Crew Resource Management: PT Riau Airlines

Crew Resource
Management
PT Riau Airlines
General Outline
• Introductions & ground rules
• Command and Leadership
• Controlled Flight Into Terrain
Avoidance
• Team Building and Maintenance
• Human Errors
Is
Aviation
Safe
Even though aviation is
safe…
What people believe is…
big
chance of
Why do most people feel that
aviation is dangerous?
• 1920s US Air Mail

• 1950s aviation accident rate
• Today’s “accident statistic rate”
• Media coverage.
The media covers
aviation accidents
because they make
“good” (bad)
headlines.
Studies have shown that
75-85% of all people
onboard an aircraft that
crashes with fatalities
will live!
So who cares what the public
thinks…we know better
• Who buys our tickets? (or

funds our department)
Two challenges
• Change public perception
• Change reality
Commercial Aircraft Accident
Statistics World Wide
“FLAT
line”
The future…
r ate)
d ent
cc i
n a
ng ei
c ha
Number of t (No
n
urre v ement
accidents C ro
Slig ht imp
What we need?
Aviation activity
Command
and
Leadership
Definition:
• Command:
–to have authority over and
responsibility for
• Leadership:
–Capacity or ability to lead
Command
• Who
?
• What
• When
• Where
• Why
• How
Leadership
?
• Is command necessary for this
• Does it shift
• What are the characteristics
• Can this be done alone
Characteristics of a leader
• Think of a bad leader you have worked for

– What were they like
– How did you perform
• Think of a good leader you have worked for
– What were they like
– How did you perform
Blake Mouton
• Concern for People - This is the degree to which
a leader considers the needs of team members,
their interests, and areas of personal
development when deciding how best to
accomplish a task
• Concern for Production - This is the degree to

which a leader emphasizes concrete objectives,
organizational efficiency and high productivity
when deciding how best to accomplish a task.
Team Leadership - High
Production/High People
These leaders stress production needs and the needs of
the people equally highly.
• employees are involved in understanding organizational
purpose and determining production needs.
• When employees are committed to, and have a stake in
the organization's success, their needs and production
needs coincide.
• This creates a team environment based on trust and
respect, which leads to high satisfaction and motivation
and, as a result, high production.
Leadership Styles
• Autocratic
• Bureaucratic
• Charismatic
• Democratic
• Laissez-faire
• People-oriented
• Servant
• Task-oriented
• Transactional
• Transformational
Transformational Leader
(Bernard Bass)
• Is a model of integrity and fairness;

• Sets clear goals;
• Has high expectations;
• Encourages;
• Provides support and recognition;
• Stirs people's emotions;
• Gets people to look beyond their self-interest;
and
• Inspires people to reach for the improbable.
Emotional Intelligence
The ability to make healthy

adaptive choices, based upon our
ability to identify, understand
and manage our own emotions
and the emotions of others
Emotional Intelligence
(four competencies)
• Self-Awareness
• Self-Regulation
–Motivation
• Empathy (social awareness)
• Social Skills
Command
• Who
!
• What
• When
• Where
• Why
• How
Delta Engine Fire
Delta Airlines
Aircraft Engine Fire
Salt Lake City International Airport
DL Flight 229 from SLC to PDX

19 June 1996, at 23:28 LT
Delta Engine Fire
The clear dialogue and good
SHARING COMMAND
between
Fire Command, DL Flight 229, and SLC tower
And due to
EXCELLENT COMMUNICATION
there were no personal injuries, and aircraft
damage was minimal.
Controlled Flight Into Terrain (CFIT)
Avoidance
Definition
Controlled flight into terrain (CFIT) occurs when
an airworthy aircraft
under the control of the flight crew is flown

unintentionally into terrain, obstacles or water, usually with
no prior awareness by the crew.

