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Introduction Human Factors Model Usability Visual Displays Non-Visual Displays Controls Environment Cognition Training Team Performance
Team Performance Module navigation.
Module Introduction
Lesson Goals
Team Use
Decision Making
Team Types
Development
Goals
Motivation
Performance
CRM
Human Error
Error Management
Avoid
Trap
Mitigate
CRM Effectiveness
Module Summary
Course Conclusion
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Team Performance Module > Error Management - 4 of 4
 
 


Mitigate Error Consequences

Action must be taken as soon as an error or failure has been identified to mitigate the consequences of the error. Captain leadership, crew assertiveness, and technical knowledge come to the fore in mitigating the error for the least adverse outcome. To mitigate error consequences, CRM emphasizes:

  • Teamwork - All members of the crew/team must contribute and work together for problem resolution.
  • Leadership - The captain must demonstrate leadership by:
    • Immediately assigning responsibilities to individual crew members,
    • Determining who is to fly the plane while the problem is being addressed by other crew members, and
    • Accepting input from the crew.
  • Responsibility - Each member of the crew must accept individual responsibility to contribute to problem resolution and make sure his/her inputs are heard and understood.

The survival of 185 of 296 passengers and crew of UA 232 was attributed to CRM. The crew used all resources available including assistance from a DC-10 instructor on board as a passenger to mitigate the consequences of an in-flight engine blowout. Shrapnel from the engine damaged all three of the triple redundant hydraulic systems--a 1,000,000,000 to 1 probability. Captain Alan Haynes and his crew brought in the DC-10 with no steering, no rudder, no ailerons, no elevators, no flaps or slats, no brakes, no spoilers--only the throttles on #1 and #3 engines.

UA 232 engine malfunction was tracked to human error during maintenance--an undetected fatigue crack.
 
 

   

  
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