to reduce the threat posed by a design that is less than perfect.

Recognition of a poor design is part of the way towards eliminating the threat it poses.

5.12 Conclusion

Automation is seen as the antidote to pilot error. In fact it has generated the potential for a different type of human error. We must guard against the threats posed by automation, by knowledge of the appropriate levels of automation and understanding of the automated systems. Appropriate feedback is vital to achieve and sustain the high levels of situational awareness required for safe operations.

6 Leadership and Team Dynamics6.1 Introduction

There are various competing theories about what makes a leader and the definition of leadership. In the flight-deck environment, the Captain is the designated “leader”, yet numerous accident and incident reports identify where the leader has failed in his role and remarkably has not exercised leadership.

This chapter will identify some of the attributes necessary for effective leadership and identify how styles of leadership vary.

6.2 Leadership

A leader is a person whose ideas and actions influence the thought and the behavior of others. Through the use of example and persuasion, and an understanding of the goals and desires of the group, the leader becomes a means of change and influence.

Leadership is needed to effectively understand and cope with a variety of situations. Personality or attitude clashes within a crew complicate the task of a leader and can have an influence on both safety and efficiency. Aircraft accident and incident investigations have demonstrated that personality differences can influence the behavior and performance of crewmembers.

There is a fundamental difference between leadership, which is acquired, and authority, which is assigned. An individual's position as captain does not automatically assume that he or she is an effective leader. An optimal situation exists when leadership and authority are combined.


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The Captain’s authority as leader is derived from the China Civil Aviation Regulations.

As leader the Captain has both responsibility and accountability. This implies a certain amount of discretion in choice of action. In fact, from a practical view point the Captain has a right, and a duty, to decide on a course of action.

6.3 Leadership Theory

Early research into leadership theory stems from the military. Some of this is relevant in the sphere of commercial aviation. An effective leader must have both technical and personal skills, and be able to maintain team morale. The leader must have a thorough technical knowledge of the aircraft and appropriate supporting systems. In addition, any limitations of this knowledge must be identified, along with recognition of the appropriate source of assistance and the correct answer when provided.

Personal qualities required are those of courage, will power, initiative and integrity. An ability to communicate and self-motivation are also vital.

6.4 Action-Centred Leadership

Pilots tend to be naturally task-focused individuals; however the leader also has other areas of responsibility. The leader must balance the demands of the task, the team and the individual.

The importance of each sphere of responsibility will change dynamically according to the situation. Jade Cargo International SOPs and technical training support this function of leadership, with use of the Assess, Action, and Manage

Decision-Making Model.

Task Team

Individuals

Figure 1: Action Centred Leadership


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6.5 Task

To achieve the task, consider the following:

Planning Communication of intent Avoid over-involvement as it reduces the capacity to think ahead. Maintain situation awareness Monitor and evaluate the task’s progress

6.6 Team Building and Maintenance

Team work is vital for an effective solution to a task. To enhance the sense of unity:

Use expertise within the team Briefing Co-ordination of effort Provide feedback

6.7 Individual Development and Satisfaction

In the two-pilot flight deck, many of the considerations for the team also apply for managing an individual’s needs. With a wide variety of background, experience and culture in Jade Cargo International the following techniques may also assist in promoting the individual’s needs:

Sensitivity to cultural needs Maintain an open environment by active listening Admission of errors and encourage Standard calls to identify deviations

6.8 The Role of Leader

The CRM Manual produced by Transport Canada identified the following four tasks that encompass the role of the leader:

6.8.1 Regulating Information Flow

The leader must regulate, manage and direct the flow of information, ideas and suggestions within the crewmembers and outside sources

Communicating flight information Asking for opinions, suggestions Giving opinions, suggestions Clarifying communication Providing feedback Regulating participation


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6.8.2 Directing and Coordinating Crew Activities

The leader must function as crew manager to provide orientation, coordination and direction for group performance

Directing and coordinating crew activities

Monitoring and assessing crew performance Providing planning and orientation Setting priorities

6.8.3 Motivating Crew Members

The leader must maintain a positive climate to encourage good crew member relations and to invite full participation in crew activities

Creating proper climate Maintain an "open" cockpit atmosphere Resolving/preventing angry conflict Maintain positive relations Providing non-punitive critique and feedback

The leader is ultimately responsible for decisions

Assuming responsibility for decision making Gathering and evaluating information Formulating decisions Implementing decisions Providing feedback on action

6.8.4 Leadership Styles

Having determined what is required of a leader, how is this delivered in practice?Leadership style refers to the degree of involvement between the leader and the team during decision-making. It can range from the extreme of autocratic or dictatorial to

“Laissez-faire”. In between, there are differing degrees of participation such as democratic and participative.


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Laissez Faire Democratic/Participative Autocratic

Figure 2: Authority Dynamic Range

While “laissez-faire” (loosely translated as anything goes) might appear to be an appropriate attitude, in this case the leader does not care whether the team

performs well or not. This differs from a “relaxed” attitude, while monitoring to assure necessary performance. It may be acceptable to be “laissez-faire” when all goes well, but not if things are going wrong. The definition used here is “laissez-faire”, regardless of performance – which is unacceptable on the flight deck.“VROOM” has isolated five categories on the scale above. These definitions below provide more detail to assist with understanding the concept.

Note that an individual need not always be associated with only one style. For most effective leadership, a different style is adopted according to the situation.

Autocrat [A1]: solves the problem or makes the decision alone, using information available at that time.

Consultative Autocrat 1 [A2]: obtains the necessary information from subordinates, and then decides on the solution to the problem alone. Does not necessarily tell subordinates what the problem is while getting the information from them. The role played by subordinates in making the decision is clearly one of providing the necessary information, rather than generating or evaluating alternative solutions.

Consultative Autocrat 2 [C1]: shares the problem with relevant subordinates individually, getting their ideas and suggestions without bringing them together as a group. Then makes the decision that may or may not reflect the subordinates’ influence.

Consultative Autocrat 3 [C2]: shares the problem with subordinates as a group, collectively obtaining their ideas and suggestions. Then makes the decision that may or may not reflect your subordinates' influence.

Consensus Seeker [G2]: shares the problem with subordinates as a group. Together, generates and evaluates alternatives and attempts to


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reach agreement (consensus) on a solution. The role is much like that of a chairman.

Trying not to influence the group to adopt "own" solution and willing to adopt and implement any solution that has the support of the entire group.

Of these classifications it is worth noting that the last, G2, avoids the Captains’ obligation and duty to make a decision and to accept responsibility.

6.9 Cockpit Authority Gradient

In addition to the style adopted by the Captain, the interaction between the flight-deck members will define the authority gradient between the two. A steep gradient results in ineffective monitoring from the co-pilot, and a flat one reduces the Captains’ authority by constant (unnecessary) challenge.

The optimum gradient, which may differ between individuals and national cultures, encourages an open atmosphere to monitor and challenge, while respecting the Captain’s legal authority.

