A11uaa31 Aircraft Maintenance Crew Management
A11uaa31 Aircraft Maintenance Crew Management
BBA
Airline & Airport Management
(Annual Pattern)
IIIrd Year
Paper No. 11
CONTENTS
Page No.
UNIT I
Lesson 1 Maintenance 7
Lesson 2 Maintenance Steering Group 24
UNIT II
Lesson 3 PP&C 43
Lesson 4 Technical Publication 52
UNIT III
Lesson 5 Crew Resource Management 63
UNIT IV
Lesson 6 Incidents/Accidents 85
Lesson 7 Communication: A Relevant Factor in Aviation Safety 101
UNIT V
Lesson 8 Line Operations and Safety Audit 123
Lesson 9 Crew Resource Management Training 129
Lesson 10 Hangar 137
Model Question Paper 147
SYLLABUS
UNIT I
Maintenance: Role of the Engineer & Mechanic – Two Types of Maintenance – Reliability Redesign – Failure
Rate Patterns – Establishing a Maintenance Program. Development of Maintenance Programs: Introduction –
Maintenance steering Group (MSG) approach – Process & Tasks – Oriented Maintenance – Maintenance
Program Documents – Maintenance Intervals defined
UNIT II
Production Planning and Control: Introduction – Forecasting – Production Planning & Control – Feedback for
Planning – Organization of PP & C. Technical Publications: Introduction – Functions of Technical Publications –
Airline Libraries – Control of Publications – Document Distribution. Technical Training: Computer Support:–
Airline uses of Computers – Computer Program Modules – Selecting a computer System
UNIT III
CRM: Evolution and Basics – Flight Control Crew Management – Maintenance Resource Management – Impact
of CRM in Aviation Safety – CRM Training Evolution and CRM Desired Skills – Performance Standards for
Instructors in CRM – CRM Standards and Training – CRIMs (CRM Instructors) and CRIMEs (CRM Instructor
Examiners)
UNIT IV
Data on Incidents/Accidents: Human Performance Analysis – Evaluation of Flight Crew CRM Skills –
Communication: A Relevant factor in Aviation Safety – Line Operations Safety Audit (LOSA) and CRM:
Relationship
UNIT V
Individual Performance: Relevant Factors – Automation and Upgradation of Skills – CRM: Training Methods
and Standardization – Competency Profile for Instructors of CRM – Maintenance Crew Skill Requirements –
Morning Meeting. Hanger Maintenance (On – Aircraft) – Introduction – Organization of Hanger Maintenance
5
Maintenance
UNIT I
6
Aircraft Maintenance &
Crew Management
7
LESSON Maintenance
1
MAINTENANCE
CONTENTS
1.0 Aims and Objectives
1.1 Introduction
1.2 Role of the Engineers and Mechanics
1.2.1 Airframe Mechanics
1.2.2 Power Plant Mechanics
1.2.3 Avionics Technicians
1.3 Reactive Maintenance
1.4 Preventive Maintenance
1.5 Predictive Maintenance
1.6 Reliability Centered Maintenance (RCM)
1.7 Aircraft Integrated Maintenance
1.8 Aircraft Engine Maintenance
1.9 Aircraft Base Maintenance
1.10 Aircraft Line Maintenance
1.11 Aircraft Engineering and Planning Services
1.12 Quality Services
1.13 Aircraft System
1.14 Maintenance Scheduling
1.15 Let us Sum up
1.16 Lesson End Activity
1.17 Keywords
1.18 Questions for Discussion
1.19 Suggested Readings
8
Aircraft Maintenance & 1.1 INTRODUCTION
Crew Management
What is maintenance and why is it performed? Past and current maintenance practices
in both the private and Government sector would imply that maintenance is the actions
associated with equipment repair after it is broken. The dictionary defines
maintenances as follows: “the work of keeping something in proper condition;
upkeep.” This would imply that maintenance should be actions taken to prevent a
device or component from failing or to repair normal equipment degradation
experienced with the operation of the device to keep it in proper working order.
Unfortunately, data obtained in many studies over the past decade indicates that most
private and Government facilities do not expend the necessary resources to maintain
equipment in proper working order. Rather, they wait for equipment failure to occur and
then take whatever actions are necessary to repair or replace the equipment. Nothing
lasts forever and all equipment has associated with it some predefined life expectancy or
operational life. For example, equipment may be designed to operate at full design load
for 5,000 hours' and may be designed to go through 15,000 start and stop cycles.
The design life of most equipment requires periodic maintenance. Belts need
adjustment, alignment needs to be maintained, proper lubrication on rotating
equipment is required and so on. In some cases, certain components need replacement,
e.g. a wheel bearing on a motor vehicle, to ensure the main piece of equipment (in this
case a car) last for its design life. Anytime we fail to perform maintenance activities
intended by the equipment's designer, we shorten the operating life of the equipment.
But what options do we have? Over the last 30 years, different approaches to how
maintenance can be performed to ensure equipment reaches or exceeds its design life
have been developed in the United States. In addition to waiting for a piece of
equipment to fail (reactive maintenance), we can utilize preventive maintenance,
predictive maintenance or reliability centred maintenance.
10 saving maintenance and capital cost, we are really spending more dollars than we
Aircraft Maintenance &
Crew Management would have under a different maintenance approach. We are spending more dollars
associated with capital cost because, while waiting for the equipment to break, we are
shortening the life of the equipment resulting in more frequent replacement. We may
incur cost upon failure of the primary device associated with its failure causing the
failure of a secondary device. This is an increased cost we would not have experienced
if our maintenance program was more proactive. Our labour cost associated with
repair will probably be higher than normal because the failure will most likely require
more extensive repairs than would have been required if the piece of equipment had
not been run to failure. Chances are the piece of equipment will fail during off hours
or close to the end of the normal workday. If it is a critical piece of equipment that
needs to be back online quickly, we will have to pay maintenance overtime cost.
Since, we expect to run equipment to failure, we will require a large material
inventory of repair parts. This is a cost we could minimize under a different
maintenance strategy.
Advantages
z Low cost
z Less staff
Disadvantages
z Increased cost due to unplanned downtime of equipment
z Increased labour cost, especially if overtime is needed
z Cost involved with repair or replacement of equipment
z Possible secondary equipment or process damage from equipment failure
z Inefficient use of staff resources
Advantages
z Cost effective in many capital intensive processes
z Flexibility allows for the adjustment of maintenance periodicity
z Increased component life cycle
z Energy savings
z Reduced equipment or process failure
z Estimated 12% to 18% cost savings over reactive maintenance program
Disadvantages
z Catastrophic failures still likely to occur
z Labour intensive
z Includes performance of unneeded maintenance
z Potential for incidental damage to components in conducting unneeded
maintenance
Advantages
z Increased component operational life/availability
z Allows for pre-emptive corrective actions
z Decrease in equipment or process downtime
z Decrease in costs for parts and labour
z Better product quality
z Improved worker and environmental safety
z Improved worker moral
z Energy savings
z Estimated 8% to 12% cost savings over preventive maintenance program
Disadvantages
z Increased investment in diagnostic equipment
z Increased investment in staff training
z Savings potential not readily seen by management
A Check
This is performed approximately every month or 500 Flight Hours (FH). This check is
usually done overnight at an airport gate. The actual occurrence of this check varies by
14 aircraft type, the cycle count (takeoff and landing is considered an aircraft "cycle"), or
Aircraft Maintenance &
Crew Management the number of hours flown since the last check. The occurrence can be delayed by the
airline if certain predetermined conditions are met.
B Check
This is performed approximately every 3 months. This check is also usually done
overnight at an airport gate. A similar occurrence schedule applies to the B check as to
the A check.
C Check
This is performed approximately every 12–18 months or a specific amount of actual
Flight Hours (FH) as defined by the manufacturer. This maintenance check puts the
aircraft out of service and requires plenty of space – usually at a hangar at a
maintenance base. The schedule of occurrence has many factors and components as
has been described, and thus varies by aircraft category and type.
D Check
This is the heaviest check for the airplane, also known as a Heavy Maintenance visit
(HMV). This check occurs approximately every 4–5 years. This is the check that,
more or less, takes the entire airplane apart for inspection. This requires even more
space and time than all other checks, and must be performed at a maintenance base.
Often, older aircraft being phased out of a particular airlines' fleet are stored or
scrapped upon reaching their next check.
Modern transport category airplanes with MSG-3 derived maintenance programs
employ usage parameters for each maintenance requirement such as flight hours,
calendar time or flight cycles. Maintenance intervals based on usage parameters allow
more flexibility in scheduling the maintenance program to optimize aircraft utilization
and minimize aircraft downtime.
Aircraft Inspections
Learning Objective: Define the types of Aircraft Inspections required for proper
maintenance and safety of naval aircraft.
Aircraft are subject to a variety of stresses, strains, vibrations and detrimental
environments. If not inspected regularly, the aircraft would soon become inoperable.
Maintenance is performed in conjunction with inspections. This enables the aircraft to
be flown safely until the next inspection. The types of inspections that are performed
by activities responsible for the maintenance of naval aircraft are defined in the
following paragraphs.
18 Acceptance Inspection
Aircraft Maintenance &
Crew Management This inspection is performed at the time a reporting custodian accepts a newly
assigned aircraft, and upon receipt of or return of an aircraft from Standard Depot
Level Maintenance (SDLM) or other major depot level work. It includes an inventory
of all equipment listed in the Aircraft Inventory Record (AIR), a configuration
verification, hydraulic fluid sampling, and a full system Functional Check Flight
(FCF). It also includes an inspection of emergency systems and egress equipment.
This should include functionally checking such items as fuel, oil. hydraulic shutoff
valves, and prop feathering, as well as the verification of Cartridge-actuated Devices
(CADS) and Aircrew Escape Propulsion Systems (AEPSs). In addition, a daily
inspection, as required by the applicable Planned Maintenance System (PMS)
publication, should also be done. Activities may elect to increase the depth of
inspection if the equipment condition indicates such action is warranted.
Transfer Inspection
This inspection is performed at the time a reporting custodian transfers an aircraft,
including transfers to SDLM. It includes an inventory of all equipment listed in the
AIR, verification of CADS and AEPS, configuration verification, hydraulic fluid
sampling, and a daily inspection as required by the applicable PMS publication.
Activities may elect to increase the depth of inspection if the equipment condition
indicates such action is warranted.
Daily Inspection
Daily inspections are accomplished between the last flight of the day and the next
scheduled flight. The daily inspection is valid for a period of 72 hours, provided no
flight occurs during this period and no maintenance other than servicing has been
performed. If more than 72 hours elapse between the inspection and the next flight,
the inspection must be repeated. This inspection is performed to check equipment that
requires a daily verification of satisfactory functioning. It also involves the search for
and correction of relatively minor problems to prevent their progressing to a state that
would require major work to remedy the problems.
Other items that require inspection at intervals more frequent than prescribed for
calendar inspections are also included on the daily inspection, and thus are done along
with the daily inspection on the day they become due.
Conditional Inspection
Conditional maintenance requirements are unscheduled events required as the result of
a specific overlimit condition, or as a result of circumstances or events that create an
administrative requirement for an inspection. A logbook entry IS required for a
conditional maintenance requirement that prescribes inspections to determine
equipment condition; for example, airframe hard landing, pre-carrier/pre-deployment,
aircraft ferry, acceptance/transfer, or engine over speed/over temperature inspections.
Those conditional requirements that specify servicing or fluid sampling need not be
logged.
Pre-flight Inspection
The pre-flight inspection consists of checking the aircraft for flight readiness by
performing visual examinations and operational tests to discover defects and
maladjustments that, if not corrected, would cause accidents or aborted missions. This
inspection is conducted before each flight to ensure the integrity of the aircraft for
flight and to verify proper servicing. It is valid for a period of 24 hours, provided no
flight and no maintenance other than servicing occurs during this period. When all
pre-flight requirements are contained within the daily card set, accomplishment of the 19
Maintenance
daily requirements before the first flight of the day satisfies the pre-flight inspection
requirements. When all pre-flight requirements are not included in the daily card set,
the pre-flight inspection must be performed before flight. The application statement
contained on the applicable model weapons system MRC introduction card states
specific requirements.
Post-flight Inspection
The post-flight inspection is accomplished after each flight or ground operation of the
aircraft. The post-flight inspection is mainly a check for obvious defects (hydraulic,
fuel, and oil leakage or structural damage) and the installation of the necessary safety
locks and pins.
Turnaround Inspection
Turnaround inspections are conducted between flights to ensure the integrity of the
aircraft for flight, verify proper servicing, and to detect degradation that may have
occurred during the previous flight. The turnaround inspection is valid for a period of
24 hours, provided that no flight and no maintenance other than servicing occur during
this period. The accomplishment of the daily inspection does not satisfy the
turnaround requirements. On aircraft that are furnished turnaround inspection
requirements, the pre-flight and post-flight requirements do not apply.
Phase Inspection
The phase maintenance concept divides the total scheduled maintenance requirements
into small packages or phases of approximately the same work content. These are
done sequentially at specified intervals. Completion of all required phases at their
specified intervals completes the phase inspection cycle. The cycle is repetitive for the
service life of the aircraft and is not interrupted during SDLM. Phase inspections are
not included in the SDLM specifications, and are not done during the SDLM process.
Aircraft returning from SDLM/special rework have the next phase due upon
expiration of the authorized interval from the last phase inspection completed.
Special Inspection
A special inspection is a scheduled inspection with a prescribed interval other than
daily or phase. These intervals are specified in the applicable PMS publication and are
based on elapsed calendar time, flight hours, operating hours, or number of
cycles/events; for example, 7, 28 days; 50, 100, 200 hours; 10, 100 arrestments; or
5,000 rounds fired.
Zonal Inspection
A zonal inspection is a general inspection of a specific area of an aircraft. These
inspections are for obvious defects, such as leaks, frayed cables, cracks, corrosion or
physical damage.
Zonal inspections are normally performed in conjunction with other scheduled
maintenance tasks by the rating assigned, such as an Aviation Electronics Technician
(AT) rating assigned to perform an inspection on a radar antenna may also be assigned
a zonal inspection of the compartment for obvious defects.
Question: What type inspection is performed at the time a reporting custodian accepts
a newly assigned aircraft?
Question: What type inspection is performed to check equipment that requires a daily
verification of satisfactory functioning?
22
Aircraft Maintenance & 1.15 LET US SUM UP
Crew Management
The design life of most equipment requires periodic maintenance. The maintenance is
segregated into several forms such as Reactive Maintenance, Preventive Maintenance,
Predictive Maintenance or Reliability Centred Maintenance. Reactive maintenance is
basically the “run it till it breaks” maintenance mode. Preventive maintenance can be
described as Actions performed on a time- or machine-run-based schedule that detect,
preclude, or mitigate degradation of a component or system with the aim of sustaining
or extending its useful life through controlling degradation to an acceptable level.
Predictive maintenance is explained as Measurements that detect the onset of a
degradation mechanism, thereby allowing causal stressors to be eliminated or
controlled prior to any significant deterioration in the component physical state.
Reliability centred maintenance is a process used to determine the maintenance
requirements of any physical asset in its operating context. Aircraft maintenance
checks are periodic checks that have to be done on all aircraft after a certain amount of
time or usage. Airlines casually refer to these checks as one of the following: A check,
B check, C check or D check. Aircraft Integrated Maintenance includes Engine
maintenance, Aircraft maintenance (base and line), Components maintenance,
Engineering and planning services, Material services and Quality services The
different types of Aircraft inspections include Acceptance inspection, Transfer
inspection, Daily inspection, Conditional inspection, Pre-flight inspection, Post flight
inspection, Turnaround inspection, Phase inspection, Special inspection and Zonal
inspection.
1.17 KEYWORDS
Airworthiness: It is a term used to dictate whether an aircraft is worthy of safe flight.
Bypass-ratio: The amount of air that is bypassed relation to the air that passes through
the core engine.
D Check: This is the heaviest check for the airplane, also known as a Heavy
Maintenance Visit (HMV). This check occurs approximately every 4–5 years.
Reconditioning: It is the situation when the aircraft is brought back to its
original/newest condition.
Zonal Inspection: A zonal inspection is a general inspection of a specific area of an
aircraft. These inspections are for obvious defects, such as leaks, frayed cables, cracks,
corrosion or physical damage.
4. What type of inspection consists of checking the aircraft for fright readiness by 23
Maintenance
performing visual examinations and operational tests to discover defects and
maladjustments that, if not corrected, would cause accidents or aborted missions?
5. What type of inspections is normally performed in conjunction with other
scheduled maintenance tasks by the rating assigned?
CYP 2
1. TAP M&E
2. Quality services include
3. maintenance scheduling
4. Aircraft
5. Acceptance inspection
24
Aircraft Maintenance &
Crew Management
LESSON
2
MAINTENANCE STEERING GROUP
CONTENTS
2.0 Aims and Objectives
2.1 Introduction
2.2 Maintenance Program Perspective
2.2.1 Maintenance Program History
2.2.2 Maintenance Steering Group (MSG) Processes
2.3 Maintenance Task Development
2.4 Maintenance Program Groupings
2.5 Maintenance Program Development
2.5.1 Maintenance Review Board Report (MRBR)
2.5.2 Maintenance Review Board
2.5.3 Industry Steering Committee
2.5.4 Establishing a Maintenance Program
2.5.5 Maintenance Working Groups
2.6 Policy and Procedures Handbook (PPH)
2.7 Maintenance Planning Document (MPD)
2.7.1 Certification Maintenance Requirements (CMR)
2.7.2 Airworthiness Limitations (AL)
2.7.3 Operators Approved Maintenance Program (OAMP)
2.8 Maintenance Program Supporting Documents
2.9 Maintenance Program Enhancement Process
2.10 Generic vs. Customized Maintenance Program
2.11 Maintenance Storage Program
2.12 Maintenance Program Bridging
2.13 Maintenance Program – Valuation Perspective
2.14 Let us Sum up
2.15 Lesson End Activity
2.16 Keywords
2.17 Questions for Discussion
2.18 Suggested Readings
25
2.0 AIMS AND OBJECTIVES Maintenance Steering
Group
After studying this lesson, you should be able to:
z Discuss the maintenance program perspective
z Describe the role of MSG 2
z Identify the importance of MSG 3
z Explain the importance of MRBR
2.1 INTRODUCTION
The industry definition of maintenance generally includes those tasks required to
restore or maintain an aircraft’s systems, components, and structures in an airworthy
condition. Maintenance is required for three principal reasons:
z Operational: To keep the aircraft in a serviceable and reliable condition so as to
generate revenue.
z Value Retention: To maintain the current and future value of the aircraft by
minimizing the physical deterioration of the aircraft throughout its life.
z Regulatory Requirements: The condition and the maintenance of aircraft are
regulated by the aviation authorities of the jurisdiction in which the aircraft is
registered. Such requirements establish standards for repair, periodic overhauls,
and alteration by requiring that the owner or operator establish an airworthiness
maintenance and inspection program to be carried out by certified individuals
qualified to issue an airworthiness certificate.
