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Consider planning a crew training activity that can take place within this module which allows crews to work with several incidents used to develop the new CRM procedures. Additional sources for incidents include:
. Incident reports from industry databases such as the ICAO incident database.
. Maintenance problems identified through operational reports.
. Poor crew performance areas identified in line and simulator proficiency checks and training.
. Airline safety reporting system.
SAMPLE INCIDENT REPORT
(see full report in Appendix G, Report 56)
BGM information 800’scattered, 1200 broken, 2300’ overcast, 2
mi. light snow, temp 27, dew point 21, winds 270 at 8 kts, altimeter 29.97, breaks in the overcast, NDB 34 approach in use, localizer 16/34 out of service, runway 34 plowed and sanded full width and length, braking action good reported by a vehicle. PF and PNF discussed possibility of using runway 28 due to surface wind component. Further inquiry with BGM approach confirmed runway 28 plowed and sanded full width and length and previous inbound company reported braking action as poor. Surface wind was also reported as unchanged. PF (PIC) requested and was cleared for VOR DME approach runway 28... The PF descended from the published segment alt (3500’ MSL) at the 18 DME position to the published straight in landing MDA of 2000’MSL. The FAF for the procedure was at the 13 DME position and the
PF’s premature descent put the aircraft 1500' below the published segment alt...

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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本文鏈接地址：Developing Advanced Crew Resource Management (ACRM) Training: A Training Manual(67)