Crew Resource Management

STANDARD OPERATING PROCEDURES AND LINE ORIENTED FLIGHT TRAINING

Standard Operating Procedures

Standard Operating Procedures (sops) are designed to enhance safety, to assist the flight crews to manage risk and to ensure consistency in the cockpit. Consider them guidelines as to who-does-what-and-when. At all times, these procedures should encourage effective communication and teamwork in the cockpit. Sops can be either general in nature or aircraft specific. Although aviation companies have a certain amount of latitude when creating their sops, under no circumstances should they contravene aviation regulations or the procedures outlined in the aircraft flight manuals.

Included in the sops should be a section on normal procedures, and it is to be considered an enhancement of the aircraft flight manual. These normal procedures include all aspects of day-to-day flight, including the start-up and normal procedures checklist, the take-off briefing, go-around procedures, IFR approaches, etc.

A section of the sops should be dedicated to emergency procedures, with the expanded version of the emergency procedures checklists. Again, this should compliment the aircraft flight manual's emergency section and streamline procedures removing any ambiguity.

Another section can include aircraft landing and take off distances charts, a JBI chart, or any other references that the flight crews may require.

Sops should be reviewed periodically and amended to maintain their relevance in changing times or aircraft fleet. Care should be taken not to include non-applicable items, as personnel may then tend to view the whole package as being irrelevant. Sops should be written in simple terminology leaving no room for subjective interpretation.

There are definite safety benefits from the use of Standard Operating Procedures but they must first be adopted by the flight crews. Company check pilots should monitor for crew adherence to the sops. Finally, there is no substitute for good judgment, and decisions made in the cockpit should be supported by management.

Standard Phraseology

Standardization of crew communications is desired to increase the efficiency of crew coordination during times of high crew workload such as take off, emergency conditions, instrument approaches, landings and in detecting partial incapacitation. The normal call-outs are one example of standard phraseology used to convey vital information with a minimum number of words that have an exact meaning to all crew members. Some other recommended words and phrases could be:

Standard Call-outs

Objective

Ensure that all crew members are aware of airplane altitude, position and instrument indications. Casual and nonessential conversation can be distracting and may interfere with normal communications, thereby reducing crew efficiency and alertness to the task at hand, i.e. The approach and landing.

Call-outs

The pilot not flying (PNF) will accomplish the appropriate call-out based on instrument indications or observations for the condition indicated on the chart on the following page. The pilot flying (PF) will verify the condition/location from their instruments and acknowledge. If the pilot not flying does not make the required call-out, the pilot flying should make it.

Crew Concept

One of the basic fundamentals of the "Crew Concept" is that each crew member must be able to supplement or act as a back-up for another crew member. Proper adherence to standard call-outs will stimulate more meaningful and standardized crew communications and provide for early detection of crew member incapacitation during critical phases of flight.

Standard Call-outs Examples

Checking the Checklist

Checklists were created so that an aircraft can be operated by a pilot safely. It is ironic that checklists are designed to cover omissions and oversights of pilots, but the built in redundancy and repetition found in checklists can also make pilots complacent. This complacency is a breeding ground for errors and negligence.

This catch-22 situation should be addressed to make checklists more efficient so that they can be utilized as designed. These suggestions may help to revamp your checklists and make them more "user-friendly."

Consult with the flight crews that fly on a regular basis to determine what changes should be made to improve efficiency. Unnecessary items should be removed to avoid skipping over checklist items and increasing the risk of omitting a critical check. For example, the "coffee pot" check on a converted cargo aircraft can be substituted with "all switches" for brevity. The chances are better that you will not miss the "boost pumps on" check if the items you are used to seeing on the checklist are all pertinent. If an item on the checklist is useful on occasion, it should be noted as "deferred" during the checklist execution, rather than purposely skipped.

The built-in redundancy in a checklist is for a specific purpose. The so-called "killer items" on the checklist should be repeated twice, in different areas of the checklist in case they be inadvertently missed. For example, if the aircraft flap setting is important to take off performance, the flap check should be included in both the taxi checklist and again in the before take-off checklist.

Items that are key to the safety of your flight, should be in the "challenge and response" format. The pilot-not-flying must monitor the pilot flying, and confirmation of the checks through the challenge and response method is an effective way to verify compliance. It is also important that both flight crew members have an awareness as to the state of the aircraft, i.e. What switches are on or off.