Jade Cargo International encourages a flat cockpit authority gradient, since there are a number of nationalities, levels of experience and different cultural

backgrounds among the workforce in the company. Nevertheless the duties and responsibilities of the pilot-in-command should in no way be affected by this need.

6.10 Followership

Followership is often perceived as a short-term necessity on the way to a leadership position. While this might be an individual’s view, from the team perspective nothing could be further from the truth. Followers are a vital part of a team, and followership is a skill in its own right. For successful team performance, supportive followers are as important as a leader.

An effective follower requires qualities of flexibility and adaptability, along with good communication skills, predictability and an appropriate level of assertiveness.

“Kelly’s” (Kelly, RE, 1988, A two-dimensional model of follower behavior in Leadership: Enhancing the Lessons of Experience, Hughes, R, Ginnett, R & Curphy, G (Eds), cited by Kern, T, 1997, Redefining Airmanship) model of followership examines two dimensions; that of dependent/independent uncritical/critical thinking and active/passive involvement in the team’s performance. The four combinations available are therefore passive/uncritical, passive/critical, active/uncritical and active/critical. A fifth group “Company men” is chameleons adopting any of the four other styles as appropriate.


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Effective followers are essential to safe flight, not afraid to speak up when necessary and challenge a flawed decision, and actively supportive without being “yes men”.

Alienated followers are those that have identified a problem with the operation, but through disillusionment and disenchantment are not prepared to speak up. They have the potential to destroy a team’s effectiveness, unless identified and brought “back onside”.

Sheep are akin to human automatons, completing tasks in silence without adding to the team’s performance.

Yes people can add an element of danger to the operation, because they actively support without thinking. Their motivation is political rather than task/team oriented. They inhibit crew decision-making and can encourage a feeling of invincibility to the pilot-in-command.

Survivors are the Company men; they are typified by mediocre performance and shift quadrants, not to foster an effective team but to avoid making waves.

6.11 Team Dynamics

Unlike military crews, airlines form new teams for practically every duty. Team building is therefore a skill that needs to be emphasized if a “scratch” crew is to perform well.

A good first impression is vital for successful team bonding and should be accomplished in the first few minutes of team formation. A poor first impression could take as long as seven hours of continual contact to undo. Using the first minutes of meeting effectively is obviously very important. An airline crew needs to be working together and communicating well from before the take-off roll. The only way to ensure this is, to give the best possible impression during the crew brief and ensure that both pilots come across as open to communication from the crew.

Good communication skills have already been identified as critical for both leaders and followers. They are also the foundation for teambuilding.

The crew briefing is probably the only opportunity to foster a vital link between the flight deck and the cabin. Making a good first impression is vital.


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7 Communication7.1 Introduction

One of the key skills required for operating a multi-crew aircraft is the ability to communicate. This chapter describes the principles of communication, the advantages of various communication styles and the requirement for conflict resolution. Barriers to communication are also identified, along with methods of eliminating them.

This chapter is aimed at producing effective crew communication in the context of multi crew operations.

7.2 Principles of Communication

Human communication is the act of sharing information. This can be verbal or non-verbal information.The actual words used accounting for about 10%.

Body Language and tone of voice makes up for the majority of human communication, as much as 90%, The actual words used accounting for only about 10%

The impact of body language is greatly reduced in a flight deck, and very rarely are raised voices heard. So, in communication within a crew, the words used tend to be very important.

Communication on the flight deck can be affected primarily by:

Tone of voice Focusing on own/others’ needs The use of emotional language or “put-downs” i.e. insulting, degrading

language.

7.3 Communication Barriers

The flight deck of an airliner is not an ideal place to have a conversation. There are many barriers to communication within a cockpit. While modern flight decks are well insulated, noise is still a factor. Between a Captain and a First Officer, rank could impinge on communication as well. In the case of Jade Cargo International, culture plays a large part, as does the fact that many of our pilots do not use English as their native language.

Communication breaks down barriers and promotes the exchange of important information. This is the most relevant definition to the task of flying an aircraft. However, verbal communication is one of the oldest forms of human interaction. It serves a complex and vital role in establishing and maintaining relationships


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between people. While a silent flight deck is desirable in some stages of flight, a lively discussion in low workload phases usually goes a long way toward “setting the tone”. Establishing a cordial and efficient working relationship can be made easier by the use of some of the techniques covered in this chapter.

The principle means of communication is by the use of Standard Operating Procedures (SOPs). The SOPs contain standard phrases and occasions when exchanging information or verifying facts is required. By adhering to these “standard calls” the danger of miscommunication is greatly reduced.

7.4 Communication Styles

To assist in analyzing effective communications, two aspects of the message content will be considered; the focus, whether on the needs of others or your own, and the manner, whether unnecessary emotional language or “put-downs” are used.

From these two aspects the following model can be constructed:

Table 1: Communication Styles

“No put-downs”(1)

“Put-downs”(2)

Focus on own needsA

Assertive A1 AggressiveA2

Focus on needs of others

S

SupportiveS1

SubmissiveS2

Four communication styles can be determined from this model; assertive, aggressive, supportive and submissive.

7.4.1 Assertive Behavior [a1]

An assertive style enables one to speak in such a way that one does not abuse or dominate others. It is stating our own needs and feeling without putting others down.Being Assertive:

Heightens self esteem Makes other people take notice Establishes authority

Assertive behavior is a desirable form of communication. This is especially in the flight deck from a person in a position of authority.


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7.4.2 Aggressive Behavior [a2]

This is when someone is being aggressive, not recommended but part of life. However, A2 behavior rarely occurs without precursors. Referring to the matrix, it is clear that aggression comes about when an individual is focused on his own needs and uses put- downs.

Being focused on one’s own needs is very human. Therefore, the key here is the use of “put downs” or abusive language. The key to identifying aggression is the use of “put downs”. This is a “no-go” area for us at work. It is important that “put

downs” or words or tone of voice that may be interpreted as such, are avoided at all times. Defining a “put down” is not easy and it is incumbent on all parties (particularly in a multi-cultural environment such as Jade Cargo International) that great care is taken to avoid anything that can be construed to be one.

When aggressive feelings burst forth we tend to regret it afterwards because serious negative consequences usually occur as a result of aggression.

Aggressive behavior will have a negative impact on a team. It is unlikely to motivate the team, and will likely isolate the aggressor.

7.4.3 Supportive Behavior [s1]

A supportive style focuses on others needs in a way that does not downgrade themselves.

A person being supportive will:

Show concern Not diminish their own or others’ worth Be willing to help and listen

In a typical crew the PNF should adopt a supportive role. However this may change depending on circumstances, such as during training or non-normal situations.

7.4.4 Submissive Behavior [s2]

The simplest definition of submissive behavior is the acceptance of “put downs”. With a submissive style the individual focuses on others’ needs in a way that diminishes their own worth. They put themselves down. A person using a submissive style of communication allows himself to be dominated.

