SAMPLE INCIDENT ANALYSIS
During the approach the crew focused on the runway choice but
lost situation awareness of the aircraft’s altitude with respect to the Minimum Safe Altitude. Crew was rushed due to the slam dunk approach into the airport which increased workload. Not setting and monitoring a bottom line for the minimum safe altitude allowed the PF to execute a premature descent to an inappropriately low altitude for that segment.
SAMPLE LESSONS LEARNED
Crews can benefit from this incident by recognizing the role of good workload management and clear communication of critical aspects of the approach. Good workload management would suggest briefing of the overall plan for the approach and relevant situational details such as the MSA prior to the high workload period of the approach or as early in the approach phase as possible. Prior briefing of the overall plan would enhance crew situation awareness during approach and reduce the number of necessary communications during approach. Setting explicit bottom lines for critical aspects of the approach such as the MSA and assigning the monitoring of the bottom line to a crewmember would help maintain situation awareness of these safety-critical conditions despite the heavy approach workload.
Event Sets and the LOFT/LOE Scenario
Crews should be given an explanation of how the event set is used under ACRM to help focus the specific aspects of crew performance in the LOFT/LOE assessment. An event set divides a LOFT/LOE session into sections, with each section or event set having specific training or assessment objectives. Event sets are designed to concentrate on specific CRM and technical training objectives allowing the crews to concentrate on a narrow range of performance.
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本文链接地址:Developing Advanced Crew Resource Management (ACRM) Training: A Training Manual(67)