SQ TEM
Transcript of SQ TEM
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Customer Services
Threat Recognition and Error ManagementThreat Recognition and Error Management(TREM)(TREM)
Singapore, 8-10 October, 2002
Airbus 16th Human Factors Symposium
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Customer Services
Airbus 16th Human Factors Symposium
Threat Recognition and Error ManagementThreat Recognition and Error Management(TREM)(TREM)
Singapore, 8-10 October, 2002
Joey M. ANCA Jr
Mike MYLANSingapore Airlines
Presented by
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The Evolution of Crew Resource Management (CRM)
Threat Recognition & Error Management (TREM)
Tools from Ground Up: An Organisational Strategy
Building a Culture of Safety
TREM in Singapore Airlines
Threat Recognition and Error Management (TREM)
ContentsContents
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25 years of CRM with key issues that need to be
addressed:
CRM regulation
Integration of CRM into the Business of airlineoperations
CRM Evaluation and its relevance to shaping
skills to minimize human error
Have we indeed given the pilot the TOOLS for betterflightdeck error management?
Have we made the necessary link between CRM and the
business?
The Evolution of CRM
A Quick Heads UpA Quick Heads Up
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1st-3rd Generation CRM
4th-5th Generation CRM
6th Generation CRM
DISCIPLINE
CONCEPT
SCIENCE & TECHNOLOGY (TOOLIN
AF90 Potomac
UAL Everglades
UAL 232 Sioux City
FOQA/QAR
LOFT Development
TREM
KAL Guam
Behavioural Markers CRM
Incident Reporting/CHIRP/ASRS
LOSA
The Evolution of CRM
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CRM Instructors Behavioural Indicators
1st-5th Generation CRM Instructor(Aspirin to Ecstasy)
CRM Zealot--one sided, either
Management or Line;
The I or Experience Syndrome of
teaching: Been there, Done that;
Uses psychobabble to impress learning;
Inability to deal with classroom issues
and its relationship to fleet or flying
school concerns;
Views CRM as the magic potion; CRM
is localised as a teambuilding
technique
Increases pilot independence with other
flightcrew (cabin crew, mechanics etc)--
the Right Stuff or Clipper Captain
attitude
Very Charismatic and well-liked
6th Generation CRM Instructor(Antibiotic)
CRM Helper--sees that CRM is just one
of a host of error prevention strategies;
Focus of error management is building
an error tolerant crew or pilot
Veers away from behaviour and focuseson systems approaches to safety
Becomes a potent aid to flight
operations administration
Concerned with long-term solutions
which may not deliver initial positive
results
Upholds Captains Authority but only
after seeking information from crew
members
Uses a Just approach to things--
respected for views but sometimes
feared because of the truth.
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Engineer
Pilot
Cabin Crew
Station Manager
Organisation
ATCWorkplace
Environment Team
Eventsanomaly
incident
accident
Error Management
An Organisational Strategy
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Overt Threats: Organisational , Team, Individual, Environmental, External,
Aircraft
THREAT
RESPONSE
OUTCOME
Overt Threats: Organisational , Team, Individual, Environmental,
External, Aircraft
Latent Threats: National, Organisational, Professional cultures;
RegulatorySystem
CRM Skill
Countermeasures: Team Management,
Planning, Task Execution, Task
Review and Modification
Inciden
t
Inconsequential Safe
Flight
Undesired
Aircraft
State
New ErrorCrew Error(s)
ThreatMan
agement
ErrorManagement
TREM
A Preventive ToolA Preventive Tool
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*Red denotes SSE area of influence.
The Safety and Service Culture Context
InformedCulture
LearningCulture
Just
Culture
Safety &
Service
Culture
Actively Listening to Staff
Chronic Unease about Safety
Instilling Greater CustomerSatisfaction
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Informed
Culture
Learning
Culture
JustCulture
Safety
Culture
Listening to the Troops Chronic Unease about
Safety
Active Event
Reporting System Incident Knowledge
Base
CCRM Flight Ops
CCRM beyondFlight Ops
LLOSA
Proactive
Investigation Focused on Error
Avoidance, Trapping,
Mitigation
IInvestigation and
Discipline Process
I
CConfidential
Incident ReportingFFDAP/ Aviation
Quality Database
*Red denotes SSE area of influence.