Hard-time (HT)
Hard-time processes mandated that all components be taken out of service when they
reached a specified age, expressed as the number of operating flight hours, flight
cycles, calendar time, or other stress units since new or since last shop visit. Removed
units were routed to repair centres and effectively zero-timed, whereby the operating
age was restored to a unity of zero by means of an overhaul. In 1960, representatives
from both the FAA and the airlines formed a task force to investigate the capabilities
of preventive maintenance.
On-condition (OC)
On-Condition requires that an appliance or part be periodically inspected or checked
against some appropriate physical standard to determine whether it can continue in
service. The purpose of the standard is to remove the unit from service before failure
during normal operation occurs. Example of an OC process is measurement of brake
wear indicator pins; compare brake wear condition against a specified standard or
limit. Brake wear will vary considerably among operators due to operational
conditions, however the wear indicator pin on-condition check will help attain near
maximum usage out of each set of brakes.
inside the acceptable level, any variation is considered to be normal. When the trend 27
Maintenance Steering
line intersects the “unacceptable” limit, removal of the unit is required to prevent a Group
failure in the future. A characteristic of CM is that it is not considered a preventive
maintenance process; the process allows failures to occur, and the failure modes of
conditioned-monitored items are considered not to have a direct adverse effect on
operating safety. MSG-2 decision logic was subsequently used to develop scheduled
maintenance programs for the aircraft of the 1970s. Maintenance tasks were derived
from one of three processes:
1. Hard Time
2. On-condition
3. Condition-monitoring or some combination of the three processes.
28 Although, there is no actual in-service operational data available when the MSG-3
Aircraft Maintenance &
Crew Management process begins for a new aircraft, there is much historical data on the performance of
similar components and systems used in earlier designs, as well as test data from the
manufacturer and component vendors. It’s the actual in-service reliability data of
similar components and systems that drives the task and interval decisions.
Another principal benefit from the MSG-3 process is that it generally produces higher
safety standards. This is primarily due to the greater degree of intelligent approach to
maintenance in terms of selecting tasks that are effective. The approach results in far
less maintenance tasks, which minimizes the infant mortality effect associated with
excessive maintenance. Studies in Human Factors clearly identified correlation
between excessive maintenance and induced incidents, or accidents, resulting from
preventive maintenance through replacement and overhaul of components.
Today, MSG-3 is the only game in town for commercial airplane manufacturers.
According to Advisory Circular AC-121-22A, FAA policy states that the latest MSG
analysis procedures must be used for the development of routine scheduled
maintenance tasks for all new or derivative [Part 121] aircraft. It is the only
methodology accepted by the airworthiness authorities. MSG-3 has also been adopted
by most major business jet manufacturers, with the encouragement of the National
Business Aviation Association (NBAA).
29
Maintenance Steering
Group
After approval by the local regulatory authorities, the MRBR is used as a framework 31
Maintenance Steering
around which each air carrier develops its own individual maintenance program. Group
Although maintenance programs may vary widely, the initial requirements for a
particular aircraft will be the same for all.
The tasks detailed in the MRBR cannot be deleted nor can the task content be changed
without approval of the MRB Chairman or appropriate national regulatory authority.
However, individual task intervals may be escalated based on satisfactory
substantiation by the operator, and review and approval by the local regulatory
authority. Task interval parameters expressed in the MRB Report can also be
converted to an individual operator’s desired units, provided this conversion does no
result in the operator exceeding the initial requirements of the MRB Report.
The process used by aircraft manufacturers in creating and updating the MRBR is
outlined in Federal Aviation Administration Advisory Circular 121-22A (Maintenance
Review Board Procedures) – see Figure 2.6. The process involves the establishment of
a Maintenance Review Board (MRB), Industry Steering Committee (ISC) and
Maintenance Working Groups (MWG). Each of these groups is composed of
representatives from the participating operators, the aircraft manufacturer and the
regulatory authorities. A description of each of these organizations follows.
33
2.7 MAINTENANCE PLANNING DOCUMENT (MPD) Maintenance Steering
Group
The MRB Report outlines the initial minimum scheduled maintenance/inspection
requirements to be used in the development of an approved continuous airworthiness
maintenance program. The Maintenance Planning Document document contains all
the MRB requirements plus mandatory scheduled maintenance requirements that may
only be changed with the permission of the applicable airworthiness authority. These
supplemental inspection tasks are detailed in the aircraft’s Certification Maintenance
Requirement (CMR) and Airworthiness Limitation (AWL) documents – Figure 2.7.
34
Aircraft Maintenance &
Crew Management
(e) Fault Reporting and Fault Isolation Manuals (FRM & FIM) 35
Maintenance Steering
(f) Illustrated Parts Catalog (IPC) Group
36 The maintenance program enhancement process (Figure 2.10) requires that the aircraft
Aircraft Maintenance &
Crew Management manufacturer and operators work together to identify tasks within the MRBR that can
be optimized. For each identified maintenance task, the aircraft manufacturer reviews
the data and analyses the positive and negative in-service results.
Once the analysis is complete, the aircraft manufacturer makes a recommendation for
each individual task under review and presents to the ISC. Accepted changes are
submitted for regulatory approval and incorporated into both the MRBR and the MPD,
which are issued to the operators for inclusion in their own scheduled maintenance
program.
The level of preservation depends on variables such as the planned length of storage 37
Maintenance Steering
and the storage environment. For example, a large transport category aircraft taken out Group
of service due to excess capacity and stored for an indefinite period outside on the
ramp at San Francisco International Airport should have a more comprehensive level
of preservation than an identical aircraft taken out of service for storage and placed in
a desert climate like Roswell, New Mexico.
An air carrier’s aircraft is considered stored when it is removed from active
operational status for any reason. The level of preservation depends on the length of
storage, the aircraft design features and the storage environment (inside/outside, etc.).
There are generally three types of storage programs:
A. Short-term storage: An aircraft is subject to short-term preservation procedures
when it is removed from operational status for less than 60 days.
B. Intermediate-term Storage: An aircraft is subject to intermediate-term
preservation procedures when it is removed from operational status for more than
60 days but less than 120 days.
C. Long-term Storage: An aircraft is subject to long-term preservation procedures
when it is removed from operational status for 120 days or more.
2.16 KEYWORDS
Correlation: A mutual relationship or connection between two or more things.
Inspected: To examine carefully and critically, especially for flaws.
Mechanical: Working or produced by machines or machinery.
Overhaul: Take apart (a piece of machinery or equipment) in order to examine it and
repair it if necessary.
Pneumatics: The branch of physics or technology concerned with the mechanical
properties of gases.
CYP 2
1. An aircraft’s Maintenance Planning Data (MPD)
2. A generic maintenance
3. An air carrier’s aircraft
4. C-checks and D-checks
5. Bridging
41
PP&C
UNIT II
42
Aircraft Maintenance &
Crew Management
43
LESSON PP&C
3
PP&C
CONTENTS
3.0 Aims and Objectives
3.1 Introduction
3.2 Forecasting
3.3 What is Production Planning?
3.4 What is Production Control?
3.5 Integrative Nature of Production Plans
3.6 Feedback for Planning
3.7 Organization of PP&C
3.8 Let us Sum up
3.9 Lesson End Activities
3.10 Keywords
3.11 Questions for Discussion
3.12 Suggested Readings
3.1 INTRODUCTION
The conversion of an order to a finished product needs generally the organisation and
planning of the manufacturing process. The overall objective of any organisation is to
improve its profitability through productivity i.e. by employing various inputs (Such
as Men, Machines, Materials, Money and Management) effectively so as to bring
about the desired manufacturing results in terms of quality, time and place.
Production Management is concerned with basically the two important functions of
Production: Production Planning and Production Control. Production Planning is
concerned with the planning of various inputs (include Men, Machines, Materials,
etc.) for a given period of time so that the customer could get the right quality of
products at right place, price and in time. Production Planning alone is not sufficient
to achieve the objective of any organisation.
44 Production Control measures the actual performance of the production units and
Aircraft Maintenance &
Crew Management taking remedial action called for to see that the production actually achieved is not
less than the target or standard set in advance. Thus Production Planning and Control
is to set the realization targets in terms of Standard Output, measure the actual
production performance against the target set in advance and take remedial action as
and when necessary.
PPC is one of the key organizations within M&E. This organization is responsible for
planning and scheduling all aircraft maintenance activity within the airlines. PP&C is
responsible for three main functions: forecasting, planning and control. Forecasting
activities include the maintenance workload for the long term and the short term based
on the existing fleet. Planning involves the scheduling of upcoming maintenance and
includes the planning and scheduling maintenance of all manpower, parts, facilities
and time frame requirements. There is an old saying “plan your work and work your
plan.” The control phase starts soon after that.
3.2 FORECASTING
Forecasting is concerned with the workload of M&E organization. It is concerned with
routine maintenance and all planned changes in the future operations. All the changes
like in fleet size and make up, changes in route structure etc. must be tracked. It also
includes changes in facilities. Forecasting plan also includes replacement of
equipment, adding new equipment, and the planned incorporation of ADs and SBs.
The forecast function to make sure that M&E is up to date on these changes and is
ready to adjust their processes. It is generally made for both long and short term.
Sometimes it is also made for intermediate term.
The long term is for 5 to 10 years. The changes that are planned are impact
scheduling, budgeting, training, manpower, and facilities within M&E. All the
adjustments are made to meet M&E goals and objectives. These plans require yearly
revision as per the requirement of the airlines.
Short term forecasts are made detailed and usually cover 1 to 2 years. The plans are
meant for manpower and budget numbers. Schedules for checks and known
modifications are finalized in the short term plans.
The intermediate plans are for 2 to 5 years but are generally maintained by larger
airlines. M&E has three forecasts to follow as per the requirement. These plans help in
achieving their goals and objectives effectively
plan, schedule, and adjusts the work for each check and for each aircraft, adding any 45
PP&C
additional tasks as necessary. Production planning involves the following:
z Daily, 48-hour and transit checks are usually standardized and require little or no
effort on the part of PP&C other than scheduling.
z All “A” checks and higher are planned, scheduled, and coordinated by PP&C and
their content varies from check to check. These activities take more than 48 hours
so it is started in advance.
z For “A” checks, the planning starts 1 to 2 week before the scheduled check.
z For the “C” check, the planning begins 4 weeks in advance.
We may break down the planning process into various stages as follows:
(i) Defining objectives and setting priorities to attain these.
(ii) Studying the environment external to the system being planned.
(iii) Studying the internal environment of the system being planned.
(iv) Determining realizable targets (quantified as far as possible).
(v) Gearing the inputs to achieve these targets.
Planning and control is concerned with the reconciliation between what the market
requires and what the operation’s resources can deliver. Planning and control
activities provide the systems, procedures and decisions which bring different aspects
of supply and demand together. The purpose is always the same – to make a
connection between supply and demand that will ensure that the operation’s processes
run effectively and efficiently and produce products and services as required by
customers. Consider, for example, the way in which routine surgery is organized in a
hospital. When a patient arrives and is admitted to the hospital, much of the planning
for the surgery will already have happened. The operating theatre will have been
reserved, and the doctors and nurses who staff the operating theatre will have been
provided with all the information regarding the patient’s condition. Appropriate
preoperative and post-operative care will have been organized. All this will involve
staff and facilities in different parts of the hospital. All must be given the same
information and their activities coordinated. Soon after the patient arrives, he or she
will be checked to make sure that their condition is as expected. Blood, if required,
will be cross-matched and reserved, and any medication will be made ready. Any last-
minute changes may require some degree of replanning. For example, if the patient
shows unexpected symptoms, observation may be necessary before the surgery can
take place. Not only will this affect the patient’s own treatment, but other patients’
treatment may also have to be rescheduled. All these activities of scheduling,
coordination and organization are concerned with the planning and control of the
hospital.
46 operation to bring it back ‘on track’– for example, finding a new supplier that can
Aircraft Maintenance &
Crew Management deliver quickly, repairing the machine which failed, or moving staff from another part
of the operation to cover for the absentees. Control makes the adjustments which
allow the operation to achieve the objectives that the plan has set, even when the
assumptions on which the plan was based do not hold true.
3.10 KEYWORDS
Cost Leadership Strategy: Strategy that aims to produce and deliver the product or
service with specified quality, at a low cost relative to its competitors.
50 Differentiation Strategy: Strategy that aims to create a new product or service which
Aircraft Maintenance &
Crew Management is unique in that industry.
Flow Shop: This is a conversion process in which successive units of output undergo
the same sequence of operations, using specialized equipment usually positioned
along a production line.
Gross Domestic Product: It is the sum of values of goods and services produced in
that nation in a year.
Productivity: It is a relationship between the output (products/services) and the input
(resources consumed in providing them) of a business system.
CYP 2
1. Production Control
2. implementation
3. M&E
4. feedback
5. centralized and decentralized
52
Aircraft Maintenance &
Crew Management
LESSON
4
TECHNICAL PUBLICATION
CONTENTS
4.0 Aims and Objectives
4.1 Introduction
4.2 Functions of Technical Publication
4.3 Airline Libraries
4.4 Control Publications
4.4.1 Manufacturer Documents
4.4.2 Document Distribution
4.5 Technical Trainings
4.6 Trainings for Aviation Maintenance
4.6.1 Formal Training
4.6.2 Organizational Training
4.6.3 Manufacturer Training
4.6.4 Quality Training
4.6.5 On-the-job Training
4.6.6 Upgrade Training
4.6.7 Refresher Training
4.6.8 Airframe Manufacturer’s Training
4.7 Computer Support
4.7.1 Airlines Uses of Computer
4.8 Computer Program Module
4.9 Selecting a Computer System for Airline
4.10 Let us Sum up
4.11 Lesson End Activity
4.12 Keywords
4.13 Questions for Discussion
4.14 Suggested Readings
53
4.1 INTRODUCTION Technical Publication
are kept up to date at. The checking is done periodically by the Technical Publication 55
Technical Publication
staff, quality control inspectors or event maintenance management.
Management of airlines’ technical publications is a seemingly never-ending process of
receiving and implementing updates from the regulator, the airline itself and the
aircraft and components manufacturers.
To compound matters the workload varies, creating a dilemma for those airlines that
opt to manage this process in-house: Do you fully staff the team, at great cost, for the
worst case or do you have a skeleton staff in place and gamble on non-compliance?
Also, the ongoing transition to digital data means airlines must manage complex,
structured data, such as XML, to produce a single master document that might then
require multi-format publishing, e.g. for the web, hard copy, iPad, Toughbook, aircraft
EFB, etc.
And unfortunately most subject matter experts, such as Fleet Captains, may have
expert knowledge of the aircraft they fly but aren’t computer programmers, requiring
them to undergo training to bring them up to speed.
Another issue with technical publications is that of management audit trail: you need
to have the capability of knowing who has what version of a particular publication.
Technical Publications service, created specifically for the aviation industry and
developed in tandem with airlines themselves, ensure the right information gets to the
right person at the right time.
Passenger Services
When you book a flight, regardless of the method, your reservation information is
processed and stored by the airline's computer system. If you book this online, your
registration information is directly stored with the company. If you book your flight
over the phone, a customer service representative will enter this information for you.
This computer-based reservation system allows you to easily modify travel
arrangements at any airport, and even to use multiple airline companies over the
course of a single trip.
Airport Services
Many aspects of an airport rely heavily on computers. Security screening machines
such as X-rays may not make use of personal computers, but they do rely on computer
technology for a great deal of their operations. Furthermore, computers are necessary
for the use of pre-screening measures such as the current U.S. counter-terrorism
efforts.
Plane Mechanics
An airplane depends on computers for a number of essential flight functions. The
autopilot, which many modern airplanes are equipped with, frequently employs a
computer. This relieves the pilots of many in-flight tasks, allowing the plane to
process navigational data and flight control systems. Computerized "fly-by-wire"
technology, which many airplanes have, transmits pilot or autopilot signals to a
computer. This allows planes to respond to subtle atmospheric variables and make
other adjustments easily. Additionally, some airplanes have wing flaps that can be
controlled by a computer. Others have power systems that can be regulated by
computer. Finally, computers are central to the efficient communication and recording
of an airplane's flight data. Such data is vital to air traffic controllers, and greatly
assists in the event of an emergency situation.
58 information such as flight time and cycles flown number and types of aircraft in
Aircraft Maintenance &
Crew Management service as well as those who are out of services.
It comprises three steps:
Step 1
It’s a two-part process. The first determines what you want computer to do and the
output you want in terms of raw data, chart and graphs. The second part determines
the input you want to meet the output.
Step 2
This process is to check the software requirements. This includes the handling of
input/output data but also the processing, calculating other data manipulations needed
to accomplish. In planning the systems, one should consider the future needs so that
all the processes work accurately. There are different approaches to software
selections:
1. off-the-shelf software packages fixed packages; they do operations like producing
standard reports, etc. This might be affordable but is limited, so it needs to change
with the growth in tech.
