Using Air Force Aviation Mishap Data to Improve C130 CRM Training

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Using Air Force Aviation Mishap Data to
Improve C-130 CRM Training

• Dr. Bob Nullmeyer
• Maj David Stella
• Air Force Research Laboratory
• John Flournoy
• Albuquerque, New Mexico
• Lt Col Don White
• Air Force Safety Center

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C-130 CRM Training Research Overview

• Research to improve CRM instruction for C-130
  Mission Qualification training
• Accident/incident report analyses
• Simulator crew skills study
• Student record trend analyses
• Products
• Specific CRM skills to guide CRM course
  content
• Measures to track trends
• Procedures for other applications

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C-130 CRM Research Partners

• DET3 AMCAOS/DOUC
• OO-ALC/YWS
• Air Force Safety Center
• Lockheed Martin
• Greg Deen
• Dave Wilson
• Anacapa Sciences -- Alan Spiker
• AFRL/HEA -- Bob Nullmeyer

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CRM Defined (AFI 11-290)

• The effective use of all available resources --
  people, weapon systems, facilities, equipment,
  and environment -- by individuals or crews to
  safely and efficiently accomplish an assigned
  mission or task.
• CRM refers to the training program, objectives,
  and key skills directed to this end.

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Six CRM Core Areas
Mission Evaluation pre-mission analysis,
planning, briefings, replanning, debrief
Task Management prioritize activities, time
control, checklists, workload management,
standard operating procedures
Situation Awareness preventing loss of SA,
avoiding terrain and threats, staying ahead of
aircraft and mission
Crew Coordination leadership, assertiveness,
crosstalk, teamwork, conflict resolution
Communication listening, feedback, intracrew and
external communication, information exchange
Risk Management/Decision Making risk assessment,
problem solving, emergency procedures, go/no-go
decisions
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A Mishap Crewmembers view of CRM

• Q How do you think the CRM was during the
  whole sequence?
• A I think the rapport was phenomenal. It was
  great. We got along very well. XXX and I have a
  lot in common with our children and wives, and
  everything else. I meanfrom the loadmaster,
  engineer and them, there were no conflicts at
  all.

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C-130 Class A Mishap Rates 1960-2002
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C-130 Mishap Analyses

• C-130 Class A flight mishaps
• 1 Million damage
• Fatality
• 65 occurred from 1971-2002
• Data sources
• Air Force Safety Center home page (http//safety
  .kirtland.af.mil)
• Narrative database with causal and contributing
  factors
• Human factors databases
• Mishap reports (Tabs T and Y)
• (Available Electronically)

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Air Force-Wide Class A Mishap RatesFY88-FY02
Source FY 2002 Flight Safety
Summary. Available at http//safety.kirtland.af.
mil/.
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C-130 Class A Mishap Types 1971-2002
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C-130 Class A Mishap Causes 1971-2002
(N 65)
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Historic and Recent Causes of C-130 Class A
Mishaps
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Errors in Commercial Aviation by Major Phase of
Flight
Source Bob Helmreich, 2001. Managing Threat
and Error, 2001 Air Force Reserve command
Conference, Scott AFB IL
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C-130 Class A Mishaps 1971-2002 by Major Phase
of Flight
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Human Factors Components in FY 2001 Air Force
Class A Mishaps
Human Factors
Environmental
Individual
Aircraft/Cockpit Design 4.2 of Class As
Physiological/Biodynamic 37.5 of Class As
Operations 33.3 of Class As
Psychological 58.3 of Class As
Psychosocial 25 of Class As
Facilities/Services 8.3 of Class As
Logistics/Maintenance 12.5 of Class As
Source Luna, T.D. USAF Aviation Safety FY
2001 in review. Available at http//safety.kirtl
and.af. mil/.
Institutional/Management 4.2 of Class As
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2001 HF Mishap BreakdownIndividual Factors
Physiologic/Biodynamic
Peer Influences Personal/Community
Biodynamic Pathophysiological Ergo/Biomechanical
Source Luna, T.D. USAF Aviation Safety FY
2001 in review. Available at http//safety.kirtl
and.af. mil/.
Psychological Mental Fatigue Perceptual/Motor Emot
ional State Personality Style
Rate Producing Class A Mishaps
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CRM in C-130 Class A Mishaps 1990-2002
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Historic and Recent C-130 Mishap Rates by CRM
Elements
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Historic and Recent C-130 Mishap Rates by CRM
Elements
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Risk Management/Decision Making
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Situational Awareness
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Crew Coordination
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Task Management
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Mission Planning
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Communication
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1992-2002 C-130 Class A MishapsMost Common
Specific CRM Factors
(N 13)
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Conclusions

• Crew error still the largest cause of mishaps
• A finite set of behaviors caused or contributed
  to most C-130 Class A mishaps
• Clusters of related factors point to targets of
  opportunity for added attention in training
• Inadequate mission planning
• Complacency / subordinate style / crew
  coordination / lack of intracockpit
  communication
• Risk assessment / course of action selected
• Air Force (and Navy) CRM areas remain relevant

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Proposed CRM Process Cycle
Teamwork Processes
Teamwork Processes
RM
RM
Coordinated Plan
Satisfy Mission Objectives
SA
SA
Shared Mental Model
Shared Mental Model
DM
DM
Decision Quality
Decision Quality
Mission Planning/Briefing
Mission Execution
Debrief
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• Questions?

Bob.Nullmeyer_at_williams.af.mil DSN 474-6283,
[phone], ext. 283