At Eight Miles a Minute! Published Nov. 19, 2013 By Mark Altenburg HQ AMC CRM/TEM Program Director Winter 2013/2014 -- Arguably, no one knows the complexities and frustrations of air mobility better than AMC's aircrews. While our effectiveness as "mission hackers" is largely due to our vaunted adaptability and flexibility, human factors experts claim these same traits are sometimes the very reason for human and, more significantly, aircrew failures. "How can this be?" you astutely ask. How can the traits directly attributable to our successes be, at times, the authors of our disasters? Enter the world of Crew Resource Management (CRM), and Threat and Error Management (TEM) where such a dichotomy must be successfully negotiated at the proverbial "eight miles a minute." Helping make sense of the constant barrage of threats thrown at aircrews, AMC Ops RAMS provides MDS Aircrew Training Contractors with annual "Topic(s) of the Year" that focus on timely CRM/TEM subjects they can use in developing "real world" simulator courses. Based on a detailed analysis of recent mishaps (or near mishaps), the topics for 2014 are: · CRM/TEM Lessons Learned Briefing · Threat and Error Management · Stabilized Approaches · Pilot Monitoring--Emphasis On Stabilized Approach Callouts · Pilot/Aircrew Decision Making and Judgment · Flight CRM/TEM Debriefing · ASAP Use A grizzled aeronaut once groused, "If you can't be an inspiration to others, at least be a dire warning!" The first topic on the list, the CRM/TEM Lessons Learned Briefing, aptly supports this maxim by crisply revisiting CRM and presenting a TEM foundation in advance of the distribution of AMC's Supplement to AFI 11-290 (USAF's CRM/TEM Training Program). This briefing highlights recent mishaps as examples of appropriate (or inappropriate) CRM/TEM application. You can also view this eye-opening briefing at your wing's Safety Office. Highly endorsed by the FAA, TEM is critical to CRM training. Designed to assist in identifying threats to mission accomplishment as well as effectively managing human error, it provides a framework for analyzing data and assessing errors. It also identifies factors that contribute to making mistakes and how aircrews manage unpredicted situations. As alluded to earlier, TEM is currently the aviation industry's gold standard for reducing human errors, consequently abating conditions that induce human error mishaps. You may have misplaced your cherished copy of AFI 11-290 or perhaps lent it to a dear friend, who lost it during a PCS. Either way, you may recall that AFI 11-290 warns of "Threats." Threats are events or conditions that normally occur outside the influence of the flight crew but require crew attention and management in order to maintain safety margins. While a listing of threats could be endless, it would surely include bad weather, maintenance or ground crew error, unfamiliar airports, automation events, unexpected missed approaches, systems malfunction, high terrain, ATC, and high traffic density. Threats can also come from the crew (fatigue, complacency, hidden agendas, personal distractions, etc.). AMC's aircrews properly manage threats during every flight, but a mismanaged threat can be--and has been--linked to flight crew errors. Errors are flight crew actions or inactions that: (1) lead to a deviation from crew or organizational intentions or expectations; (2) reduce safety margins; and (3) increase the probability of adverse operational events on the ground or during flight. Flights that occur without an error are rare because aircrews are human, and humans do make mistakes. Consequently, aircrew members need to "trap" (negate) errors through techniques such as VVM (verbalize, verify, and monitor) and cultivate a teamwork mentality to keep errors from putting the aircraft into a UAS. What the heck is a UAS? Great question! An Undesired Aircraft State (UAS) is a deviation in aircraft position, speed or attitude, or incorrect configuration of an aircraft that: (1) results from flight crew error, actions, or inaction; and (2) clearly reduces safety margins. Examples are heading and altitude errors, unnecessarily high or low air speed, a near miss, fuel level below minimums, a long landing, a hard landing, wrong runway or taxiway, wrong airport, an unstable approach, etc. No doubt, you've clued into the fact that a UAS is never good and preventing or mitigating it is quite high on the priority list. Aviation history has shown a substantial correlation between unstable approaches and runway excursions. As a UAS, unstable approaches are primary contributors to numerous aviation mishaps. HQ AMC's MFOQA analysis indicates that over 12 percent of all operational and training approaches flown deviate from stable approach criteria--overwhelmingly for poor airspeed control. Supporting the need for a stable approach, The Flight Safety Foundation reviewed 16 years of accidents worldwide and determined that 30 percent of the accidents involved runway excursions, the vast majority of which were due to unstable approaches. Additionally, the Foundation's 1998 Analysis of Critical Factors During Approach and Landing