Non-critical items, such as the environmental setting or noting the take-off time, might be better off completed by the pilot-not-flying. Once a checklist is complete, the pilot-not-flying must advise the pilot-flying and announce ". . . Checklist complete."

The checklists should be clear, easy to read plastic laminated sheets and easily accessible in the cockpit. The emergency checklist should be uniquely marked so it can be quickly located. It is also suggested that crews review an "emergency du jour" from this checklist.

Checklists were created to eliminate errors of omission in the cockpit. Involving the flight crew and revising a tired checklist will result in a safer and more efficient cockpit.

Crew Briefings

A crew briefing is not limited to reviewing an instrument approach procedure, or detailing aspects of the flight to the flight attendants. In fact, the cockpit crew briefing is an important tool for improving safety during any critical phase of flight. In a somewhat modified form, it's of use to the single-pilot flight operation as well.

In the simplest terms, your crew briefing is the verbalization of your plan for executing a critical phase of your flight. Given a normal transport flight ops profile, most would agree takeoffs and departures, as well as descents and arrivals, constitute critical flight segments. For the novice briefer, verbalizing the elements of these two major events is an excellent beginning.

As you would expect, you will not easily brief something you have not planned. Also one must avoid becoming too ritualistic or institutionalized with their crew briefing. Conducting appropriate and meaningful briefing enhances individual as well as crew performance. It is a learned art born of practice in identifying the key elements of every departure and arrival conveyed with clarity and brevity.

A Brief Beginning

The takeoff and departure briefing is not as common as the arrival brief, yet it's no less critical. In fact, given the pilot flying/pilot not flying discipline so widely accepted today, the departure crew briefing goes far to establish or clarify what's expected of crew members in their respective roles. This is the opportune time for the captain to establish or promote the atmosphere of enlightened leadership within the confines of the workplace. Even if the captain is the pilot not flying on a particular leg, the responsibilities of command dictate that he or she include amendments or modifications to the pilot flying's crew briefing should it be warranted.

A typical takeoff and departure crew briefing should include:

• Weather and related precautions
• Any special modification to the standard takeoff and initial climb profile
• Initial routing via designated SID and/or vector fix
• Initial clearance altitude including the transition altitude
• Com and nav radio configuration to include the assigned transponder code
• Contingencies for critical emergency situations

Weather conditions for your takeoff and departure should be part of every briefing. Special procedural precautions such as the use of engine or wing anti-ice, modified takeoff computations, or restrictions on the applicability of using a reduced power takeoff are examples of weather-related modifications best reviewed before getting involved in the actual activity.

Include in your briefing any special noise abatement takeoff and climb profile to be flown, a high terrain/obstacle clearance maneuver to execute, or a possible windshear complication. When briefing the departure climb, either by reference to a published SID or radar vector clearance, be sure to emphasize your initial clearance altitude. The nav radio setup should be noted, crossing restrictions discussed, and any special switchology or pilot not flying duties clarified.

Many different emergencies are possible during any takeoff and climb out. Reviewing the basics of "who will do what" in the event of a reject or engine failure are commonly briefed. Attempting to address further emergencies could run your brief too long to be effective.

Once cleared onto the runway for take-off, the pilot flying should re-brief (1) the initial heading and/or route to be flown, (2) the initial clearance altitude, and (3) confirm the takeoff flap settings and respective takeoff flap settings and takeoff speeds. Conducting this last chance mini-brief will focus the crew on the details at hand.

Pilot workload increases relative to your distance from touchdown. For this reason, the best time to conduct the approach briefing is before or soon after, commencing your initial descent. This scheduling may not work in some situations but the intent is to avoid trying to brief and fly at the same time. Neither is done well. As your briefings become more polished, you will be better able to accommodate last-minute alterations like a runway change However, if what you have briefed is rendered totally inappropriate, make the time to do an approach and landing briefing that's relative to your actual situation.

Mindful of the intent to promote crew coordination and enhance communication with your fellow pilots, the content of the approach and landing briefing should contain no more than 8 to 10 key elements beyond a common understanding of the current weather conditions;

• Name and effective date of the instrument approach procedure
• Minimum sector altitudes(s)
• Airport elevation
• Initial approach maneuver and respective minimum altitude(s)
• Final approach course and defining navaid
• Final approach fix minimum altitude
• Applicable approach minimums (DH or MDA)
• MAP for the non-precision approach
• Published missed approach procedure
• Approach lighting and runway information

It is imperative to clarify the name and currency of the instrument approach procedure (IAP) to be used. It is a good idea to state the airport elevation as an overall awareness factor.

