Threat and Error Management Flight Safety Foundation

Threat and Error Management Flight Safety Foundation
for Business Aviation Salutation. Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph.D.

A Threat & Error Management Model

Threat & Error Management
External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Outcomes Organizational System Professional Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

Some Definitions

THREATS Threats are events that occur outside the influence of the flight crew, but which require crew attention and management if safety margins are to be maintained Threats increase the complexity of the operation and weaken barriers against error Observable Threats Known e. g., Thunderstorms, delays Unexpected e. g., Engine failure on take off Threats = Red Flags! Heinrich 2007

Fortunately, not all events become accidents…
1 10 30 200 600 Serious incident Significant event Routine occurrence The BASIS risk model is a well established model which illustrates that there are many more minor events and routine occurrences than the more significant events and isolated accidents. In practice, these lesser events may be unreported or treated as part of normal operations. It is by the proactive control of the trends within these numerous less serious events that the possibility of an accident can be reduced to a minimum. This forward-looking philosophy allows preventive measures to be taken before the trend has escalated to a significant event. The Flight Crew reports and the DFDR monitoring or FOQA program are essential parts of establishing enough information to control the significant trends and reduce the company’s exposure to risk and liability. Statistical event …but events/occurrences can lead to incidents and accidents Flight Safety Foundation, 2006; Adapted with permission.

Latent Threats Latent Threats – factors residing in the system, organization or individual that increase risk. Latent threats are not directly observable at the ‘sharp end’ of operations Latent threats are usually uncovered by analysis of aggregate data such as confidential incident reports, e.g., Equipment design issues Optical illusions Air traffic system design Training philosophy and practices Organizational culture (positive or negative) Heinrich 2007

Note that these are all management problems!
Typical Latent Errors Poor planning or scheduling Inadequate design/poor equipment Improper allocation/lack of resources Flawed procedures Defective communications Training deficiencies Inadequate selection procedures Inspection and oversight flaws Neglect of known hazards Lack of motivation This chart lists some typical latent errors. Note that these are all management problems! Flight Safety Foundation, 2006; Adapted with permission.

System Failures Contribute to Accidents
OPERATIONAL (ACTIVE) Types of Failure ORGANIZATIONAL (LATENT) Fig. 91 However, it is not only line personnel who make mistakes or errors. Mistakes can be others in the system who are not directly working on the line. They can make latent errors, sometimes made long before, that lie buried until they combine with an active error to cause the accident. Experience tells us that there are many more latent errors lurking in the system than there are active errors and that such mistakes can be made by anyone. Particularly, that can include management or even the regulator. There are typically far more latent failures than active failures in the system

ERRORS Errors are actions or inactions by the flight crew that lead to deviations from intention or expectation Traditional thinking focused on eliminating error in the cockpit, i.e., Zero Error! Contemporary thinking acknowledges that error is a part of life, i.e., humans make mistakes! Intentional non-compliance is not an error Types of errors: Flight handling errors (e.g., unintentional speed deviation) Procedural errors (e.g., performing checklist items from memory) Communications errors (e.g., missed ATC call) Heinrich 2007

Primary Causes of Aircraft Accidents *
Pilots are human… and humans make errors! (Note: this does not mean that errors are OK!) Primary Causes of Aircraft Accidents * Percentage of Total Accidents with Known Causes Primary Factor 10 20 30 40 50 60 70 Flight Crew Airplane Maintenance Weather Airport/ATC Other The landing phase represents only 1% of flight time but 45% of the accidents. According to investigative authorities, the flight crew is the primary cause in 62% of the accidents. Excludes: • Sabotage • Military Action • Turbulence Injury • Evacuation Injury • Servicing Injury The Crew usually makes the last mistake! * Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.

