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Quarterly TP Newsletter October 2013

Risk Management-A Critical Element of Single Pilot Resource Management-Part 1

(Submitted for the October 2013 TP newsletter by Robert Wright on 9-27-13)

Risk management expertise is critical to safe operation of any aircraft, especially high performance light business aircraft (LBA) operated by a single pilot. Risk management skills are a subset of a larger skill set known as single pilot resource management (SRM) which, in addition to risk management, includes skills such as automation management, task and workload management, and maintaining situational awareness. Risk management can be broken down into three distinct phases: identification, assessment, and mitigation. In this article, I’ll briefly describe the risk identification process and in future articles I’ll cover risk assessment and risk mitigation.

Risk identification begins by identifying various types of hazards that may affect your planned or on-going flight. These may be classified into four categories by using the simple acronym “PAVE,” which stands for Pilot, Aircraft, Environment, External pressures. Pilots must identify all existing hazards in each category before and during flight in order to conduct effective risk identification. Pilot-related hazards include qualification, currency, and aeromedical related risks. Qualification refers to the basic license and other qualifications for the flight in question. A pilot’s level of recent experience will have similar consequences if he/she has not maintained currency and proficiency. The aeromedical category includes a wide range of issues including use of prescription and non-prescription drugs, illness, fatigue, and other factors.

Aircraft-related hazards include availability of installed equipment, the operability of that equipment, and aircraft performance issues.  Limitations in aircraft performance capabilities, such as range and takeoff performance, can also present hazards and risks under certain conditions.

Environment-related hazards cover a wide range of conditions and include weather, terrain, airport, airspace, night operations and other potential risks. Each of these environmental sub-elements warrant their own discussion and environment-related risks are perhaps pilots’ biggest risk management challenges.

External pressure-related hazards include work, family, passenger, air traffic control, and other elements that can impact pilots and create overt or subtle pressures to begin or continue a flight in the face of high risks associated with other hazards. Your job as a single pilot of an LBA is to practice effective SRM and risk management and identify all risks associated with a planned or continuing flights. Of course, not all risks are created equal and your next task is to assess risks in terms of their likelihood and severity. I’ll cover risk assessment, as well as risk mitigation, in future articles.

You can improve your SRM and risk management skills by taking the Single Pilot Resource Management course offered by TrainingPort (www.trainingport.net). If you are a multi-pilot crew, Crew Resource Management courses are also available at TrainingPort.net. All of these courses were developed by subject matter experts at Crew Resource Management LLC (www.criticalcrm.com).

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Asiana Flight 214

On July 6, 2013 Asiana flight 214 struck the seawall while approaching runway 28L at SFO airport. The Boeing 777 broke apart with the gear, tail section, and both engines separating from the aircraft. The broken airliner came to rest 2400 feet from the impact point, left of the centerline of the runway. In the days after this accident, several pilots’ friends called to ask the obvious question: “How does a Boeing 777 crash in VFR conditions?”

When an accident occurs, we pilots naturally begin to run a checklist of things in our minds to try to determine how this could happen, and more importantly, what we can learn from this sad event. As the NTSB begins to reassemble the threats and errors that cause an accident, we also try to pull from our own experiences and quietly form our undisclosed opinions. Some pilots go through a post accident ritual, being careful to not label a cause. Yet we seem to always consider things like the weather, windshear, equipment failure, and unfortunately, the possibility of terrorism.   Having flown many transpacific flights in my career, my first thought about a potential cause for this accident was fatigue. Fatigue is the silent, ominous threat that is always present at the conclusion of a long international flight. The more times a pilot flies an approach where fatigue is a factor, the more he or she begins to develop a serious respect for this concern.  82 seconds before impact the autopilot and auto throttles were disconnected.  So in other words, the pilots of Asiana flight 214 were flying the end of the approach by hand after they had crossed the Pacific Ocean. Whenever I witness a fellow pilot disconnect the autopilot and auto thrust late in an approach to try to prevent a go around, it automatically heightens my awareness of the situation.  This action can create considerable reason for concern, especially during approaches in which fatigue is a factor.

An approach into SFO at the end of a long transpacific crossing when the weather is IFR or Low IFR will always raise the crew’s level of concentration and focus due to the potential loss of visual conditions. But VFR weather can pose a threat that may be under emphasized or even overlooked: being complacent. IFR weather forces ATC to sequence aircraft at a rate to accommodate IFR spacing with intercepts to the localize and glide slope that are within the TERPS guidelines. However, when the weather is VFR, the potential for ATC to assign a visual approach that can end up in a high and fast to low and slow profile is very real.

