This topic is very interesting for those of us on the maintenance side =
of CRM (MRM). We at Northwest are trying to change the way we look at =
human error in maintenance by reviewing incidents that have happened, =
but also by asking for situations that workers feel are more at risk for =
error. I too would like to be much more proactive in this area than we =
are and am hoping for many ideas from this group. Getting people to =
have a better sense of when they are about to step into the "swiss =
cheese" (Reason's model) is one more way of making them more =
situationally aware.
-----Original Message-----
From: Vince Mancuso [SMTP:vince_mancuso_at_CompuServe.COM]
Sent: Wednesday, January 28, 1998 9:50 PM
To: INTERNET:crm-devel_at_db.erau.edu
Subject: Re: Error Chains
Hello CRMer's
Doug asks:=20
>'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. =20
=20
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.=20
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
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