in Accidents and Normal Flight Final Report revealed that approximately 56 percent of the world's jet fleet accidents between 1959 and 1996 occurred during the approach and landing phase and accounted for 44 percent of all fatalities. Interestingly, the approach and landing phase only accounts for 16 percent of the total flight time! Per current MDS Vol 3 and FCIF guidance, aircrews are to take immediate corrective actions to stabilize the approach when outside designated parameters or conduct a Go Around. As a result, during your next simulator adventure, expect simulator instructors to discuss stable approach criteria and to debrief all notable deviations after approaches. Simulator instructors will also debrief the Pilot Monitor(ing) (PM) if the PM neglected to observe or comment on deviations from stable or failed to call "Go Around" if warranted during the approach. Stressing the importance of the PM, the National Transportation Safety Board has highlighted PM duties as causal or contributory in numerous aviation mishaps. Combatting this weakness, several airlines are establishing "How Can I be a Better PM" working groups. Though the PM's duties are numerous, of special note is their responsibility to help maintain aircrew situational awareness (a CRM core skill). Other aircrew members (including ACMs) bear a similar responsibility, whether official or unofficial. In addition, when aircraft commanders are the PMs, they must lead by example, emphasizing continual "lean forward," situationally aware PM engagement. Flight Ops safety reps from the airline industry repeatedly ponder, "What makes aircrews take unnecessary risks? Why do they continue an unstable approach?" To answer such questions, let's look into the inner workings of aircrew members. Human Factors experts speak of self-efficacy, which they define as a person's degree of confidence with task completion. The stronger the self-efficacy, the longer the person will persist and exert effort to accomplish the task. In the aviation context, conditions often arise in which self-efficacy and overconfidence in one's ability can impair performance, especially during high workload, high stress situations--conditions AMC aircrews face on nearly every flight. Per the Aeronautic Learning Laboratory for Science, Technology, and Research (ALLSTAR Network), the causal factor in 80 percent to 85 percent of aviation accidents is the human element (pilot error), a poor decision or a series of poor decisions made by the captain (aircraft commander) and/or pilot flying (PF). Known as the Poor Judgment Chain, it is a situation when one poor decision increases the probability of another. As the Poor Judgment Chain lengthens, the probability of a safe flight significantly decreases. Highlighting the issues of judgment and decisionmaking, aviation safety expert and Director of Global Programs at the Flight Safety Foundation, Rudy Quevedo, revealed that aircrews are reluctant to abort landings, saying, "One of the biggest things that we see is that the pilots don't feel a threat--they feel they can recover." Unfortunately, in too many instances, they cannot. So how do we gauge ourselves? As noted by CRM/TEM instructors and aviation professionals, one skill set central to aviation safety is the post-mission debrief conducted by the crew. At a minimum, a good CRM/TEM debrief answers the following questions: · What were the threats on this mission, and how did we manage them as a crew? · What were the decisions we made as a crew? How did we arrive at these decisions? Did we use all available resources? How did these decisions affect the mission? · Did we make any errors on this mission, and how did we trap those errors? · Were there any undesired aircraft states? How did we identify and correct them? Rounding out the 2014 CRM/TEM topics is the promotion of AMC's ASAP program. As a voluntary self-reporting system, this valuable program uncovers hazards and potential CRM/TEM issues not recorded via any other system. Though the ASAP program does not replace mandatory reporting methods (e.g., HATR), the information obtained is used to identify aircrew errors and threats to aircrew, and is a source for data correlation with other data-gathering systems. The ASAP scoreboard and submission website is located at http://www.safety-masap.com. In summary, it is a huge understatement to say that our air mobility world is filled with threats to safety--on the ground, in the air, and sometimes mechanically within our aging aircraft. Too often, such threats and pilot-induced errors lead to a UAS and, unfortunately, mishaps. However, Dr. Erik Hollnagel, a prominent expert in the study of human factors, was "spot on" during his speech at the International Symposium on Aviation Psychology when he said, "Things go right because people adapt their performance to meet demands, interpret and apply procedures to match conditions, and detect and correct conditions when things go wrong." Although effective CRM/TEM "at eight miles a minute" is not easy, it is crucial to practice it at every opportunity. If you do so, rest assured that it will be there when needed most.