Cover
Half Title
Title Page
Copyright Page
Table of Contents
Preface
Acknowledgements
Author
List of Abbreviations
Introduction
Chapter 1 Why a ‘Competence-based’ Approach to Crew Resource Management Training?
1.1 Introduction
1.2 A Short History of CRM
1.3 What Does Expertise Look Like?
1.4 Developing Expertise
1.5 Developing Training Interventions
1.6 Instructional Design vs Competency-based Training
1.7 Understanding ‘Success’
1.8 Conclusion
References
Chapter 2 Thinking about Failure
2.1 Introduction
2.2 What Is Safety?
2.3 The Building Blocks of Safety Thinking
2.4 The Pelee Island Crash
2.5 Linear Models of Accident Causation
2.6 Normal Accident Theory (NAT) and High Reliability Organisations
2.7 Organisational Error
2.8 Why Historical Models Are Problematic
2.9 Conclusion
References
Chapter 3 A Systems Model of Aviation
3.1 Introduction
3.2 Systems Thinking and Safety
3.3 The Structure of the Aviation System – Aviation as Hierarchical Decision-Making
3.4 Behaviour within a System
3.5 Pelee Island as a System
3.6 Exploring Structural Elements of a Resilient System
3.7 Systems and Scale Effects
3.8 Systems, Drift and the Distortion of Buffering
3.9 Conclusion
References
Chapter 4 On Being Human – Frailties, Vulnerabilities and Their Effect on Performance
4.1 Introduction
4.2 ‘Personality’ – How Evolution Shapes Behaviour
4.3 Stress as a Biological Process
4.4 Stress, Fear and ‘Startle’
4.5 Sleep and Fatigue
4.6 What Is Sleep?
4.7 Acute Fatigue in Pilots
4.8 Acclimatisation and Night Flying
4.9 Chronic Fatigue in Airline Pilots
4.10 Recuperation
4.11 Anxiety and Psychological Fatigue
4.12 Fatigue Mitigation
4.13 Fatigue and Pilot Health
4.14 Fatigue and Safety – Cause or Risk Factor?
4.15 Conclusion
References
Chapter 5 Doing Normal Work – Processes at Level 1
5.1 Introduction
5.2 Work as Thought
5.3 Goals, Boundaries and Margins – The Structure of Tasks
5.4 Buffering and Efficacy – The Management of Goal States
5.5 Goal States and Resilience
5.6 Human Information Processing
5.7 Situational Awareness, Distributed Cognition and Sense-Making
5.8 Performance as Approximation
5.9 Acting in an Under-specified World
5.10 Decision-Making as Task Management
5.11 Decision-Making and Goal State Modification
5.12 The Special Case of Problem-Solving
5.13 Safety Drift at the Individual Level – Behavioural Templates
5.14 Conclusion – Working at Level 1
References
Chapter 6 Error as Performance Feedback
6.1 Introduction
6.2 The Helios B-737 Crash Near Athens, 2005
6.3 What Is an ‘Error’?
6.4 Slips – Executing Trained Behaviour Patterns
6.5 Lapses – Forgetting as a part of work
6.6 Mistakes – The Failure of Rules
6.7 Bringing Knowledge into Play
6.8 Sense-making, Rule-based and Knowledge-based Action
6.9 Performance under Normal Circumstances
6.10 Factors That Shape Performance
6.11 Variability
6.12 Keeping Control
6.13 ‘Wrong Work’ and Violations as Improvisations
6.14 Performance Approaching the Boundary
6.15 Conclusion: Errors as Signals of System Behaviour
References
Chapter 7 Acting in the Public Domain – Collaboration to Achieve Operational Goals
7.1 Introduction
7.2 Collaboration in a Systems Context
7.3 Collaboration as Shared Decision-Making
7.4 Collaboration in Normal Work
7.5 Engagement as a Transitory State
7.6 Control in Work Groups – Monitoring as Collaborative Task Management
7.7 Within-Group Social Dynamics
7.8 Leadership – A Special Case in Self-directed Teams?
7.9 Culture
7.10 Conflict Resolution
7.11 Behaviour between Groups
7.12 Conclusion
References
Chapter 8 Communication
8.1 Introduction
8.2 The Evolution of Communication
8.3 San Juan, Puerto Rico
8.4 What Is ‘Communication’?
8.5 Communication in an Aviation Context – What It Does?
8.6 How Speech Works?
8.7 A Functional Model of Communication
8.8 Exploring Communication Dynamics: Control and Verification
8.9 Communication, Option Selection and Decision-Making
8.10 Creating Future Plans: Shared Understanding
8.11 Social Chat
8.12 What ‘Normal’ Communication Looks Like?
8.13 Communication in a Systems Model
8.13 Distributed Communication
8.14 Communication as Information Propagation across a Network
8.15 Communication as Hierarchical Control
8.16 Communication, Safety Drift and Scale Law at a Systems Level
8.17 Conclusion
References
Chapter 9 Organisational Factors – Level 3
9.1 Introduction
9.2 What Is an Airline?
9.3 How Things Get Done in Aviation
9.4 Fundamental Challenges at the Heart of Organisations
9.5 Management Control and Worker Responses
9.6 Control, Management Legitimacy or Chaos and Abuse?
9.7 Demand and Overwork – Employee Sickness/Absence as Resistance
9.8 Delegating Control: Challenges to Autonomy – Why Fuel Efficiency Measures Are Resisted
9.9 Striving for Efficiency: Contradictions in Employee Involvement – Why Safety Reporting Fails
9.10 Do Organisations Learn?
9.11 How Level 3 Works
9.12 Conclusion
References
Chapter 10 Facilitating Aviation – Decision-Making at Level 4
10.1 Introduction
10.2 The Nature of Regulation
10.3 Regulation as Hierarchical Control
10.4 Regulatory Failure
10.5 Change Management and Regulatory Failure
10.6 Failure, Capture and Crisis – Regulators, Aircraft Manufacturers and the Construction of Safety
10.7 Investigation as Feedback
10.8 The Pel Air Westwind Ditching
10.9 The Fallout
10.10 Postscript to Pel Air
10.11 Regulation, Investigation, Control and Feedback
10.12 Conclusion
References
Chapter 11 Training for Competence
11.1 Introduction
11.2 The Training Problem
11.3 Assessment Frameworks and ‘Competence’
11.4 A Systems View of Competence
11.4.1 Competence as ‘Normal Work’
11.4.2 Competence as Management of Anomalies – Performance in Transitional States
11.4.3 Competence in a Crisis – Performance at the Boundary
11.4.4 An Outline Competence Model
11.5 Non-Training Interventions
11.6 Are Stress and Fatigue a Special Case?
11.7 Developing Training Interventions
11.8 Mapping Competencies onto Training Methods
11.9 Conclusion
References
Chapter 12 Assessment of Performance
12.1 Introduction
12.2 Why Assess?
12.3 What to Assess?
12.4 Assigning a Value to the Performance
12.5 Assessors as Sources of Bias
12.6 Establishing Reliability and Validity
12.7 Training Assessors
12.8 Conducting the Assessment
12.9 Conclusion
References
Index