If you anticipate radar vectors to intercept the final approach course, it is important to brief the published minimum final approach fix (FAF) altitude. In the absence of radar vectors to final, your briefing must be expanded to include depicted transitions, procedure turns, arcs or other published routings and the associated minimum altitudes.

Focus attention on the frequency of the defining navaid as well as the published final approach course. You may want to brief the pilot not flying on a special sequence for tuning and identifying navaids specific to your radios.

All crew members must know the decision height(DH) or minimum descent altitude (MDA) and the advisory minimum visibility. For non-precision iaps, step-down fixes and the corresponding minimum descent altitudes and missed approach point (MAP) should be called out by the pilot not flying. Brief the timing or DME fix for every IAP as a means of identifying the MAP. Granted, the MAP for the ILS is the DH, but should you lose the glideslope signal inside the FAF, you have the option to descend to the LOC minimums and a better reference for the location of the MAP.

In the absence of ATC intervention, your clearance for the published IAP includes a clearance for the published missed approach procedure. It is good practice to emphasize the initial route and altitude in your briefing. Should nav radio changes be required, these are best included as pilot not flying duties. And if the missed approach procedure culminates in a holding pattern, the type of entry is worth mentioning.

Do not be too brief

Do not complete your briefing with just the approach. The airport chart contains an abundance of valuable information. If you are faced with conducting an approach and making a landing in IMC, or at night, or in particularly low-visibility situations, briefing the type of approach light system available is critical. Whoever is not monitoring the instruments will be looking for the lights, so it is appropriate to know what to look for. The lighting codes are deciphered in the Canada Flight Supplement and the Canada Air Pilot. Also useable runway length and width are worthy parts of every briefing you make.

A Brief Example

Departure Brief

"Let's plan on runway three five for takeoff. We're cleared via the Mccoy two and the Colliers Transition. We'll use our standard takeoff and departure climb profile. With these rain showers and wet runway, I prefer to use full power for takeoff. We'll maintain the assigned heading and climb to cross the Orlando one one five at or above 2600 and the zero niner zero at or above 3000. Our initial altitude is 5000 and that's set in the altitude alerter. I've got Orlando tuned and three three eight in my window. You're tuned to Orlando and please monitor those radials. We should have no problem meeting the crossing restrictions. Let's stay with the number one comm for ATC and our squawk is set on 3531.

"As far as emergencies go, if something happens prior to V1, i'll stop the aircraft, you call the tower and i'll get on the PA after we've stopped. Beyond V1, we go. I'll continue to fly. Let's not do anything in a hurry. I'll call for the checklists and let's stick with our procedures. If possible, i'll use the autopilot and get in the loop ASAP. Any time you have a question about anything we're doing or not doing, please ask. Any questions? Comments?

Arrival Brief

"Let's plan on the Pueblo two six right ILS and the glideslope is out of service. The effective date on my chart is March 5th. The MSA's are 7700 to the northwest and 7100 to the southeast of Aruba with an airport elevation of forty seven twenty six. Since we're cleared via Huner and the 10 DME arc, let's keep both nav radios on Pueblo and tune the ADF to Aruba. Once we're on the arc, i'll descend to 7000. As we near the Pueblo zero eight niner radial tune and identify my nav radio on one zero eight point three and i'll set two fifty seven in my window. Call me passing the zero eight niner on your CDI and once i've turned to intercept the localizer, come on over on your nav radio and we'll switch the RMI's to ADF. Established on the localizer, i'll descend to the final approach fix altitude of 6600. Our minimums are five thousand sixty feet and one and a quarter mile. Let's time the approach for two minutes and forty five seconds and call me two minutes and five seconds after we pass Aruba.

"The missed approach is a climb to 7000 direct to Mertz. If we go around, tune Mertz on the ADF. Let's keep approach flaps and i'll use a hundred and sixty knots max. We'll plan on a teardrop entry to that holding pattern.

"Runway two six right has hirls, reils and VASI on the left side. That's not much in the way of lighting. We'll likely see the reils first. That runway is over ten thousand feet long and 150 feet wide. Any questions? Suggestions?

Line Oriented Flight Training

In analyzing airline accidents over the last 20 years, it was evident that approximately 70% occurred as a direct result of inadequacies related to crew coordination, workload management and decision making. It was also revealed that the causes of these accidents were unrelated to the way pilots were being trained. They occurred not as the result of a lack of individual technical proficiency in the cockpit, but because of a human failure.

