Post on 27-Mar-2015
Captain Don GuntherManaging Director Human Factors & Safety
““Threat & Error Threat & Error Management (TEM) Management (TEM)
Workshop”Workshop”
““Threat & Error Threat & Error Management (TEM) Management (TEM)
Workshop”Workshop”
3rd IATA –ICAOLOSA & TEM Conference
September 13-14, 2005Kuala Lumpur, Malaysia
3rd IATA –ICAOLOSA & TEM Conference
September 13-14, 2005Kuala Lumpur, Malaysia
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
TEM Workshop Agenda
Developing a TEM program• LOSA
TEM and an Automation Policy TEM applied outside of Flight
Operations TEM applied to incident and accident
analysis TEM as an integral part of a Safety
Management System (SMS)
Flight OperationsTEM Training
Flight OperationsTEM Training
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Why are we still doing CRM training?
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1965 1975 1985 1995 2005 2015
Year
Hull loss accidentsper year
Hull loss accident rate
Airplanes in service
Millions of departures
25,400
2015
Business as usual
19,077
2004
Ac
cid
en
t R
ate
/ M
illi
on
De
pa
rtu
re
Our Goal
Departures 2004
17.5 Million
438
1960
We Need to Continuously ImproveAviation Safety
1965 - 2004
Boeing 2004 Statistical Data – May 2005
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Accidents by Primary Cause1994 - 2003
Primary Factor
Flight crew
Airplane
Weather
Miscellaneous/other
Maintenance
Airport/ATC
Total with knowncauses
Unknown or awaitingreports
Total
84
19
16
7
5
5
136
50
186
Number of accidents
Total 10 20 30 40 50 60 70
Percentage of total accidents with known causes
Excludes: Sabotage Military action
62%
14%
12%
5%
4%
4%
Boeing 2003 Statistical Data – May 2004
66%69.1%
1994 -2003
1991 -2000
1959 -1995
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Accidents by Primary CauseHull Loss Accidents – Worldwide Commercial Jet Fleet –
1995 through 2004-
56%
17%
13%
6%
4%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Flight Crew
Airplane
Weather
Misc./Other
Maintenance
Airport/Air Traffic Control
Total with known causes
Unknown or awaiting reports
Total
75
23
17
8
5
5
133
44
177 *As determined by the investigating authority, percent of accidents with known causes.
4%
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Aviation Week Article on Healthy Organizations
“Investing the time and money needed to get at the root cause of a problem takes total commitment at the most senior levels of a company or organization. In most organizational settings, communicators learn early in life how bad news can impact their leaders. If the news is valued and the communicator is If the news is valued and the communicator is protected, there is a real chance information can and protected, there is a real chance information can and will routinely flow upward in time for proper action to will routinely flow upward in time for proper action to be takenbe taken.”
Safety Culture
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
The Safety Change Program“Tailored to Continental”“Tailored to Continental”
To properly target change we need current operational data, specifically for Continental, which is unique due to its…• History & Culture• Areas of operation (CMI, polar routes, etc.)• Philosophy
Line Observation Safety Audit(LOSA)
Line Observation Safety Audit(LOSA)
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“Normal” Performance
Angel Normal
FAA CheckAirmen LOSA 1 LOSA 2
• Distance between “Perfect” and “Normal performance varies as a function of culture, training, etc.
• LOSA enables us to get as closer to normal performance than was previously possible.
Perfect
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
The Continental LOSA Process
1st year • LOSA and data analysis followed by course
development
2nd & 3rd years • Training course for all crewmembers, Check Airmen
training and imbedding of TEM into courseware, policy & procedures, etc.
4th year • Preparation for next LOSA and targeting areas to be
measured and new areas to be emphasized.
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Line Observation Safety AuditLine Observation Safety AuditLOSA 1996LOSA 1996
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Error Management’s early focus was:
Managing crew errorcrew error
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Line Observation Safety AuditLOSA 2000
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LOSA 1996 vs. 2000
A 70% reduction in Checklist errors A 60% reduction in unstable
approaches (confirmed by FOQA data) Overall improvement in crew
performance Still a need for improvement in
Leadership skills
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Threat and Error ManagementThreat and Error Management
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Threats
Threats • Do not equal errors• Increase error potential
Threats = Red Flags
"A threat is anything external to the crew that increases operation complexity and, if not managed
properly, can decrease the safety margins."
