CAP 737 Crew Resource Management (CRM) Training 机组资源管理培训(61)

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Situational violations occur due to the particular factors that exist at the time, such as time pressure, high workload, unworkable procedures, poorly designed man-machine interface in the cockpit. These occur often when, in order to get the job done, pilots consider that a procedure cannot be followed.
Optimising violations involve breaking the rules for ‘kicks’. These are often quite unrelated to the actual task. The person just uses the opportunity to satisfy a personal need. Flying an illegal circuit over a friend's house might be an example.
Time pressure and high workload increase the likelihood of all types of violations occurring. People weigh up the perceived risks against the perceived benefits, unfortunately the actual risks can be much higher.
CAP 737  Crew Resource Management (CRM) Training
3  Error Management 
One of the key concepts associated with error management is that of "defences in depth", based on the premise that there are many stages in any system where errors can occur, and similarly many stages where defences can be built to prevent and trap errors. Professor James Reason covers error management in his book "Human Error". 
3.1  Reason's ‘Swiss Cheese Model’ 
In his research, Reason has highlighted the concept of ‘defences’ against human error within an organisation, and has coined the notion of ‘defences in depth’. Examples of defences are pre-flight checks, automatic warnings, challenge-response procedures, etc., which help prevent to ‘trap’ human errors, reducing the likelihood of negative consequences. It is when these defences are weakened and breached that human errors can result in incidents or accidents. These defences have been portrayed diagrammatically, as several slices of Swiss cheese (and hence the model has become known as Professor Reason’s “Swiss cheese” model) (see Figure 4). 

Figure 4 Reason’s Swiss Cheese Model
Some failures are 'latent', meaning that they have been made at some point in the past and lay dormant. This may be introduced at the time an aircraft was designed or may associated with a management decision. Errors made by front line personnel, such as flight crew, are ‘active’ failures. The more holes in a system’s defences, the more likely it is that errors result in incidents or accidents, but it is only in certain circumstances, when all holes ‘line up’, that these occur. Usually, if an error has breached the design or engineering defences, it reaches the flight operations defences (e.g. in flight warning) and is detected and handled at this stage. However, occasionally in aviation, an error can breach all the defences (e.g. a pilot ignores an in flight warning, believing it to be a false alarm) and a catastrophic situation ensues.
3.2 Error detection and prevention
The concept of redundancy should be applied at all stages of the aviation system, never assuming that one single mechanism, especially if human, will detect and prevent an error. CRM provides a form of redundancy in that it emphasises the role of the second pilot to check what the first pilot has done. There is a potential danger with independent checks that the second person will trust the first person not to have done anything wrong, and therefore not to carry out the second check properly. CRM dual checking is one of the last lines of defence, especially if no automatic system checks and alerts are present, and pilots should always be alert for the possibility that their colleague may have made an error, when carrying running through SOPs which require challenge-response checks, no matter how much they might trust and respect the other pilot. Similarly, the pilot carrying out the first action should never become complacent and rely upon the other pilot detecting an error. (The same applies with pilot-ATC communications, and readbacks). It is essential to remember that we are all human therefore we all make mistakes from time to time, so assume the worst.
　
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