Doug asks:
>'How do we know when a normal sequence has metamorphosed into an error
chain?'<
For us developers and managers, the natural follow-on questions should be:
1. "How do we teach people to RECOGNIZE the error producing conditions
(developing error chains)?"
2. "How do we teach people to RESPOND after they RECOGNIZE?"
I agree with Doug that we are panning for gold with these discussions. I
believe that there is much undiscovered gold in the area of RECOGNITION
training. I believe that the RECOGNITION aspect of CRM training is
tremendously underdeveloped and mostly ignored. Most recognition training
is limited to academic discussions and post-mortem reviews of others
mistakes. This may build awareness but it does little to build RECOGNIZE
and RESPOND skills. It is one thing to talk about "RED FLAGS" but it is
quite a different to recognize and respond to these cues when you have your
hands full of airplane. Very few, if any, CRM programs systematically
categorize error producing conditions, then systematically expose their
crews to these conditions.
On 16 December I wrote:
"We cannot respond to something we do not recognize...."
"The next generation of LOS design will challenge and test the crew's
ability to both "Recognize and Respond" to a spectrum of conditions that
trigger the need for CRM and/or Procedural skills. Our triggers are often
isolated to the blatantly obvious like a fire light. Fire lights are easy
to recognize and have a clear and well practiced procedural response.
These are important but do not challenge the crew to recognize some of the
more subtle conditions that lead to error or non-compliance."
For the past several months I have been slowly compiling a list of error
producing conditions that can be used as a framework for systematic
RECOGNITION training. It's not quite ready for prime time but I would bet
there are some fundamental parallels to the book chapter on red flags that
did not make it into Doug's book.
I look forward to this ongoing and lively dialogue
Vince Mancuso