Fatalities by Accident Categories
Fatal Accidents, Worldwide Commercial Jet Fleet
(1990-1999)
CFIT
•25% Accidents
•32% Fatalities
Two-thirds of
the accidents
happened
within 8 miles
CFIT In most of
the CFIT
of the runway accidents,
the airplane
Map location of CFIT accidents/incidents was lined up
From runway threshold, 40 accidents/incidents with the
runway.
Runway
threshold 5
Tracks where a map display

10
would have probably helped
pilot(s) identify and correct
problem
15
Fatal accident track
Incident track
CFIT
Vertical profile of some recent CFIT
accidents/incidents
Note that many
of these
3000 approaches are
3º Outer marker, 5nm
stabilized 3
2000
degrees right
Altitude into the ground.
(feet)
1000
0
10 9 8 7 6 5 4 3 2 1 0
Distance to runway threshold (nm)
200 180 160 140 120 100 80 60 40 20 0

Average time (seconds)
CFIT Precursors
Terrain critical airport
Night or IMC (remember night = IMC)

No radar
Non-precision approach
Non-English first language speaking pilots or
controllers
Primary Errors That Contribute to
CFIT Accidents
• Communication Error
• Navigational Error
• Procedural Error
• System Operation Error
• Decision Error
• Monitoring / Challenging Error
(Lack of) Situational Awareness

No global standard practiced by all users
Settings
Inches of Mercury Hectopascals Millibars
• QNE – Standard pressure setting (not adjusted for current

conditions, airport elevation will be “off”)
• QNH – Field elevation above sea level upon landing
(adjusted for current conditions)
• QFE – Reads zero on field when take-off or landing
(adjusted for current conditions)
Altimeters
Inches of Mercury Hectopascals Millibars
• Know what altimeter units of measurement are used for the area.
• Be vigilant during radio transmission. Verify if in doubt. Read back ALL numbers
(not 992)
• Know the phase of flight to apply the appropriate altimeter setting.
• Cross-check radio altimeter and barometric altimeter readings.

Situational Awareness
Awareness determines what
part of the world exists for us.
The skill of focus
• Cluttered field of view, your ability to count

the passes.
• Count the completed passes between the
white team
Awareness determines what
part of the world exists for us.
We can only respond to

that which we are
aware of.
Theory of Practice
Skills that we build up over time
– Training
– Experience
Part of our long term memory

Theory of Situation
• Fit the world into our memory of it (theory of
practice)
• Creatures of deletion
When YOU examine the world, when you look

around… what do you see with?
• I won’t believe it till I see it!
• If I hadn’t believed it, I

wouldn’t have seen it.
We Look/Hear with
our eyes and ears
BUT
We See/Listen with
our brains.
We are creatures of deletion
– Good – allows us to focus
– Bad – may delete critical information so that we

do not even know it is there
THEORY of situation
• Based on:
– Awareness of the current
environment
• Plus:
– Our stable long term memory.
– Experience / Training / Beliefs
Decision making
Decisions are based on our Theory Of
Situation.
The information you have
The way that information has been

interpreted
Task Loading
Tasks
Task Loading =
Available Time
More errors are likely to

occur when task loading is high
Case Study: AA 965 “Cali”
• Experienced, Good B757 crew
• Capt. had been there 13 times prior, FO’s

first trip
• Night with no significant weather
CFIT Precursors
Terrain critical airport
Night or IMC (remember night = IMC)
No radar
Non-precision approach (but switched to)
Non-English first language speaking pilots or
controllers
The real world…
Reenactment (from transcript)
Factors That Contribute to
CFIT Avoidance
• Briefings
• Altimeters
• Safe Altitude
• Air Traffic Control
• Flight Crew Alertness
• Standard Operating Procedures
• Training
If NOT visual day
When you hear:
“that’s odd”
“what’s going on”
“how did that happen”
Immediately
check altitude, go to sector if not there or
above
If NOT visual day
When you hear:
“WHOOP, WHOOP…Pull UP”
Immediately pull up
Safe Altitude
Don’t descend below “Safety-

Altitude”
• Make sure adequate charts are available.

