CAP 737 Crew Resource Management (CRM) Training 机组资源管理培训(62)

4 Practical Notes
It is important for both students and facilitators to accept the fact, from the outset, that human error is inevitable to some extent. Whilst CRM training should aim to reduce error as far as possible, it should also concentrate upon detecting and controlling error. As with HPL and information processing, teaching unrelated theory should be avoided; the emphasis should be upon practical guidance as to how to avoid and detect errors made by self and others.
It may be useful to link in this module with information about the company's occurrence reporting scheme, stressing the importance of open and frank reporting of errors in order that lessons can be learned from them. However, this can be a sensitive area, and care should be taken not to jeopardise any confidentiality agreements, if using real examples of errors from the occurrence database.

5 Initial Training and Objectives
It is quite important to understand the theory of error, in particular the distinctions between slips, lapses, mistakes and violations, and their possible causes. It is also important for company managers to appreciate the concept of layers of defence, and what can be done to ensure that error provoking situations (e.g. poor procedures, poorly designed cockpits, undue commercial pressure, bad rosters, etc.) are minimised, and that the pilot does not become the one and only layer of defence.

6 Recurrent Training and Objectives
LOFT exercise debriefs are probably the best way to learn from ones own errors and those of the crew, but care should be taken to ensure that errors are treated as learning exercises, and not as criticisms of personnel performance.
For recurrent training carried out in a classroom environment, use of scenarios where errors have taken place is probably the most effective means of learning how to detect and prevent such errors in the future. Positive examples, as well as negative, can be useful.
CAP 737  Crew Resource Management (CRM) Training
7  Examples and Suggested Training Material 
Videos featuring errors, and how they should be detected and rectified. 
Examples of common errors (e.g. keying in FL100 instead of FL110). 
Occurrences from the company database where errors have occurred, and how they might have been prevented or detected earlier. 
Occurrences from other sources (e.g. CHIRP, AAIB reports, ASRS, etc.). 
Studies of types and frequency of errors. 
8  References and Useful Additional Reading 
8.1  Further Reading on Human Error: 
a) Reason, J. Human Error. Cambridge University Press. 1990 ISBN 0-521-31419-4 
b) Reason, J. Managing the Risks of Organisational Accidents. 1997. Ashgate. ISBN-1 84014-105-0 
c) ICAO Digest No 2. Flight Crew Training: CRM and LOFT. ICAO Circular 217-AN/ 132 (now out of print) - reprinted as CAP 720. d) HSE. Reducing Error and Influencing Behaviour. HSG48, 2nd Edition, 1999. HSE Books. http://www.hsebooks.co.uk/homepage.html 
　
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