Error Outcomes Crew Response Exacerbate Errors Miss Errors
Mitigate Errors Trap Errors Increased Probability of Incident or Accident Increased Probability of Safe Flight * Helmreich, 1998

Strategies/Countermeasures
Strategies/Countermeasures are employed… to reduce the number of threats and errors, and to increase the awareness of potential threats and errors Errors must be recognized and corrected before negative consequences occur! Focus on managing your future! Countermeasures (Gurney, 2006) Flight crews must, as part of the normal discharge of their operational duties, employ countermeasures to keep threats, errors and undesired aircraft states from reducing margins of safety in flight operations. Examples of countermeasures include checklists, briefings, call-outs and SOPs, as well as personal strategies and tactics. Flight crews dedicate significant amounts of time and energy to the application of countermeasures to ensure margins of safety during flight operations. Empirical observations during training and checking suggest that as much as 70% of flight crew activities may be countermeasures-related activities. All countermeasures are necessarily flight crew actions. However, some countermeasures to threats, errors, and undesired aircraft states that flight crews employ build upon “hard” resources provided by the aviation system. These resources are already in place in the system before flight crews report for duty, and are therefore considered as systemic-based countermeasures. The following are examples of “hard” resources that flight crews employ as systemic-based countermeasures: Airborne Collision Avoidance System (ACAS) Ground Proximity Warning System (GPWS) Standard Operation Procedures (SOPs) Checklists Briefings Training Other countermeasures are more directly related to the human contribution to the safety of flight operations. These are personal strategies and tactics, individual and team countermeasures, that typically include canvassed skills, knowledge and attitudes developed by human performance training, most notably, by Crew Resource Management (CRM) training. There are basically three categories of individual and team countermeasures: Planning countermeasures: essential for managing anticipated and unexpected threats Execution countermeasures: essential for error detection and error response Review countermeasures: essential for managing the changing conditions of a flight Heinrich 2007

Safeguards Safeguards are the hardware & software that serve as additional barriers to problems*: GPWS TCAS EVS MANUALS SOPs CHECKLISTS AUTOMATION ATC Safeguards are the hardware & software that exist before the human enters the equation. They include but are not limited to: GPWS TCAS EVS Manuals SOPs Checklists Automation ATC *Note: Because these are also developed by humans, the potential still exists for latent defects and errors. Heinrich 2007

Awareness, Anticipation
Awareness and anticipation are important characteristics of effective CRM and TEM Awareness includes Search Perception Spatial orientation Knowledge of mission goals Anticipation includes Projection/forecasting Planning Threat awareness Heinrich 2007

Desired OUTCOMES or Undesired CONSEQUENCES ?
Successful Threat and Error Management results in outcomes that are desirable, i.e., safe flight Consequences of errors that are not corrected or not contained can result in an undesired aircraft state (UAS) An undesired aircraft state is an aircraft deviation or incorrect configuration associated with a clear reduction in safety margins Heinrich 2007

TEM Principles

The objective of Threat and Error Management (TEM) …
TEM Principles The objective of Threat and Error Management (TEM) … to obtain an understanding of how to assess the various risk levels of threats to gain an insight on logical approaches (strategies) to deal with them, and to reduce human error in dynamic daily operations. Heinrich 2007

TEM Principles TEM is central to all safety processes and provides defences against hazards in operational situations; it involves… Identifying hazards to safety, i.e., threats, errors, or undesired states (deviations) Assessing the risks of these hazards (the consequence of accepting hazards) Avoiding or trapping threats and errors Containing the end result (mitigation) Heinrich 2007

Important TEM Concepts

TEM Concepts The “mission” (i.e., safe, effective mission/objective) may be a flight, an aircraft repair, a trip plan, or even an ops manual or company procedure… … i.e., TEM can be applied to all aviation organizational entities. The crew is only one resource to the “operator” or “systems manager” who must make accurate and timely decisions for successful results. The operator is only as effective as the information he or she receives from all resources (The TEAM). Heinrich 2007

TEM Concepts Individuals are humans, and humans (all humans!) make mistakes. The aviation mission or objective is dynamic. TEM is not a sequential system! Because all organizational entities are made up of individuals, threats (hopefully with innovative threat solutions!) and human error (with error resolutions!) are introduced throughout the timeline of the particular “mission.” External threats also continuously occur and must be dealt with utilizing all appropriate resources available. Heinrich 2007