2. to develop software specifically for the organization; this is more expenses but it
satisfies the operation
3. it is only open to those who have the skills to develop the software as and what is
required at a reasonable price. Generally, large airlines do this and are successful.
Step 3
The last step is to select the hardware needed to run the software. This could be a
mainframe or a group of networked desktop computers.
A single computer might be sufficient for an air taxi services with only one airplane.
to Airsoft's FTP site (where the customer can download their own environment at any 59
Technical Publication
time) or any FTP location preferred by the customer.
4.12 KEYWORDS
Airframe: The airframe of an aircraft is its mechanical structure. It is typically
considered to include fuselage, wings and undercarriage and exclude the propulsion
system.
Technical: Relating to a particular subject, art, or craft, or its techniques.
Vendor: A vendor or a supplier in a supply chain is an enterprise that contributes
goods or services in a supply chain.
Training: Training is the acquisition of knowledge, skills, and competencies as a
result of the teaching of vocational or practical skills and knowledge that relate to
specific useful competencies.
Reservation: The action of reserving something.
60
Aircraft Maintenance & 4.13 QUESTIONS FOR DISCUSSION
Crew Management
1. Define technical publication in aviation.
2. Briefly discuss the importance of computers in aviation industry. Give suitable
examples.
3. Explain computer support.
4. Describe the functions of technical publication.
5. Explain different types of technical training.
CYP 2
1. hardware
2. computerized
3. flight functions
4. fly safely
61
Crew Resource
Management
UNIT III
62
Aircraft Maintenance &
Crew Management
63
LESSON Crew Resource
Management
5
CREW RESOURCE MANAGEMENT
CONTENTS
5.0 Aims and Objectives
5.1 Introduction
5.2 CRM
5.3 CRM: Evolution and Basics
5.4 Management of CRM
5.4.1 Maintenance Resource Management
5.5 Performance Standard for Instructors in CRM
5.6 CRM Standards and Training
5.6.1 CRM Standards
5.7 CRM Instructors (CRMI)
5.7.1 Requirements – General
5.7.2 Instructor Requirements
5.7.3 Grandfather Rights for CRMIs (Aeroplanes)
5.7.4 Grandfather Rights for CRMIs (Helicopters)
5.8 Accreditation for CRMIs
5.9 Revalidation Criteria for CRMIs
5.9.1 Instructors Ground
5.9.2 Instructors Simulator/Base
5.9.3 Line Training Captains
5.9.4 Record Keeping
5.10 CRM Instructors – Examiners (CRMIEs)
5.10.1 Requirements – General
5.10.2 Examiner Requirements
5.10.3 Examiners Ground School
5.10.4 Examiners Simulator/Base
5.10.5 Examiners Line
5.11 Initial Accreditation
5.11.1 Accreditation
5.12 Revalidation Criteria
5.13 Crew Resource Management
5.14 Crew Resource Management as a Model of Safety Management
Contd…
5.1 INTRODUCTION
Crew Resource is concerned not so much with the technical knowledge and skills
required to fly and operate an aircraft but rather with the cognitive and interpersonal
skills needed to manage the flight within an organised aviation system. In this context,
cognitive skills are defined as the mental processes used for gaining and maintaining
situational awareness, for solving problems and for making decisions. Interpersonal
skills are regarded as communications and a range of behavioural activities associated
with teamwork. In aviation, as in other walks of life, these skill areas often overlap
with each other, and they also overlap with the required technical skills. Furthermore,
they are not confined to multi-crew aircraft, but also relate to single pilot operations,
which invariably need to interface with other aircraft and with various ground support
agencies in order to complete their missions successfully. CRM training for crew has
been introduced and developed by aviation organisations including major airlines and
military aviation worldwide. CRM training is now a mandated requirement for
commercial pilots working under most regulatory bodies worldwide.
CRM was developed as a response to new insights into the causes of aircraft accidents
which followed from the introduction of flight recorders and cockpit voice recorders
into modern jet aircraft. Information gathered from these devices has suggested that
many accidents result not from a technical malfunction of the aircraft or its systems,
nor from a failure of aircraft handling skills or a lack of technical knowledge on the
part of the crew; it appears instead that they are caused by the inability of crews to
respond appropriately to the situation in which they find themselves. For example,
inadequate communications between crew members and other parties could lead in
turn to a loss of situational awareness, a breakdown in teamwork in the aircraft, and
ultimately to a wrong decision or series of decisions which result in a serious incident
or a fatal accident.
The widespread introduction of the dynamic flight simulator as a training aid, allowed
various new theories about the causes of aircraft accidents to be studied under
experimental conditions. On the basis of these results, and in an attempt to remedy the
apparent deficiency in crew skills, additional training in flight deck management
5.2 CRM
CRM encompasses a wide range of knowledge, skills and attitudes including
communications, situational awareness, problem solving, decision making, and
teamwork; together with all the attendant sub-disciplines which each of these areas
entails. The elements which comprise CRM are not new but have been recognised in
one form or another since aviation began, usually under more general headings such
as ‘Airmanship’, ‘Captaincy’, ‘Crew Co-operation’, etc. In the past, however, these
terms have not been defined, structured or articulated in a formal way, and CRM can
be seen as an attempt to remedy this deficiency. CRM can therefore be defined as a
management system which makes optimum use of all available resources –
equipment, procedures and people – to promote safety and enhance the efficiency of
flight operations.
CRM is concerned not so much with the technical knowledge and skills required to fly
and operate an aircraft but rather with the cognitive and interpersonal skills needed to
manage the flight within an organised aviation system. In this context, cognitive skills
are defined as the mental processes used for gaining and maintaining situational
awareness, for solving problems and for taking decisions. Interpersonal skills are
regarded as communications and a range of behavioural activities associated with
teamwork. In aviation, as in other walks of life, these skill areas often overlap with
each other, and they also overlap with the required technical skills. Furthermore, they
are not confined to multi-crew aircraft, but also relate to single pilot operations, which
invariably need to interface with other aircraft and with various ground support
agencies in order to complete their missions successfully.
66 mean that the training manual need contain every reference to CRM. It could contain
Aircraft Maintenance &
Crew Management the reference to the CRM manual, which could be a separate book but yet remain a
controlled document within the overall training manual. The coordination of all the
revalidations for the CRMIs and CRMIEs would also be the responsibility of the CRM
Manager.
Some operators may not wish to conduct their own CRM training. They may appoint a
CRMI from another organisation to run their courses for them, but they (the operator)
will be responsible for the standard of the course and its syllabus as well as the
standard of the training given.
Requirements
Whilst CRM applies to all areas of flying operations, from commercial air transport to
corporate and to private operations, currently this requirement is only mandated for
commercial air transport aeroplanes and helicopters. However, best aviation practice
is that all operators should study and implement CRM procedures. Nevertheless, in the
application of CRM principles, the CAA recognises that the operations to which this
CAP will apply are numerous and varied and will endeavour to adopt as flexible an
approach as is consistent with the maintenance of good standards. Small aircraft
operators should bear this in mind when reading this document and considering its
implications for their style of operations.
CRM skills assessment should be included in an overall assessment of flight crew
members’ performance and be in accordance with approved standards. The purpose of
such assessment is to: (a) provide feedback to the crew collectively and individually
and serve to identify retraining, and (b) be used to improve the CRM training system.
Management (CRM). One of the reasons is that errors made by pilots are highly
visible and have immediate consequences on safety. In addition, pilots are also seen as
the last line of defense against errors. For these reasons, research on activities such as
communication and team working skills initially focused on pilots. In contrast, errors
made by maintenance personnel are latent and thus Maintenance Resource
Management (MRM), the maintenance version of CRM has received considerably less
attention.
In their efforts to enhance safety, the aviation industry as a whole has recognised that
there is a need to minimise errors across all facets of aviation. Because of this, the
trend nowadays is to move further in their approach to reduce errors. Thus human
factor programmes have expanded to include people in all facets of aviation such as
air traffic controllers and of course maintenance personnel.
Maintaining aircrafts is a complex and demanding endeavour. It consists of numerous
interrelated human and machine components. The complexity of such interface mean
that errors are likely to be introduced and ways to detect errors and deal with them are
needed. The safety of the flying public is first and foremost dependent on the proper
functioning of the aircraft and its components. In any maintenance process, it is the
ability of maintenance personnel to work together that determines its success. The
very nature of the industry is such that engineers and mechanics will often need to
work together, therefore communication and team working skills are important.
Although most errors in the maintenance environment are latent, they cannot be
ignored as they have the potential to contribute towards fatal consequences in flight.
Once an aircraft leaves the hanger, the sound functioning of all systems on board will
be one of the important precursors to whether a flight will get from one point to
another safely. Indeed, maintenance plays such a crucial role in flight safety that it is
the responsibility of the aircraft's owner or operator to ensure that they are properly
maintained. In United States, studies have shown that a maintenance factor is a
contributing factor in 18% of all accidents. History is abound with notorious examples
of how maintenance errors contribute to accidents.
Table 5.1: Maintenance Errors
Airline Location Date Cause
Aloha Airlines Hawaii 28th April 1988 Fuse ledge failure in flight caused by
Flight 243 inspection failure
United Airlines Iowa 19th July 1989 Inspection failure which led to uncontrolled
Flight 232 engine failure and loss of flight controls
Continental Texas 11th September Separation of horizontal stabilizer.
Express Flight 1991 Maintenance personnel did not replace screws
on it.
Northwest Airlines Tokyo 01st March 1994 Engine separation caused by incomplete
assembly
There is an urgent need for changes in aspects of the organisation relating to human
performance. Increasing diligence in maintenance will probably have prevented these
accidents. In addition MRM will help airlines avoid significant financial burdens
imposed by loss of lives, flight delays, cancellations, turn backs and diversions.
MRM was developed from CRM after the fuselage of Aloha Airlines Flight 243 was
ripped off in flight and had to make an emergency landing. Investigations led to
attention being turned to maintenance errors as a potential cause of accidents. MRM
and maintenance human factors training are thus developed.
68
Aircraft Maintenance & 5.5 PERFORMANCE STANDARD FOR INSTRUCTORS IN
Crew Management
CRM
z In 2001, FODCOM 6/2001 advised of the requirement for formal accreditation of
CRM Instructors and CRMI Standards. Document 29 contains details of the
scheme.
z In order to make understanding of the system as simple as possible, it was decided
to model this system on the existing one for the approval and verification of TRI
ratings and TRE authorisations. This procedure would have the benefit of using a
proven system and one which would be both efficient and cost effective.
z The accreditation process has been divided into three contexts for the qualification
of CRMI: Instructor – Ground School, Instructor – Simulator/Base, and Instructor
– Line. An instructor may be qualified in more than one role.
z JAR-OPS (AMC OPS 1.943) requires all CRM Instructors to have current
operational experience in the relevant role. Some alleviations from this
requirement will be given and will be subject to the discretion of the CAA.
z The CAA will appoint a CRMIE – Ground School after observation by a suitably
trained Flight Operations Inspector (FOI), Training Inspector (TI) or a suitably
qualified
z The CRMIE – Ground School may then accredit CRMIs – Ground School after
ensuring that they have been suitably trained and have reached the required
standard as an instructor of CRM.
z A CRMIE – Simulator/Base will be appointed after observation in the relevant
role by a TI. In the case of TRE/TRIs who are qualified on both aircraft and
simulator only one observation will normally be necessary. RETREs and TRI(E)s
may assume grandfather rights as a CRMIE – Simulator/Base until their first
revalidation observation of their authorities by a TI.
z A CRMIE – line will be appointed by the AOC company who should ensure that
the person appointed is a senior training captain with the relevant knowledge of
CRM. This post should be agreed with the company's assigned inspector and
recorded in the training manual. The CAA will carry out observations of the
CRMIE – line on an opportunity basis.
z These proposals were implemented over a three-year transition period to allow
operators to adapt to them. “Grandfather rights” applied, during this period, to
those instructors who have a proven track record and demonstrated instructional
experience with a recognised training organisation.
is to identify and define the categories of behaviour and the second is to define the
levels or standards of performance in each category which distinguish competence
from non-competence.
The standards are competency based and therefore can be assessed against specific
performance criteria. Much work has been done worldwide on these subjects, and
although there is not yet an internationally agreed set of reference points, there is
obvious overlap among categories and standards defined in the documents. This
contains a selection of behavioural markers and competency standards currently used
by various organisations.
The objectives of CRM training are as follows:
(a) To enhance crew and management awareness of human factors which could cause
or exacerbate incidents which affect the safe conduct of air operations.
(b) To enhance knowledge of human factors and develop CRM skills and attitudes
which when applied appropriately could extricate an aircraft operation from
incipient accidents and incidents whether perpetrated by technical or human factor
failings.
(c) To use CRM knowledge, skills and attitudes to conduct and manage aircraft
operations, and fully integrate these techniques throughout every facet of the
organisation culture, so as to prevent the onset of incidents and potential
accidents.
(d) To use these skills to integrate commercially efficient aircraft operations with
safety.
(e) To improve the working environment for crews and all those associated with
aircraft operations.
(f) To enhance the prevention and management of crew error.
Instructors Simulator/Base
A CRMI (Simulator/Base) must meet the minimum standards contained in “The Short
Guide” and should at least;
(a) hold a TRI, TRE, CRI, CRE, SFI or SFE authority;
(b) have or have had commercial air transport experience as a flight crew member;
and
(i) have successfully passed the Human Performance and Limitations (HPL)
examination whilst obtaining the ATPL; or
(ii) if holding a Flight Crew Licence acceptable under JAR-OPS 1.940 (a)(3) prior 71
Crew Resource
to the introduction of HPL into the ATPL syllabus, have completed a Management
theoretical HPL course covering the whole syllabus of that course; or
(iii) have theoretical experience in the subject of CRM or Human Factors training.
Notwithstanding the above, and when acceptable to the CAA:
(c) a flight crew member holding a recent qualification as a CRM trainer may
continue to be a CRM trainer after the cessation of active flying duties.
The CRMI must:
(a) have completed initial CRM training; and
(b) have the knowledge.
The CRMI must demonstrate that they:
(a) have the knowledge specified for their relevant role;
(b) have the necessary instructional skills;
(c) are able to evaluate and assess crews’ CRM performance; and are able to facilitate
a constructive debrief of CRM issues.
Instructors Line
A CRMI (Line) must meet the minimum standards contained in “The Short Guide”,
and should at least:
(a) have completed a basic instructional technique course;
(b) have commercial air transport experience as a flight crew member; and
(i) have successfully passed the Human Performance and Limitations (HPL)
examination whilst obtaining the ATPL; or
(ii) if holding a Flight Crew Licence acceptable under JAR-OPS 1.940 (a)(3)
prior to the introduction of HPL into the ATPL syllabus, have completed a
theoretical HPL course covering the whole syllabus of that course; or
(iii) have theoretical experience in the subject of CRM or Human Factors training.
The CRMI must:
(a) have completed initial CRM training; and
(b) have the knowledge.
The CRMI must demonstrate that they:
(a) have the knowledge specified for their relevant role;
(b) have the necessary instructional skills;
(c) are able to evaluate and assess crews’ CRM performance;
(d) are able to facilitate a constructive debrief of CRM issues; and
(e) are able to meet the standards in 'The Start Guide' (Appendix 12) or company
equivalent.
72 with “grandfather rights” as CRMIs for the period to 30th September 2004, provided
Aircraft Maintenance &
Crew Management they had been conducting CRM instruction for at least six months and had run part of
at least two CRM courses. New instructors and any instructors who did not register for
grandfather rights prior to 30th November 2001 who wish to give CRM tuition will
need to be accredited by a CRMI Examiner (CRMIE) in accordance with Standards
Document.
Simulator/Base
TRI, TRE, SFI or SFEs who conduct simulator or aircraft training were initially given
grandfather rights until 1st October 2001. These grandfather rights remained in place
until such time as their ratings or authorities were due for revalidation. All TRI, TRE,
CRI, CRE, SFI and SFEs should have been accredited by 30th September 2004. New
TRI, TRE, SFI and SFEs will need to obtain accreditation coincident with granting of
their initial approval.
Instructor Line
Training Captains should have been accredited by 31st March 2003.
Instructors Simulator/Base
Requirements are as Standards Document 29. All TRE/CREs revalidating their
authority will have to be accredited as CRMIs as from 1st May 2005.
Instructors Line
Requirements are as Standards Document 29, therefore all new line trainers will have
to be accredited as CRMIs as from 1st January 2006. Existing trainers will have to be
accredited by 1st January 2007. This is a Company Appointment.
73
5.9 REVALIDATION CRITERIA FOR CRMIs Crew Resource
Management
5.9.1 Instructors Ground
With the exception of any period of grandfather rights, initial accreditation is for a
period of three years. Thereafter, re-accreditation will be at the discretion of the CAA
and subject to the following:
(a) The instructor should have conducted at least two courses of training in every
yearly period within the three year accreditation period; and
(b) For re-accreditation, one course of training, or a part thereof, within the last 12
months of the accreditation period will be observed by a CRMIE, who may be a
company examiner, a CAA Inspector, or a suitably qualified member of the CRM
Advisory Panel.
74
Aircraft Maintenance & 5.10 CRM INSTRUCTORS – EXAMINERS (CRMIEs)
Crew Management
5.10.1 Requirements – General
The role of the CRMIE derives from the JAR-OPS Subpart N and subsequent
revisions. The CAA will authorise suitably experienced and qualified individuals as
examiners to facilitate the accreditation of instructors as being competent to carry out
CRM training. CRMIEs may be qualified in the three contexts of Ground School,
Simulator/Base and Line. The CRMIE shall meet all the requirements of the CRMI in
the context in which he is to be a CRMIE.
A CRMIE may be qualified in more than one context. All company CRMIEs should
be nominated in the company Operations Manual (Training). When exercising the
privileges of a CRMIE in an aircraft, the individual shall hold an appropriate valid and
current licence.