The concept of crew resource management (CRM) was developed to address the deficiencies of human behaviour in the cockpit. In conjunction, line oriented flight training (LOFT) began, and allowed flight crews to combine their technical proficiency and CRM theory into practical skills in simulator scenarios. As a result, flight crews become better problem-solvers and resource managers in an effort to reduce the risk of an incident or accident.

The Benefits of LOFT

The objective of LOFT is to assess how a flight crew manages the operation of an "aircraft" during a situation which is outside the parameters of what would be considered normal operations. It is not an emergency situation per se, where the flight crew reverts to the predetermined response of an emergency procedure. Instead it is a series of events impacting on the conduct of the flight that must be addressed by the crew and for which there is no one correct solution. Flight crews are required to demonstrate how they manage the operational environment and process information available within the irregularity. The goal for the flight crew is to make a series of low-risk, safe operational decisions resulting in the successful termination of the exercise - normally a safe landing.

Spin-off benefits of LOFT include the validation of company training. Any weak areas in flight crew training or those that require further emphasis are exposed. Standard Operating Procedures (sops) can be assessed for their effectiveness and adaptation into the cockpit. If a variety of flight crews make similar mistakes, it could be an indication of incorrect or conflicting manuals or procedures. LOFT allows for improved flight crew aircraft transition or pilot upgrade training.

Problem Solving in the LOFT Environment

Humans have three different ways to solve a problem:

Skills-based actions are those actions that can be accomplished with little effort once the basic skill is mastered (such as driving a car)

Rules-based actions are those that have well prescribed procedures (such as if X happens, accomplish Y) similar to the flight crew's reaction to an emergency situation.

Knowledged-based actions are the ones addressed in LOFT sessions. They are usually the result of an ambiguous situation, or one that does not have clearly prescribed procedures, and offer a variety of options to the flight crew.

Because of uncertainty, knowledge-based actions can require considerable time and thought in order to deal with the task.

This is where the evaluation of the flight crew's ability to assess all available information takes place.

Malfunctions in the LOFT Environment

A recent study of NASA's Aviation Safety Reporting System (ASRS) incident reports evaluates how flight crews manage malfunctions in the cockpit. Two types of malfunctions were identified:

• Type A malfunctions were judged to be critical emergencies which triggered "by the book" (skills or rules-based actions) responses by flight crews. Flight crew training and check rides concentrate on the flight crew's ability to handle major aircraft malfunctions.

• Type B malfunctions are relatively minor, or abnormal. The malfunction resolution procedure is less defined, requiring the flight crews to revert to knowledge-based actions and CRM principles to properly assess and resolve the situation. This may require time-consuming thought, discussion, and trial and error procedures.

The danger of a Type B malfunction response is that too much of the crew's time and attention can be diverted from the normal duties involved in safe piloting and a loss of situational awareness can occur (as in the infamous Everglades and Portland accidents.)

This is where the evaluation of a flight crew's ability to manage the operational environment takes place.

A paradox is introduced - the less serious malfunctions appear more likely to induce flight crew behaviour leading to a loss of situational awareness than do the serious malfunctions. Fixation, distraction, no one flying the aircraft and work overload were found in a number of the ASRS reports, and are of particular concern because they have been identified in many fatal aircraft accidents. Flight crew training to prevent the loss of situational awareness must be addressed to reduce the 70% of aviation accidents that occur as a result of a human failure.

Training to Prevent the Loss of Situational Awareness

Resolving Type A malfunctions often occurs quickly, leaving less time for distraction from sops and a loss of situational awareness. When faced with a serious malfunction, the flight crew is likely to be in a state of all around heightened awareness, referring to an emergency procedure checklist or memory items. The loss of situational awareness is less likely to enter the error chain.

Resolution of Type B malfunctions pose a risk to flight crews who become absorbed with resolving the malfunction, often at the expense of proper aircraft control. Pilots should always fly the aircraft, assess the situation, take appropriate action, and evaluate the results. Flight crew training should emphasize that an aircraft malfunction can serve as an immediate red flag in warning against the loss of situational awareness.

In analyzing the way that flight crews handle Type A and B malfunctions, significant differences have been revealed in altitude and course/heading deviations denoting a possible loss of situational awareness. Of the Type A malfunctions, flight deviations were observed in 23% of the incidents. Of the Type B malfunctions, a loss of situational awareness occurred in varying degrees in 100% of the incidents.

