Flashcards in Decision making / TEM Deck (22):
What are the 5 principles to the decision making process?
1. Define the problem
2. Identify possible solutions
3. Gather data / resources
4. Make a decision / implementation
Whats the key to decision making?
- situational awareness: ability to perceive potential hazards given the state.
- Look for multiple cues from available resources that point to the exact nature of the problem.
- state symptoms, not conclusions
- What do all these symptoms indicate?
Example: extended taxi SE.
- We could create a fuel imbalance.
- Scan gauges and reference limitations.
- How long till an undesirable state? (794lbs, EICAS message)
- What are our options? (crossfeed, shutdown engines, APU, RTG for more fuel)
- "Hey we could get a fuel imbalance. I'm going to crossfeed."
How do we identify possible solutions?
- Evaluate different courses of action
- do they solve the problem?
- discuss: talk to the other pilot, dispatch, jumpseater
How do you make the best course of action after identifying possible solutions?
Gather data / resources:
- solicit info: FO, dispatch, crew, ATC
- QRH, manuals
- what would it be like if you carried out each course of action to the end?
- Do the different courses of action solve the problem?
What do you do after gathering all the date?
Make a decision:
- QRH procedure
- Divert / Land nearest suitable
How do you know if you've made the right decision?
- issue resolved?
- are there more or less problem as a result?
- if so, resort back to defining the problem
What is vital to solving any problem?
Communication: the process of identifying problems, seeking alternative, selecting the best alternative, and implementing a solution.
- talk the problem out
How do we mitigate problems at SkyWest?
Threat and Error Application Model
What is the first step in the TEM?
Evaluate the Threat: Anticipated or Unanticipated
How do we anticipate threats?
- Takeoff / approach briefing
- identify threats as they come up
- define the problems and follow decision making process
- fuel imbalance
- vectored off approach
How do we handle unanticipated threats?
- Who's flying the plane (PF/PM)
- delegate duties: most often FO fly, CA fix
Yes - create a PLAN and COMMUNICATE
NO - (Fire, smoke, life threatening, Memory item) - ACT, then COMMUNICATE
After managing the Threat what do we do?
- was that effective?
- what did we do right?
- how would we do it different?
What are the 4 steps in the brake down chain that leads to an accident?
3. Undesired AC state
4. Incident / Accident
Whats the purpose of TEM?
To provide the best possible support for crew members in preventing incidents / accidents by effectively managing threats, errors, and undesired aircraft states
What is a threat? What kinds of threats are there?
A. Event or concern that:
1. occurs outside of the influence of the crew
2. Increases operational complexity
3. Requires crew attention if safety margins are to be maintained
1. Operational: Clear and obvious to the crew
- aircraft systems / malfunctions, adverse weather, incorrect paperwork, passenger issues, unfamiliar airports, maintenance, ATC
2. Latent: difficult to recognize / hidden
- complacency, distractions, fatigue, personality conflicts
What is an error? What kinds of errors are there?
A. Crew action or interaction that:
1. leads to deviations from intentions or expectations
2. reduces safety margins
3. doesn't meet company expectations
B. Kinds: intentional / unintentional
1. Procedures: incorrect execution of procedure
2. Communication: missing / misinterpreted
3. Proficiency: lack of knowledge or skill
4. Decision making: decision unnecessarily increases risk.
What are some causes of errors?
1. Lack of experience: more errors when new
2. Rushed: feeling time critical
3. Distractions: spread too thin
4. Human performance / limitations: personal abilities and tendencies
5. Stress: inability to think clearly
What is an Undesired aircraft state?
unacceptable condition of an aircraft:
- results from crew error, actions, or inactions
- clearly reduces safety margins
How do you mitigate a threat?
1. IOM / SOPM - follow procedures
2. Communication: Briefings, active listening, solicit ideas, discuss and anticipate threats
- discuss known threats / assess risks
- ALWAYS brief a mitigation plan / strategy for any known / potential / anticipated threat
How do you manage errors?
1. Execute procedures effectively
2. Workload management: divide duties
3. Automation management: reduce task saturation
4. Monitor / crosscheck: actions, automation, position against expectations
5. Diagnose / adapt / repair:
What are SkyWest TEM / CRM skills?
1. Situational Awareness: identify / brief
2. Decision Making: prioritize / plan
3. Communication: relay plan / keep informed
4. Workload management: briefings