The CRMIE authorisation will remain valid subject to the examiner’s continued
employment with the sponsoring company. Should the examiner cease to be employed
on examining duties, or leave the sponsoring company, the authorization will
automatically lapse.
A CRMIE may carry out accreditation checks on instructors not employed by the
company sponsoring that examiner’s authorisation subject to a written agreement
between the sponsoring company and the third party. Copies of such written
agreements must be forwarded to the Head of Training Standards at the CAA for his
approval. The CAA will, on receipt of this copy agreement, reserve the right without
prejudice, to refuse to sanction any such agreements.
Standardisation will be maintained by CAA Inspectors observing CRMIEs
undertaking assessment of CRMIs at ground school training, LOFT training,
simulator/base checks and line training/checks on an opportunity basis.
75
5.11 INITIAL ACCREDITATION Crew Resource
Management
The accreditation process is divided into the three contexts of Ground School,
Simulator/Base and Line.
Ground School
Initial accreditation of CRMIEs (Ground) will be by observation of the candidate
CRMIE accrediting a CRMI (Ground) during a course, or part of a course of ground
training. The observation will be carried out by a CAA Inspector or a suitably
qualified member of the CRM Advisory Panel. The accreditation will be for an initial
period of three years.
Simulator/Base
TRI(E)s and RETREs who conduct TRI and TRE revalidations in simulators or
aircraft have been given grandfather rights since 1st October 2001. These grandfather
rights will remain in place until such time as the appropriate authority is revalidated.
This revalidation is carried out by a CAA Training Inspector.
Extension of the existing authority to include CRM accreditation will be in accordance
with Standards Document 29. All TRI(E)s and RETREs need to have been accredited
by 30th September 2004.
New TRI(E) and RETREs will need to obtain accreditation coincident with granting
of their initial approval.
Line
Initial accreditation of CRMIEs (Line) will be by observation of the candidate CRMIE
accrediting a CRMI (Line) in a workshop, on an actual line flight, or in the case of
multipilot operators, on a simulator LOFT detail.
Alternatively, a company may nominate a senior trainer as a CRMIE (Line). This
appointment is subject to acceptance by the CAA.
The accreditation will be for an initial period of three years.
5.11.1 Accreditation
In order to become accredited all instructor examiners will need to demonstrate to a
CAA Inspector or a suitably qualified member of the CRM Advisory Panel that they:
(a) have the knowledge specified for their relevant role;
(b) have the necessary instructional and assessment skills;
(c) are able to assess instructors’ teaching, evaluating and debriefing of CRM
performance in accordance with 'The Short Guide' (Appendix 12); and
(d) are able to facilitate a constructive debrief of CRM issues.
On recommendation the CAA will accredit suitably experienced and qualified persons
to conduct instructor examining for an initial period of three years. This accreditation
will remain valid subject to the individual’s continued employment as a CRM
instructor examiner.
Examiners Ground
All CRMIEs (Ground) will require to become accredited prior to being authorised to
examine CRMI candidates.
76 Examiners Simulator/Base
Aircraft Maintenance &
Crew Management All TRI(E)s and RETREs, who held valid authorisations at 30th September 2001 were
given grandfather rights. These grandfather rights remain valid until the expiry of that
authority at which time they will require to become accredited. To achieve
accreditation an assessment will be made of their CRMIE performance to assess the
teaching, evaluating and debriefing of the CRM aspects of LOFT and competency
checks during the recurrent three-yearly revalidation observation.
All candidates put forward by their companies subsequent to 30th September 2001
were required to demonstrate their CRM instructor examiner performance to assess
the teaching, evaluating and debriefing of the CRM aspects of LOFT and competency
checks during the initial observation by a CAA Inspector.
Examiners Line
Line Training or Line Checking Captains have not received grandfather rights as
CRMIEs (Line). Companies may nominate a senior trainer as a CRMIE (Line). Such
appointment is subject to acceptance by the CAA, and standardisation will be
achieved by periodic observation by a CAA Inspector observing the accreditation
process.
Examiners Simulator/Base
TRI(E)s and RETREs will be accredited with CRM instructional and assessment skills
when their authority is revalidated by a CAA Training Inspector.
Examiners Line
Line examiners will be accredited by a CAA Inspector on a three yearly renewal basis.
The revalidation may be achieved by observation of the CRMIE conducting a CRMI
(Line) accreditation in a workshop, during actual line training or during a simulator
LOFT detail in the multi-crew environment.
Record Keeping
Records of all checks conducted by examiners must be kept for a period of three
years. These records should show the instructional course dates, the type of course or
check, the name(s) of the candidate(s) and the type of simulator or aircraft (if any) that
was used.
potential for loss of life when an incident does occur (as modern transport aircraft can 77
Crew Resource
carry hundreds of passengers at a time). It has been touted widely during the past Management
several decades that 85% of accidents are caused by human error but what this term
fails to recognize is that humans are but one part of the wider environment – they must
interact with many components including weather, technology, social systems etc.
Despite this, humans are at the most very basic level the root cause of any incident
because humans ultimately design and/or interact with all elements of the wider
environment. The core reason for the existence of air carriers (airlines) is to safely
transport people and goods from one place to another. Management of risk and threat
is the key to managing safety and therefore many aviation systems (such as weather
planning, air traffic control and flight deck warning systems) exist to manage risk. The
practice of crew resource management is an integral part of commercial airline
operations. Modern crew resource management focuses upon the management of
resources to reduce error by many groups of aviation specialists (e.g. air traffic
controllers, pilots, cabin crewmembers, mechanics and dispatchers) through goal
setting, teamwork, awareness and both pro- and reactive feedback. These same
components of crew resource management are facets of Perezgonzales’ model of
health and safety management. Crew resource management aims to allow numerous
people in various roles to manage various core elements and throughputs to achieve an
outcome (safer flight); therefore, crew resource management in practice can be
thought of a micro-model for safety management existing as part of a larger
organizational model.
78
Aircraft Maintenance & 5.15 IMPACT OF CRM IN AVIATION SAFETY
Crew Management
‘Natural limitations on human performance and complexity of the environment make
error inevitable’ (Helm Reich Pub.257). In the aviation industry, safety is the utmost
priority even though they (aviation industry) can justifiably or boast about how much
safer it is to travel by air then on road. The field of human factors has been a great
concern since the early days of commercial aviation (Hawkins 1987). Human factors
evolved from an initial combination of engineering and psychology with focus on
‘knobs and dials’ to an multidisciplinary field that draws on the methods and
principles of behavioural-social sciences, engineering and physiology to optimize
human performance and to reduce human error (National Research Council 1989).
Crew Resource Management (CRM) is an application in order to reduce errors
committed by human. We will now go in-depth to discuss on what is CRM, and the
impact it has on the aviation industry worldwide. Human errors accounts for about
75% of aviation accidents, therefore, human performance is one of the major concerns
towards safety in aviation (Hawkins 1987). Recognition of this human performance
problem stimulated a number of independent efforts classified under the term ‘pilot
error’. The researchers are focused on what can be done to reduce such errors. One of
the most outstanding developments in aviation safety for the past decade has been the
implementations of training programs aiming to increase effectiveness and efficient in
crew’s teamwork as well as flight-deck management. This development was first
introduced when aircraft investigators concluded that ‘pilot error’ documented in past
accidents and incidents were reflected to team-communication and coordination rather
than pilots ‘stick and rudder’ skills proficiency (Murphy 1980). The original label for
such training was known as cockpit resource management, but with recognition to its
applicability of the approach to others members of the aviation community; it changes
into Crew Resource Management (CRM). CRM is the application of human factors in
the aviation system which uses all available resources (equipment and people) to
achieve safe flight operations. CRM combines individual technical efficiency with the
broader goal of crew coordination. CRM courses aims to allow all aviation personnel
to have effective performance which consist of technical proficiency and interpersonal
skills. The primary focus will be directed to team coordination, the attitudes and
behaviours of individual. CRM courses are design to address human behaviour which
is a product of knowledge and thought process, personality, attitude and background.
It is not design to change ones’ personality. In order to achieve those key-points
mentioned above; most CRM courses worldwide are similar in terms of its content.
All CRM courses consist of three main clusters of skills namely, communication,
team-building and workload.
fatal communication error occurs when the first officer relay the message to turn 79
Crew Resource
starboard instead of turning port. This massage made the B707-321B fly a longer loop Management
thus burning more fuel. Communications between the ATC and the first officer clearly
shows a misinterpretation about fuel level. The first officer assumed that the ATC had
acknowledged the low fuel status of the Flight 052 but in fact, the ATC interpreted the
transmission as ‘Flight 052 has sufficient fuel’. Words like ‘emergency’ was not used
by the first officer thus it leads to a different outcome of interpretation. This air
accident shows us a total breakdown in communication by the flight crews in attempt
to relay important situations to the ATC. The flight crew was reported to have
limitations in their individual abilities in English language. Proper knowledge of CRM
training which focus on inter-personal communication will perhaps prevent this
accident as the pilots may have better proficiency in English language, communicate
better and clearly, standardisation of phraseology which will prevent
misinterpretations and the pilots may repeat to the other party about the message and
make sure they understood what the situation was before engaging in other
conversations (Shari Stamford Krause, Ph.D.), With good attributes of CRM,
decision-making by the captain or the first officer to declare an emergency and seek
for help from the ATC might prevent this fatal accident. CRM training in
communication and decision-making allows aviation personals to increase team
effectiveness, reduces fewer errors which eventually increases the safety aspects.
80 5.15.3 Workload
Aircraft Maintenance &
Crew Management Lastly, the final clusters of skills for CRM will be workload. These include concepts
like mission planning, stress management and workload distribution. Accidents often
happen when workload demands are greater than team capabilities. In pilot’s
perspective, most accidents happen during take-off and landing phrases. These phrases
are periods on high workload. But surprisingly, low workload can also cause
accidents. In flight crew perspective, during the long cruise segments, the pilots may
be less attentive then when they are working frantically. This low workload periods
are times where complacency is the most common. This is known as the low-arousal
level factor from the Yerkes-Dowson Law (Wickens & Hollands 2000). Workload
management is crucially important. Most of the aviation-operations jobs required shift
duties, thus proper workload management must be planned as circadian rhythms will
causes performance to decrease which results in reduction of safely aspects. On 3rd
September 1989 2045 hour, VARIG airline flight RG 254 made a forced landing into
a jungle near Sao Jose do Xingu, Brazil due to fuel exhaustion (ICAO Adrep
Summary 5/89 #11). The flight, a B737-241 took off at 1725 hour from Maraba
towards Belem, Brazil. The flying time was approximately 45mins. The flight crew
entered into the flight computer 270 degrees instead of 027 degrees. After 2 hours of
flying, the captain finally realized that they were flying towards the wrong direction.
Amendments were made to fly back to their original route, but it was too late. The
plane was 600NM off course. Fuel exhaustion occurred which leads to the forced
landing in the jungle. The navigation mistake went unnoticed because the flight crews
were reported listening to the World Cup Qualification Match between Brazil vs.
Chile. From this example, we can see that how poor workload management causes
such an accident. If the crew/team manages to priories their workload and if the crew
doubled-check their computer inputs, such accidents will not even occur. With quality
CRM training, teams are train to follow procedures and to double-check their work.
Good leaders will distribute even workload to each member’s capacity, in order to
have optimal performance. From this accident, if captain has order the co-pilot to
make scheduled checks on the flight computer, such accidents could be prevented.
Distractions such as listening to radios should be minimised. The pilots should
increase their arousal level by going through cruising procedures in order to have
optimal performance during cruising. CRM training for personnel will prevent such
accidents which increases aviation’s safety. From the three examples given above
which demonstrated human factors being a key failure which result in massive
destruction, proper CRM training must be applied in order to increase safety in
aviation. CRM knowledge will reduce the above mentioned slips/mistakes which will
prevent the accidents.
81
5.16 LET US SUM UP Crew Resource
Management
Crew resource management aims to allow numerous people in various roles to manage
various core elements and throughputs to achieve an outcome (safer flight); therefore,
crew resource management in practice can be thought of a micro-model for safety
management existing as part of a larger organizational model. Crew resource
management is a model of management used to respond (manage) threat and error in
aviation. There are various core elements of CRM. These core elements allow
throughputs to be created which enhance system performance. Crew Resource
Management (CRM) is an application in order to reduce errors committed by human.
Communication and Decision-making Skills is the first cluster of CRM modules. It is
to build up interpersonal skills in which crew will need to ensure optimal
performance. The second clusters of skills will be Team Building. Team building
consists of two major concepts which are leadership and team management. Lastly,
the final clusters of skills for CRM will be workload. These include concepts like
mission planning, stress management and workload distribution.
5.18 KEYWORDS
Air Traffic Control (ATC): Air Traffic Control is a service provided by ground-based
controllers who direct aircraft on the ground and through controlled airspace.
Crew Resource Management (CRM): Crew Resource Management can be defined as
a management system which makes optimum use of all available resources –
equipment, procedures and people – to promote safety and enhance the efficiency of
flight operations.
Perezgonzales’ Model of Health and Safety Management: It consists of a number of
layers and components in a causal chain whereby each element has influence upon the
total system and allows for the logical, effective flow of information to achieve goals.
The purpose of this system is to influence the operational system so that it is operated
in such a way that health and safety are maintained.
Throughputs: In Perezgonzales’ model, these enhance the core elements and lead to
greater outputs.
82 5. CRMI
Aircraft Maintenance &
Crew Management
CYP 2
1. Air transport
2. The accreditation process
3. ground school training
4. CRMIEs (Line)
5. errors
83
Incidents/Accidents
UNIT IV
84
Aircraft Maintenance &
Crew Management
85
LESSON Incidents/Accidents
6
INCIDENTS/ACCIDENTS
CONTENTS
6.0 Aims and Objectives
6.1 Introduction
6.2 Accident
6.3 Preliminary Report
6.3.1 Responsibility of the State Conducting the Investigation Accidents to
Aircraft Over 2250 kg
6.3.2 Accidents to Aircraft of 2250 kg or less
6.3.3 Language
6.3.4 Dispatch
6.4 Accident/Incident Data Report
6.4.1 Responsibility of the State Conducting the Investigation Accidents to
Aircraft over 2250 kg
6.4.2 Additional Information
6.4.3 Incidents to Aircraft over 5700 kg
6.5 Accident Prevention Measures
6.5.1 Incident Reporting Systems
6.6 Database Systems
6.7 Analysis of Data – Preventive Actions
6.8 Exchange of Safety Information
6.9 Evaluation of Flight Crew CRM Skills
6.10 Crew CRM Skills
6.11 Let us Sum up
6.12 Lesson End Activity
6.13 Keywords
6.14 Questions for Discussion
6.15 Suggested Readings
86
Aircraft Maintenance & 6.1 INTRODUCTION
Crew Management
An occurrence associated with the operation of an airplane that takes place between
the times any person boards the airplane with the intention of flight and such time as
all such persons have landed, in which:
z The airplane sustains substantial damage, or
z The airplane is missing or is completely inaccessible, or
z Death or serious injury results from:
Being in the airplane, or
Direct contact with the airplane or anything attached thereto, or
Direct exposure to jet blast.
In general, this expression is a measure of accidents per million departures. Departures
(or flight cycles) are used as the basis for calculating rates, since there is a stronger
statistical correlation between accidents and departures than there is between accidents
and flight hours, or between accidents and the number of airplanes in service, or
between accidents and passenger miles or freight miles. Airplane departures data are
continually updated and revised as new information become available. These form the
baseline for the measure of accident rates and, as a consequence, rates may vary
between editions of this publication.
6.2 ACCIDENT
An occurrence associated with the operation of an aircraft which takes place between
the times any person boards the aircraft with the intention of flight until such time as
all such persons have landed, in which:
(a) a person is fatally or seriously injured as a result of:
being in the aircraft, or
direct contact with any part of the aircraft, including parts which have become
detached from the aircraft, or
direct exposure to jet blast, except when the injuries are from natural causes,
self-inflicted or inflicted by other persons, or when the injuries are to
stowaways hiding outside the areas normally available to the passengers and
crew; or
(b) the aircraft sustains damage or structural failure which:
adversely affects the structural strength, performance or flight characteristics
of the aircraft, and
would normally require major repair or replacement of the affected
component, except for engine failure or damage, when the damage is limited
to the engine, its cowlings or accessories; or for damage limited to propellers,
wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the
aircraft skin; or
(c) the aircraft is missing or is completely inaccessible.
Note: For statistical uniformity only. An injury resulting in death within thirty days of
the date of the accident is classified as a fatal injury by ICAO.
Note: An aircraft is considered to be missing when the official search has been
terminated and the wreckage has not been located.
Overall, incidents and accidents involve the entire range of CRM and Human Factors 87
Incidents/Accidents
aspects.
In incident and accident reports, the flight crew’s contribution often is considered to
be just what the flight crew did or did not do.
The following discussion is a focused but limited overview of the broad CRM subject.
CRM concepts and techniques enhance effective cross monitoring and backup by each
crewmember.
The minimum content of CRM training is defined by regulations and airlines should
consider additional CRM training to account for specific requirements, such as multi-
cultural flight crews and different areas of operation.
CRM issues have been identified as circumstantial factors in more than 70% of
approach-and-landing incidents or accidents.
Because CRM practices are a key factor in flight crew adherence to and performance
of normal and non-normal procedures and in the interaction with automated systems,
CRM issues are involved to some degree in every incident or accident.
The captain’s role and attitude in opening the line of communication with the first
officer and cabin crew is of prime importance for setting the flight deck atmosphere
and ensuring effective:
z Teamwork (e.g., creating a synergy among crew members, allowing the authority
and duty for the first officer to voice any concern as to the progress of the flight
and overall safety)
z Crew coordination, mutual monitoring and backup
z Human relations (e.g., effective intra-crew communications)
Performing a pre-flight briefing that includes the flight crew and cabin crew
establishes the basis for effective teamwork. Flight attendants may hesitate to report
technical occurrences to flight crew (i.e., because of cultural aspects, company
policies or intimidation). To overcome this reluctance, the implementation and
interpretation of the sterile cockpit rule (as applicable) should be discussed during
cabin crew CRM training and recalled by the captain during the pre-flight briefing.
