Sterile Cockpit - Theory and Practice

The Sterile Cockpit

Train staff to stay focussed in safety critical tasks, no matter what their job.

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Sterile Cockpit - Theory and Practice

Working in a Sterile Cockpit

Theory and Practice
The following is the story of the plane crash which occurred in the 1970s. Following this and other similar crashes, the concept of sterile cockpit was developed. The concept and practice is now used across many industries. The story A DC-9 crashed 3.3 miles short of the runway at Douglas Municipal airport, Charlotte, North Carolina. Ten people survived the crash and 72 people died. During the descent to the airport, through patchy, dense ground fog, the voice recorder revealed that flight crew engaged in conversations covering politics, used cars, and other topics not pertinent to the operation of the aircraft. Crew members expressed strong views and some aggravation on the topics being discussed. The final conversation consisted of both operational communications and a discussion of the local landmarks.

Exercise 1 - a role play

The following is the transcript from the voice recorder of the last minutes of the flight. Ask for three participants to volunteer to read out the parts of the Captain, the First Officer and a narrator. Captain Theres Carowinds. I think thats what that is. First Officer Ah, that tower, would that tower be it or not? Captain Carowinds, I dont think it is. Were too far, too far in First Officer I believe it is Captain That looks like it. You know its Carowinds. First Officer Its supposed to be real nice Captain Yeah, thats the tower. Thats what that is. Narrator At this time the first officer requested gear down and the beforelanding checklist. Then came the steady warning of the terrain warning system indicating the aircraft was 1,000 feet or less above the ground. This aural warning was silenced. Captain Thats Carowinds there. Narrator The sounds on the voice recorder indicated that that the items on the before landing checklist were being accomplished.
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Sterile Cockpit - Theory and Practice

Captain Theres ah Ross. Now we can go down. First Officer How about 50 degrees, please Captain 50 Narrator The Captain advised Charlotte Tower that they were at the Ross intersection and the local controller cleared the flight for landing. Captain Yeah, were all ready. All we got to do is find the airport. First Officer Yeah Narrator One and a half seconds later both captain and first officer screamed out. And then the DC-9 plane crashed, 3.3 miles short of the runway. Ten people survived the crash and 72 people died.

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Sterile Cockpit - Theory and Practice

Situation awareness - the main types of error

The simplest definition of situation awareness is knowing what is going on around you. So, information gathering and processing is a critical step. There are the 3 main types of error relating to information. 1. Interpretation errors 2. Gathering information errors 3. Anticipation errors

Exercise 2 - Which error type leads to the most accidents?

Circle the color that matches the errors: 1. Interpretation errors Blue 2. Gathering information errors Blue 3. Anticipation errors Blue Yellow Yellow Yellow Red Red Red

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Sterile Cockpit - Theory and Practice

How did you do? The answer 1. Gathering information errors 2. Interpretation errors 3. Anticipation errors 77% 20% 3%

These estimates depend upon the industry. The point to make is that the vast majority of errors are related to not having the right information in the first place. If you have the right information, it is more than likely that you will interpret the information correctly and then very little chance of not anticipating certain outcomes.

What causes gathering information errors?

The reasons behind this type of error can be further broken down into the following: 1. Information not available 2. Information not observed 3. Information difficult to detect 4. Memory error

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Sterile Cockpit - Theory and Practice

Exercise 3 - Which error caused the plane crash?

Revisit the plane crash story and the cockpit dialogue. Think about what took place. The crew had not gathered the information required to do their task safely, that is, land the plane, but which of the four reasons created that error? The answer Information not observed The crew had all of the information available but the distractions meant that the crew was not gathering the information which would have saved their lives and many others.

Factors affecting situation awareness

There are many factors that impact on situation awareness. The factors in the crash were a trigger for the concept of the sterile cockpit. That is, distraction. The following is a transcript from a training video of Situation Awareness, where Professor Rhona Flin describes the sterile cockpit concept. Factors that are being looked at the moment particularly in the aviation industry and surgery are factors to do with protecting the work space . There is a concept in aviation called Sterile Cockpit where the pilots are at a critical stage of the flight such as take off or landing, and they are not allowed to talk about things unrelated to the task. So you are not allowed to have a conversation about the football game or some television program you have watched. You are only allowed to talk about things that are task related. And that is an interesting concept I have seen picked up elsewhere, that when there is a safety critical phase in the task, people only talk because those other conversations are distracting, they pull attention away from the task. So there is work just now looking at distraction, looking at interruption. People in teams being protective of other peoples situation awareness. You may have finished the safety critical phase, the difficult phase of the task, but somebody else in the team is at a phase where they need to concentrate. So the example we are sometimes using in operating theatres is that the surgeon has finished the difficult bit and now wants the music put back on, but actually the scrub nurses are now doing the very difficult bit for them which is checking and counting all these instruments and swabs and so maybe the music should stay down until the nurses have finished the safety critical task as well. Excerpt from the DVD - Unclear and Present Danger - Situation Awareness Training to Improve Safety.
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