Description:<\/strong><\/p>\n\n\n\nAs in our daily lives, discrepancies in aviation can relate to opinions, information, but also changing conditions.<\/p>\n\n\n\n
CRM Concepts:<\/strong><\/p>\n\n\n\n\n- good teamwork from all members in order to address discrepancies constructively<\/li>\n\n\n\n
- Communication: addressing discrepancies assertively and suggesting solutions<\/li>\n\n\n\n
- Shared mental model: Have we all got the same picture of the sitation?<\/li>\n<\/ul>\n\n\n\n
3.9. The Failure to Meet Targets Belongs to the Error Chain<\/h3>\n\n\n\n
Description:<\/strong><\/p>\n\n\n\nIn aviation, the failure to meet targets includes, for instance, the estimated arrival time (ETA), an assigned level or heading.<\/p>\n\n\n\n
When a crew fails to meet a target, this is not considered done deliberately. Thus, it is not a violation of regulations as in item 3.7.<\/p>\n\n\n\n
Helpful CRM Concepts:<\/strong><\/p>\n\n\n\n\n- Workload management in order to keep an overview, to recognise tasks and then assign them to persons, as well as time slots<\/li>\n\n\n\n
- Wise use of all personal and material resources<\/li>\n\n\n\n
- timely communication of the goals, discussion of the progress<\/li>\n<\/ul>\n\n\n\n
3.10. Departure from SOP<\/h3>\n\n\n\n
Description:<\/strong><\/p>\n\n\n\nHere, a crew deviates from existing SOPs. Organisations write SOPs as solutions to potentially problematic situations. Pressure, complexity, and a lack of time may precede such deviations. <\/p>\n\n\n\n
CRM Concepts:<\/strong><\/p>\n\n\n\n\n- Using all available resources as a team, before such a departure from an SOP becomes necessary<\/li>\n\n\n\n
- 10-for-10 concept in order to discuss all options together<\/li>\n\n\n\n
- Decision-making including the use of standardised models<\/li>\n<\/ul>\n\n\n\n
3.11. Incomplete Communication<\/h3>\n\n\n\n
Example:<\/strong><\/p>\n\n\n\nYou haven\u00b4t been given important instructions concerning a task and now you are wondering how to proceed. Due to the incomplete instructions, you have to spend time and make an effort to obtain the information you need.<\/p>\n\n\n\n
Description:<\/strong><\/p>\n\n\n\nOn the one hand, incomplete communication means withholding important information, opinions, suggestions, and questions. On the other hand, we also subsume miscommunication here, during which discrepancies are not resolved.<\/p>\n\n\n\n
CRM Concepts:<\/strong><\/p>\n\n\n\n\n- Communication techniques: closed loop communication, standard phraseology, speak up<\/li>\n\n\n\n
- Knowledge, skills, attitude: Showing a professional attitude, we convey all information we have.<\/li>\n\n\n\n
- Good teamwork: A working atmosphere in which we can sort ambiguities out.<\/li>\n<\/ul>\n\n\n\n
<\/span>4. The Error Chain Is Not a Chain of Events<\/span><\/h2>\n\n\n\nAs we have seen above, the eleven links of the error chain are clearly defined and pertain to the human factors. Thus, they highlight human errors which are made before an accident.<\/p>\n\n\n\n
A chain of events, however, contains environmental factors, as well, such as adverse weather conditions or technical malfunctions. These, in turn, can trigger the links of the error chain: For instance, a technical problem may attract everyone\u00b4s attention, while no-one is flying the aircraft any more.<\/p>\n\n\n\n
<\/span>5. We Recognise and Break the Links in Our Work<\/span><\/h2>\n\n\n\nWhen you look at the error chain and its links, which of them surface in your profession or daily work? Which CRM concepts would you use to break them? <\/p>\n\n\n\n
Let us now look at a few examples from the medical world together, which have happened in reality.<\/p>\n\n\n\n
5.1.No-One is Recuscitating the Patient<\/strong><\/h3>\n\n\n\nDuring simulator training, but, unfortunately, also in real emergency rooms it has occurred that everyone involved participated in securing the patient\u00b4s airway. Thus, no-one carried out the all-important chest compressions for several minutes.<\/p>\n\n\n\n
5.2. Confusion<\/strong> in the Emergency Department<\/h3>\n\n\n\nA young doctor with only little expericence has to stich a wound on the head of a small, crying child in an overcrowded emergency department. Right before she starts, her consultant reprimands her harshly in front of the parents and the child due to the treatment she had offered another patient. <\/p>\n\n\n\n
You can easily imagine that in this situation her startling, the child who cannot be calmed down, her inexperience, and the pressure created by the never-ending stream of patients confuse the young doctor. How can she now produce a fine suture with non-shaking hands?<\/p>\n\n\n\n