The Safety and Service Culture Context
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Engineering &
Maintenance
Station
Managers
Cabin
Crew
Pilots
TCS-OASIS
TREM
TREM
SAFE Program
The Transcending Customer Service
& TREM Education Program
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Individual
Team
Workplace
Organisation
GreaterGreater
ProtectionProtection
GreaterGreater
VulnerabilityVulnerability
Sleeves Always in Motion MaturingCulture Values andBeliefsCompatibilitythroughoutLayers ofSleeves
Less Incidenceof Non-protected
Areas Predicting
Vulnerability is aWay of Life
DecreasingLoyalty tothe Companyand Business Unitsengaged inSelf-Protectionistaffairs ratherthanCollectiveWins Leaders aremore
concernedabout Self-preservation Safetyinformationresides witha critical few
A Culture of Safety Model: Overlapping Sleeves of Protection
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Flight OperationsFlight Operations
Cabin Crew
EngineeringCustomer Service
Officers
Ramp Operations IntegratedCRM
Practical Application
Joint Tech-Cabin CRM
embedded in SEP
Maintenance Resource
Management (MRM)
Context of CRM Integration (Areas of Influence)
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The Customers Line of Sight
Our Line of Sight
Takeoff
Initial
climb Landing
Final
approachLoad,
taxi,
unload
Climb Cruise Descent
Initial
approach
Flaps retracted
Outer markerNav fix
Ring
Reservat
ions
Check-In
CIQ/Baggag
e
Home
Service
Recovery
ERRORS?Service
Error Free
Product
Building in the Business: Excellent Service + Error Free Product)
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They are corrected
Behavior is readapted:- Margins are increased- Attention level is raised- Monitoring is improved
In a tolerantsystem, whenerrors are
detected ...
Short term performance is adaptedLong term performance is improved (learning)
Slide c/o Dedale Asia Pacific
Errors and Performance
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LOSA and the SIA Safety Agenda
Quality Assurance
Safety InformationSystemInvestigationManagement
LOSA
Safety, Efficiency, ReliabilitySafety, Efficiency, Reliability
System & Individual
Learning Process
IDP
Discipline
FDAP
Flight Ops Quality Management
Flight Safety PilotsFlight Safety Champions
CHFIRPS
Incident Reporting
Voyage Reports
Regular Audits
Executive Feedback
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Violation + Intent = Death and DestructionViolation + Intent = Death and Destruction
The New ICON of Intent
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Threats
& Errors
Threats / Errors detected
and managedSuccessful
flight
Threats /
Errors not
detected /
managed
Undesiredaircraft
stateACCIDENT/
INCIDENTUndesired aircraft
state not managed
Undesired aircraft
state managed
Inconsequential
Slide c/o Dedale Asia Pacific
Threat and Error Management
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Violations Matter
Fl ight Safety Fou ndat ion Report
Helmreich: US LO SA data
40% of accidents in the global fatal accident
database had violations
Those who violate make twice as many other errors
as those who do not
Their errors are twice as likely to be consequential
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Forgetting to...
Time pressure
Distraction
Inattention
Manage time
Prioritise tasks
Use check list
Seeing / hearing
what was expected
Highly experienced/
Too much anticipation
What if my expectation
is incorrect?
Slip Routine errors
More attention
More monitoring
What may be different?
Wrong reasoning Inadequate knowledgeMake it simple
Stick to SOP
What happened? Why? What did you learn?
Slide c/o Dedale Asia Pacific
Learning From Errors
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Have we provided more tools than theory to addressoperational reality?
What are the opportunities to build TREM as an integral
component of airline business? Thinking Pilot + Thinking Crew = Error Tolerant Operation?
A Culture of Safety: Where is the balance betweeninvesting on the Hearts and Mind vv. Shaping the
Environment?
TREM is focused on the CEO of the Aircraft. What elsecan be done to focus on the CEO of the airline?
Threat Recognition and Error Management (TREM)
ConclusionConclusion