Further study of the ASRS reports provided evidence of crews using improper actions, such as not completing a checklist because of haste, using the wrong checklist or activating the wrong system control switches. Training should stress crew coordination and emphasize all crew members verify intended actions before initiation.

LOFT Event Sets

A LOFT scenario comprises a staged event set, a group of related events that are part of the scenario and are inserted into the LOFT session for specific CRM and technical training objectives. The event set is made up of one or more events, including:

• The event trigger is the condition under which the event is fully activated (example, landing gear malfunction)
• The distracters are conditions inserted within the even set time frame that are designed to divert the crew's attention from other events that are occurring or are about the occur (example, course change)
• Supporting events are other events taking place within the event set designed to further CRM and technical training objectives (example, ILS off at destination)

Simple events have no further consequences on the conduct of the flight once they have been diagnosed and corrected. Overuse of simple problems or events detracts from LOFT realism. Routine pre-start problems, followed by a start problem, followed by a taxi problem, intrude on the crew's perception that the LOFT is an actual flight.

Complex events have ongoing consequences that must be dealt with in flight and cannot be solved by simply selecting and executing an emergency or abnormal checklist. This requires the coordinated actions of all crew members for successful completion, but not to the extent that they induce complete crew failure. Complex event set problems tend to be relatively ambiguous, with no simple corrective solution.

The properly designed event set uses both simple and complex events offering a number of possible and reasonable solutions to promote the management of a complex situation. The objective is for the flight crew to make low-risk, safe operational decisions and live with them until landing.

One misconception that should be avoided is the belief that LOFT should continuously increase crew workload until the crew becomes overloaded. This is not the purpose or intent of LOFT and can actually help to defeat its effectiveness. LOFT scenarios are most beneficial if they are realistic and straightforward, combining technical skills with CRM theory, in a marriage of simple and complex events.

Elements of LOFT

• LOFT is pure training; a learning experience designed to emphasize crew command, coordination, communication and the full management of available resources

• LOFT is not the venue for assessing the performance of individuals, but the session should not be artificially stress-free. Flight crew members should maintain reasonable performance parameters applicable to their phase of training. If the LOFT facilitator identifies flight crew member performance deficiencies, additional training or instruction would be provided with no stigma or recrimination

• Scenarios consist of typical daily operations with reasonable and realistic difficulties and emergencies. LOFT scenarios must last long enough for crew traits to become evident and should require CRM skills to be displayed in response to specific circumstances

• LOFT sessions should not be interrupted, the simulator should not be repositioned or problems repeated. The facilitator should not interfere regardless of developments; mistakes may be made but flight crews should continue since there is no book solution to a LOFT exercise

• Choose scenarios that can have a wide variety of choices and outcomes. The flight crew must live with their decisions and course of action until the situation is either resolved or the aircraft is back on the ground. Scenarios must be kept current with respect to navigation, communications, regulations, company procedures, manuals and aircraft modifications

• Pacing and tempo of a scenario must be appropriate to certain factors - location, departure time, phase of flight, communications. Designers should avoid totally filling a flight period, leaving time for lulls and inactivity

• Scripts should be designed in as much detail as possible in order to simulate the real world. A lack of detail requires the LOFT facilitator to improvise, which takes considerable time away from the observation and evaluation of the flight crew

• The flight crew is able to quickly appreciate the results of their operational decisions, whether they be positive or negative. An accident should never be inevitable, although it is an outcome that may occur

• The flight crews will benefit from a facilitator's immediate debriefing session afterwards using video or notes; the flight crew normally is more critical in their own performance assessment
• Procedures and practices in the flight operations manuals that are frequently misunderstood should be considered for inclusion in a LOFT scenario. Use incident reports from a variety of databases, maintenance difficulty areas identified in line flying, and poor performance areas in simulator proficiency checks and training

• Event set problems could include:

Operational problems

• Pre-flight, dispatch release
• Hazardous cargo
• Fuelling operations
• NOTAMS
• MEL items
• Weight and balance
• Flight crew problems, incapacitation
• Cabin crew or passenger problems
• Duty day
• Alternate airports
• Low fuel during excessive vectoring
• Re-routing/amended clearances
• Air traffic control delayed approaches
• Similar call signs

Environmental problems

• Weather
• Wind
• Temperature
• Contaminated or closed runways
• Touchdown zone lighting problems

Equipment problems

• Airborne
• Autoflight incidents
• Ground support
• Nav aids

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