In a non-critical situation, is it better to be submissive in order to defuse a situation? Sometimes it may be preferable to “let it go” in order to preserve harmony.


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Sometimes a person will prefer not to say anything for fear of being laughed or shouted at.

In fact submissive behavior often comes about as a result of aggressive behavior on the part of another person.

If someone is submissive, the assumption might be that they have nothing to contribute, and perhaps discount their views even in a crisis

7.5 Dealing with Aggression

If aggression is met with aggressive behavior, it is likely communication that will break down completely. If the other person is submissive, their needs will be overlooked.

Dealing with aggression is not easy. The best response is to focus on the other person’s needs (where this does not compromise safety) and ignore the perceived put-downs. In other words, be supportive. This brings the focus back to the task at hand and reduces conflict.

An assertive response might also be effective, provided that the intent is to stop the use of put-downs. Since the safety of the flight is of paramount importance and is a common need between all parties, focusing on this usually helps in restoring harmony.

Assertive and supportive behavior styles are those that promote the most efficient communication.

The use of the communication styles model identifies boundaries between own/others needs and the use of “put-downs”. These boundaries are not necessarily static or evenly divided. It may be necessary to vary the style of communication according to the situation. Each individual and in fact every team, will find a style that works well for them. Establishing the position of the lines can be difficult, but leads to good understanding when accomplished.

Some of the factors that affect the position of these lines are:

Race Culture Nationality Age Seniority / Rank

It must be emphasized that the lines move all the time. Being aware of this and expecting it from yourself and others goes a long way toward fostering good communication.


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7.6 Conflict Resolution

Any time two or more people are brought to work together, the stage is set for potential conflict. If conflict does occur, the results may be positive or negative, depending on how those involved choose to approach it.

Conflict should not be taken as another word for not working together. It is possible to cooperate with conflict arising. Conflict is not a necessary component of human behavior, but unfortunately does occur a great deal.

What is important when conflict does occur is that the issue is resolved and that safety is not compromised. Conflict is usually present because of:

Differences in needs, objectives and values. Differences in perceiving motives, words, actions and situations. Differing expectations of outcomes - favorable versus unfavorable. Unwillingness to work through issues, collaborate or compromise.

Resolving conflict requires an analysis of the root cause of the conflict. Reference to the Action-Centred Leadership model1 can assist in probing

sources of differences. Conflict becomes unhealthy when it is avoided or approached on a win/ lose basis. Animosities can develop, communications may breakdown, trust and support will deteriorate. When sides are chosen, productivity will diminish or stop, and the damage is usually difficult to repair.

Conflict resolution can be achieved on a win/win basis and this produces the best results.

Conflict is healthy when it causes the parties to explore new ideas, test their position and beliefs, and stretch their imagination. When conflict is dealt with constructively, people can be stimulated to greater creativity, which will lead to better results.

The two key learning points in resolving a conflict are:

7.7 Problem Solving Needs of both parties are legitimate and important. High respect for mutual support. Assertive and cooperative. No one makes major concessions.

7.8 Compromising Important all parties achieve basic goals and maintain good relationship. There is more than one way to do anything. You must give to get. No one person or idea is perfect.


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Provided these concepts are borne in mind, it is possible for diverse personality types from widely disparate cultures to work together harmoniously and ensure safe flight.

8 Problem Solving and Decision Making8.1 Introduction

Problem-solving and decision-making are activities we conduct instinctively every day. However, once in a while, a situation arises that is beyond our scope or experience. This chapter introduces the Company decision-making model, which provides a structured approach to problem solving and decision-making, either for routine or novel situations.

Using a structured approach for problem solving and decision making leads to a better outcome, and reduces the risk of omissions and errors in the assessment phase of the problem. The importance of time management is also covered in this chapter.

8.2 Structured Decision Making

Research has identified numerous occasions where similar accidents nearly occurred. This raises the question as to whether we should consider good or bad decisions, or good or bad outcomes. It is the end result that we are interested in, however it is the industry’s belief that a structured decision making process will reduce the risk of a poor outcome.

GOOD OUTCOMES ARE GENERALLY ENSURED BY THE USE OF

Briefings Sharing the workload Planning for change Using aircraft equipment to your best advantage

POOR OUTCOMES ARE CAUSED IN PART BY:

Attitudes Failures of judgment Deviation from SOPs Lack of briefings leading to misunderstandings and omissions Emotions overcoming good judgment

Various structured models are in use in airlines around the world. Most of them are based on the original CRM loop of Inquiry, Advocacy, Conflict Resolution, Action and Critique. It is not which model that is used that is important, rather that a model is used. Using a structured approach is a form of SOP for decision making.


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The Jade Cargo International, Risk Management Model (RMM) is for the two man crew cockpit.

The RMM is based on the assumption that the crew is fully proficient with the following;

Handling skills (manual and auto-flight)

Technical knowledge (Type specific)

Procedures (Manufacturer and Company)

Basic Knowledge in Human Factors Principles

It must be emphasized at the outset that the RMM and CRM is intended to provide an extra dimension to the Pilot’s management skills and not to make up for a lack of knowledge or skills in any of the above mentioned documents.

8.2.1 The Model “Footprint”

The model is based on the “Battelle” “Situational Assessment Model” that had been developed for the FAA.

“The Situational Assessment Model focuses on factors that influence a flight crew’s assessment of a situation and the subsequent management of available resources”.

This model was expanded to accommodate the following:

Procedures to rectify / contain the problemMaking a decisionImplementing the decision

However, it is felt that the process to “Rectify / contain the problem” had very specific needs that could only be accommodated by allocating it to a phase of its own. Because this additional phase consists mainly of corrective actions, according to the manufacturers non-normal checklist and or company procedures, it was decided to call this the “Action Phase”.

8.2.2 Providing “Seamless Integration”

To provide the required “seamless integration” as required by Advanced Qualification Program (AQP), further modification to the RMM was required.

During each of the phases specific guidance is provided, indicating when manufacturer’s company procedures should be applied, as well as the appropriate CRM principals.

Flying skills and good management of the auto-flight systems is also applicable throughout the application of the RMM.


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8.3 A Problem-Solving Model

Prior to deciding on a course of action, it is essential to accurately determine what the exact nature of the problem is, its implications and how much time is available. Jade Cargo International uses a problem-solving model to focus on the problem until these questions are answered.

Whenever a problem is encountered at work, there are two typical responses; immediately come up with a solution or stay with the problem by further defining it, seeking more information about it, to make sure we fully understand the implications.

Men in general and particularly pilots tend to go straight to a solution. This does not always produce the best solution. The situation can be considered in two separate domains, the problem and the solution. Any communication relating to this issue can also be considered as either information about the problem/solution or an enquiry.

Using these classifications we can use a model to identify the appropriate type of communication to best assist with resolving the situation.