Accurate Decision-Making
The primary key to a successful mission outcome is accurate decision-making by the individual or individuals who are “steering the ship.” Accurate Decision-Making = Successful Outcome! In the operational setting, the operator is only as effective as the information (not data!) he or she receives through proper teamwork and resource management. The operator is the final authority regarding the safety of the mission; e.g., a pilot can always elect to abandon a dangerous approach. Heinrich 2007

A Case Study

Case Study G-III Fatal Accident, Aspen, March 2001
The Accident: On March 29, 2001, about 1902 MST, a Gulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, CO. The charter flight had departed Los Angeles International Airport (LAX) about 1711 with 2 pilots, 1 flight attendant, and 15 passengers. The airplane crashed into sloping terrain about 2,400 feet short of the runway threshold. All of the passengers and crewmembers were killed, and the airplane was destroyed. The flight was being operated on an IFR flight plan under CFR Part 135.

Case Study G-III Fatal Accident, Aspen, March 2001

System Professional Latent Threats: Organizational Threat & Error
External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Outcomes Organizational System Professional Latent Threats: (Factors residing in the system, organization or individual that increase risk ) Organizational Company management Organization management Resources System SOPs Policies Procedures Techniques Professional Operators Crew Team Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

What are some of the Latent Threats in the Aspen Accident?
Organizational System Professional What are some of the Latent Threats in the Aspen Accident? ?

Some of the Latent Threats in the Aspen Accident
Organizational System Professional Some of the Latent Threats in the Aspen Accident The March 27, 2001, NOTAM regarding the nighttime restriction on the VOR/DME-C approach was vaguely worded and ineffectively distributed: The NOTAM stated, “circling NA at night,” but the intended meaning was to prohibit the entire approach procedure at night. Pilots might have inferred that an approach without a circle-to-land maneuver to runway 15 was still authorized. If the FAA had worded the first NOTAM more clearly, it might have made more of an impression on the first officer when he received the preflight briefing from the Automated Flight Service Station and might have affected the conduct of the flight. The local controller could not notify the flight crew of the NOTAM because Denver Center had not sent a copy to the ASE tower. Heinrich 2007

Some of the Latent Threats in the Aspen Accident
Organizational System Professional Some of the Latent Threats in the Aspen Accident Company Standard Operating Procedures Manual incomplete: No sterile cockpit procedure No procedure/restrictions regarding the use of cockpit observers (jump seat) No guidance regarding weather minimums for mountain operation Heinrich 2007

Time Out!

What would have happened if the Organization…
…Utilized Corporate Flight Operations Quality Assurance (C-FOQA) to uncover latent threats and dangerous procedures/techniques? Had an effective Safety Management System and Incident Reporting System? Conducted Line Operational Safety Audits (LOSA)? Conducted confidential surveys? Regularly performed training evaluations? Redesigned policies, procedures, tasks, and equipment? Safe Flight Safe Flight Safe Flight Safe Flight Safe Flight Safe Flight Heinrich 2007

Threats/Events/Risks Expected External Threats/Events/Risks
Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Outcomes Unexpected External Threats/Events/Risks Latent threats System failures WX/ Environmental changes Other dynamics Threats Events that occur outside the influence of the flight crew, but which require crew attention and management if safety margins are to be maintained. Organizational System Professional Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Expected External Threats/Events/Risks Destination issues Terrain Environmental problems Logistics Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors External Error ATC errors Other aircraft Communication issues Time pressures Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

External Threats & Errors
Unexpected Events/Risks Expected Events/Risks External Error What are some of the External Threats & Errors in the Aspen Accident? ?

External Threats & Errors
Unexpected Events/Risks Expected Events/Risks External Error Some of the External Threats and Errors The Flight Crew was under pressure to land at ASE Because of the flight’s delayed departure from LAX and the landing curfew at ASE, the crew could attempt only one approach before having to divert to the alternate. The charter customer had a strong desire to land at ASE, and his communications before and during the flight most likely heightened the pressure on the flight crew. The presence of a passenger on the jumpseat, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land. Darkness, reduced visibility, and light snow showers significantly degraded the flight crew’s ability to see and safely avoid terrain. Heinrich 2007

Time Out!

