CRM: Lessons Learned from LOSA

James Klinect
The University of Texas Human Factors Research Project CRM Conference 2000 Southwest Airlines

Human Factors Research Project

The Many Generations of CRM

First Generation Cockpit Resource Management
Strong focus on personality and interpersonal behavior

Second Generation Crew Resource Management

More team oriented and specific to flight operations

Third Generation CRM training in context

Considered the environment (e.g., org culture) Extended CRM to other groups (e.g., Check airmen and flight attendants)

Fourth Generation CRM integration and proceduralization

Doing away with stand-alone CRM training Full integration of CRM with technical training (e.g., AQP)

Fifth Generation CRM

Criticisms of previous CRM generations
1. CRM had lost its focus What is CRM? Not just training that helps pilots work together as a team 2. CRM had become an end unto itself Trained and evaluated CRM in independently of technical

performance

Fifth generation CRM Needed to make the original purpose of CRM more explicit and universal
Purpose - Error management

LOSA and CRM

Problem Little data supporting fifth generation CRM
How do flightcrews detect and manage error in normal operations? What are effective and ineffective error management strategies? What magnitude does CRM play in error management?

LOSA - provides the needed data As a result of LOSA data, our perspective of CRM is starting to become more refined
1. Expand the definition of fifth generation CRM 2. Individual CRM skills play specific roles as threat and error countermeasures

An Expanded Definition of CRM

Fifth Generation CRM
Error Avoidance

Threat Management CRM Skills Error Management

Undesired Aircraft State Management

Threat and Error Countermeasures

After 4000 LOSA observations.

Behavioral markers as threat and error countermeasures

As a result, four groupings of threat and error countermeasures have emerged

1. 2. 3. 4. Team building Planning Execution Review / Modify

Team Building Countermeasures

Two markers
1. LEADERSHIP In command, decisive, and encouraged participation 2. COMMUNICATION ENVIRONMENT Communication channels established and maintained

Critical for all levels of performance:

Error avoidance Threat management Error management Undesired aircraft state management

Planning Countermeasures
Four markers
1. BRIEFING Quality of required briefings 2. PLANS STATED Plans were communicated shared mental model

3. WORKLOAD ASSIGNMENT Roles and responsibilities were defined

4. CONTINGENCY MANAGEMENT Strategies to anticipate and manage threats

Most critical in:

Error avoidance Threat management when the threat is expected (e.g., adverse weather)

Execution Countermeasures
Four markers
1. MONITOR / CROSSCHECK Crosschecking of systems and crew members 2. WORKLOAD MANAGEMENT Prioritization staying ahead of the curve

3. VIGILANCE Remained alert of the environment and aircraft position

4. AUTOMATION MANAGEMENT Proper balance of automation and workload

Most critical in:

Error management

Review / Modify Countermeasures

Three markers
1. EVALUATION OF PLANS Reviewed and modified plans when necessary 2. INQUIRY Asked questions to clarify nothing taken for granted 3. ASSERTIVENESS Stated critical information with appropriate persistence

Most critical in:

Undesired aircraft state management Threat management when the threat is unexpected (e.g., A/C malfunction)

Fifth Generation CRM: Sixth Generation?

Restating the purpose with validation from data
Error avoidance Threat management Error management Undesired aircraft state management

CRM as threat and error countermeasures

Team building Leadership and Communication Environment Planning Briefing, Plans Stated, Workload Assignment, and Contingency Planning Execution Monitor/Crosscheck, Vigilance, Workload, and Automation Management Review/Modify Evaluation of Plans, Inquiry, and Assertiveness

University of Texas Human Factors Research Project

www.psy.utexas.edu/psy/helmreich/nasaut.htm