"A threat is anything external to the crew that increases operation complexity and, if not managed
properly, can decrease the safety margins."
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
THREATS
Influences that can lead to crew error
Weather
Maintenance
Ground Crew
Cabin Crew
Passenger eventsATC
Terrain
Similar call sign
Time pressures
Heavy traffic
Unfamiliar airport
Automation event Missed approach
Flight diversion
System malfunction
Distractions
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Threat and Error ManagementThreat and Error Management
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Threat Management
Strategies/Countermeasures (Industry, Corporate and/or Personal)
• To reduce the number of errors
• To improve the error management process by increasing the awareness of potential errors
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Threat and Error ManagementThreat and Error Management
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Error
Actions or inactions by the flight crew that lead to deviations from organizational or flightcrew intentions or expectations
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Error Management
Actions taken to deal with errors committed by either
Detecting and correcting them, or by
Containing and reducing the severity
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Error Management
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RESISTRESISTHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS
Error Management
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RESISTANCERESISTANCE
HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERSHUMAN ENTERS
•GPWS
•TCAS
•TRAINING
•MANUALS
•SOP’s SOP’s
•CHECKLISTSCHECKLISTS
•AUTOMATION
•ATC
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
RESISTRESISTHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS
RESOLVERESOLVEWHAT THE HUMAN BRINGS TOWHAT THE HUMAN BRINGS TO THETHE SYSTEMSYSTEM
Error Management
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
RESOLVE
WHAT THE HUMAN BRINGS TO THE SYSTEMWHAT THE HUMAN BRINGS TO THE SYSTEM
• PROFICIENCY
• VIGILANCE
• ASSERTIVENESS
• MONITORING &
CROSSCHECKING
• DECISION MAKING
• EXPERIENCE
• LEADERSHIP
• SIT. ASSESSMENT
• CHECKLIST DISCIPLINE
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Threat and Error ManagementThreat and Error Management
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NASA Guidelines
Monitoring & CrosscheckingMonitoring & Crosschecking
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NASA Guidelines
Positively delegate flying and monitoringmonitoring duties
MonitoringMonitoring is as important as flying
Flying pilot does not become involved with secondary tasks
When conflict arises-resolve with outside source
When in doubt-must express!
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Error ResolvedError Resolved
Monitoring and Crosschecking
Pilot Monitoring(PM)
Pilot Monitoring(PM)
Express Your ViewExpress
Your View
Take ActionTake ActionCrosschecking
StepsCrosschecking
Steps
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Error ResolvedError Resolved
Monitoring and Crosschecking
Pilot Monitoring(PM)
Pilot Monitoring(PM)
Express Your ViewExpress
Your View
Take ActionTake ActionCrosschecking
StepsCrosschecking
Steps
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Error ResolvedError Resolved
Monitoring and Crosschecking
Pilot Monitoring(PM)
Pilot Monitoring(PM)
Express Your ViewExpress
Your View
Take ActionTake ActionCrosschecking
StepsCrosschecking
Steps
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Error ResolvedError Resolved
Monitoring and Crosschecking
(PM)(PM)
Crosschecking Steps
Crosschecking Steps
Express Your ViewExpress
Your View
Take ActionTake Action
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Case Studies““Look in the mirror first”Look in the mirror first”
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TEM“the challenge”
How to improve How to improve
““Threat”Threat”
Identification?
““Get it on the Radar!”Get it on the Radar!”
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Distractions
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LOW VISIBILITY TAXI
DE - ICING
ALTITUDE DEVIATION
WRONG TURN
Threat and Error Management
Decision MakingDecision Making&&
LeadershipLeadership
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DECISION-MAKING“Plan, Review, Monitor & Modify”
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Perceive Situation
Develop Plan
Share Plan
Execute Plan
Monitor Results
Decision Making
Strategic
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Perceive Situation
Develop Plan
Share Plan
Execute Plan
Monitor Results
Decision Making
Situation AssessmentSelect a Course of Action
StrategicTactical
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Situation Assessment
The The Nature of the ThreatsNature of the Threats
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Leadership
What have you seen?
