1. Human Performance and Crew Resource Management Safety and Accident Investigation MSc

2. CRM Case Examples Human Factor CRM 7 CRM 2 3. 3 United Airlines, Flight 173 28 1978 - . - , ! 4. 3 2006 , C-5 Thrust Reverser Not Locked #2 / #2 , #3 idle * 4 USAF Galaxy C-5 5. ... ; 5 6. 6 7. / (briefing) 7 8. SHEL(L) Edwards, 1972 Hawkins, 1975 LIVEWARE HARDWARE SOFTWARE ENVIRONMENT 8 9. Human Factors 1. 2. 3. 4. 9 10. 1. 10 11. -COCKPIT 11 12. (, ) (, , ) 2. : ( ) : ( 12 13. 13 14. 14 15. 4. 15 16. 16 17. 17 18. 18 19. Generic Error Model System / Rassmussen / / 19 20. Reason 1997 : - ; ; ; ; ; ; , ; ; ; 20 21. 21 22. 22 23. 23 24. : 1 2 3 4 24 25. 25 26. CRM 5 Error Management4 AQP Stress (, ) 1990-2000 2005 2007 3 , (FAA) 6 Threat and Error Management 2010 26 27. 27 28. 28 29. TI EINAI CRM CRM ; , 29 30. 7 CRM 30 31. . 31 32. - , , , , . , , , , , . 32 33. - , ("Don't tell me") - ("Do it quickly") - , ("I can do it.") - , ("What's the use?") 33 34. - - - - - 34 35. . - - - . 35 US Airways pilot Chesley Sullenberger 36. ... P - (Pool the facts) I - (Identify problem) L - (Look for solutions) O - (Operate) T - (Take stock) 37. - M - - / - - - - / - - - - 37 38. 38 39. T "When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always long to return. Leonardo da Vinci 39