Enquiry Information

Solution SE SI

Problem PE PI

Examples of each category are:

Solution Enquiry [SE] – Suggestion

Solution Information [SI] – Instruction

Problem Enquiry [PE] - Information seeking, questions

Problem Information [PI] – Analysis

Sometimes it is more appropriate to spend time in gathering information before developing a solution. A key factor in making this decision depends on how much time is available.

Jade Cargo International uses the catch phrase “stay below the line” to help crews focus on the issues related to the problem before taking action.

The line in question determines whether the discussion is centred on the problem (below the line) or on solutions to the problem (above the line). By staying below the line as much as possible, a better understanding of the problem itself can be gained.


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The key of “staying below the line” allows us to fully assess the problem within the available time.

The use of open questions can assist in staying below the line. Consider the likely responses to these two questions:

Where do you think we should divert to? Or Do you think we should divert to Munich?

The first question is an open question [PE?], whereas the second is almost a suggestion [SE]. Open questions allow more options. A solution in the form of a question however, may at best get a query in response, but will probably be accepted, losing vital feedback.Moving above the line is significant because it involves a suggestion or an instruction. In the latter case, all conversation tends to stop and the decision is implemented. It is for this very reason that moving above the line should be done with caution.

8.4 Time Management

Some situations require an immediate response; others may be less time dependent. Assessment of how much time we have is essential in problem-solving. Once a time frame has been established, it is possible to prioritize accordingly.

EFIS architecture, both in Boeing (EICAS) or Airbus (ECAM), is a valuable problem- solving resource. In many cases it assists with our assessment of time.Time can be considered as; critical, available and required.

Time Critical situations require immediate action; this limits the opportunity for assessment. Warnings and Time-Critical Warnings are coded red on EFIS displays. They may be associated with immediate action drills (such as GPWS), recall actions (Engine Fire) or a checklist (Fire Wheel Well). In all cases, immediate action is required. Time spent “below the line” is kept to a minimum.

Time Available: Cautions require a timely response, time is available to consider the problem and when is appropriate to take action. Caution level alerts are amber on EFIS.

Time Required: Other levels of alert may or may not necessarily be identified with color coding on EFIS. However there will be some occasions where it may be necessary to slow down or enter into a holding pattern.

The key to these different types of time is that EICAS/ECAM will assist with our assessment of time, using a traffic light system.

The effective use of time is very important in problem solving. A fast decision may not always be the correct one. On the other hand, taking too much time to collect information and make a decision, when there is little available, might compound


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difficulties. An early calculation of the time situation will assist with decision-making.

8.5 The Jade Cargo International Decision-Making Model

RISK MANAGEMENT MODELAVIATE, NAVIGATE, COMMUNICATE CONTINUOUSLY

[Use Autopilot if available] ASSESSMENT PHASE[Seek information, test understanding, propose, prioritize, summarize]

CHECK CB’s AND SWITCHES

DIAGNOSE: What is wrong? ● IDENTIFY• VERIFY

How to RECTIFY • Identify procedure ACTION PHASE

[Monitor, test understanding, keep partner in the loop]PROCEDURE TO RECTIFY / RECALL ITEMS / USE EICAS, QRH

If needed: “stop the checklist” MANAGEMENT PHASE

[summarize, prioritize, seek information, test understanding propose, build]

EVENT STATUS

Making the Decision Consider:

TASK NEEDS

Aircraft performanceEROPSAWOPSATCDDM/MEL

GROUP NEEDS

crewcompany

passengers

INDIVIDUAL NEEDS

control stressindividual crew members

passenger

Options(Itemize best option, Open Participation) Brainstorm options and check for poor judgment Summaries DECIDE[selling if requiredIMPLEMENTING THE DECISION

Satisfy TASK, GROUP AND INDIVUDUAL needs MONITOR PROGRESS – continually check for poor judgment

(PJ)[Participation, delegation]

Remember that in complex situations, the Captain must manage. This means that the F/O is best assigned the task of flying. Achieving the best solution demands good teamwork. Good teamwork needs good communication.


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8.6 Assess

The assessment phase is characterized by problem-solving and time assessment. However, the first priority is to maintain control of the aircraft, including the navigation away from terrain, obstacles and weather.

Both the assessment and time factor may be provided by EICAS/ ECAM indications. Individual type procedures will determine what other action may be required.

An important point here is that you do not rush. Undue haste has led to more accidents than most people realize.

Once the problem is clearly defined and summarized should we then move above the line.

8.7 Action

During this phase the emphasis is placed on procedural/technical knowledge combined with good communication and monitoring techniques.

The specific action and or checklist required may be dictated by the type of situation. Information may come from SOPs or other sources such as QRH or other manuals and will need to be clearly defined.

8.8 Manage

Once the action has been completed, it is time to manage. “Did the action solve the problem?” “Are you sure?” These are good questions to ask of oneself, if there were any elements of confusion during the initial assess phase.

When the process is complete, we must come back to summarizing our actions and again reflect and analyze our actions. It is a circular or iterative process.

Use Action-Centered leadership to meet the needs of the task, the team and the individual. Action centered leadership is based on the principle that during a normal flight, all the circles are the same size. It is only when you have to make decisions in somewhat abnormal situations that the weighting of the circles change.

For example in the first stages of a diversion, the task need is paramount. Once this is under control, it diminishes in importance and the group need comes to the fore. With the aircraft descending and flying in the desired direction, a good commander will then address the passengers and crew and explain to them the steps taken. Once the Group is informed and placated, individual needs (a cup of coffee or a visit to the restroom perhaps) can be attended to.


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9 Cognition9.1 Introduction

Cognition is all about how humans process information. This chapter looks in particular at some of the limitations of the human brain and the typical errors that can occur as a result. An awareness of these limitations and errors can reduce their impact on flight operations.

9.2 Models

Psychologists use models to produce a simple explanation of how something complex works. A model may not be a very good literal representation of a system, but functionally can be quite accurate. The importance of the model is that it is effective in assisting understanding.

In the same way, individuals create internal representations of how systems work, these are known as “mental models”. Mental models are vital to users for controlling systems and problem-solving. Mental models are also a key component of situation awareness.

Some characteristics of mental models are:

They are incomplete and constantly evolving

They are usually not completely accurate; they typically contain errors and contradictions

They provide simplified explanations of complex phenomena

They can be represented by sets of condition-action rules (If… then…)

9.3 A Model of the Cognitive Brain

As in most processing flows, we will consider the brain in terms of input functions, output functions and an internal processing function.

INPUT PROCESSING OUTPUT

Figure 1: Basic Cognition FlowVery simply, we receive information, do something with that information and then act on it.


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9.4 Input functions

9.4.1 Senses

We have five senses through which we receive information; sight, sound, touch, smell and taste. Flight-deck design typically makes use only of the first three of these – sight, sound and touch.

The advantage of sight is that quite complex information can be transferred to the user as long as they are looking at the signal. Sound on the other hand is omni-directional, but only a limited signal can be conveyed. Routine (status) information is therefore conveyed by visual cues, warnings or “attention-getters” use audible alarms.