Asiana 214, like most accidents, is a culmination of a series of threats that lead to a tragic and unacceptable conclusion. The Reason Model, discussed in many CRM training programs of how an accident occurs, vividly comes to mind. The image of Swiss cheese with all the holes lining up to create a path to an unmitigated series of errors that end up with a broken airplane is the classic image of this accident. The answer to the question of how a Boeing 777 could crash in VFR conditions is hard to imagine. My younger brother has flown the 777 for many years. I distinctly remember him saying that if he were to build an airplane to fly passengers around the world, he would build the 777.  In his opinion, the Boeing 777 is a joy to fly and it is truly a pilot-friendly aircraft. One of the benefits of flying new generation aircraft is the level of automation that has been incorporated into the cockpit. While this automation has many advantages, it has also created its own set of unforeseen complications for pilots. As the NTSB disclosed information about the approach and impact, it became evident that the high and fast profile that this crew was given eventually did become a classic case of low and slow. Pilots generally do not look at VFR conditions as a threat, but being fatigued while approaching a runway with the glide slope out of service and then turning off the autopilot and autothrust can be disastrous if not managed correctly.

This past June, our subject matter expert and author of our single pilot risk management course (SRM), Mr. Bob Wright, was speaking to a major aviation university that hosts students from various counties around the world. Bob was speaking about cultural issues that can be very difficult to change when a person comes from a place that has a deeply engrained respect for authority. There are counties in the world that foster respect to the point where authority is rarely, if ever, challenged. Bob spoke about our conflict resolution program that specifically addresses the issue of power distance. There are places in the world where power distance presents significant problems, and there are companies and organizations that harbor the same type of issue with challenging authority. This phenomenon is not restricted to aviation. It is also engrained in the medical profession, the military, and many other high-risk industries. Power distance issues are very real, and are important to bear in mind while trying to understand the chain of events that lead to an accident like the one seen with Asiana flight 214.

Reflecting on this tragedy, I can’t help but think that the basics of CRM are absolutely essential to the safe conclusion on any flight. The older I get, the more convinced I am that the CRM pillars of communication and team building can make significant contributions to the pursuit of keeping all aviation careers blemish-free. Making a point to tell each of the crewmembers, including the most junior person, that they are an integral part of the team and encouraging their input regarding safety has become a regular part of my preflight briefings. The other two pillars of CRM, workload management and technical proficiency, should be under constant consideration as well. It is of utmost importance to verbalize any and all potential threats, even something as simple as a visual approach with no glide slope. While this may seem mundane, it could possibly set the tone for a go around command instead of an accident.

 

Captain Tom Perillo,
CRM, LLC Partner

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Breaking News! CRM LLC announces new online courses for Maintenance Resource Management and Single Pilot Resource Management!

CRM LLC is proud to offer two incredibly important new courses to its online selection. After the success of our Crew Resource Management (CRM) courses online, we have been regularly rolling out new classes for every kind of aviation operator.

Starting next week (just in time for NBAA!) customers can sign up for Maintenance Resource Management and Single Pilot Resource Management classes through our great partner TrainingPort.net.

 

About Single Pilot Resource Management (SRM)

Our online modules for SRM are a natural extension of our work with CRM. SRM will reduce risk and increase operational safety through awareness and tools tailored to single pilots.

“This is the first comprehensive online Single Pilot Resource Management course created with the Light Business Aircraft pilot in mind.” – Robert Wright

This course has been created under the direction of Robert Wright, president of Wright Aviation Solutions, LLC and a former Federal Aviation Administration executive.

 

About Maintenance Resource Management (MRM)

Our online modules for Maintenance Resource Management (MRM) include every topic recommended by the FAA and the EASA.

  • Safety Culture/ Organizational Factors
  • Human Errors
  • Leadership
  • Effective Communication
  • Shift Turnover
  • Assertiveness
  • Teamwork
  • Conflict Resolution
  • Workload Management
  • Decision Making
  • Situational Awareness
  • Norms
  • Professionalism and Integrity
  • Cross-cultural perspective

This course has been created under the direction of a highly qualified and respected expert in the field of human factors in aviation maintenance who holds a Ph.D. and M.S. in Human Factors Engineering/ Industrial Engineering and is employed as a maintenance human factors engineer with a major, global aircraft manufacturer.

Sign up for our email newsletter to keep in touch if you want to be notified when these courses are live and ready to go!

 

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Are you a Part 135 operator? Here’s what CRM means for you!

The FAA has mandated Crew Resources Management training for all Part 135 operators by March 22, 2013.

Not only is CRM training a requirement, but it means safer flying.

We evaluated Part 135 accidents over eleven years (March 20, 1997 through March 7, 2008). During this time period, there were 24 accidents (18 involving airplanes and 6 involving helicopters) with causal factors directly related to a lack of effective CRM. These accidents were responsible for 83 fatalities (66 involving airplanes and 17 involving helicopters) and 12 serious injuries (all involving airplanes).

Furthermore, of the 18 airplane accidents, 8 involved single-pilot operations and 10 involved dual-pilot operations. All 6 of the helicopter accidents involved single-pilot operations. The individual accident histories are in the Final Regulatory Evaluation, which is in the docket.