• Study the altitude information, using detailed charts.
• Know and fly at or above the safe altitudes for your area of
operation.
• Understand terrain clearance limitations for approaches.
“Proceed direct to “Roger that…I better check
airport.” my altitude requirement.”
ATC
Accepting clearance is accepting
responsibility
• Challenge or refuse ATC instructions when they are not clearly

understood, or conflict with your assessment of aircraft position
relative to the terrain.
• Exercise good radio communication discipline.
• Know the height of the highest terrain or obstacle in the operating area.
• Know your aircraft’s position in relation to the surrounding high terrain.
Procedures
Remember! Many procedures
have a history written in
BLOOD
• Do not invent your own procedures.
• Use all available approach and runway aids.
• Use every aid to assist you in knowing your position.
• Follow the SOP

Stabilized Approaches
“I’m not stabilized. I’m
going around!”
• Fly stabilized approaches.

• Execute a missed approach if not stabilized.
• Use all available aids
• If not comfortable on approach – GO AROUND

Briefings
Briefings Set the Tone for the

Mission
• Crews must conduct proper brief before Take Off & Landing
• They must adhere to SOPs.
• Both pilots should anticipate and promote a common understanding of what is to
be expected.
Team Building and
Maintenance
NASA & Joint European Studies
Team Effectiveness
Markers
(10 TEMs)
NASA & JES
#1 Briefings
and the communication
that follows
NASA’s 10 TEM
1. Briefings
2. Acknowledgement
3. Inquiry/Assertion/Advocacy
4. Communications/Decisions
5. Leadership/Followership/Concern for Task
6. Preparation/Planning/Vigilance
7. Workload Distributed/Distractions Avoided
8. Conflict Resolution
9. Self Critique/Debriefing Decisions & Actions
10.Interpersonal Relationship / Team Climate
NASA’s 10 TEM
1. Briefings
The effective briefing should be
thorough, interesting and should
address all the work requirements.
Although primarily the Captain’s and
supervisor’s responsibility, other
members may add significantly to the
process.
Briefings
Establishes atmosphere for open

communication and participation
Briefings
Team Briefing
35
30
25
20
15 Effective
10 Damaging
5
0
Briefing
Percent of Times Cited
Captains greatest impact on crew

performance, positive or negative, is in
the crew briefing
NASA
NASA Flight
Flight Crew
Crew Observation
Observation
Briefings
Break
Barriers
Briefings
Let me find out
about…
All mammals need sleep
7-10 hours in every 24 is “right” for most humans
NASA’s 10 TEM
2. Acknowledgement
Assess the consistent use of
acknowledgement in both giving
and receiving information to
ensure complete communication.

Key to Undistorted
Communication is…
Making sure the message gets
through.
(acknowledgement)
The message isn’t sent unless its
acknowledged.
Communication
Process
Clear & concise,

sent, received, understood,
accepted, acted upon
NASA’s 10 TEM
3. Inquiry/Assertion/Advocacy
Assesses the extent to which individual
advocate the course of action they feel is
best in a clear specific manner, avoiding
hints (trial balloons), even when it
involves conflict or disagreement with
others.
NASA’s 10 TEM
4. Communications/Decisions
Reflects the extent to which clear and
open communication is practiced. This
includes providing necessary information
at the appropriate time (initiating
checklists and alerting others to
developing problems).
D.E.C.I.D.E.
• Detect change
• Estimate Significance
• Choose outcome objective
• Identify options
• Do something
• Evaluate its effect
Let’s not follow in their
wake…
Aircraft – an A-320
• Departed Toronto, the aircraft “rotated
itself” on the take-off roll and struck its
tail
• The take-off was rejected and the
aircraft taxied back to the gate.
wake…
• Flight planned from Toronto, to
Montreal, to Margarita Venezuela.
• Bulk of passengers board in Montreal.
• To speed up boarding in Montreal the
agents in Toronto came up with an
excellent plan…
wake…
• All 89 passengers departing
Toronto were seated in the
very back of the aircraft.
wake…
• Computer loading over-ridden…
• Paperwork given to flight deck
normal…
• Flight attendants noticed…
• Ground agents noticed…
• Ramp agents noticed…
wake…
BUT
No-one told the flight deck