When performing the operational and human factors analysis of operational events,
Airbus qualifies teamwork aspects, using the following markers:
z Flight preparation and planning
z Intra-cockpit communications
z Cockpit crew/cabin crew communications
z Cultural/language factors
z Priority setting
z Quality of briefings
z Flight monitoring
z Workload management
z Mutual cross-check and back-up
z Adherence to standard calls
z Strategic (long-term) decision making
z Tactical (short-term) decision making
88 z Situational awareness
Aircraft Maintenance &
Crew Management z Interruptions and distractions management
z Effective use of all crew resources
Accredited Representative
A person designated by a State, on the basis of his or her qualifications, for the
purpose of participating in an investigation conducted by another State.
Adviser
A person appointed by a State, on the basis of his or her qualifications, for the purpose
of assisting its accredited representative in an investigation.
Aircraft
Any machine that can derive support in the atmosphere from the reactions of the air
other than the reactions of the air against the earth’s surface.
Causes
Actions, omissions, events, conditions, or a combination thereof, which led to the
accident or incident.
Flight Recorder
Any type of recorder installed in the aircraft for the purpose of complementing
accident/incident investigation.
Note: The provisions of this chapter may require two separate reports for anyone
accident or incident. They are:
z Preliminary Report
z Accident/Incident Data Report
Note: Guidance for preparing the Preliminary Report and the Accident/Incident Data
Report is given in the Accident/Incident Reporting Manual.
Incident
An occurrence, other than an accident, associated with the operation of an aircraft
which affects or could affect the safety of operation.
Note: The types of incidents which are of main interest to the International Civil
Aviation Organization for accident prevention studies are listed in the
Accident/Incident Reporting Manual.
Investigation
A process conducted for the purpose of accident prevention which includes the
gathering and analysis of information, the drawing of conclusions, including the
determination of causes and, when appropriate, the making of safety
recommendations.
Investigator-in-charge
A person charged, on the basis of his or her qualifications, with the responsibility for
the organization, conduct and control of an investigation.
Note: Nothing in the above definition is intended to preclude the functions of an
investigator-in-charge being assigned to a commission or other body.
Operator 89
Incidents/Accidents
A person, organization or enterprise engaged in or offering to engage in an aircraft
operation.
Preliminary Report
The communication used for the prompt dissemination of data obtained during the
early stages of the investigation.
Safety Recommendation
A proposal of the accident investigation authority of the State conducting the
investigation, based on information derived from the investigation, made with the
intention of preventing accidents or incidents.
Serious Incident
An incident involving circumstances indicating that an accident nearly occurred. Like,
z Collisions flight into terrain only marginally avoided.
z Aborted take-offs on a closed or engaged runway.
z Take-offs from a closed or engaged with marginal separate from obstacle(s)
z Landings or attempted landings on a closed or engaged runway.
z Gross failures to achieve predicted performance during take-off or initial climb.
z Fires and smoke in the passenger compartment, in cargo compartments or engine
fires, even though such fires were extinguished by the use of extinguishing agents.
z Events requiring the emergency use of oxygen by the flight crew.
z Aircraft structural failures or engine disintegrations not classified as an accident.
z Multiple malfunctions of one or more aircraft systems seriously affecting the
operation of the aircraft.
z Flight crew incapacitation in flight.
z Fuel quantity requiring the declaration of an emergency by the pilot.
Note: The difference between an accident and a serious incident lies only in the result.
Serious Injury
An injury which is sustained by a person in an accident and which:
(a) requires hospitalization for more than 48 hours, commencing within seven days
from the date the injury was received; or
(b) results in a fracture of any bone (except simple fractures of fingers, toes or nose);
or
(c) involves lacerations which cause severe hemorrhage, nerve, muscle or tendon
damage; or
(d) involves injury to any internal organ; or
(e) involves second or third degree bums, or any bums affecting more than 5 per cent
of the body surface; or
(f) involves verified exposure to infectious substances or injurious radiation.
90 State of Design
Aircraft Maintenance &
Crew Management The State having jurisdiction over the organization responsible for the type of design.
State of Manufacture
The State having jurisdiction over the organization responsible for the final assembly
of the aircraft.
State of Occurrence
The State 111 the territory of which an accident or incident occurs.
6.3.3 Language
The Preliminary Report shall be submitted to appropriate States and to the
International Civil Aviation Organization in one of the working languages of ICAO.
6.3.4 Dispatch
The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days
of the date of the accident unless the Accident/Incident Data Report has been sent by
that time. When matters directly affecting safety are involved, it shall be sent as soon
as the information is available and by the most suitable and quickest means available.
Recommendation
A State should establish a voluntary incident reporting system to facilitate the
collection of information that may not be captured by a mandatory incident reporting
system.
A voluntary incident reporting system shall be non-punitive and afford protection to
the sources of the information.
Note 1: A non-punitive environment is fundamental to voluntary reporting.
Note 2: States are encouraged to facilitate and promote the voluntary reporting of
events that could affect aviation safety by adjusting their applicable laws, regulations
and policies, as necessary.
Note 3: Guidance related to both mandatory and voluntary incident reporting systems
is contained in the Accident Prevention Manual.
Table 6.2: Causes of Fatal Accidents by Decade (percentage)
Cause 1950s 1960s 1970s 1980s 1990s 2000s All
Pilot Error 40 34 24 26 27 30 29
Pilot Error (weather related) 10 17 14 18 19 19 15
Pilot Error (mechanical related) 6 5 5 2 5 5 5
Total Pilot Error 57 56 43 46 51 54 50
Other Human Error 2 9 9 6 9 5 7
Weather 16 9 14 14 10 8 12
Mechanical Failure 21 19 20 20 18 24 22
Sabotage 5 5 13 13 11 9 9
Other Cause 0 2 1 1 1 0 1
93
Incidents/Accidents
Source: Statistical Summary of Commercial Jet Airplane Accidents, 1959 - 2008, Boeing
94
Aircraft Maintenance & 6.9 EVALUATION OF FLIGHT CREW CRM SKILLS
Crew Management
In order to ascertain whether CRM training has been effective, it would be necessary
to assess the CRM skills of flight crew members from time to time. CRM assessment
is inevitable and essential if standards that address this major threat to safety are to be
maintained and improved. However, if implemented inappropriately, assessment could
be potentially damaging to increased safety in the long term. Trainers and examiners
may be reluctant to explore CRM issues, so the objective of having CRM discussed in
depth during briefings might be threatened.
Some methods exist for assessment of CRM skills (the NOTECHS system being one
method), but operators and training providers are advised to familiarise themselves
with the arguments concerning assessment of CRM and the application of behavioural
marker systems before implementing such assessment. (Further information and some
papers on the subject can be found on the CRM page of the Royal Aeronautical
Society Human Factors Group website: www.raes-hfg.com. In particular, the paper
entitled “The assessment of non-technical skills in JAR-OPS and JAR-FCL”).
Assessment is the process of observing, recording, interpreting and assessing, where
appropriate, crew performance and knowledge against a required standard in the
context of overall performance. It includes the concept of self-critique and feedback
which can be given continuously during training, or in summary following a check.
There are four instances under which the assessment of Non-technical skills (NTS) or
CRM takes place, namely the Licence Skill Test (LST), Licence Proficiency Check
(LPC), Operator’s Proficiency Check (OPC) and Line Check.
This assessment is in accordance with a methodology acceptable to the CAA and the
purpose is to:
(a) provide feedback to the crew collectively and individually and serve to identify
retraining where necessary; and
(b) be used to improve the CRM training system.
At all other stages of the CRM training process, (i.e. initial CRM training, operators
conversion course CRM training (whether a change of aircraft type or a change of
operator), command course CRM training and recurrent CRM training, CRM should
NOT be assessed with respect to pass/fail competence. However, there remains a
requirement that crew members progress through the CRM training cycle should be
evaluated such that feedback can be provided to the individual, any requirement for
retraining can be identified, and continued improvement of the CRM training system
can be implemented.
The subtle difference between assessment and evaluation is that assessment is made
against a required standard. An assessment below that required, will require the pilot’s
CRM performance to be recorded as unsatisfactory and may require remedial training.
CRM skills assessment should be included in an overall assessment of the flight crew
member’s performance and should be in accordance with approved standards. When
operating in a multi-pilot role it may be difficult to make an assessment of an
individual crew member. However, this should be done where possible in order that
the pilot concerned gains maximum advantage from the assessment and any
recommendations that the instructor may make. If it is not possible to make individual
assessments then this should be done as a crew. Individual assessments are not
appropriate until the crew member has completed the full cycle of CRM recurrent
training.
CRM assessment should only be tied to the assessment of technical issues, and not
carried out as a stand-alone assessment. Suitable methods of assessment should be
established, together with the selection criteria and training requirements of the 95
Incidents/Accidents
assessors, and their relevant qualifications, knowledge and skills.
A crew member should not fail a licence or type rating revalidation check due to poor
CRM unless this is associated with a technical failure (e.g. violation of SOPs, failure
to observe company policies, etc.). However, an Operator Proficiency Check should
not be considered as being satisfactorily completed unless the CRM performance of
the pilot meets with company requirements. This does not prevent instructors and
examiners from giving feedback on CRM issues where appropriate even if there has
not been an effect on the technical performance of the flight.
Foreign TREs (non CAA approved) must be accredited as CRMIs in order to test for
OPCs. For individual CRM skills assessment, the following methodology is
considered appropriate:
z An operator should establish the CRM training programme including an agreed
terminology. This should be evaluated with regards to methods, length of training,
depth of subjects and effectiveness.
z The CRM standards to be used (e.g. NOTECHS) have been agreed by crews,
operators and regulators, and reflect best practice.
z The standards are clear, briefed, and published (in the Operations Manual).
z The methodology for assessing, recording and feeding back has been agreed and
validated.
z Training courses are provided to ensure that crews can achieve the agreed
standards.
z Procedures are in place for individuals who do not achieve the agreed standards to
have access to additional training, and independent appeal.
z Instructors and examiners are qualified to standards agreed by all parties, and are
required to demonstrate their competency to the CAA or such persons as the CAA
may nominate.
z A training and standardisation programme for training personnel should be
established.
For a defined transition period (normally the full cycle of CRM recurrent training), the
evaluation system should be crew rather than individually based.
Prior to the introduction of CRM skills assessment, a detailed description of the
methodology (including standard terminology to be used) acceptable to the CAA,
should be published in the Operations Manual (Training). This methodology should
include procedures to be applied in the event that crew members do not achieve, or
maintain the required standards. Until recently the assessment of CRM training has
lacked any formal measurement criteria resulting in subjective and extremely variable
standards.
Research into means of assessment has determined that acquired CRM skills are
reflected in recognizable behaviours, whose characteristics are identifiable as
measurable behavioural markers. CRM skills assessment should be accomplished via
a behavioural marker system (a behavioural marker is a taxonomy or listing of key
nontechnical skills associated with effective, safe task performance in a given
operational job position). The need for a clear and simple system focusing on general
concepts and their application is fundamental, as is the need for the training of the
users of the system. Currently the two main validated systems being (i) NOTECHS
and (ii) the UT markers. A number of airlines have developed their own behavioural
96 marker systems, and provided that these systems can demonstrate a similar level of
Aircraft Maintenance &
Crew Management robustness, there should be no reason why they should not be utilized.
Instructors and examiners should be familiar with the marker system in use by the
operator in order to enable them to make constructive debriefs and give guidance to
crews to improve future performance and also to make recommendations for further
training where this is necessary. However, they should not use these markers as a
check list when making assessments. CRM assessment should not be conducted as an
activity survey for each phase of flight, but should be carried out within the overall
assessment of the flight check.
Key to the use of any behavioural marker system is the training and standardization of
the assessors within the company. Regular re-standardization is necessary as it has
been shown that assessors’ skills are degradable, and require regular re-evaluation and
sharpening.
Liveware-Liveware
z Communication skills
z Listening skills
z Observation skills
z Operational management skills; leadership and followership
z Problem solving
z Decision-making
Liveware-Hardware 97
Incidents/Accidents
z Scanning
z Detection
z Decision-making
z Cockpit adjustment
z Instrument interpretation/situational awareness
z Manual dexterity
z Selection of alternative procedures
z Reaction to breakdowns/failures/defects
z Emergency warnings
z Workload; physical, allocation of tasks
z Vigilance
Liveware-Environment
z Adaptation
z Observation
z Situational awareness
z Stress management
z Risk management
z Prioritisation and attention management
z Coping/emotional control
z Decision making
Liveware-Software
z Computer literacy
z Self-discipline and procedural behaviour
z Interpretation
z Time management
z Self-motivation
z Task allocation
The proposed ICAO curriculum detailed above includes an interface not considered as
such in the SHEL model, namely the Human Element. Human Factors skills under this
heading include those relating to the psychological state and well-being of operational
personnel themselves (this should not be confused with the Liveware-Liveware
interface, which deals with interpersonal contacts):
Human Element
z Recognition/coping: disorientation (motion systems), stress
z Fatigue
z Pressure effects
98 z Self-discipline/control
Aircraft Maintenance &
Crew Management z Perception
z Attitudes and the application of knowledge and exercise of judgement
It will be readily appreciated from the foregoing that the development of skills for
practical application during flight operations is an important evolution from
theoretical Human Factors knowledge to actual operational settings. While the
emphasis in this document is necessarily directed mainly towards pure knowledge
requirements, it is important to reiterate that, where possible, practical Human Factors
considerations should be built into all relevant aspects of instructional activity. This
should apply throughout all stages of pilot and instructor training. Instruction directed
at the acquisition of Human Factors skills is the activity which is expected to yield the
greatest benefit in the future.
It is anticipated that specialist training directed towards the acquisition of suitable
skills will be further developed in the coming years and that suitable training
techniques will be fully integrated into all pilot training activities. It is especially
undesirable that, after meeting the different knowledge requirement, trainees come to
see human performance training as an academic exercise lacking in operational
relevance.
Excluding
z Fatal and nonfatal injuries from natural causes, and
z Fatal and nonfatal self-inflicted injuries or injuries inflicted by other persons, and 99
Incidents/Accidents
z Fatal and nonfatal injuries of stowaways hiding outside the areas normally
available to the passengers and crew, and
z Non-fatal injuries resulting from atmospheric turbulence, normal manoeuvring,
loose objects, boarding, disembarking, evacuation, and maintenance and
servicing, and
z Non-fatal injuries to persons not aboard the airplane.
In order to ascertain whether CRM training has been effective, it would be necessary
to assess the CRM skills of flight crew members from time to time. CRM assessment
is inevitable and essential if standards that address this major threat to safety are to be
maintained and improved. The subtle difference between assessment and evaluation is
that assessment is made against a required standard. An assessment below that
required, will require the pilot’s CRM performance to be recorded as unsatisfactory
and may require remedial training. CRM skills assessment should be included in an
overall assessment of the flight crew member’s performance and should be in
accordance with approved standards.
6.13 KEYWORDS
Accident Rates: This expression is a measure of accidents per million departures.
Departures (or flight cycles) are used as the basis for calculating rates, since there is a
stronger statistical correlation between accidents and departures than there is between
accidents and flight hours, or between accidents and the number of airplanes in
service, or between accidents and passenger miles or freight miles.
Airplane Collisions: Events involving two or more airplanes are counted as separate
events, one for each airplane. For example, destruction of two airplanes in a collision
is considered to be two separate accidents.
Fatal Accident: An accident that results in fatal injury.
Hull Loss: Airplane totally destroyed or damaged and not repaired.
100 4. aircraft
Aircraft Maintenance &
Crew Management 5. Airplane departures
CYP 2
1. safety information
2. training and standardization
3. Procedures
4. CRM, flight check
5. behavioural marker systems
101
LESSON Communication: A Relevant
Factor in Aviation Safety
7
COMMUNICATION: A RELEVANT FACTOR IN
AVIATION SAFETY
CONTENTS
7.0 Aims and Objectives
7.1 Introduction
7.2 Communication
7.2.1 Modes of Communication
7.2.2 Verbal Communication
7.2.3 Non-verbal Communication
7.2.4 Communication Problems
7.3 Communication Provides Information
7.4 Communication Establishes Predictable Behaviour Patterns
7.5 Communication Maintains Attention to Task and Monitoring
7.6 Communication is a Management Tool
7.7 Need for Communication Training
7.8 Let us Sum up
7.9 Lesson End Activity
7.10 Keywords
7.11 Questions for Discussion
7.12 Suggested Readings
7.1 INTRODUCTION
From the foregoing discussion on cognitive skills, it is evident that effective
communication between crew members is an essential prerequisite for good CRM.
Research has shown that in addition to its most widely perceived function of
transferring information, the communication process in an aircraft fulfils several other
important functions as well. It not only helps the crew to develop a shared mental
model of the problems which need to be resolved in the course of the flight, thereby
102 enhancing situational awareness, but it also allows problem solving to be shared
Aircraft Maintenance &
Crew Management amongst crew members by enabling individual crew members to contribute
appropriately and effectively to the decision-making process. Most importantly, it
establishes the interpersonal climate between crew members and is therefore a key
element in setting the tone for the management of the flight.
The communication process invariably takes place in a social and organizational
context and it is therefore profoundly influenced by company culture. Its effectiveness
also depends on the experience level of the pilot or crew members involved in the
transaction and their perception of their roles and position in the chain of command.
The effectiveness of the communication process also depends on the nature of the task
and operational context in which the flight is taking place, e.g. the phase of flight, and
whether it is being conducted under normal, non-normal or emergency conditions. In
addition, it is affected by the mode of speech employed and the linguistic context in
which the transaction takes place. In this context, individual styles, body language,
grammatical styles and speech patterns all have their part to play. Because of these
complexities, crew members need to be aware of and sensitive to the nuances of
effective communication. They also need to understand and avoid where possible
those elements which constitute a barrier to effective communication.