9.4.2 Attention

Our senses are constantly receiving and discarding signals, not all of them get through to the processing stage. This is quite normal, as many of the signals are neither intended for us nor relevant to us. However the brain does have a mechanism for making sure that we do attend to matters that affect us. Attention is directed by the processing function and can be thought of as a filter to the overload of sensations all around us.

9.4.3 Divided Attention

Problems occur when we need to attend to more than one matter at a time. We are unable to effectively monitor our principle task. The “cocktail party” syndrome provides a useful example of this. During a busy, noisy social function it is quite possible to sustain a conversation with someone, even though they do not have the loudest voice. The brain will filter the unwanted background noise, but it is not being ignored completely. If someone nearby were to mention a key topic of interest to you (such as your name), it would become increasingly difficult to maintain the original conversation, as firstly you would detect this new signal and secondly try to monitor it as well as the initial conversation.

Attention is believed to be a single-channel function. It is only possible to concentrate on one signal at a time. Those who believe that they can monitor two channels simultaneously, are actually switching from one to the other, at some point they will lose part of one or other signal.

9.5 Perception

Perception can also be thought of as another filter by the processing function. This refers to a “pre-processing” stage where the brain interprets what it thinks it has seen before dealing with it.

Perception is incredibly powerful, so much that, if we miss-perceive an event, it is very difficult to subsequently identify it correctly and take the correct action to


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deal with the problem. Perception is considered to be the first stage of Situational Awareness.

The mind can have difficulty perceiving something it has never seen before or that appears to be impossible. Psychology text-books (and the internet) have numerous examples of such illusions.

9.6 Processing Functions

9.6.1 Memory

Memory is the storage area of the brain. The processing function is considered to have two types of memory, short-term and long-term. Another type of memory is sensory memory, which really belongs with the input functions.

9.6.2 Sensory Memory

Sensory memory refers to how long the senses maintain received data before it is consciously dealt with or lost.

An example might be an R/T call that interrupts a conversation, typically with the response “…was that for us?” but by the time the question is asked, the original message has been replayed by the mind. In this case the “echoic” memory (of the auditory system) can retain the data for as long as 10 seconds.

Iconic memory (for visual stimuli) is almost literally gone in a flash, for instance if you are looking in the general direction of the EICAS/ECAM and a message pops up and disappears, you have as little as 0.5 second to replay the stimulus before it is lost.

Sensory memory data is lost by decay, and retained by conscious attention.

9.6.3 Short-Term Memory

Short-term or “Working” memory is extremely limited and slow in operation. It has a capacity of approximately seven bits of information. New information received on top of this will replace the current contents of working memory, unless it is consciously being dealt with.

We can increase the effectiveness of our short-term memory by “chunking” information.

The string “28531018015011972” is clearly longer than seven digits. However it becomes more manageable even with additional information in the form – “Heading 285, speed 310, descend 180, expect 150 by xxx, and contact 119.72”.


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Chunking has reduced this sequence to just five bits of information, manageable by most.

Short-term memory data is lost by displacement and retained by rehearsal.

9.6.4 Long-Term Memory

Information transfers to the long-term or permanent memory by rehearsal and repetition. It is believed to be unlimited in capacity and lasts forever. However the problem is not with forgetting, but with inability to retrieve or access the information.

Data in the long-term memory can be in the form of single bits of data or in the form of learned routines, patterns or mini theories. This enables this “knowledge-base” to handle recurrent routines, using “motor actions” without recourse to the conscious workspace.

Retrieval of information is fast and effortless and parallel processing is available.Data is stored in one of two methods by the long-term memory; episodic memory gives an autobiographical view of events, whereas semantic memory stores similar data in a form of hierarchical tree. This enables the brain to come up with a “sensible wrong answer”, even if the correct data has never been learned.

For example, if you were told that Lexus have developed a new luxury car, but it is top secret, you would be able to state with a fair degree of confidence that:

It has four wheels

It has leather seats

It has an amazing stereo

It will be available in black and silver

….. some secret?

Long-term memory data is not lost, but becomes irretrievable due to interference.

One technique to assist with retrieval is the use of mnemonics, such as ATM (Avoid, Trap, and Mitigate).

9.6.5 Flashbulb Memory

This is a phenomenon which describes what happens when an event so incredible occurs that the information is immediately placed in long-term storage. Usually the event and what you were doing at the time are inextricably linked as one memory. For this reason it is normally possible to date these events quite accurately, long after the event.


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Examples of events producing a “flash-bulb” effect are; the assassination of JFK[November 1963], the explosion of the Space Shuttle Challenger [January 1986], the death of Princess Diana [August 1997] and the crash of Concorde [July 2000].

The events of September 11, 2001 are slightly different in this respect, as they are referred to by the date itself.

9.6.6 Central Processor/Decision-Maker

The processor in the brain is exceptionally powerful; however it is a single channel device.

It can only deal with one issue at a time. There may be occasions where it appears to be doing several tasks, but in fact it is just switching quickly between them.

There are other occasions where humans can do more than one thing at a time, this is when the action has become a learned routine, a response and is handled by the knowledge-base in the form of “motor-actions”.

It is the intention in pilot training to transfer emergency drills into over-learned routines, in particular responses to RTO, GPWS and Wind-shear warnings fall into this category. This prevents the cognitive functions from reaching overload and resulting inaction.

9.6.7 Problems with Decision Making

As powerful as it is, human decisions have numerous sources of bias that may hinder optimal performance. The process tends to be dominated by vision and can only work sequentially.

Common psychological traps that humans may encounter include:

Confirmation bias – only accepting evidence that confirms our position and rejecting contradictory evidence.

Availability – Solutions selected because they are available and simple to execute regardless of effectiveness.

Overconfidence

Sunk Cost – “throwing good money after bad”

Wishful thinking

Outguessing Randomness

Plan Continuation Error – The most significant trap that we fall into as pilots is that we find it hard to discontinue a bad approach, or we press on


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towards a landing with significant issues not resolved.

9.7 ConclusionThe brain is exceptionally powerful but typically limited to dealing consciously with one issue at a time. It is easily overloaded and can also produce biased results. This chapter highlights some of the issues now that they have been identified, your brain knows how to deal with them…

10 Stress and Alertness10.1 Introduction

Stress may be defined as the demands that act on the human body. Some of these place physical strains on the body, others mental strains, some a combination of both.

This chapter covers the effects of stress, sleeps loss and disruption on the body and discusses techniques to manage stress and alertness.

Our interest is human performance. Performance varies with a number of factors, including workload and circadian rhythms. In this respect, stress and fatigue produce similar results. Alertness is a term used to describe the state of the body as it reacts to stress and also to describe a state of awareness. The term arousal will be used as the generic term for both.