NASA’s 10 TEM
5. Leadership/Followership/Concern for
Task
To evaluate the extent to which
appropriate leadership and
followership is practiced as well as
the extent to which the team is
concerned with the effective
accomplishment of necessary tasks.
NASA’s 10 TEM
6. Preparation/Planning/Vigilance
Indicates the extent to which individuals
anticipate contingencies and actions that
may be required. Whether the team was
“ahead of the curve” or constantly playing
catch-up. Did the team devote
appropriate attention to tasks and
respond immediately to new information.
NASA’s 10 TEM
7. Workload Distributed/Distractions Avoided
This is a rating of time and workload
management. How well were tasks
distributed and was any individual
overloaded. Also considers how well work
is prioritized and how the team avoids
being distracted from essential activities.
NASA’s 10 TEM
8. Conflict Resolution
How well the team resolved
interpersonal conflict if it
occurred any time during the
flight.
A Crew is a Relationship
Our differences and interdependence can

breed conflict
Fist Fight Erupts in A340 Cockpit:
Two pilots slugged it out with each other in
the cockpit of their Airbus A340 during an
April flight from Bangkok to Istanbul.
Colleagues had to separate a furious fist fight
between the Captain and a First Officer after
they started arguing over what altitude they
had been assigned by ATC.
A junior co-pilot took the controls while the
pair were pacified.
Conflict & the “I message”
 “I have a problem.”
 “I feel…”
 “When you…”
 “Because…”
 Pause for discussion
Define the possible solutions.
 “I would like…” OR
 “ I want/need…” OR
 “I will settle for…”
Remember that 93% of all communications is
Tone and Body Language!!
Constructive VS Destructive
Conflict Skills
“I” Statements
“I feel…….” “You Always……”

“I think ……” “You Never……”
“I need……” “You need to……”
“problems are only opportunities in work clothes”

>>Henry Kaiser
Constructive Conflict Skills
How To Have A Difficult
Conversation
Learn their story
– Check your perceptions/assumptions
– Use “open” questions
Express your views and feelings
– Use “I” statements
– Don’t exaggerate with “Never” and “Always”
Problem solve together

– Be aware of your contribution
– Shift from “My way” to “Our way”
– Respect the relationship
People are different
People are different
Type A, Type B
5 hazardous thought patterns
 Anti Authority – NOBODY tells *me* what to do!
 Impulsivity – I must act NOW there is no time!
 Invulnerability – It won’t happen to me
 Macho – I’ll show them! I can do it
 Resignation – What’s the use…
5 antidotes
 Anti Authority – Follow the rules, they
are usually right
 Impulsivity – Wait, think first.
 Invulnerability – It will happen to me
 Macho – taking chances is foolish
 Resignation – I am not helpless, I can
make a difference
Which “Haz” Attitude?
Who is BEST?
Homework Assignment
NASA’s 10 TEM
9. Self Critique/Debriefing Decisions &
Actions
Evaluates the extent to which individuals
participate in debriefing, operational
review, and critique of activities. Critique
can, and should occur during, and/or after
the completion of an activity. Critique
does not necessarily imply negative
evaluations of performance. It may be
positive in nature as well.
NASA’s 10 TEM
10. Interpersonal Relationship /
Team Climate
This reflects the observed
quality of interpersonal
relationships among the team
and the overall climate.
Human Errors
When there is an accident what
do we do?
What causes an Accident/Incident?
Accident Chain
The sequence of events that culminate in
an accident or incident.
Accidents are not the result of a single

factor.
Typically 7 or more links in an accident

chain.
Lots of SMALL errors

not big errors.
Lots of SMALL errors

not big errors.
This common link (Human Factors) is the key to
preventing accidents. NOT the stumbling block we’ve
fallen to believing it is.
“Error can be
eliminated if
people are
sufficiently
vigilant,
conscientious, and
proficient.”
What do you think ? – True or False?

