MENTALPILOTE GIVE AN EXTRA DIMENSION TO YOUR CRM/SPRM COURSE.

Transcription

1 MENTALPILOTE GIVE AN EXTRA DIMENSION TO YOUR

2 MENTALPILOTE A SYSTEMIC APPROACH An event It is night and the weather is specially bad. The crew decides to continue the approach and at landing the plane skids out of the runway. Multiple causes Is this the result of a decision error, a perception error, a lack of flying skills? Is it a problem of attitude? Or is this the result of a mix of all these? A new approach synonimous of Proficiency What are the factors which originated this runway overrun? MENTALPILOTE proposes new analysis tools and a structured approach which permits to clearly understand this crew fragilities. «Operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context». Captain Dan Maurino

3 PROFICIENCY AND PERFORMANCE THE PILOT RESSOURCES CONCEPT OF PERFORMANCE Procedures Situation awareness Problem solving Flight path automation Communication Emotion Stress Flight path manual Decision making Workload management Leadership Teamwork Physiology Pressure Attitude Culture SAFETY OBSERVABLE + NON OBSERVABLE Anticipation (TEM) Global approach Combination of ressources Attitude, values, beliefs, affect

4 ANALYSIS MODEL A PILOT S PERFORMANCE MODEL* WHY A MODEL? Reduces complexity Visualisation of the interactions Improves understanding In-depth analysis of vulnerabilities Systemic and constructivist approach The pilot act as a whole Visualisation of coupling threats E.g. Stress will reduce SA *Adaptation ITQI Core competencies

5 PERFORMANCE AND THREATS PERFORMANCE IMPLIES 2 SIDES ALWAYS THE SAME THREATS BAD ATTITUDE GOOD Errors and threats Well known in aviation Countermeasures or best practices Well known in aviation THREATS COUNTERMEASURES Engagement A catalogue of : Threats and countermeasures Resigna6on Catalogue customization Possible adaptation to the activity

6 A RUNWAY EXCURSION ANALYSIS* 1.Lookwhatcouldbethefaultyelementswiththemodel.& 2. Make your analysis seeking to go as far as possible in the treecauses. 3. Search threats to each of the selected elements with the catalogue.& 4.Developthescenariooftheeventwiththeserious&game. 5.Concludetheanalysis *Simplified analysis

7 1. SELECT FAULTY ELEMENTS SELECT ELEMENTS OK WEAKNESS : FACTS, ASSUMPTIONS.RUNWAYEXCURSION.ATTITUDE.NEWLYTYPERATED.WINDGUSTNOTTAKEINTO ACCOUNT.A/CAHEADGOAROUND.F/OSUGGESTSTODIVERT.NOQUESTIONNINGABOUT ANOTHERDECISION.RUNWAYEXCURSION.POORSITUATION AWARENESS Coupling factors.attitude.runwayexcursion.newlytyperated.runwaycontamination.windlimitation

8 c" c c" 2. DOWN AS DEEPLY AS POSSIBLE Procedures? Flight path manual Flight path automation Situation awareness Problem solving Communication Emotion Stress Decision making Workload management Leadership Teamwork Physiology Pressure Attitude Culture Human factors is a contribu6ng cause in around 70 percentofallincidentsandaccidents.approximately 85 percent of incident reports include a men6on of loss of situa6onal awareness. Degraded situa6onal awareness can lead to inadequate decision making andinappropriateac6ons.atsb/airbus# The link between safety aztudes and observed performanceinflightj.#bryan#sexton#&#james#r.#klinect

9 3. SEARCH THE THREATS TEM CATALOGUE WITH COUNTERMEASURES THREATS AND ERRORS Catalogue Internal threats Externalthreats Errors Undesirableaircraftstate MENTAPILOTE+ V1 CHOOSE THE THREAT(S) FOR EACH SELECTED ELEMENT THREATS:SITUATIONAWARENESS Confusion between two pieces of information An insufficient vigilance A bad use of the system, an error of procedure Deviation from the regulation, a norm, a procedure A change in the flight plan An ambiguity between several information A divergence between the pilot and his/her colleagues Focus on one element of the flight Lack of information Work overload Etc. COUNTERMEASURE:Workoverload When tasks in waiting start to pile up, the pressure will mount, stress will appear, it s a viscious circle. If you can, reduce your speed, hence saving precious dozens of seconds to prepare your arrival. More generally, anticipate every task that can be.

10 4.1 THE SERIOUS GAME WHAT WAS THE SCENARIO? PRESSURE& It(would(be(great( beast,i m(almost(there.(& ( 20cards Internal( Interne LEADERSHIP& TEAMWORK& (charrier(2013( Reçu,(la(piste( 38(en(service( (charrier(2013( Internal( ATTITUDE& Don t(worry,(( it(will(pass( DECISION& I(pass(on(the(right(or( on(the(led(of(the(cloud( THREATS& (charrier(2013( Internal( Internal( PROCEDURES& SITUATION& AWARENESS& I(forgot(approach( charts(( Seatbelt,(rudder,(door(:( ok,(reday(for(take(off( (charrier(2013( Internal( (charrier(2013( HAND&FLYING& NAVIGATION& Everything(is(ok.( (Oh(shit,(my(speed(( ( (charrier(2013( Internal( (charrier(2013( SELECT THE CARDS FOR EACH ELEMENT CONCERNED BY A THREAT From an event chosen by the instructor, trainees must reconstruct the chronology of the flight by selecting and ordering the fields likely to have generated threats. Each card contains a range of information designed to facilitate understanding. Internal or external threats Pictogram intended to symbolize the concept Level of criticality of the element (1 to 3) Color field concerned Wheel designed to highlight the combinations between the different elements An example related to the threats of the element THREAT DECISION I#pass#on#the#right#or# on#the#le?#of#the#cloud# Internal# # #charrier#2013#