Optimum Stimulation Creativity Rationality

Problem Solving Progress

Under Stimulation Over Stimulation Boredom Overload

Frustration Confusion Dissatisfaction Distress


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The diagram above can be used to explain the effects of both stress and fatigue and these are covered below. The left side of the curve shows a person in a state of under- stimulation. The right side shows over stimulation. Optimum human performance takes place in the shaded area at the top of the curve. It is preferable to remain on the left hand side of the curve, within easy reach of peak performance if new demands arise.

Critical phases of flight, such as take-off and landing, require the crew to be at optimal performance, but the time spent in these phases is relatively short. Sustained operation in the shaded area is however, largely impossible. Performance tends to degrade very rapidly if an attempt is made to remain at optimum for a long period.

10.2 Stress

Stress is not necessarily a bad thing. A small amount of stress acts as a stimulus and results in improved performance. In the diagram above, consider that arousal refers to stress. Initially, as stress increases, performance improves, from being somewhat dormant, into the optimum performance range (shaded). As stress increases further, performance actually peaks, and then falls away. After a certain point, which differs according to individuals and within individuals, performance declines below optimum or satisfactory performance and enters a rapid decline thereafter.

Stress has been necessary for the evolutionary survival of the human. The well-known “fight or flight” or “adrenalin rush” syndromes are as a result of stress. These prepare the body to react when presented with danger. Stress is also a factor in achieving peak performance due to the release of adrenalin.

Too much stress decreases a person’s ability to function. Too little stress causes complacency. The body needs an optimum level of stress to operate.

10.3 Types of Stress

Stress can be divided into two types, acute and chronic. The American Psychological Association explains these as follows:

10.3.1 Acute Stress

Acute stress is the most common form of stress. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. Acute stress is thrilling and exciting in small doses, but too much is exhausting. A fast run down a challenging ski slope, for example, is exhilarating early in the day. That same ski run late in the day is taxing and wearing. Skiing beyond your limits can lead to falls and broken bones. By the same token, overdoing on short-term stress can lead to psychological distress, tension headaches, upset stomach, and other symptoms.


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Fortunately, most people recognize acute stress symptoms themselves. It's a laundry list of what has gone awry in their lives: the auto accident that crumpled the car fender, the loss of an important contract, a deadline they're rushing to meet, their child's occasional problems at school, and so on.

Because it is short term, acute stress doesn't have enough time to do the extensive damage associated with long-term stress. The most common symptoms are:

emotional distress--some combination of anger or irritability, anxiety, and

depression, the three stress emotions;

muscular problems including tension headache, back pain, jaw pain, and the muscular tensions that lead to pulled muscles and tendon and ligament problems;

stomach, gut and bowel problems such as heartburn, acid stomach,

flatulence, diarrhea, constipation, and irritable bowel syndrome;

transient over arousal leads to elevation in blood pressure, rapid heartbeat, sweaty palms, heart palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, and chest pain.

Acute stress can crop up in anyone's life, and it is highly treatable and manageable.

10.3.2 Episodic Acute Stress

There are those, however, who suffer acute stress frequently, whose lives are so disordered that they are studies in chaos and crisis. They're always in a rush, but always late. If something can go wrong, it does. They take on too much, have too many irons in the fire, and can't organize the slew of self-inflicted demands and pressures clamoring for their attention. They seem perpetually in the clutches of acute stress.

It is common for people with acute stress reactions to be over aroused, short-tempered, irritable, anxious, and tense. Often, they describe themselves as having "a lot of nervous energy." Always in a hurry, they tend to be abrupt, and sometimes their irritability comes across as hostility. Interpersonal relationships deteriorate rapidly when others respond with real hostility. The work becomes a very stressful place for them.

The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent tension headaches, migraines, hypertension, chest pain, and heart disease. Treating episodic acute stress requires intervention on a number of levels, generally requiring professional help.


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Often, lifestyle and personality issues are so ingrained and habitual with these individuals that they see nothing wrong with the way they conduct their lives. They blame their woes on other people and external events. Frequently, they see their lifestyle, their patterns of interacting with others, and their ways of perceiving the world as part and parcel of who and what they are.

10.3.3 Chronic Stress

While acute stress can be thrilling and exciting, chronic stress is not. This is the grinding stress that wears people away day after day, year after year. Chronic stress destroys bodies, minds and lives. It wreaks havoc through long-term attrition. It's the stress of poverty, of dysfunctional families, of being trapped in an unhappy marriage or in a despised job or career.

Chronic stress comes when a person never sees a way out of a miserable situation. It's the stress of unrelenting demands and pressures for seemingly interminable periods of time. With no hope, the individual gives up searching for solutions.

The worst aspect of chronic stress is that people get used to it. They forget it's there. People are immediately aware of acute stress because it is new; they ignore chronic stress because it is old, familiar, and sometimes, almost comfortable.

Chronic stress kills through suicide, violence, heart attack, stroke, and, perhaps, even cancer. People wear down to a final, fatal breakdown. Because physical and mental resources are depleted through long-term attrition, the symptoms of chronic stress are difficult to treat and may require extended medical as well as behavioral treatment and stress management.

10.3.4 Sources of Stress

A stressor is the term used to define the cause of stress. Generally, stress is accepted as the human response to these stressors, which exhibits as either a physical response e.g., sweating, tremors, hyperventilation, heart arrhythmia, or a mental response such as irritability. There are three broad sources of stressor: life, environmental and cognitive.

10.3.5 Life Stress

Life stress typically results from a person’s particular lifestyle. More precisely, a change in lifestyle is a source for this type of stress. This could come in many different forms. Some examples are: marriage or divorce, change in job or responsibilities (i.e. promotion to Captain), the illness or death of a close relative or friend.


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Research carried out by various organizations suggests a strong link between life stress events and aircraft accidents. The original research was carried out by US Navy psychologists during the Vietnam era and has been expanded since.

The most quoted example is that of a pilot experiencing marital difficulties, who collided with a ground vehicle whilst landing. His accident statement directly attributed the incident to his state of mind.

However, as it is a mental “picture” it is extremely difficult to establish any direct causal link between life stress and an aircraft accident. Suffice to say that life stress is almost definitely a threat to aircraft safety, especially when it involves an operating pilot.

10.3.6 Environmental Stress

Environmental stress results from the physical environment surrounding an individual. Two common examples could be heat and noise. Sleep disturbance is also a source of environmental stress; this will be covered later in the chapter.Heat causes a subtle and unseen form of incapacitation. Temperatures in the cockpits rise rapidly on the ground during summer.Noise is an unavoidable factor with aircraft operation, either on the apron, or in the flight- deck. In the long-term, most pilots will experience some degree of hearing loss. Noise is generated internally (radios) and externally (airflow and engine). Pilots using noise attenuating headsets report less fatigue over long sectors. Noise arouses the individual, but exposure for extended periods also causes a drop in performance.

10.3.7 Cognitive Stress

Cognitive stress refers to the mental workload imposed on a person. This is caused by the limited ability of humans to process information.