Communication has long been suggested as a critical issue in all aspects of human
interaction. The above example from the ASRS database amply illustrates just how
critical communication is in aviation and aviation safety, from the cockpit-controller
interface to coordination in the cockpit to cockpit-cabin interaction to the management
of safety and creation of a safety culture.
7.2 COMMUNICATION
Good communication is important in every industry. In aircraft operations, it is vital.
Communication, or more often a breakdown in communication, is often cited as a
contributor to aviation incidents and accidents. Communication is defined in the
Penguin Dictionary of Psychology as:
“The transmission of something from one location to another. The ‘thing’ that is
transmitted may be a message, a signal, a meaning, etc. In order to have
communication both the transmitter and the receiver must share a common code, so
that the meaning or information contained in the message may be interpreted without
error”.
Communication is essential for organizational and managerial performance and
success in any endeavour, including in the aviation environment. Chester Barnard, the
father of management theory, stated that the primary function of a manager is to
develop and maintain a system of communication (Barnard, 1938). Herbert Simon, a
Nobel-prize winner in economics, feels that communication is essential to the
functioning of an organization, especially with regard to effective decision-making
(Simon, 1957). Indeed, “information flow is the ‘lifeblood’ of an organization. In
order for decision makers to arrive at the best possible decisions from a set of
alternative decisions, accurate information is a necessity”.
As in any human activity, communication plays an integral function in air travel,
especially from the perspective of aviation safety. There are numerous findings noting
the crucial nature of communication in aviation safety. Young (1994) made this
connection when she indicated that:
“The overall objective is to prevent accidents through improved communication in air
carrier operations, and keep safety at the highest possible level.”
Helmreich and Foushee (1993) note that 70% of aircraft accidents involve human 103
Communication: A Relevant
error, listing several specific accidents as examples (see also Foushee, 1982, 1984; Factor in Aviation Safety
Kayten, 1993; Krifka, Martens, & Schwarz, 2003; O’Hare, Wiggins, Blatt, &
Morrison, 1994; Sexton & Helmreich, 2000; and Taneja, 2002 for treatment of the
relationship between human error and aircraft accidents and incidents). They go on to
state that: “The theme of these cases is human error resulting from failures in
interpersonal communication” (Helmreich and Foushee, 1993). Factors related to
interpersonal communication have been implicated in up to 80% of all aviation
accidents in the past 20 years” (p. 1). The FAA also estimates that human error is a
contributing factor in 60-80% of all air carrier incidents and accidents, citing
ineffective communication and other communication-related indicators as underlying
causes of such human error.
Communication is essential for the safety and efficiency of any flight; the crew needs
to convey information, communicate to issue orders, acknowledge commands,
conduct briefings, execute callouts, and ask questions: In order for cockpit
crewmembers to share a “mental model,” or common understanding of the nature of
events relevant to the safety and efficiency of the flight, communication is critical.
This is not to say that effective communication can overcome inadequate technical
flying proficiency, but rather the contrary, that good “stick & rudder” skills cannot
overcome the adverse effects of poor communication.
Smith-Christensen and Durkert (1995) says that effective communication in the ockpit
is a prerequisite for safety. Foushee (1982) notes that
“At the very least, communication patterns are crucial determinants of information
transfer and crew coordination.”
The results of communication errors in aviation can lead to serious impacts on
margins of safety. “Perhaps no other essential activity is as vulnerable to failure
through human error and performance limitations as spoken communication”.
One of the basic underlying premises of CRM is that a team can, and should, perform
better than two (or three) individuals in the cockpit. The aim of CRM is to ensure that
1+1>2, as opposed to 1+1<2 (in a two pilot cockpit), and that team performance takes
precedence over individual performance. Good CRM is getting the balance right as a
team, whilst recognising that the Captain has the final say and responsibility for the
safety of the aircraft.
In order to be effective, team members must be able to talk to each other, listen to
each other, share information and be assertive when required. Commanders should
take particular responsibility for ensuring that the crew function effectively as a team.
Whilst the emphasis in CRM is primarily upon the cockpit crew, and how they work
as a team, it is also important to look at wider team effectiveness, namely the whole
flight crew. CRM principles may also extend to situations where ATC, maintenance,
company experts, etc., are considered to be part of the team (especially in emergency
situations).
104 As the sender of a message, he will typically expect some kind of response from the
Aircraft Maintenance &
Crew Management person he is communicating with (the recipient), which could range from a simple
acknowledgement that his message has been received (and hopefully understood), to a
considered and detailed reply. The response constitutes feedback.
precautionary emergency landing, but fails to tell them not to evacuate the cabin. Both 105
Communication: A Relevant
problems can lead to subsequent human error. Factor in Aviation Safety
Communication also goes wrong when one of the parties involved makes some kind
of assumption. The sender of a message may assume that the receiver understands the
terms he has used. The receiver of a message may assume that the message means one
thing when in fact he has misinterpreted it. Assumptions may be based on context and
expectations, which have already been mentioned in this lesson.
Problems with assumptions can be minimised if messages are unambiguous and
proper feedback is given.
There are several hazards which reduce the quality of communications:
z failures during the transmitting process (e.g. the sending of unclear or ambiguous
messages, language problems);
z difficulties caused by the medium of transmission (e.g. background noises or
distortion of the information);
z failures during receiving (e.g. the expectation of another message, wrong
interpretation of the arriving message or even its disregard);
z failures due to interference between the rational and emotional levels of
communication (e.g. arguments); and
z physical problems in listening or speaking (e.g. impaired hearing or wearing of the
oxygen mask).
It is the task of Human Factors training to prevent or minimise communication errors.
This task includes the explanation of common communication problems as well as the
reinforcement of a standard of language to ensure the error-free transmission of a
message and its correct interpretation. Ambiguous, misleading, inappropriate or
poorly constructed communication, combined with expectancy, have been listed as
elements of many accidents, the most notorious one being the double 747 disaster in
Tenerife.
Communication-related issues have comprised a sizeable portion of NASA’s Aviation
Safety Reporting System (ASRS) database since its inception. Over 70% of the reports
to the ASRS database between 1976 and 1981, the first five years of the reporting
system, were either directly or indirectly related to communication issues and
problems; (Billings & Reynard, 1981; Grayson & Billings, 1981; see also, Billings &
Cheaney, 1981; Monan, 1988, 1991 for further explication of these findings), and
continue to make up a large part of ASRS reports “Communication problems are
mentioned in a high percentage of incidents reported to ASRS” (Callback, 2003,
October, p. 1). Billings and Reynard (1981) go even further when they say that
communication problems involve an even larger proportion of problems in the
aviation system that the 70% that was found in their study.
Kanki and Palmer (1993) highlight the importance of communication in aviation
safety when they state that
“. . . we would like to underscore the importance of communication for efficiency and
safety in aviation . . .”
They further note that:
“By now it should be evident that communication at its simplest is a multi-faceted,
slippery concept It is clearly a means to an end; that is, communication is required in
accomplishing the flying task” (Kanki & Palmer, 1993, p. 129).
106 While communication, in its multi-faceted nature, can have myriad functions in a
Aircraft Maintenance &
Crew Management variety of settings and situations, Kanki and Palmer (1993) provide an excellent
structure for the functions communication plays in aviation and aviation safety,
especially as it affects crew performance:
1. Communication provides information
2. Communication establishes interpersonal relationships
3. Communication establishes predictable behaviour patterns
4. Communication maintains attention to task and monitoring
5. Communication is a management tool
“Pilots heard what they expected to hear, heard what they wanted to hear and 107
Communication: A Relevant
frequently did not hear what they did not anticipate hearing . . .”. Factor in Aviation Safety
A concept allied to that of expectation is that of making assumptions. When we make
assumptions, we interpret the message—or situation—to mean what we assume it to
mean, not necessarily what was actually said or perceived.
The following cases from the ASRS database not only illustrate how making
assumptions can lead to misunderstandings, but also how such unchecked assumptions
can impact safety:
(a) Engine start was uneventful until the after start flows were accomplished. At that
point we experienced a problem with the left bleed air valve. The MEL (Minimum
Equipment List) showed this as a "return to gate" item. At this point, I told the
mechanic we needed to be towed back in. His response sounded like he was
asking us to release the parking brake; however, neither of us quite understood
what he had said about the brakes. I asked him if he was asking us to release the
parking brake, to which he responded, "Release parking brake." I released the
parking brake and the tug operation commenced. With the tug operation
underway, I turned my attention towards the logbook, thinking about how I was
going to write up this problem. The First Officer was looking over the MEL. What
seemed like a few seconds after we began to be tugged, the First Officer asked,
"Where is this guy taking us?" I looked up I saw the end of the paved ramp
approaching rapidly and heard the First Officer say something about stopping the
aircraft. At that point we were both simultaneously on the brakes. After leaving
about 20 feet of skid marks on the ramp, the aircraft came to a stop with the nose
wheel approximately eight feet from the end of the paved surface... without the
tug connected! When the aircraft was stopped and the engines shut down, my next
concern was the location of the mechanic and whether he was okay. He was.
Although this mechanic speaks fairly good English, I was truly surprised at the
level of communication breakdown that had just occurred. The mechanic told me
he thought I was telling him that I was releasing the parking brake. Once we
started rolling he did not tell us to stop, but instead simply unplugged his headset
and got out of the way. What lessons can be learned or relearned from all of this?
First of all, this is a reminder of something we all know, that being towed is an
operation which requires someone to be monitoring the aircraft. Secondly, never
assume anything. Since we never saw the tug pull away (it pulled away while we
were in the books) and we were told to release the parking brake, we thought we
were under tow. During approach briefings, simulator training, and line non-
normal operations flight, someone is always assigned the task of monitoring the
aircraft. Let this serve as a reminder to do the same during tow operations. Thank
goodness no one was hurt, no metal was bent, and no careers were put in jeopardy,
but we sure came darn close (Callback, 2005, November, p. 1; emphasis added).
(b) While being vectored on a downwind leg to Runway 01L, Tower asked if we had
the field in sight, which we did. At that time we were cleared for a visual approach
to Runway 01L and a left turn back to the field was initiated to result in a final of
approximately 6 miles. When approximately 60° from the runway heading, Tower
reported traffic (a B-757) joining a final for runway 01R. While looking for the
traffic the First Officer, who was flying the aircraft, took his eyes off the field and
shallowed his bank... When I realized he was not just squaring off his final but
was going to overshoot the runway I told him he was going to overshoot and
ordered a turn back to our runway. He seemed disoriented and was slow in
responding, resulting in a significant overshoot approaching the approach corridor
for Runway 01R. A TCAS II-Resolution Advisory resulted with a "monitor
vertical speed" command which was complied with. Tower questioned if we had
108 the traffic in sight which we answered in the affirmative. We corrected back to the
Aircraft Maintenance &
Crew Management 01L centerline and landed with no further incident.
This type of misinterpretation can occur whether it is based on expectation,
making assumptions, or the fact that we can interpret the meaning of a message to
fits our frame of reference, not necessarily what the sender had intended the
message to mean. As Redding and Sincoff (1984), communication is not like a
conveyor belt where the meaning is transferred from person to another, arriving—
and being interpreted—exactly same way that it was sent.
(c) Approaching [destination airport] from the east we were cleared to 1l,000 feet/250
knots. We checked in with Approach at 11,000 feet with the ATIS information.
When Approach acknowledged our check they issued a new altimeter setting of
30.00. We acknowledged the updated information. As I reset the two altimeters on
the Captain's side, I inadvertently said 3000 (3 thousand), referring to the altimeter
setting rather than a more appropriate verbiage of 30.00 (three zero zero zero). No
other conversation was ongoing at the time. We were both monitoring Approach
Control and at the time I thought my meaning was clear. Several moments later I
noticed we were descending out of 11,000 feet and 3,000 was set in the altitude
window. We began a climb back to 11,000 as I reconfirmed our assigned
altitude...
After landing, the incident was discussed further and how a similar situation might
be avoided in the future. The First Officer is relatively new a month or two with
the irline. It was learned that he had misinterpreted verbalization of the altimeter
setting as a newly assigned altitude and thought when he restated it that he wanted
him to reset the altitude select window he explained that he would be more precise
in the future. We also used this event as a basis for discussing why, per our
procedures, the Pilot Not Flying always is the person to reset the assigned altitude
and that it is verified by the Pilot Flying prior to any altitude changes.
(d) Prior to engine start, company procedure requires securing the cockpit door. This
procedure was followed and the door indicated "locked." During climb out, the
flight attendant called the flight deck. The Captain answered and after a brief
conversation, he instructed me to level the aircraft and prepare to return to due to a
disturbance in the cabin. During the descent, the Captain assumed control of the
aircraft. As we were nearing [destination], the light attendant called the flight deck
to ask if we were landing. I replied that we were. The Captain took this
opportunity to get additional information regarding the situation in the cabin. She
advised him that the only problem was that the cockpit door was open. The door
was then secured and the flight continued to its original destination. Apparently in
her initial report to the Captain, the flight attendant had simply stated, "Turn
around." Her intent was for the Captain to see the open door, but the Captain
perceived her comment to mean that the flight was in jeopardy and the aircraft
should be turned around and returned to [departure airport]. The fact that English
is the international language of aviation can also lead to misunderstandings. As
has been noted, it is easy enough for native speakers of English to misinterpret
other peoples’ messages. Putting non-native English speakers into the mix can
compound the problem. Prinzo, Hendrix, and Hendrix (2006) note that issues
related to English language proficiency in the aviation safety system need to be
addressed. Again, the ASRS database provides numerous examples of the impact
and problems associated with English as the language of aviation. Here are two,
both of which include the ASRS analyst’s comments that illustrate the
communication issues involved. U.S. flight crews must exercise extra vigilance
when operating internationally into airports where accented English, and the use
of native languages by air traffic controllers, can create confusion and uncertainty
about ATC instructions. A recent ASRS report describes how an alert flight crew 109
Communication: A Relevant
relied on "gut instincts" and prior experience to avoid a ground collision. Factor in Aviation Safety
(e) We were cleared for an immediate departure on Runway 09L, but we had to do a
low-speed abort because the prior aircraft that landed took an excessively long
time to clear the runway. We also had a hard time clarifying our clearance because
Tower was having a long conversation in non-English language. When we were
finally able to inform them of our actions, they told us to taxi clear of the runway
and to contact Ground. We elected to stop immediately after leaving Runway 09L
because taxiing well clear of Runway 09L would have placed us on a taxiway
which also doubles as Runway 09R. We wanted to make sure that it was safe to
proceed any further. It is fortunate we did because Tower had cleared another
aircraft to land on Runway 09R/taxiway and following their instructions could
have resulted in a collision. The Captain's report added this clarifying information
To clear Runway 09L conservatively would take us on to taxiway/Runway 09R.
Taxiway/Runway 09R had not been used as a runway since we had been in the
vicinity [but]...I decided to stay on Tower frequency wait and look first aware that
our tail might be in close As we can see, information transfer—and attendant
hazards—can occur in any facet of the aviation environment, not just in the
cockpit or between the cockpit and ATC or cabin. The cabin is an area where
information transfer is also important. One of the basic information functions of
the cabin crew is sending messages to keep passengers informed about safety
issues. The messages that flight attendants convey to passengers may take the
form of information about on-board services, connection gate data, required safety
briefings, and information passengers need to cope with and survive emergency
situations, including evacuations. For the airline passenger this type of
information transfer may be vital to survival in an emergency. For a thorough
treatment of pre-flight safety briefing and other aspects of information transfer in
the cabin—and the potential communication problems that may occur in that
environment, see Parker (2006), Barkow and Rutenberg (2002), Darby (2006),
and Krivonos (2005). Jargon, the use of language in a profession, trade, or in a
specialized situation (as in aviation), provides a shorthand means for
communicating well—when everyone understands the jargon. The aviation safety
environment is loaded with jargon that often makes communication more efficient
and effective. However, when others don’t understand the jargon or use it
incorrectly, then problems of misunderstanding and misinterpretation can easily
occur. The following example from the ASRS database provided by Matchette
(1995) illustrates how such difficulties can arise with the misuse of jargon, as it
did for one unfortunate pilot:
The Pilot-Controller Glossary defines squawk as "activate specific
mode/code/function on the aircraft transponder." Therefore, "squawk your
altitude" is a controller's instruction to activate the altitude function of a Mode 3/A
transponder. Squawking 7500 is the international code to indicate a hijacking. The
AIM instructs pilots of hijacked aircraft to set 7500 into the aircraft transponder,
which triggers a flashing "HIJK" in the aircraft's data block on the Controller's
radar screen. The Controller will then ask the pilot to "verify squawking 7500." If
the pilot verifies the code or makes no response at all, the Controller will not ask
further questions, but will continue to flight-follow, respond to pilot requests, and
notify appropriate authorities.
(f) "Burbank assigned me a squawk code. Several minutes later the Controller asked
me my altitude and I responded 7,500 feet. He told me to squawk my altitude. I
replied, 'Squawking 7500', and the Controller confirmed my code...After landing,
Ground directed me to a specific parking area, and I was immediately surrounded
by three police cars with a number of officers pointing their weapons at me...They
110 frisked me and handcuffed me. They really roughed me up...I would suggest that
Aircraft Maintenance &
Crew Management Controllers never use the terminology 'squawk your altitude.' This poor pilot
forgot to review his AIM, which would have informed him that:
"Code 7500 will never be assigned by ATC without prior notification from the
pilot that his aircraft is being subjected to unlawful interference [hijacking]. The
pilot should refuse the assignment of Code 7500 in any other situation and inform
the controller accordingly".
One of the problems with the use of jargon is that if someone isn’t familiar with
the jargon, you might as well be speaking a foreign language. Using jargon when
others don’t know what it means is an example of what I term the COIK
principle—Clear Only If Known. Again, if we know what the jargon means, it is a
handy way to help in the information transfer process. If we do not know what the
jargon means, then the information is seldom, if ever, transferred effectively.