11 Interne* 1. MODEL Le*vent*est*fort*ici,*ça* Le*vent*est*fort*ici,*ça* craint*un*peu.* craint*un*peu.* LEADERSHIP& DECISION& DECISION& TEAMWORK& Don t*worry,** Don t*worry,** it*will*pass* it*will*pass* PHYSIOLOGIE& PHYSIOLOGI Ce*n est*pas*la* Ce*n est*pas*l grande*forme* grande*form & & Everything*is*ok.* Je*pilote*avant* Je*pilote*avant* *Oh*shit,*my*speed** toute*chose*** toute*chose*** * MECONNAISSANCE& MECONNAISSAN &ENGAGEM INEXPERIENCE& INEXPERIENCE Reçu,*la*piste* I*pass*on*the*right*or* I*pass*on*the*right*or* 38*en*service* on*the*leg*of*the*cloud* on*the*leg*of*the*cloud* GOOD Intern PRACTI Interne* Interne* CONDUITE& FLIGHT&PATH& CONDUITE& DU&VOL& MANUAL& DU&VOL& Ce*n est*pas*la* I*forgot*approach* I*forgot*approach* grande*forme* charts** charts** Don t*worry,** it*will*pass* Interne 1 SITUATION& SITUATION& PHYSIOLOGIE& AWARENESS& AWARENESS& ATTITUDE& Le*vent*est*fort*ici,*ça* craint*un*peu.* Interne 2 Scenario 3 STRESS& PRESSURE& It*would*be*great* beast,i m*almost*there.*& * Interne* Y a*pas*de*lézar 5*kilo*de*visi*c est*quand* 5*kilo*de*visi*c est*qua un*animal*à*sa même*pas*beaucoup* même*pas*beaucou MENTALPILOTE MENTALPILOTE AWARENESS CONDUITE& THREATS& DECISION FLIGHTPATH MANUAL INEXPERIENCE& Anewsitua6on Lackofexperience Emo6onalburden 5*kilo*de*visi*c est*quand* même*pas*beaucoup* Problem Timepressure Workoverload Acomplextask Ex External* MAKING MECONNAISSANCE& DECISION& DU&VOL& Confusionbetween informa6on Aninsufficientvigilance Je*pilote*avant* I*pass*on*the*right*or* toute*chose*** on*the*leg*of*the*cloud* Abaduseofthesystem Lackofexperience Devia6onfromSOP Anambiguity Interne* PROCEDURES& Seatbelt,*rudder,*door*:* ok,*reday*for*take*off* Nonapplica6onof Procedures Lackofskill WEATHER& Flytothelimits C est*vraiment*pas*top* Viola6onoflimita6ons cebe*ligne*d orages** Lackofrigour Doesnotknowlimita6ons *MENACE EXTERNE *Autres*menaces* & Interne* SITUATION Negligence,carelessness SITUATION& Autosa6sfac6on AWARENESS& Excessofselfconfidence LackofselfconfidenceI*forgot*approach* charts** Impulsive An6authority Invulnerable MENTALPILOTE MachoaZtude ATTITUDE ATTITUDE& ATTITUDE& STRESS& STRESS& 2. ELEMENTS 3. THREATS It*would*be*great* It*would*be*great* beast,i m*almost*there.*& beast,i m*almost*there.*& * * PRESSURE& PRESSURE& MENACE Inte 4.2 DEVELOP THE SCENARIO Interne* Le*NOTAM*n ét pas*sor].*

12 5. FINAL ANALYSIS PERFORMANCE ANALYSIS The pilot had pretty good flying skills. His capacities, that were combined with a career without any trouble, have led him to some overconfidence. Busy with his own tasks, he did not noticed the intensity of some wind gusts that was given by the controller to the preceding aircraft. Despite a contaminated runway and a strong crosswind he decided to continue the final approach although his copilot had suggested a diversion. He was lacking experience on this new aircraft type but decided he could do it and avoid to divert. As many experienced pilots he was used to fly up to his aircraft limitations, with the risk to override them and encounter and undesirable situation. ATTITUDE SITUATION AWARENESS DECISION MAKING FLIGHT HANDLING

13 PROCESS MENTALPILOTE FLYTOTHELIMIT AIRMANSHIP THE OBJECTIVE Do not fool yourself. The objective of this course is to highlight the roots causes of most accidents. The results of the analysis are not important. However, the proposed scenarios should enable students to conclude their analysis as close as possible to reality. JUDGEMENTBIAISES I$diverted$twice$ this$month$$ We$are$going$to$be$ minimum$fuel$ The$cross$wind$ is$not$so$strong$ Ooooh$ $ Shit$$ NEGLIGENCE CARELENESS EXTERNAL PRESSURE PRESSURE' ATTITUDE' DECISION' MANUAL' CONTROL'

14 PILOT ACT AS A WHOLE & LINEARAPPROACH PILOT CREW CONTEXT AIRCRAFT GLOBALAPPROACH PILOT ACFT CREW CONTEXT jg.charrier@free.fr mentalpilote.com

15 Mentalpilote.com