The effects of cognitive stress overload are most often experienced in high workload situations. High workload causes a skilled pilot to commit what are termed “action slips”. These occur when a pilot follows a “motor-action” response and selects a control very similar to the desired one, but with a dissimilar function. Examples are the auto-brake selector instead of brake fans, or the selecting SPD instead of HDG.

When workload is high, humans tend to become victims of “intentional selectivity”, as their brains try to accept large and unmanageable chunks of information. The effect is that pilots will become focused on a task, and mismanage priorities. This is referred to as “tunnel vision”.

Another not uncommon consequence of high workload is the tendency to trade accuracy for speed. This is again caused by the brain trying to manage large chunks of information in short periods. In trying to complete a task and move to


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the next, humans will trade off speed against accuracy. The tendency is to accept a less than optimum solution to a problem, thereby inducing further errors.

Although this can be an effective strategy, self- discipline must be exercised to ensure a review is completed checking the suitability of actions performed.

Response time, or experiencing difficulty in responding to another task is another possible symptom. Again this is caused by the inability to manage large amounts of information. Where pilots have actually assigned priorities to other tasks, they may become bogged down in processing the data. Typically, this occurs during pre-flight where the workload is high with pre-assigned priorities. For example, a F/O may experience difficulty in calculating the take-off speeds because he feels the need to check the ATIS for the latest temperature. The inevitable result is a slowdown in completing the task.

10.4 Alertness

Consider that arousal now refers to alertness, or state of awake ness. Immediately after awakening, the mind and body are still in a state of drowsiness. Depending on the individual, it may take some time before performance reaches an acceptable level. After some time of being awake, the range of optimal performance is reached. As in the case of stress, this continues to improve performance until, after reaching a peak, it starts to decline as fatigue or weariness sets in. This might be due to time since awake, workload (physical exertion), lack of stimulus (stress) or circadian rhythms. Other factors affecting alertness might be the quality and/or quantity of the previous sleep (sleep debt).Managing alertness is an essential skill for long-haul flying. Jade Cargo International aircraft have advanced automation features that manage most routine tasks. However, this can have a negative effect during the cruise, when workload is at an absolute minimum. On a night flight, inactivity and a lack of interaction in a low-light environment can result in insufficient stimulation and loss of vigilance. Techniques for maintaining vigilance in such a situation are similar to those for combating fatigue.

10.5 Sleep Management

Sleep is a vital physiological function. It cannot be stored, but conversely a sleep debt can build up, if we do not achieve enough sleep at the right time. A loss of sleep leads to suppressed Rapid Eye Movement (REM), leading to withdrawal effects and further disrupted sleep.

Sleep quality is also affected by our body clock. Better quality sleep is achieved during our natural night. Sleep achieved as the body temperature starts to rise can be disrupted by mid-morning, with an inability to sleep further. Getting eight hours of disrupted sleep can have effects similar to too little sleep.The consequences of sleepiness are:

Decreased physical and mental performance


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Decreased positive and increased negative mood

Increased vulnerability to performance decrements

Following sleep loss, sleep is deeper rather than longer.

An individual with a significant “sleep-debt” (accumulated sleep disruption) is often irritable, inattentive and has an increased reaction time. Longer term effects include depression and chronic fatigue.

Stress and fatigue combine to pose a significant challenge to airline operations. Knowing how to combat the ill-effects caused by these factors is an acquired skill that needs to be practiced actively by the modern airline crewmember.

10.6 Circadian Rhythms

A well-rested individual operating within their normal circadian rhythms, will have little problem achieving optimal performance at short notice should it become necessary. However, the nature of long-haul operations means that pilots are more often than not, neither well rested nor within their circadian rhythms.

The typical biological clock works on a 25-hour cycle. It is kept synchronized on a daily basis by exposure to bright light and regular social interaction.

The longer body-day also makes it easier to adjust to time zone changes on westbound routings, which extend the operating day, rather than eastbound which compresses the day.

Following the disturbance of a time-zone change, not all body functions re-synchronize at the same rate, this can leave the pilot somewhat disoriented for several days after a trip involving several time-zone changes. This is known as jet-lag.

Jet-lag can be described as external or internal. External refers to the body being “out of sync” with the environment, on the wrong time zone. Internal refers to the different body functions being “out of sync” with each other. Shift-work has similar effects to jet-lag, which include:

Disturbed sleep (inability to fall asleep or stay asleep)

Increased waking (work-time) sleepiness

Decreased physical or mental performance

Increased reports of fatigue

More negative mood

Gastrointestinal problems


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Circadian RhythmsAs with the other threats that we face, circadian disrhythmia is not sufficient cause to cease operations. It is another warning flag, providing awareness and in need of management.

10.7 Stress and Alertness Management

The FOM requires pilots to be in good physical and mental health – fit for duty. Managing stress and sleep effectively, is the duty of every crewmember.

Exercise is often used as a form of stress relief. In extreme cases this can take the form of dangerous sports. Others prefer mental stimulation. The use of card and board games has historically been a popular form of stress relief. In the modern world, computer games appear to be increasingly filling this role.

The use of alcohol is not recommended as a form of stress relief. As any medical practitioner will verify, this is a potentially dangerous practice, with dire consequences in the aviation industry.

10.8 Controlled Rest in the Flight Deck

The FOM also provides for controlled sleep during low workload situations. This acts as an effective fatigue prevention tool and allows a satisfactory level of alertness to be maintained.

The duration of rest is limited to prevent sleep inertia. This practice is based on extensive research done by NASA among others. It has proven that controlled rest is a very effective tool for combating fatigue and maintaining alertness, when conducted in a structured fashion.

11 Situational Awareness11.1 Introduction

Situational awareness is frequently stated as a factor in accidents and incidents. However it is often quoted without really being explained. In accidents involving human error, a staggering 88% have been identified as involving a loss of situational awareness.

This chapter will explain what it is, who has it and the skills necessary for maintaining and sharing situational awareness.

11.2 Levels of Situation Awareness (SA)

“Endsley” has produced the commonly accepted definition of situation awareness as: “The perception of the elements within a volume of time and space, the


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comprehension of their meaning and the projection of their status in the near future.”

This is quite complex, but what it means is that there are three levels of situational awareness. It is not just enough to notice a situation; one must understand and think ahead.

The problems with SA in accident cases have mostly revolved around pilots failing to notice!

Figure 1: Levels of Situational Awareness

The key to situational awareness knows what comes next.

In addition to three levels of SA, there are different domains that must be monitored by the pilot. The pilot must monitor the aircraft (flight-path, automation modes, systems, fuel and time), the environment (terrain and weather) and the people (ATC, crew, passengers and company). In a well-known phrase: Aviate, Navigate, and Communicate.

The Importance of Situational Awareness

Now that we know what SA is, why is it so important? Situational awareness is considered to be the driving force behind good decisions. If we are aware of all the relevant factors (good SA), then our decisions will be well founded and good performance will follow.

Situational Awareness + Decision-Making = Performance

SA is our current “mental mode” and not only directs attention where required, but it guides our selection of goals by providing understanding and projection.