CRM LLC provides the training Part 135 operators need. Check out our online courses and get what you need to keep flying safely!

 

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Experienced Pilots make fatal error that cost the lives of 199 people

On July 17, 2001 the lives of 199 people abruptly ended when the A320 Airbus that they were on skidded off the Runway 35L at the Congonhas Airport in Sao Paulo, Brazil. This airport is considered to be one of the most dangerous airports in the world with many Threats that pilots face when operating in and out of this field.

The pilot’s judgment and actions were the last line of defense to mitigate the effects of the asphalt, weather and the compound effects of the stress that these pilots faced.

This screenshot from CRM’s online training module shows how the aircrew is the last line of defense to avoid an incident or accident like what happened in Sao Paolo.

 

If you want to learn more about the Sao Paolo incident,  here is a short feature about it produced by the Smithsonian Channel.

CRM LLC is an industry leader in Threat & Error management training.

 

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Learning from our mistakes

Aviation, as we know, “is terribly unforgiving” of mistakes and errors. When they happen, we must take the opportunity to learn from them.

During childhood, it was our parents who reminded us to learn from our mistakes. In the cockpit we don’t have a parent there to remind us, so we use each other to help us learn from our own mistakes as well as the mistakes of others. That’s where CRM, and the Threat and Error Model come in, giving us the opportunity to examine what went wrong.

For years, many of our more popular Aviation Publications have dedicated a portion of their publication to Accident/Incident Review. Flying magazine is one such publication that immediately comes to mind with its monthly column titled “I Learned About Flying From That.”

Recently, one of our nations larger Aircraft insurers has joined the ranks by sending out unidentified accident reviews courtesy of the NTSB in its “safe flight series” as a CRM tool to educating pilots by learning from our mistakes. Their latest excerpt relates to Fuel Issues and is well worth checking out.

In their words, “an educated pilot is a safe Pilot” and we at CRM LLC could not agree more. That’s why we have added a dedicated accident review module to our current course selections.

In this module, we pick a Crew Performance Indicator (CPI) of the CRM model and examine what went wrong to cause the accident, as well as what could have been done to prevent it using the tools of CRM  and Threat & Error Management in some engaging online content. We have also added accident review as part of the Threat And Error module this year to show the value of applying the concepts of Threat & Error Management and “Learn from our Mistakes” as an aviation community.

Click here for more about all of our CRM course offerings, including “Accident Review.”

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What was the “Miracle on the Hudson?”

… and what does it have to do with CRM?

On January 15, 2009, US Airways flight 1549 made history when the aircraft successfully ditched in the Hudson River adjacent to midtown Manhattan.

The flight was disabled by ingesting a flock of Canadian geese during its initial climb out. The crew of US Airways Flight 1549 had only minutes to assess the situation, communicate with each other, air traffic control, the flight attendants, passengers and then enact a plan.

Captain Sullenberger lead his team successfully through an emergency ditch landing and the safe evacuation of all the passengers and crew.  The incident became known as the “Miracle on the Hudson.”

The “miracle” that allowed the flight to safely land in the Hudson was a direct result of proper CRM training and employment: concise communication and superior workload management.

In other words, the individuals were working together as a crew.

When President Obama invited him to the inauguration, Sullenberger insisted he would only accept if his crew were invited as well—that’s how much he saw the entire crew as sharing the success. Read more »

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What is Crew Resource Management?

Aviation has always been a complex environment in which mistakes can be deadly. For a long time, the risk associated with aviation was generally accepted as “the cost of doing business.”

After the infamous “black box” was developed, we gained a new insight into what caused accidents. As the technology had increased, the flight recordings revealed that human error was at the heart of the majority of commercial airline accidents. In other words, those accidents and the loss of life were absolutely avoidable.

In 1972, the black box showed that Eastern 401 crashed in the Florida Everglades while the crew was focused on a problem that turned out to be nothing more than a burned-out lightbulb. Six years later, United 183 ran out of gas and crashed short of the field because the crew was troubleshooting a minor mechanical issue.

Aircraft crews, although technically proficient as individuals, were functioning completely independently. They didn’t communicate critical information at critical times. In other words, they weren’t functioning as a “crew.”

After this became more widely understood, in 1980 industry leaders formulated a solution: Cockpit Resource Management—later re-named and redefined as “Crew Resource Management,” which emphasizes the use of the entire crew, extending far beyond the cockpit. Read more »

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Crew Resource Management is now on Twitter & Facebook!

CRM is joining the social media revolution and getting its Twitter and Facebook accounts squared away.

We know how important it is for you to keep up to date with changing regulations and industry standards, and we will use Facebook and Twitter to give you the information you need to fly safely and in full compliance with the FAA.

So please follow us on Twitter and like our Facebook page, and together let’s start a conversation about the future of safety and risk management in the aviation industry!