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Threat and Error ManagementThreat and Error Management““Training”Training”
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
TEM TRAINING CLASS
Ideal class size 15-20 The value of the introduction
• Opening question
Facilitation training• Line pilots
Follow-on Check Airmen training
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Crew Resource ManagementCrew Resource Management
Effective Crew Resource Management is the bedrock of Threat and Error
Management.
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NewsletterFeedback to the pilots is essential for continued
program success.
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The Role of the Check Airman inThe Role of the Check Airman inThreat & Error ManagementThreat & Error Management
TEM &
Automation
TEM &
Automation
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To ERR is Human
To REALLY make a mess of To REALLY make a mess of things, you need a computer!things, you need a computer!
Verbalize Verify
Monitor
The Continental Airlines The Continental Airlines
Automation PolicyAutomation Policy
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TEMTEM““the challenge”the challenge”
Improve “Improve “Threat & ErrorThreat & Error” ” identification by usingidentification by using
To help “Get it on the To help “Get it on the RADARRADAR””
Verbalize, Verify, Monitor
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Threat and Error ManagementThreat and Error Management
What the human brings to the system
Hardware & Software that exists before the human enters
`
Verbalize, Verify, Monitor
TEM Trainingoutside of
Flight Operations
TEM Trainingoutside of
Flight Operations
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Maintenance Threat & Error Management (MTEM)
Food Services Threat & Error Management
Field Services Threat & Error Management
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Influences that can lead to agent error
Weather
Maintenance
New Agent
Cabin Crew
Passenger eventsLate Bags
Time pressures
Heavy traffic
Unfamiliar gate
Flight Crew
Flight diversion
System malfunction
DistractionsDistractions
Threats
Ramp slope
Late Gate Change
Late Cargo
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Ramp LOSA
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Why Ramp LOSA?
The first step in managing threats is to collect data• Precursors (Threats) are identified and
evaluated• Countermeasures (Strategies) are developed,
communicated throughout the organization, and then implemented in the system
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Identified Threats
Threats can be prioritized according to• The probability of an incident or accident
occurring and then by• The severity of an incident or accident that may
occur if the “threat” is mismanaged
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Threat Management
• The objective of “Threat Management” is to• Obtain an understanding of how to assess the
various risk levels of the threats and to• Gain an insight on logical approaches
(strategies) to deal them
TEM applied toIncident & Accident
Analysis
TEM applied toIncident & Accident
Analysis
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TEM Toolkitfor
Incident & Accident (IA)Analysis
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IATA Safety Advisory CommitteeIATA Safety Advisory CommitteeIncident & Accident analysisIncident & Accident analysis
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IATA Safety Advisory CommitteeIncident & Accident analysis
THREAT AND ERROR MANAGEMENT (TEM): ANALYTICAL TOOLKIT
Introduction The TEM Analytical toolkit has been developed for Manager’s to facilitate presenting and sharing events and lessons learned. The toolkit is comprised of this document, explaining the TEM concept, and the presentation template.
Background Threat and Error Management (TEM) is proposed as a useful tool to analyse incidents and occurrences. Using this model naturally leads to prevention strategies, remedial actions and countermeasures. The model helps to reinforce positive strategies and highlights areas and issues that need to be addressed. It also helps to keep the focus on the relevant lessons learned from the event, moving away from the who and what and towards understanding the WHY.
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Incident Example
Aircraft taxiing toward the gate 757 parked at adjacent gate Catering truck parked properly within the adjacent
gate clearance zone Arrival gate has an auxiliary J-line, requires 2
marshallers and clearance zones overlap Pre-arrival briefing not done Wing-walker had less than 30 days on job &
unfamiliar with these gates New wing-walker panicked and failed to give the
STOP signal when he saw the wing was going to strike the catering truck
Damage to wing and catering truck
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Diagram of incident
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Diagram of incident
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Diagram of incident
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Threat and Error Management (TEM)
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Threats
1. List of the Threats2. 3.4.5.6.7.8.
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Threats
1. 757 parked at adjacent gate2. Catering truck3. Arrival gate has an auxiliary J-line, requires 2
marshallers and clearance zones overlap4. Wing-walker had less than 30 days on job &
unfamiliar with these gates
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Threat Management
1. Identify the Threat 1. Was the threat managed or mismanaged? How?
3.