11.3 Loss of Situational Awareness

Individuals have differing levels of situational awareness; those with normally high SA tend to recognize when they are losing SA, which mitigates part of the problem.


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Clues that indicate a possible loss of SA are ambiguity, fixation and confusion. These may indicate that an error chain is in progress. Most accidents involving human error include at least four of the following:

Ambiguity - information from two or more sources that doesn't agree

Fixation - focusing on any one thing to the exclusion of everything else

Confusion - uncertainty about a situation (often accompanied by anxiety or uneasiness)

Failure to fly the plane: everyone is focused on non-flying activities

Failure to look outside: everyone heads down

Failure to meet expected checkpoint on flight plan or profile-ETA, fuel burn, etc

Failure to adhere to standard operating procedures

Failure to comply with limitations, minimums, regulations etc

Failure to resolve discrepancies - contradictory data or personal conflicts

Failure to communicate fully and effectively - vague or incomplete statements

11.4 The Safety Window

Reviews of accident trend data continue to indicate that most accidents occur close to the ground, during the take-off and landing phases. In fact most are within seven miles of the airport.

Jade Cargo International uses the concept of the “Safety Window”. When below 2000’ AGL (approximately 7nm from the airport) there is limited time to troubleshoot an unresolved problem. The philosophy is to stay out or get out of the safety window where ambiguity, fixation and confusion exist.Results from observations at several different airlines, identified that most of the consequential and additional errors occurred during the descent and landing phase. Since historically over 70% of accidents have occurred in this phase, there is much to be concerned about here.

A three-stage model “Avoid, Trap, Mitigate” is one solution to the problem. Avoiding error is the initial course of action, if potential problems can be identified in time. Prior to descent, clear briefings and good communication should take place to achieve this.

After descent initiation, less time is available for noticing and avoiding, so the emphasis should switch to trapping any errors that do occur. Additional errors should be guarded against as these could lead to an error-chain forming. The trapping phase begins at top-of- descent and leads up to the approach.


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In the final stages of the approach, an undesired aircraft state (i.e. unstabilized approach, too high, too fast etc) must be avoided. Should such a state occur, there is very little time left to correct it. The best strategy is to “Mitigate” the problem by going-around. The Mitigate phase commences at the start of the Safety Window (2000’ AGL).

11.5 Situational Awareness and Error Management

Using “Threat and Error” management principles, potential problems that are identified early allow the opportunity to avoid, indicating that the crew is thinking ahead [Level 3 SA]. If the crew is trapping a lot of errors, this may indicate they are operating at understanding [Level 2 SA]. Finally, if mitigation seems to be the key factor, then the crew is only noticing problems [Level 1 SA].

Human error is inevitable. By analyzing how we deal with the problem, we can make the link to identify at which level of SA we are operating at, so that we can take action to improve it.

11.6 Factors Affecting Situational Awareness

Studies have revealed a ten-fold difference in SA between pilots within the same airline. It has also been observed that crews flying non-glass aircraft have better SA than those with the latest technology.

Basic skills that high SA crews exhibit are; communications, scan patterns and checklist use. Advanced skills include pre-flight planning, contingency planning, self-monitoring, task management and prioritization.

Situational awareness can be trained to a certain extent. Skills relating to spatial ability, perceptual speed and working memory capacity are inborn. However, attention-sharing, psychomotor skills and pattern matching are trainable.

11.7 Communication and Shared Situational Awareness

For a crew to be most effective they must share the same high SA, otherwise crew SA tends to fall to that of the weaker crewmember. Information can be shared at all three levels of SA.

Consider the case of an unexpected tailwind on approach, identified by the PM: PM: “Looks like a 15 knot tailwind on approach”

This is shared perception – they have noticed the problemPF: “OK, I’ll reduce speed xx miles earlier than briefed, and use the speed brake if necessary.”This identifies shared comprehension – the PF understands.

PM: “They might change runways if the surface wind picks up.”Flight Crew Training Centre

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This is shared projection – they are thinking ahead.

Typically crews are comfortable with “perception” level communication, but for various reasons feel inhibited in offering more processed information for fear of offending the other pilot.

It is essential to confirm a level of understanding when communicating at the perception level. The response “Ok” is no guarantee that the other pilot has even noticed – he may just be acknowledging that you have stopped speaking!

11.8 Techniques for Better Situational Awareness Management

Predetermine crew roles for high-workload phases of flight.

Develop a plan and assign responsibilities for handling problems and distractions.

Solicit input from all crew-members including cabin, ATC, maintenance, dispatch, etc.

Rotate attention from plane to path to people - don't fixate.

Monitor and evaluate current status relative to your plan.

Project ahead and consider contingencies.

Focus on the details and scan the big picture.

Create visual and/or aural reminders of interrupted tasks

Watch for clues of degraded SA.

Speak up when you see SA breaking down.


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12 Reference NotesHelmreich, R.L., & Merritt, A.C. (1996, April). Cultural issues in crewresource management. Paper presented at the ICAO Global Human Fac-tors Seminar, Auckland, New Zealand, April, 1996.

Helmreich, R.L., & Merritt, A.C. (1997). Local solutions for global prob-lems: The need for specificity in addressing human factors issues. Paperpresented at the IXth International Symposium on Aviation Psychology,Colombus, Ohio, April-May, 1997.

Merritt, A.C., & Helmreich, R.L. (1995). CRM in 1995: Where to fromhere? In Proceedings of the Third Australian Aviation Psychology Sym-posium, Sydney, November 20-24, 1995.

Merritt, A.C., & Helmreich, R.L. (1996). Creating and sustaining a SafetyCulture. CRM Advocate, 1, 8-12.

Merritt, A.C., & Helmreich, R.L. (1996). CRM: I hate it, what is it? (Er-ror, stress, and culture) Paper presented at the Orient Airlines Associa-tion Air Safety Seminar, Jakarta, Indonesia. April 23-25, 1996.

Merritt, A.C., Helmreich, R.L., Wilhelm, J.A., & Sherman, P.J. (1996).Flight management attitudes questionnaire 2.0 (International) & 2.1(USA/Anglo) (Technical Report 96-4). University of Texas: AerospaceCrew Research Project.

Merritt, A.,C., (1995). Designing culturally sensitive CRM training:CRM in China. Paper presented at the Training and Safety Symposium,Guangzhou, P.R.C., May 1995.

Merritt, A.C., (1997). Replicating Hofstede: a study of pilots in eighteencountries. Paper presented at the IXth International Symposium on Avia-tion Psychology, Colombus, Ohio, April-May, 1997.

Ooi, T.S.,. (1991). Cultural influences on flight operations. Paper pre-sented at the SAS Flight Academy Training Conference, November 26-28,1991.

Taggart, W.R., (1995). The Aerospace Crew Research Project Line-LOS-Checklist: Assessing system safety and crew performance. In proceed-ings of the VIIIth International Symposium on Aviation Psychology. Co-lumbus: Ohio State University.


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