Crew Resource Management Phil O'Donnell

Crew Resource Management
Phil O’Donnell
Manager Operations and Planning
Audits
W E S T E R N E L E C T R I C I T Y C O O R D I N A T I N G C O U N C I L
2
In 2013, there were 36.4 million commercial flights

worldwide carrying more than 3 billion passengers.
There were 224 fatalities!
3
What is Crew Resource Management?

• Definition(s)
• Beginnings
• Evolution
• Elements of CRM
• Why you should add it to your training
program
– Case study for comparison to the power industry.
4
Definitions
• Crew Resource Management (CRM) is a
management system which makes optimal use
of all available resources—equipment,
procedures and people—to promote safety
and enhance the efficiency of flight
operations.
• CRM is a tool created to optimize human
performance by reducing the effect of human
error through the use of all resources.
5
Definition
• Slightly modified for consideration by the
power industry…
• A management system which makes optimal
use of all available resources—equipment,
procedures and people—to promote safety
and reliability and enhance the efficiency of
system operations.
6
1979 NASA Workshop
• Focused on causes
and recommended
solutions to
commercial aviation
accidents
7
Common Elements of Accidents

• Preoccupation with minor mechanical problems
• Inadequate leadership
• Failure to delegate tasks and assign
responsibilities
• Failure to set priorities
• Inadequate monitoring
• Failure to utilize available data
• Failure to communicate intent and plans
8
Environments for CRM

• High-impact, adverse (or life threatening)
outcomes when mistakes are made
• Technical complexity
• Multiple path/task options
• Team/individual interactions
• Communications
9
Evolution beyond the “Cockpit”

• All available resources
– Non-flying crew members
– Airline dispatchers
– Maintenance personnel
– Air traffic control
10
Evolution beyond the “Cockpit”

• Other industries
– Military (primarily aviation)
– Medicine
– First responders (firefighters)
– Maritime industry
– Bulk electric system operations?
11
Obstacles to Success
• Professional Culture
• Organizational Culture
12
Cultural Challenges
• In 2013, a study published in the Journal of

Patient Safety put the number of premature
deaths associated with preventable harm at
more than 40,000 per year.
13
Culture
• Medical doctors at pinnacle of their industry
(and society)
• Need to look good
• Striving for perfection
• Reluctance of anyone to speak up
• Pilots were no different
• Requires a significant cultural shift
14
What does your “Crew” Look Like?

• How many have a formal shift supervisor?
• System Operations “Crew”
• Transmission Operator (how many)
• Balancing Desk or Generator Dispatch
• Transmission Schedulers
• Engineering Support
• IT/Data Support
• Your Reliability Coordinator
15
Components for Training

• Communications
• Situational awareness
• Decision making
• Teamwork
• Barriers
16
Communications Competencies
• Efficient
• Clear
• Professional
17
Situational Awareness
• System monitoring
– Part of technical competency
• Forecasting and anticipation
– Goal of no surprises
• Cross-training
18
Planning and Decision Making

• Operations and outage planning
– Are conditions as expected
– Go/No Go
– Pre evolution brief
– And…
19
Teamwork Competencies
• Leadership
– Inspiring leadership is good
– Authoritarian leadership—not so good
• Team workload management
– Pace tasks when possible
– Use available resources
• Adaptability
– Cross-training
20
Barriers
• Stress
– Task saturation
– Time pressure
– Confusion (Automation and MMI)
21
Barriers
Lack of Assertiveness
Can be related to teamwork, communications,
leadership or culture
• Get attention
• State concern
• Identify the problem
• Offer a solution
• Obtain agreement
22
Case Study - Air France Flight 447
23
Case Study - Air France Flight 447
• Rio de Janeiro – Paris: June 1, 2009

– Weather
– Complex, automatic flight systems
– Alarm displays and task saturation
– Time of day and crew rest
– Leadership and teamwork
24
Air France Flight 447

Airbus A330-203 Aircraft
• 3 experienced flight crew,
– Collectively 61 years experience, 20,471 hours behind the controls
• 9 cabin crew and 216 passengers also on board
• Departed 10:29 p.m. local time
• The flight data recorder was found and brought to the surface
on May 1, 2011, and the cockpit voice recorder on the next
day
– Almost 2 years after the accident
25
447 Cause of Accident

• Sensor inputs for airspeed indication failed.
• The crew did not make the connection between
the loss of indicated airspeeds and the
appropriate procedure.
• Inappropriate control inputs that destabilized the
flight path.
• One pilot’s late identification that other pilot was
not making proper corrections.
• The crew’s failure to diagnose the situation and,
consequently, the lack of any actions that would
have made recovery possible.
26
Time Element
• First problem at 2 hours 10 minutes and 5
seconds into the flight
• Impact with the sea at 2 hours 14 minutes and
28 seconds
• 4 minutes and 23 seconds
27
Time Element
During the September 8, 2011 Southwest
Blackout
• Initial trip of the Hassayampa-North Gila 500-
kV line at 15:27:38
• Collapse of the San Diego, Yuma, CFE island at
15:38:39
• 10 minutes and 59 seconds
28
Air France Flight 447

41 Safety Recommendations related to:
• Flight recorders;
• Certification, training, and recurrent training of pilots;
• Relief of the captain;
• Search and rescue;
• Air traffic control;
• Flight simulators;
• Cockpit ergonomics; and
• Operational feedback and oversight of operators by the national oversight
authority.
29
2011 Southwest Blackout

27 Recommendations related to:
• Next-day planning;
• Seasonal planning;
• Modeling deficiencies;
• Situational awareness tools;
• External visibility;
• Staffing and training of the Reliability Coordinator;
• Communications;
• System analysis;
• IROLs; and
• Protection systems.
30
Weather
31
Control Rooms
32
Operating Limits
33
Alarm Displays
EMS Alarm Display Screen
34
35
Controls
36
Air France CRM Training
• Flight crew attend an initial two-day course

– First day when rated to fly an aircraft
– Second day after 6 months experience
• Each year ½ day
• Twice per year during simulator training
37
Improving CRM can Enhance Reliability

• It’s NOT a silver bullet.
• Takes more than one effort.
• Challenge to make it realistic.
• Like any training, focus on weak areas or
barriers.
38
Defense in Depth
• It is rarely one failure that results in an incident or
accident
• Every resource, when used correctly, can help stop
the progression
39
Thank You
Phil O’Donnell
Manager Operations and Planning Audits

Crew Resource Management Phil O'Donnell

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Crew Resource Management Phil O'Donnell

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Crew Resource Management

Crew Resource Management

In 2013, there were 36.4 million commercial flights

What is Crew Resource Management?

1979 NASA Workshop

Common Elements of Accidents

Environments for CRM

Evolution beyond the “Cockpit”

Evolution beyond the “Cockpit”

• In 2013, a study published in the Journal of

What does your “Crew” Look Like?

Components for Training

Planning and Decision Making

Case Study - Air France Flight 447

Case Study - Air France Flight 447

• Rio de Janeiro – Paris: June 1, 2009

Air France Flight 447

447 Cause of Accident

Air France Flight 447

2011 Southwest Blackout

EMS Alarm Display Screen

Air France CRM Training

• Flight crew attend an initial two-day course

Improving CRM can Enhance Reliability

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