HUMAN Errors
• Beginner
• Expert
• Workload
Error Chain
• Each error forms a link in the accident chain
• Forge enough links, the accident will happen
• Break enough links, the

accident will NOT
happen
HUMAN Errors
?
• Beginner
• Expert
• Workload
What are they, how are they countered?

Beginner Errors
• Knowledge based
• Skill based
Solved by:
• Standard Operating Procedures

• Training
• Guided On the Job Training
• Mentoring
• Supervision
HUMAN Errors
?
• Beginner
• Expert
• Workload

One Decision Related Expert
Error
• Cutting corners….
• Failure to follow the SOP

Expert Error Number One
ABC’s of Human Behavior
• Activator
– occurs prior to the behavior
• (direct us)
• Behavior
– observable act
• (what we do)
• Consequences
– the potential results of the behavior
• (motivate us)
ABC’s of Human Behavior
• Activator
– occurs prior to the behavior
• (direct us)
• Behavior
– observable act
• (what we do)
• Consequences
– the potential results of the behavior
• (motivate us)
Attributes of
Consequences
Positive or Negative
Sooner or Later
Certain or Uncertain
Attributes of
Consequences
Positive or Negative
Sooner or Later
Certain or Uncertain
Why do we cut corners?
Potential outcomes / consequences
Lots and Lots (Positive, Soon, Certain)
Get Hurt (Negative, Later,Uncertain)
Get in trouble (Negative, Later, Uncertain)
Consequences of not crouching
A - Procedure requires
B – Cut corner
C – Save time and energy
Because the Negative, Later, Uncertain so

strong…
It will not
happen
here…
Risk
Denial
Error
Error
• Cutting corners….
• Failure to follow the SOP

Mirror images
Error
• Error is the result of the way the mind works
• The stronger the skill, the more prone the
person is to make “absent minded” error
• These “absent minded” errors are the domain
of the expert
– 4 kinds of these
Skill & Error
Simply trying hard will not prevent

errors.
Skill & Error
The more skilled we become, the more

automatic the action becomes.
We can perform a task more quickly with

less conscious attention.
timed test
Pink
Blue
Green
Red
Black
Orange
Grey
Blue
Pink
White
Green
Orange
Yellow
Yellow, Green, Blue,
White, Black, Red, Blue,
Green, Blue, Yellow,
White, Green, Blue, Blue,
Green, Black, White,
Black, Yellow, Green,
Red
Expert Error… (?)
Expert Errors
Slip of habit
Expert Errors
Losing track of past actions
Expert Errors
Losing track of past actions
Recognition Failure
Expert Errors
Recognition Failure
SHE
SELLS
SEA
SHELLS
BY THE
THE SEA SHORE
Memory Block
Expert Errors
BOTTOM line about Expert
Errors…
We are DOOMED!!!!!
Open COMMUNICATION to accept the
possibility that
you can be wrong.
Thank people when they try to point it

out.
Don’t criticize someone (including

yourself) when they make an error.
BOTTOM line about Expert Errors…
They are inevitable…
which means that the journey towards
is impossible
Recently, I was asked if I was going to fire an
employee who made a mistake that cost the
company $600,000. No, I replied, I just spent
$600,000 training
him. Why would I want somebody to hire
his experience?
-Thomas J.Watson,
industrialist
(1874-1956)
This doesn’t work!
HUMAN Errors
?
• Beginner
• Expert
• Workload

Can YOU
multi-task?
Let us find out shall we?
• Follow these directions….
– Take the piece of paper provided
– Fold in half lengthwise
– On the one side, at the very top print:
Multi Tasking Is Worse Than A Lie

