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  • Nancy Baldwin

SMS Perspectives: February 2015

Aviation Safety Connection

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SMS Perspectives: February 2015

Concluding Thoughts—SMS and CRM.

We start from the premise that pilots make mistakes and no organization is perfect. Then we add its all-important corollary, that flight departments need to supply guidance and training to support its flight crews, and pilots need to master their craft and assume leadership positions that are called for by developing situations.

The flight environment demands that we, individually, willingly accept responsibility and be held accountable for our actions. It also requires that we, collectively, freely support one another to ensure that actions taken are based on thoughtful assessment and sound judgment.

Over the years Aviation Safety Connection, Inc. has promoted flight safety through its website Aviation.Org and email newsletters, Cockpit Concepts and SMS Perspectives. The former focuses primarily on pilot performance while the latter looks at organizational issues. Their interdependence is readily apparent as demonstrated by the last two newsletters1 on CRM. With reference to the two accidents reviewed, Pete in our LinkedIn group stated “the cockpit teams were set up to fail.” How true! Yet we also know that the flight crews represent the final defense barrier and must be prepared to act accordingly.

Both of these accidents illustrate flight crew failures and organizational weaknesses. Both resulted in fatalities after attempting missed approach or go around procedures. To some it may seem unkind to appear to be critical of an accident flight crew. That is not our intent. Rather it is to examine how and why a particular chain of events was allowed to occur and learn to prevent repeating similar errors. By not doing so we fail each other again.

Based on these discussions we can construct cockpit CRM guidelines that apply to the organization and the flight crew. Here is one person’s listing, in no particular order or priority.

**SOPs: Realistic performance expectations, continually reviewed; Crew acceptance and adherence. SOPs need to reflect the organization's operating philosophy and be applied consistently.

**Briefings: Standard requirement, designed to define roles and flight strategies; Crew responsibility to reach agreement before flight and in-flight when change occurs. Effective briefings are relevant and interactive.

**Debriefings: Stated policy; Candid crew review to improve team performance and resolve misunderstandings. Debriefings may provide feedback to improve SOPs.

**Flight Strategies: Encourage systematic evaluation of options; Crews establish Go/No Go criteria, explore What If? Scenarios. Always have an out.

**Cockpit Leadership: Encourage individual initiative and acceptance of leadership roles; Crew members back each other up. Items such as checklists and approach briefings are never overlooked.

**Sterile Cockpit: Defined policy to cover high workload situations; Crews focus on the tasks at hand. As one example, configuration changes are always announced and acknowledged.

**Aircraft Performance: Provide aircraft/systems training and appropriate checklists; Crew knowledge and understanding of capabilities and limitations. From the accidents reviewed, the failure to comply with published anti-skid and lift-dump procedures was crucial.

**Team Awareness: Promote team situational awareness; Crews strive for a common understanding of the flight’s progress. Potential conflicts are minimized and quality decisions flow more naturally.

**CRM Training: Conduct meaningful training in-house with own crew pairings to internal policies and procedures; Active crew participation including contribution of experiences/lessons learned. Training feedback leads to improving SOPs and team effectiveness.

**Risk Management: Encourage reporting and provide follow-up action; Crews to report anomalies for the benefit of others. Hazardous situations thereby become documented.

Please treat this summary list as a starting point. Add to it or clarify items to fit you organization’s operating philosophy and standards. Above all, be as specific as possible in defining your program and providing guidance to your cockpit crews.

Comments are always welcome.

--Bob Jenney (

1Safety Management and CRM, SMS Perspectives, December 2014; Once Again, CRM, Cockpit Concepts, January 2015.

Aviation.Org Update: February 2015

Join us on LinkedIn:

**Sustaining Safe Flight Operations at

**Aviation Pilot Lounge at

This and prior issues of SMS Perspectives are posted to Hangar 13's Flight Line.

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