(g) Majoros (1990) offers a personal example that effectively captures the essence of
the COIK principle: I would like to relate an incident that happened as I was
boarding a plane in Orange County to come to Washington. At this time the John
Wayne Airport is undergoing a major building program and does not have jetways
or other motorized conveniences for planing and deplaning, Planes must line up
on the apron or tarmac or gate area one-by-one and passengers have to walk to the
aircraft. Just before I boarded the flight, the boarding agent said over the public
address system, “Flight 1256 is in final boarding. Passengers should proceed
through Gate C. The plane is in the middle of the runway, it is facing south, and it
is a Boeing.” Other than the experienced traveller, who would know where to go
with these instructions? How much of our communication in maintenance could
take on similar tones because the communication is not clear and the maintainer
does not know where to go with the instructions? While there are a number of
communication and information transfer issues and problems that are apparent in
the above discussion, there are some effective communication principles that can
lead to greater safety and less risk and error in the system. Although more
effective listening skills would be generally helpful, two specific communication
skills that can be applied to create more effective information transfer in the
aviation environment are using feedback and asking questions. Given that a
substantial number of ASRS reports involve readback/hearback problems
(Callback, 2001, March), these skills are especially important. With regard to
feedback both Ruffell Smith (1979) and Foushee and Manos (1981) note that
feedback in the form of acknowledgement, monitoring, and cross-checking are
important aspects of communication for effective flight operations. The following
example from the ASRS data base, including the analyst’s comments, illustrates
the importance of feedback.
Mandatory readback of certain parts of clearances provides a mechanism to
reduce misunderstandings between ATC and flight crews. An ATC supervisor
reports on a readback error that slipped by both him and an ATC trainee, with a
potentially hazardous result.
Aircraft A was given a descent from 8,000 feet to only 7,000 feet (6,000 feet
would be the norm on this route). Pilot read back 6,000 feet, which was not caught
by either of us. We tried to get him back to 7,000 feet, but he went to 6,500 before
he climbed back. Aircraft B was one mile in trail at 6,000 feet, same speed.
A contributing factor was my over-reliance on the trainee, who is fairly well along
in training. I was assuming he would catch the problem, so I was not listening as
intently. Also, the [typical] descent from 8,000 to 6,000 feet probably had the pilot
expecting to hear 6,000. Only goes to prove the importance of readbacks being 111
Communication: A Relevant
heard and understood (Callback, 1997, October, p. 1). Factor in Aviation Safety
The following comment by an ASRS analyst about the example provided above
concerning the misinterpretation of “position and hold” provides an excellent
justification for asking questions:
The reporter realized after the fact that the crew either misheard or misinterpreted
the Controller's clearance. Regardless, the reporter's suggestion is a good one:
seek clarification by rephrasing the clearance in plain, simple words, different
from those used by the controller. Although some foreign controllers may not
have a broad command of English, they often will understand the crew's restated
questions and be able to provide clarification (Callback, 1996, November, p. 1).
These reports certainly underscore the need for feedback to clear up unchecked
assumptions and expectations.
Asking questions is another effective communication skill that can help reduce
information transfer problems in the aviation safety environment, thus minimizing
risk.
Krifka, et al. (2003) found that questions were slightly more frequent in good
crews and that good crews also answered a considerably higher number of
questions; in contrast to good crews, commands were more frequent in poor
crews. Flight Safety Foundation (2000) indicates that the failure to request
clarification or to question ATC instructions is an ineffective aspect of pilots’
communication.
(h) After completing our run-up, we taxied to the hold short line of Runway 16. My
student was at the controls in the left seat. He called the tower saying "Skyhawk
holding short Runway 16, ready for takeoff." The tower replied, "Skyhawk, taxi
up and hold." I thought the tower meant taxi into position and hold...and we
crossed the hold short line. Tower then told us to stop and clear the runway. We
complied immediately, but the inbound plane elected to go around. Factors
contributing to this incident were the use of non-standard phraseology by the
tower, and my failure to verify whether he meant "hold short" or "taxi into
position and hold." To avoid this type of situation in the future, I will always ask
if I am not sure of a clearance, especially before entering the active runway
(Callback, 2004, April, p. 2; emphasis added): The crew did not request
clarification about the weather conditions or change its course of action to take
these conditions into account. The winds associated with the storm forced the
plane down precipitously, causing an emergency landing without the landing
gear’s being fully extended. The plane skidded off the runway, causing serious
damage to the aircraft and an emergency evacuation of the passengers (Federal
Aviation Administration, 1997, p.11; emphasis added).
Monan (1991) effectively sums up the importance of asking questions when he
states:
“Ask for verification of any ATC instruction about which there is doubt”. This
suggestion goes for any communication interaction in the aviation safety
environment, not just between pilot and ATC. It is useful advice within the
cockpit or cabin, between cockpit and cabin, or for any aspect of the aviation
safety system.
Kismukes, and Barshi (2003), the importance of communication and coordination 113
Communication: A Relevant
during emergency situations and as an example note that communication problems Factor in Aviation Safety
between the cabin and cockpit had negative consequences the evacuation of a flight
into LaGuardia in 2003.
Flight Safety Foundation (2003) indicates that poor communication can contribute to
problems during evacuation procedures. Transportation Safety Board of Canada
(1995) reports several evacuations in which ineffective cabin crew communication
jeopardized the chances of successful evacuations in several incidents. Effective crew
coordination is crucial to a successful evacuation, but ineffective crew communication
leads to ineffective crew coordination. As evidenced by the occurrence data, poor
crew communication may result in unnecessary injuries or fatalities and unnecessary
exposure to risk for passengers and aircrew alike.
Effective coordination between cabin crew and flight deck crew is also essential for
the safe operation of an aircraft. Since 9/11, effective communication from the cabin
crew to the flight crew is even more important. “The ‘sealed’ cockpit environment has
increased the reliance on Flight Attendants for the transfer of vital information”
(Callback, 2003, 17th March). The FAA clearly states that effective communication
between all crewmembers is a prerequisite for such coordination (Federal Aviation
Administration, 1988). ASRS reinforces this point: “Flight attendants are an integral
part of the aircraft crew and their primary responsibilities are safety related”
(Callback, 2003). Rice (2001, May-June) suggests that better communication between
cabin crew and flight crew have resulted in fewer fatalities. Chute and Wiener (1995)
make the tie between communication and safety even more explicit There are two
critical safety obligations for the flight attendant. The first is to prevent accidents,
primarily by means of conveyance of information regarding hazardous conditions to
the flight deck. If the accident cannot be prevented, the second is to maximize
survivability. Both roles require effective communication between the two cultures.
There are a large number of reports that confirm the success with regard to safety of
effective communication in the cabin-cockpit interaction. Yet, the working and
relationship and communication interaction between cabin crew and flight crew
continues to be a vexing one. “Communication and coordination problems between
cockpit crewmembers and flight attendants continue to challenge air carriers and the
FAA” (Federal Aviation Administration, 2004, p. 15).
Helmreich, Wiener, and Kanki (1993) and Kayten (1993) cite numerous examples
where crew coordination problems and poor communication were contributing factors
in several accident reports. Murphy (2001) conveys stories from flight attendants who
felt that vital information they tried to pass along to the cockpit was ignored. In their
study of flight attendants and pilots, Chute & Wiener (1996) found cabin-cockpit
communication to be ineffective. Chute (2001) also maintains that cabin-cockpit
communication is not always necessarily effective.
In a report on evacuation procedures, the Transportation Safety Board of Canada
(1995) indicated that poor communication between flight and cabin crew possibly
jeopardized safe evacuations in several instances. Regarding one specific incident, the
report states that: Inadequate communication between the cabin and the flight deck
resulted in a significant delay before the flight crew was aware of the existence and
seriousness of the fire and contributed to the fact that the evacuation was not initiated
until one minute 55 seconds following the rejected take-off (Transportation Safety
Board of Canada, 1995, p. 19).
114
Aircraft Maintenance & 7.5 COMMUNICATION MAINTAINS ATTENTION TO
Crew Management
TASK AND MONITORING
Another problem with information transfer is that while information is important to
make good decisions, too much information—information overload—can lead to
tension and errors, and communication or information overload often occurs in the
aviation environment. Prinzo & Morrow (2002) found that: “Communication
problems arise in part because of complex air traffic control (ATC) messages
sometimes overload pilot memory (p 1);” especially with that longer messages which
increased demands on pilots’ memories. Majoros (1990) notes that excess information
can lead to communication overload and that the challenge is to communicate
essential information. Prinzo, et al. (2006) states that controllers should be encouraged
to transmit shorter and less complex messages that limit the occurrence of
communication problems and misunderstandings.
Wever, Ven Es, and Verbeek (2006) found that pilots suggested reducing the amount
information in the voice communication and observed that shorter messages may help
to reduce misunderstandings.
Along with other factors, such as poor listening skills, information overload can lead
to lack of attention and distraction. Billings and Cheaney (1981) “conclude that
distraction is a serious problem that inhibits effective performance, both in the cockpit
and in air traffic control” (p. 92). Dismukes, Young, and Sumwalt (1998) examined
107 ASRS reports in which flight crew paid inadequate attention to one task while
performing another task. Their examination revealed a wide range of activities that
distracted or preoccupied the pilots, most of which were communication related. A
number of recent incidents and accidents, including the near miss at LAX between a
SkyWest flight and that of a business jet in September 2006 and the crash of Comair
Flight 5191 in Lexington, Kentucky in August 2006, can be attributed to lack of
attention and distraction.
The following reports from the ASRS database illustrate the effects of distraction on
safety. After landing I began to think about the [clearance] the controller had given
me.... I think he may have said that he needed me at 500 feet while en route for
passing under the Runway 33 approach course. If that was true, I should have
descended to 500 feet and then proceeded on course. The bottom line is, I should have
known exactly what he wanted, but I did not. I believe that I made a mistake in not
giving 100% attention to the ATC instructions. When flying a multi-task job, i.e.
EMS, power line [patrol], lift work, etc., there can be many distractions from the
customer that have little or nothing to do with the immediate job of flying the aircraft.
In the future, I will lock out the [company] radios while receiving a clearance or ATC
instructions.... I am going back to the basics- first the aircraft and ATC, then I'll take
care of any company business (Callback, 2005, May, p. 2.).
115
7.7 NEED FOR COMMUNICATION TRAINING Communication: A Relevant
Factor in Aviation Safety
There have been numerous calls for communication training, both as an independent
effort and as part of Crew Resource Management (CRM) for flight crews and for
flight attendants (Baker & Frost; 1994; Butler, 1993; Chidester & Vaughn, 1994;
Chute & Wiener, 1996; Edwards, 1992; Federal Aviation Administration, 1988, 2004;
Grommes and Dietrich, 2002; Helmreich, 2000; Sexton & Helmreich, 2000; Young,
1994). Perhaps, more important have been the calls for joint pilot-flight attendant
training (Baker & Frost, 1994; Butler, 1993; Chidester & Vaughn, 1994; Chute &
Wiener, 1995, 1996; ETSC, 1996; Federal Aviation Administration, 2004; Helmreich,
Wiener, & Kanki, 1993; Kayten, 1993; Murphy, 2001; Moshansky, 1994, NTSB,
2000). “We must teach crews that communication and cooperation are safety issues”
(Chute, Wiener, Dunbar, & Hoang, 1996, p. 17).
Flight and cabin crew, while a critical part of the aviation environment, should not be
the only focus of communication training as part of an aviation safety training
program. Flight Safety Foundation (2000) notes that training programs should include
special emphasis on pilot controller communication. Thomas (2005b) and Thomas and
Petrilli (2004) argue for communication training as part of error management.
Latorella and Prabhu (2000) and Petrowski (1990) note that the importance of
communication in aviation maintenance training. Baron (2002) emphasizes the
importance of providing training about runway incursions for pilots, controllers, and
ground vehicle operators. Etem & Patten (1998) suggest the need for communication
training in flight instruction.
However, such calls for training generally do not often include or indicate which
communication topics are needed, especially when it comes to interpersonal
communication training; nor are the specific subtopics needed to help increase
communication effectiveness generally explicated. With regard to communication
training, including interpersonal communication, listening skills, decision-making
skills, and conflict management, though they did indicate, as noted above that cockpit-
cabin crew communication coordination continues to challenge the aviation system
(Federal Aviation Administration, 2004). The Federal Aviation Administration (2004)
also offers some specific areas where joint cabin-cockpit communication training can
focus, including pre-flight briefings, post incident and accident procedures, sterile
cockpit procedures, notifications and pre-flight, pre-landing and turbulence passenger-
handling issues.
In addition, the Federal Aviation Administration (2004) notes that the “importance of
clear and unambiguous communication must be stressed in all training activities
involving pilots, flight attendants, and aircraft dispatchers”. Communication is a two-
way transaction, not a one-way transfer. Thus the concepts of perception and meaning
are important to include in any communication training. We communicate about the
world in the way we perceive it, therefore, everyone in the aviation safety system
needs to understand how perception operates and how people differ, sometimes
radically, in the ways they perceive a situation.
Layered upon differing perceptions is the concept that when we communicate about
the world, we do so in symbolically, so that we give meaning to our perceptions. As
we have seen, people will interpret messages in such a way that makes sense to them
and makes sense of the world around them. George (1993) and Matchette (1995)
provide several suggestions, some including the use or misuse of jargon, for
improving communication between pilots and controllers that can be incorporated into
any communication training for aviation safety. Thus, the areas of perception,
language (including meaning and jargon) need to be part of any communication
training for aviation safety. As we indicated earlier, feedback and asking questions are
introspection. The best methods for this type of training would include experiential 117
Communication: A Relevant
exercises, practicing communication skills, role playing, small group and team Factor in Aviation Safety
building exercises and discussion, case study scenarios, and self-assessment tools (for
example, the Thomas-Kilman Conflict Mode Instrument)—all centered around
communication in aviation safety, with particular emphasis on communication
specific, applicable situation, such as in the cockpit, the cabin, and between cabin and
flight deck crews.
ASRS publications, especially Callback and Direct line, afford abundant examples of
both poor and good communication in the aviation system that can be used to create
case studies and scenarios which can be used to gain insight into effective
communication skills. These actual communication occurrences in the aviation safety
environment need to be integrated into cabin safety communication training. Young
(1994) and Flight Safety Foundation (1994), in addition to numerous ASRS reports,
provide incidents in which cockpit crew, flight attendants, ATCs, and maintenance
personnel were able to use their good sense in emergency or potentially unsafe
situations in order to prevent possible tragedies. While examples of poor communication
can provide excellent examples for scenarios that would be useful for training, so too
should such examples of good communication be used for training purposes.
118 as a team, it is also important to look at wider team effectiveness, namely the whole
Aircraft Maintenance &
Crew Management flight crew.
7.10 KEYWORDS
Cockpit: Cockpit a compartment for the pilot and sometimes also the crew in an
aircraft or spacecraft.
Commanders: Commanders is a person in authority, esp. over a body of troops or a
military operation.
Coordination: Coordination is the organization of the different elements of a complex
body or activity so as to enable them to work together effectively.
Jeopardized: Put (someone or something) into a situation in which there is a danger of
loss, harm, or failure.
Skidded: Skidded (of a vehicle) slide, typically sideways or obliquely, on slippery
ground or as a result of stopping or turning too quickly.
CYP 2
1. Active
2. defensive and disconfirming
3. Understanding
4. conflict
119
7.12 SUGGESTED READINGS Communication: A Relevant
Factor in Aviation Safety
Federal Aviation Administration, Aircraft Inspection, Repair & Alterations:
Acceptable Methods, Techniques, & Practices (FAA Handbooks), Aviation Supplies
& Academics, Inc. (August 1, 2008)
Federal Aviation Administration (FAA), FAR/AMT 2011: Federal Aviation
Regulations for Aviation Maintenance Technicians (FAR/AIM series), Aviation
Supplies & Academics, Inc.; 2011 Edition
Icon Group International, The 2010-2015 World Outlook for Aircraft Maintenance,
Repair, and Overhaul (MRO) Services, ICON Group International, Inc. (July 7, 2009)
Federal Aviation Administration (2009), “Aviation Instructor's Handbook”, Skyhorse
Publishing Inc.
121
Line Operations and
Safety Audit
UNIT V
122
Aircraft Maintenance &
Crew Management
123
LESSON Line Operations and
Safety Audit
8
LINE OPERATIONS AND SAFETY AUDIT
CONTENTS
8.0 Aims and Objectives
8.1 Introduction
8.2 History
8.3 Threat and Error Management Model
8.3.1 Threats
8.3.2 Errors
8.4 LOSA and CRM Relationship
8.5 Let us Sum up
8.6 Lesson End Activity
8.7 Keywords
8.8 Questions for Discussion
8.9 Suggested Readings
8.1 INTRODUCTION
LOSA is proposed as a critical organizational strategy aimed at developing
countermeasures to operational errors. It is an organizational tool used to identify
threats to aviation safety, minimize the risks such threats may generate and implement
measures to manage human error in operational contexts. LOSA enables operators to
assess their level of resilience to systemic threats, operational risks and front-line
personnel errors, thus providing a principled, data-driven approach to prioritize and
implement actions to enhance safety. LOSA uses expert and highly trained observers
to collect data about flight crew behaviour and situational factors on “normal” flights.
The audits are conducted under strict no-jeopardy conditions; therefore, flight crews
are not held accountable for their actions and errors that are observed. During flights
that are being audited, observers record and code potential threats to safety; how the
threats are addressed; the errors such threats generate; how flight crews manage these
errors; and specific behaviours that have been known to be associated with accidents
and incident. LOSA is closely linked with Crew Resource Management (CRM)
training. Since CRM is essentially error management training for operational
personnel, data from LOSA form the basis for contemporary CRM training focuses on
threat and error training.