– Now draw a line from one side to the other that

you can write above and below
– WHEN we start (not yet) what you will do is,

alternate the letters from the sentence above the
line and the number of the letter in sequence below

m
1

mu
1

mu
12


mu
12
– When I say start… and not before,
– You will complete the task
– As fast as you can
mu
12
• WHEN you are finished, look up and notice the time on the
screen, write that time down beside your completed work.
(and stay quiet till everyone is finished)
PART TWO
• On the flip side

• Write the sentence again
PART TWO
Multi tasking is worse than a lie
• Draw a line down the center again

PART TWO
• Draw a line down the center again

PART TWO
• THIS time, you get to write the sentence

out completely, and then
PART TWO
Multi

PART TWO
Multi tasking

PART TWO
Multi tasking is worse

PART TWO
Multi tasking is worse than a

PART TWO

PART TWO
• Come back to the start and number the

letters in sequence
PART TWO
12345…
• Come back to the start and number the

letters in sequence
PART TWO
12345…
• WHEN you are finished, look up and notice the time on the
screen, write that time down beside your completed work.
(and stay quiet till everyone is finished)
Results?
• Single track
• Switch cost
Crew
Resource
Management
• Command and Leadership
• Controlled Flight Into Terrain
Avoidance
• Team Building and Maintenance
• Human Errors
Change
Successes and Failures
Human Factors (HF) Training has
been validated
Human Factors (HF) Training does

not always move from classroom
to the operational environment.
Terima Kasih
Reediting by
Arif Nursid
Chief FLOPS PT Riau Airlines
Street Street
Alley Alley
Street Street
Street
Street
Street Street
Alley Alley
Street Street
Street
Street
Street Street
Alley Alley
Street Street
Street
Street
Street Street
Alley Alley
Street Street
Street
Street
THE Right Answer?
• Good decision
– With the information you had at the time, made sense,
turned out correct
• Wrong decision
– With the information you had at the time, made sense,
turned out you were missing other information which
made the decision incorrect
• Bad decision
– With the information you had at the time… you should
have known better

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Crew Resource

• 1920s US Air Mail

• Who buys our tickets? (or

• Think of a bad leader you have worked for

• Concern for Production - This is the degree to

• Is a model of integrity and fairness;

The ability to make healthy

DL Flight 229 from SLC to PDX

under the control of the flight crew is flown

no prior awareness by the crew.

Tracks where a map display

Fatal accident track

200 180 160 140 120 100 80 60 40 20 0

Night or IMC (remember night = IMC)

(Lack of) Situational Awareness

Inches of Mercury Hectopascals Millibars

• QNE – Standard pressure setting (not adjusted for current

Inches of Mercury Hectopascals Millibars

• Know the phase of flight to apply the appropriate altimeter setting.

• Cross-check radio altimeter and barometric altimeter readings.

• Cluttered field of view, your ability to count

We can only respond to

Part of our long term memory

When YOU examine the world, when you look

• If I hadn’t believed it, I

– Good – allows us to focus

– Bad – may delete critical information so that we

The information you have

The way that information has been

More errors are likely to

• Experienced, Good B757 crew

• Capt. had been there 13 times prior, FO’s

Don’t descend below “Safety-

• Make sure adequate charts are available.

• Challenge or refuse ATC instructions when they are not clearly

• Do not invent your own procedures.

• Use all available approach and runway aids.

• Use every aid to assist you in knowing your position.

• Follow the SOP

• Fly stabilized approaches.

• If not comfortable on approach – GO AROUND

Briefings Set the Tone for the

Establishes atmosphere for open

Captains greatest impact on crew

Clear & concise,

No-one told the flight deck

Our differences and interdependence can

“I feel…….” “You Always……”

“problems are only opportunities in work clothes”

Problem solve together

Accidents are not the result of a single

Typically 7 or more links in an accident

Lots of SMALL errors

Lots of SMALL errors

What do you think ? – True or False?

• Break enough links, the

What are they, how are they countered?

• Standard Operating Procedures

What are they, how are they countered?

• Failure to follow the SOP

Because the Negative, Later, Uncertain so

• Failure to follow the SOP