Culture and Errors
CRMDEEN (CRMDEEN_at_aol.com)
Thu, 26 Mar 1998 10:13:22 EST
Hello, Guy Standen,
Welcome to the group. You've got a couple of good observations, and I, for
one, like your style already. As a newbie myself I ask questions similar to
yours. The research community does great work, and many of the studies reveal
significant knowledge. Sometimes, it is difficult to translate the findings
and conclusions to classroom usage. The recent work by Helmreich's team
concerning culture and error was quite helpful to me.
Culture: Part of my challenge is to present a series of CRM courses to
aviators of a very similar aircraft, but with dissimilar missions and
organizations. Years ago, for example, the Air Force asked a contractor to
take over training. Part of that tasking was to present MOST (LOFT) missions.
The course developers were tasked to prepare a series of mission scripts for
the "typical airlift mission". The initial philosophy was that "one size fits
all". A CRM proponent advised that some units have missions and
qualifications that are so different from the target scripts, that the scripts
would not work well. The advice was rejected. Now, ten years later, the
organizations are more different than before, and, due to the mis-match of the
mission scripts, some units do not do the MOST training any more. Their
excuse? "The missions don't match what we do".
So, what does this mean to us? Helmreich and Merritt's culture research is
what one needs to go to management and say something profound like "the
training needs to reflect the organizational culture". Translated more
specifically, what type aircraft, make-up of crews, typical missions,
communication barriers, etc. Taking a course or package from another company
or country and trying to "plug-it-in" to an existing flight culture will have
limited success. Your program must be yours. An understanding of the errors
commonly made is a great help.
It is for this reason our courseware progression has an interim course
between initial training and annual refresher training: we call it
"Operational Orientation", and it's designed to be mission-specific, and
requires the unit commander to participate in the class. The main thrust is
"how does the CRM teachings of the initial REALLY work in THIS
organization(culture)?"
Error Management? This is even easier to put into a class than "culture". A
lot of CRM classes, ours included, spend a great deal of time in studying
accidents of the past, case studies, and watching films. So often, class
members say they would not have made the same mistakes. I then challenge them
to convince me that had they been in the aircraft, would they have really done
anything different? The people who climbed into the fateful aircraft did not
plan to crash, and more often that not, they were highly qualified. If you
had asked them, at the take-off point, if they were planning to die today,
they would have looked at you with mystical and confused eyes. So what
happened?
Understanding the conditions that present the opportunity for error is the
teaching challenge. Recognizing and correcting error is the survival secret.
When an aircraft crossed a runway threshold 26 knots too fast, and at a
descent angle that touchdown was destined to be in the middle of a runway,
that was too short from the beginning; the last thing the co-pilot said to the
pilot was "looking good". The pilot had long since become so overwhelmed by
the challenging approach and airfield, that he was incapacitated and non-
functional. The copilot appeared to recognize that, and tried to use
encouragement and stroking to settle the pilot. The only thing that would
have saved the crew was a forceful intervention into the series of errors that
were mounting. Unfortunately, listening the cockpit voice tape reveals an
interesting insight; there was no fear in the tone of the voices. Everyone on
that aircraft sounded un-afraid.
Crewmembers must recognize errors, and correct them immediately. "Feelings"
should have a lower priority than operating procedures. If a crewmember
recognizes a procedural violation, or error, they should challenge it
immediately, because it is the right thing to do. The goal of CRM is "safe
and efficient operation of the aircraft", not "getting along with the mates".
Too many crewmembers hold their criticisms because they are afraid of "hurting
the feelings" of another aviator.
Just last night, in a simulator mission, the crew was attempting to land with
two engines failed on the same side, and at an airfield that was "high and
hot." The pilot was having great difficulty keeping the airplane aligned with
the runway, and as he tried to flare, he mumbled with strained speech, "help
me with the rudder". He was also trying to stand up to see over the
glareshield. The aircraft drifted off the side of the runway, and bounced. The
co-pilot yelled "go around". The pilot immediately advanced the two good
engines to full thrust, and the aircraft went into a severe side-slip,
buffeted for about 15 seconds, and crashed. As the crew sat in silence,
wondering what went wrong, I asked the co-pilot (who had pronounced he's ready
for upgrade to PIC) if he had any suggestions on how the approach could have
been done differently. His answer was "I think he should have extend flaps
for the low airspeed, and that would have improved the rudder control also."
Wonderful advice, from a silent copilot.
Error management can and should be included in the CRM teachings. I see two
approaches to doing this: prevention, and intervention. Extending the flight
beyond crew duty-day restrictions, whether it's done by the management or the
flight crew, increases the likelihood of error. Allowing, or forcing a single
crewmember to take on so much work that the workload becomes excessive, is
inviting error. Trusting automated devices to the point of not monitoring, is
an error in itself, because I've seen automated devices make errors also.
This was a long opinion, to a simple question. Start studying case studies
with the intent to identify the errors of the event. Then assign the errors
to a source, such as management, or crew, or some other part of the aviation
system. Perhaps that will give us a clue as to how to adjust the culture to
avoid the opportunity for those errors. Good luck, and I hope this helps.
Greg Deen
Raytheon