124
Aircraft Maintenance & 8.2 HISTORY
Crew Management
Human Factors Research Project, with funding from the FAA (Human Factors Division,
AAR-100), developed LOSA to monitor normal line operations. In its early form,
LOSA mostly focused on CRM performance. The reason for this was that researchers
and airlines alike wanted to know more about the actual practice of CRM rather than
just formulating conclusions about its effectiveness from data collected within the
training environment, as were the established practice. The actual practice of CRM was
quite different than the one depicted within the typical training department.
After several years of development and refinement, LOSA has turned into a strategy
of systematic line observations to provide safety data on the way an airline’s flight
operations system is functioning. The data generated from LOSA observations provide
diagnostic indicators of organizational strengths and weaknesses in flight operations
as well as an overall assessment of crew performance, both in the technical and human
performance areas. LOSA is a data-driven approach to the development of
countermeasures to operational threats and errors.
LOSA is a critical organisational strategy aimed at developing countermeasures to
operational errors. It is an organisational tool used to identify threat to aviation safety,
minimise the risk such threats may generate and implement measures to manage
human error in operational contexts. LOSA enables operators to assess their level of
resilience to systemic threats, operational risks, and front-line personnel errors, thus
providing a principled, data-driven approach to prioritise and implement actions to
enhance safety.
LOSA uses expert and highly trained observers to collect data about flight crew
behaviour and situational factors on "normal" flights. The audits are conducted under
strict no-jeopardy conditions; therefore flight crews are not held accountable for their
actions and errors that are observed. During flights that are being audited, observers
record and code potential threats to safety; how the threats are addressed; the errors
such threats generate; how flight crews manage these errors; and specific behaviours
that have been known to be associated with accidents and incidents.
LOSA is closely linked with CRM training. Since CRM is essentially error
management training for operational personnel, data from LOSA form the basis for
contemporary CRM training refocus and/or design known as Threat and Error
Management (TREM) training. Data from LOSA also provide a real-time picture of
system operations that can guide organisational strategies in regard to safety, training
and operations. A particular strength of LOSA is that it identifies examples of superior
performance that can be reinforced and used as models for training. In this way,
training interventions can be reshaped and reinforced based on successful
performance, that is to say, positive feedback.
125
8.3 THREAT AND ERROR MANAGEMENT MODEL Line Operations and
Safety Audit
LOSA is premised on the University of Texas Threat and Error Management
(UTTEM) Model. Essentially, the model posits that threats and errors are integral
parts of daily flight operations and must be managed. LOSA is premised on The
University of Texas Threat and Error Management (UTTEM) Model. Essentially, the
model posits that threats and errors are integral parts of daily flight operations and
must be managed. Idea of managing the threats has great relevance to them, more so
than error management, which still retains negative connotations despite attempts to
acknowledge its ubiquity and necessity in human intelligence and information
processing. Crew countermeasures are then seen as the tools that pilots develop to
handle these daily threats and errors.
The UTTEM Model has been successfully incorporated into training programmes and
in some cases has replaced existing CRM training The UTTEM Model provides a
quantifiable framework to collect and categorize data. Some questions that can be
addressed using this framework include the following:
z What type of threats do flight crews most frequently encounter? When and where
do they occur, and what types are the most difficult to manage?
z What are the most frequently committed crew errors, and which ones are the most
difficult to manage?
z What outcomes are associated with mismanaged errors? How many result in an
Undesired Aircraft State?
z Are there significant differences between airports, fleets, routes or phases of flight
vis-à-vis threats and errors?
The following paragraphs introduce a brief overview of the most important building
blocks of the UTTEM Model.
8.3.1 Threats
Threats are external situations that must be managed by the cockpit crew during
normal, everyday flights. Such events increase the operational complexity of the flight
and pose a safety risk to the flight at some level. Threats may be expected or
anticipated and, therefore, the crew may brief in advance. Threats may also be
unexpected.
As they occur suddenly and without any warning, there is no possibility for the crew
to brief in advance. External threats may be relatively minor or major. Observers
should record all external threats that are on the code sheet or any others that may be
considered significant. Errors originated by non-cockpit personnel are considered
external threats. For example, if the cockpit crew detects a fuel loading error made by
ground staff, it would be entered as an external threat, not an error. The crew was not
the source of the error (although they must manage it, as they would any other
external threat). Other examples of non-cockpit crew errors that would be entered as
external threats are errors in Air Traffic Control (ATC) clearances discovered by the
crew, dispatch paperwork errors and discrepancies in passenger boarding counts by
cabin attendant.
8.3.2 Errors
Cockpit crew error is defined as an action or inaction by the crew that leads to
deviations from organizational or flight crew intentions or expectations. Errors in the
operational context tend to reduce the margin of safety and increase the probability of
accidents or incidents. Errors may be defined in terms of non-compliance with
8.7 KEYWORDS
Audit: An evaluation of a person, organization, system, process, enterprise, project or
product. The term most commonly refers to audits in accounting, quality management,
water management, and energy conservation.
Errors: An 'error' is a deviation from accuracy or correctness. A 'mistake' is an error
caused by a fault: the fault being misjudgment, carelessness, or forgetfulness.
Operating: Control the functioning of (a machine, process, or system).
Panel: A small group of people brought together to discuss, investigate, or decide on a
particular matter, esp. in the context of business or government.
128 Threats: A statement of an intention to inflict pain, injury, damage, or other hostile
Aircraft Maintenance &
Crew Management action on someone in retribution for something done or not done.
CYP 2
1. Crew countermeasures
2. Threats
3. External threats
4. Cockpit crew error
5. training
129
LESSON Crew Resource
Management Training
9
CREW RESOURCE MANAGEMENT TRAINING
CONTENTS
9.0 Aims and Objectives
9.1 Introduction
9.2 CRM Training Syllabus
9.3 CRM Training Methods
9.4 Competency Profile for Instructors of CRM
9.4.1 Instructors Ground School
9.4.2 Instructors Simulator/Base
9.4.3 Instructors Line
9.4.4 Authorisation
9.5 Maintenance Crew Skill Requirements
9.6 Morning Meeting
9.7 Let us Sum up
9.8 Lesson End Activity
9.9 Keywords
9.10 Questions for Discussion
9.11 Suggested Readings
9.1 INTRODUCTION
Crew Resource is concerned not so much with the technical knowledge and skills
required to fly and operate an aircraft but rather with the cognitive and interpersonal
skills needed to manage the flight within an organised aviation system. In this context,
cognitive skills are defined as the mental processes used for gaining and maintaining
situational awareness, for solving problems and for making decisions. Interpersonal
skills are regarded as communications and a range of behavioural activities associated
with teamwork. In aviation, as in other walks of life, these skill areas often overlap
with each other, and they also overlap with the required technical skills. It should be
stressed that these are only examples and an operator may wish to use other sources of
information when formulating a detailed CRM syllabus appropriate to their own type
130 of operation. The aim should be to incorporate, where possible, CRM training into
Aircraft Maintenance &
Crew Management other initial and recurrent training but stand-alone modules should be given where
appropriate. The objectives of training methods would be to ensure that participants
develop the right knowledge, skills and attitudes.
(c) A former flight crew member having knowledge of HPL may become a CRM 133
Crew Resource
Instructor if he maintains adequate knowledge of the operation and aircraft type Management Training
and meets the provisions of paragraphs (a) and (b) above;
(d) An instructor not meeting the above requirements may become a CRM Instructor
at the discretion of the CAA and after an observation by a CAA Training
Inspector.
9.4.4 Authorisation
All instructors will need to demonstrate that:
(a) They have the knowledge specified for their relevant role,
(b) They have the necessary instructional skills,
(c) They are able to assess crews' CRM performance, and
(d) They are able to facilitate a constructive debrief of the above.
For Ground School Instructors the demonstration of ability should be carried out with
a class of "live" trainees and be of sufficient length to confirm the CRMI's depth of
knowledge and ability to facilitate learning where necessary. It is unlikely, therefore,
that a course of less than one day or four trainees including some flight crew would be
considered adequate.
134
Aircraft Maintenance & 9.6 MORNING MEETING
Crew Management
Morning meeting is one of the important operations of M&E. this is the first thing
held in the morning, this consists of (a) the days flight schedule, (b) the maintenance
status of each aircraft in service, (c) specific needs of maintenance and (d) any
significant problems or changes which may affect the days flight of work schedules.
This might include discussion on upcoming hangar and shop maintenance attitudes of
problems. The purpose of these meetings is that M&E can keep close check in the
maintenance area to solve the problems as soon as possible.
accordingly. To maintain the integrity of the training process, training methods should 135
Crew Resource
be focused on objectives; rather than be activity driven, which tends to encourage a Management Training
'tick in the box' mentality. The objectives would be to ensure that participants develop
the right knowledge, skills and attitudes. CRM training has developed over the last
two decades and has now reached a sufficient stage of maturity to benefit from a more
formal structure. In order to formalize the training and to further enhance the
effectiveness of CRM it is essential that instructors of CRM meet certain performance
standards. Line mechanics have to face the different problems on different aircraft,
each flight comes.
9.9 KEYWORDS
Cognitive: Of or relating to cognition. The mental action or process of acquiring
knowledge and understanding through thought, experience, and the senses.
Instructors: A person who teaches something.
Interpersonal: Of or relating to relationships or communication between people.
Line mechanics: The branch of applied mathematics dealing with motion and forces
producing motion.
Technical: It is related to a particular subject, art, or craft, or its techniques.
136
Aircraft Maintenance & 9.11 SUGGESTED READINGS
Crew Management
Kanki, B.G. et. al. (2010) Crew Resource Management Academic Press
Harvey, G. and Turnbull, P.J. (2006) ‘Employment Relations, Management Style and
Flight Crew Attitudes at Low Cost Airline Subsidiaries: The Cases of British
Airways/Go and big/bmibaby’, European Management Journal, 24(5), pp. 330-337.
LeSage, P. et al. (2010) Crew Resource Management; Jones & Bartlett Learning 2012
FAR for Flight Crew Book – ASA
137
LESSON Hangar
10
HANGAR
CONTENTS
10.0 Aims and Objectives
10.1 Introduction
10.2 Hangar Maintenance
10.3 Types of Hangar
10.3.1 Type I Hangar
10.3.2 Type II Hangar
10.3.3 Type III Hangar
10.4 Organisation of Hangar Maintenance
10.5 Individual Performance: Upgradation and Automation
10.5.1 Guidelines on the use of Automation
10.5.2 Assessment of Training Requirements
10.6 Tailoring of CRM and LOFT Training
10.7 Let us Sum up
10.8 Lesson End Activity
10.9 Keywords
10.10 Questions for Discussion
10.11 Suggested Readings
10.1 INTRODUCTION
Aircraft hangars comprise of three distinct areas; the hangar bay (OH space), the
Shop/Maintenance Area (O1 level); and the Squadron Administration and Operations
area (O2 level). The levels are designations from shipboard levels and are not specific
to the hangar design.
The hangar bay provides “O” level maintenance to aircraft within the hangar bay. O
level maintenance includes removing engines, changing tires, etc. Layout of this space
is determined by the planning documents for the module configuration identified. The
net area of the hangar bay is defined in the module layout and is considered a fixed
138 area. The hangar bay may not be increased in size nor shall the dimensions be
Aircraft Maintenance &
Crew Management modified.
140 Area allocated to sliding door pockets is not included in the Gross Area Calculations,
Aircraft Maintenance &
Crew Management however area required for depth of staggered door panels are included in the Gross
Area Calculation. Allowed gross area is provided to allow for various wall types.
Excess area may not be reallocated to 01 or 02 spaces.
Hangar door width shall be determined by the structural elements at the edge of the
door opening. The width of the opening shall not be less than 3' less than the width of
the hangar bay.
Clearances are measured from the face of walls and columns or permanent
obstructions such as power points, bollards, and similar features. Floor markings will
be moved to reflect the clearance requirement.
Height of hangar door may be reduced to provide a clearance of 4' above the tail
height of the aircraft anticipated to be the hangar bay. Reduction in the height of the
door may only with the permission of NAVFAC Atlantic CI ENG.
Dimensions for width, depth and height are considered to be "standard". Variations in
hangar bay sizes are not permitted without authorization of the NAVFAC Atlantic CI
ENG. Additionally, Marine Corps hangar bay configurations may be modified by
Headquarters, USMC (LF).
Hangar Maintenance is a position under director of aircraft maintenance Aircraft
maintenance is responsible for all hangar maintenance activities. This controls flow of
aircraft into & out of check, maintenance crews, coordinates with overhaul & support
shops, materiel, PP&C, flight line maintenance and OPS regarding aircraft in hangar
GSE and facilities are also responsible of aircraft maintenance. All GSE required, and
hangar facilities and flight line maintenance Support Shops Welding shops, avionics,
engine, mechanical, upholstery, seats & interior.
One controversial issue already mentioned has been the changing role of the flight 141
Hangar
crew in automated flight deck aircraft.
It comprises at least two basic questions:
z Is the pilot a control operator, a systems manager, or both?
z If a difference exists, is it in the pilot's role, or in the elements of that role?
Analysis suggests that the primary role of the transport pilot has not changed at all:
since the goal is (as it has always been) to complete the planned flight safely and
efficiently and with a maximum of passenger comfort, the role is to achieve that goal-
to fly safely and efficiently from point A to point B. The functions still include
monitoring, planning, and making decisions in reference to the operations, and the
tasks are those traditionally performed (communicating, navigating and operating).
The question is how best to train pilots for advanced technology aircraft. The
consensus seems to indicate that, as a general approach, automation should take a
greater role in maintaining basic stability and control of the aircraft. Higher-level
functions, such as flight planning/pre-planning, system status management and
decision-making, should be performed primarily by humans with the help of
automation. Training should reflect the increased emphasis on the pilot's decision-
making, knowledge of systems, monitoring and crew co-ordination. One point is clear,
however: automation has not reduced the need for the basic airmanship skills and
knowledge which have always been required of airline pilots. The importance of those
fundamentals should be emphasised in the early phases of training, and general
aircraft instruction should always precede detailed instruction in automatic features.
The training should be sensitive to the varying needs of a pilot population that differs
widely in areas such as total flight experience, corporate experience, recency of last
transition training, computer literacy, etc.
142 of the existing training programmes for new technology aircraft were originally
Aircraft Maintenance &
Crew Management developed for conventional aircraft.
workload and stress of the crew in a realistic manner, but the automated flight deck 143
Hangar
has enough built-in stressors to do this job, especially in the area of ATC instructions.
The “glass cockpit” presents new opportunities for scenario design that does not
require abnormal conditions or emergencies – difficult problems at the human-
automation interface will suffice. There now exists the opportunity to design scenarios
that will address the problems and opportunities of working in automated flight decks,
where their peculiar characteristics can be stressed and where CRM principles can be
easily exercised. For example, an ATC instruction including an unexpected,
non-depicted holding pattern over a fix defined by a radial/DME value provides
considerable opportunities to practice CRM principles without the necessity of
introducing any system failure.
Aircraft manufacturers are giving more importance to human performance issues in
automated flight decks. At least one of them has joined efforts with a training
development company to integrate present and future training programmes in Cockpit
Resource Management into the transition training courses for its aircraft. The
manufacturer's instructor pilots will receive CRM training. Current training courses
for pilots and maintenance technicians will also incorporate CRM programmes. This
particular manufacturer claims that CRM courses to be developed will be airplane-
tailored, with a different CRM course for each specific model of aircraft in the
production line. The justification for this decision is based on the need to align
training with longer-term behavioural education, as well as to concentrate on the
assigned duties and responsibilities of the flight crews. Most importantly, it is the tacit
recognition that Human Factors education is no longer an exclusive responsibility of
the operators, but an integral part of present-day system operations.
Adequate instructor/check pilot training is necessary, and must be emphasised, since
some instructors may have only a little more meaningful (i.e. operational) experience
and knowledge than the students. A strong case can be made for practical experience
input to instructor and student training. The need for more emphasis on behavioural
issues (CRM and LOFT training) has also been suggested. Though the Human Factors
profession has recognised the problem, the issue of instructor training in relation to
automation has not yet been properly addressed, and training specialists have no
source to consult for guidance on the question of training for automation. Instructor
selection and training continues to be determined by the same time-honoured methods
and criteria applied for conventional flight decks, although the training issues are quite
different on automated flight decks.
144
Aircraft Maintenance & 10.7 LET US SUM UP
Crew Management
Hangar maintenance refers to the maintenance which is done on out-of-service-
aircraft. This includes maintenance or modifications of that part which is temporarily
removed from the flight schedule. The maintenance is done on a specially assigned
hangar.
The knowledge, skills and attitudes required to meet these standards should be equally
well specified, so that they can be thoroughly and systematically integrated with other
aspects of aircrew training and training standards.
These knowledge, skills and attitudes have wide applicability and CRM standards of
performance have a bearing on flight safety and the efficiency of aircraft operations,
and are essentially more explicit and refined versions of professional standards
implicit in the common sense should be incorporated into basic training of all
personnel and their respective managers who are involved in the operation and
dispatch of aircraft.
10.9 KEYWORDS
Hangar: A hangar is a closed structure to hold aircraft or spacecraft in protective
storage.
Hangar Maintenance: Hangar maintenance refers to the maintenance which is done
on out-of-service-aircraft.
Glass cockpit: A glass cockpit is an aircraft cockpit that features electronic (digital)
instrument displays, typically large LCD screens, rather than the traditional style of
analog dials and gauges.
Line-Oriented Flight Training (Loft Training): It is training in a simulator with a
complete crew using representative flight segments that contain normal, abnormal,
and emergency procedures that may be expected in line operations.
Automation: It is the use of various control systems for operating equipment such as
machinery, processes in factories, boilers and heat treating ovens, switching in
telephone networks, steering and stabilization of ships, aircraft and other applications
with minimal or reduced human intervention. Some processes have been completely
automated.
CYP 1
1. Hangar maintenance
2. large
3. Type I
4. one bridge
5. patrol
CYP 2
1. hangar
2. support shops
3. structural
4. Pilot
5. safely efficiently
146
Aircraft Maintenance &
Crew Management
Logistic and
Supply Chain Management
148
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