2.
4. 4.
3.
2.
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Threat Management
1. 757 parked at adjacent gate
1. Managed
3. Mismanaged – clearance zone not properly marked (latent)
2. Managed
4. Mismanaged – Crew brief not accomplished
4. Wing-walker had less than 30 days on job & unfamiliar with gates
3. Arrival gate… auxiliary J-line… clearance zones overlap
2. Catering truck
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Errors
1. List of the Errors2.3.4.5.6.7.8.
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Errors
1. Pre-arrival briefing not accomplished2. Catering truck parked in clearance zone3. Wing-walker did not give stop signal4.
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Error Management
1. Identify the Error 1. Was the error managed or mismanaged? How?
4.
3.
2.
3.
2.
4.
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Error Management
1. Pre-arrival briefing not accomplished
1. Mismanaged – Awareness of threat not established
4.
3. Wing-walker did not give stop signal
2. Catering truck parked in over-lapping clearance zone
3. Mismanaged – (latent?) training/ crew brief (E1)
2. Mismanaged – improper markings not detected (T3)
4.
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Undesired State Management
List how the Undesired State was managed or mismanaged.
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Undesired State Management
Managed• Post mishap procedures followed• PAX, fuel spill, etc• Etc.
Mismanaged…
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Prevention Strategies
List initial corrective actions at the present time and any proposed actions.• Crew Briefs• Training• Auditing procedures/policy
TEM an integral part of a Safety Management System
(SMS)
TEM an integral part of a Safety Management System
(SMS)
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Continental AirlinesSafety Management System
(SMS)
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IATA & ICAO
SMS Documents and Training
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SMS Essential Prerequisites
A comprehensive corporate approach to safety,
An effective organization for delivering safety, and
Systems to achieve safety oversight.
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Developing the ContinentalSafety Management System (SMS)
Safety statement from CEO Corporate Safety Policy
• Add SMS description and Corporate Safety Policy to the Safety manual
Establish the Corporate Safety Review Board• Begin development of the Safety Action Team
within each division
Audit the remainder of the Continental SMS
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Corporate Safety Review Board (CSRB)
Accountability
The CSRB is chaired by the CEO
Membership
CSRB membership comprises the CEO, (Sr/Exec) VPs of Flight Operations, Field Services, Tech Ops and Marketing (heads of the ‘functional areas’). The Director of Safety will attend the CSRB as the facilitator.
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Safety Action Team (SAT)
Accountability SATs are responsible to the Corporate Safety Review Board and the
chair is determined by the appropriate (Sr/Exec) VP. Membership
SAT membership will normally be drawn from directors, managers, supervisors and staff, from within the appropriate functional area and when appropriate the FAA and labor.
Terms of Reference As a minimum each SAT is responsible for the following: To oversee operational safety within the functional area. To ensure that any necessary corrective action is taken in a timely
manner. To report to and accept strategic direction from the Corporate Safety
Review Board via the appropriate Exec/Sr VP.
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Continental SMS
Corporate Safety Review BoardCSRB
Flight OperationsSafety Action Team
Tech OpsSafety Action Team
Field ServicesSafety Action Team
Director of Safety
Mkt/RsvSafety Action Team
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Flight OperationsSafety Action Team (SAT)
Develop the process by which safety data and Develop the process by which safety data and crew performance and behavior data fromcrew performance and behavior data from
FOQA, LOSA, ASAP, CASIS, Line Checks,… FOQA, LOSA, ASAP, CASIS, Line Checks,… are analyzed by are analyzed by
Safety, Flight Operations, Inflight, Flight Safety, Flight Operations, Inflight, Flight Standards & Training, FAA and ALPA Safety Standards & Training, FAA and ALPA Safety in order to facilitate change.in order to facilitate change.
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
To have an effective SMS…
Safety & Operational Efficiency
need to be combined into a
Corporate “Safety CultureSafety Culture”
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Goal
Become a better Threat Manager – actively identify threats in your operation
“Threat Management is managing your future.”
“Error Management is managing your past”
Continue building a Safety Culture by encouraging open, honest communications
Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005
Threat and Error ManagementThreat and Error Management