In the Dynamic environment… What would have happened if…
…The organization had advised the passengers of the need to arrive on time because of the night curfew at Aspen? The flight attendant had recognized the potential problems associated with allowing passengers to occupy the jumpseat, especially in adverse conditions? The crew had advised the jumpseat passenger of an organization sterile cockpit rule? Safe Flight Safe Flight Safe Flight Heinrich 2007

Crew Errors * * All humans make mistakes! Non-compliance (violation)
External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Outcomes Crew Errors * Non-compliance (violation) Communication Procedural Proficiency Poor or uninformed decision * All humans make mistakes! Organizational System Professional Crew Errors Actions or inactions by the flight crew that lead to deviations from intention or expectation Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

What are some of the Crew Errors in the Aspen Accident?
Violations, Communication, Procedural, Proficiency, Decision What are some of the Crew Errors in the Aspen Accident? ?

Crew Errors Some of the Crew Errors
Violations, Communication, Procedural, Proficiency, Decision Some of the Crew Errors Procedural errors & deviations during Final Approach Segment: Crossed step-down fixes below minimum specified altitudes Descended below the MDA, even though aircraft maneuvers and comments on CVR indicated neither pilot had established or maintained visual contact with the runway or its environment. Contrary to manufacturer’s procedures, the captain deployed spoilers after gear and final flap extension and set power to 55% N2 rather than 64% N2 When the aircraft was 1.4 miles from the runway (21 sec before impact), captain asked, “where’s it at?” but did not abandon the approach, even though he had not identified, or had lost sight of, the runway. Radar data and CVR comments indicated that, until the aircraft began turning left about 10 sec. before impact, the crew probably did not have the runway or its environment in sight. Heinrich 2007

Some of the Crew Errors (continued)
Violations, Communication, Procedural, Proficiency, Decision Some of the Crew Errors (continued) Poor Crew Coordination/CRM: Captain failed to discuss the instrument approach procedure, the missed approach procedure, and other required elements during his approach briefing because he anticipated using a visual approach. The first officer never challenged the captain even though he crossed step-down fixes below minimum specified altitudes. The captain and the first officer failed to make required instrument approach callouts, and the first officer did not call out required course, fix, & altimeter information. The crew failed to discuss a missed approach after receiving a third report of a missed approach to the airport and a report of deteriorating visibility in the direction of the approach course. Heinrich 2007

Time Out!

…The first office would have challenged the captain about missing stepdown altitudes? The crew would have briefed and planned on an instrument approach, especially after hearing that three other aircraft had executed the missed approach procedure? The crew would have abandoned their obsession with finding visual landmarks? The crew would have altered their thinking from “landing unless…” to “go around unless…” ? Safe Flight Safe Flight Safe Flight Safe Flight Heinrich 2007

Error Management Behaviors Undesired State Management Behaviors
External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Outcomes TRM/CRM Behaviors Decision-making – must have “information” from all Team resources (integration) Situation Awareness and “Projection” in a very dynamic environment Threat recognition Error avoidance Safeguards – hardware and software that serve as additional barriers to problems Countermeasures – increase awareness and reduce number of threats/errors Error Management Behaviors Avoid Trap Contain Mitigate Exacerbate Fail to respond Undesired State Management Behaviors Errors/deviations require immediate action before negative consequences occur! Additional error can lead to an incident or accident Note: Pilots can always elect to abandon a dangerous approach or phase of flight! Organizational System Professional Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

What are some of the TRM/CRM Behaviors in the Aspen Accident?
Decision-making, SA, Threat recognition, Error avoidance , Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) What are some of the TRM/CRM Behaviors in the Aspen Accident? ? Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-)

Some TRM/CRM Behaviors
Decision-making, SA, Threat recognition, Error avoidance , Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) Some TRM/CRM Behaviors Captain and another Avjet captain discussed nighttime landing restriction at ASE. Captain asked controller whether the pilot of N527JA was practicing or had actually missed. When airplane is at 10,400 feet, captain states, “Okay...I'm breaking out," and asks local controller, about 5 seconds later, whether runway lights are all way up. The controller indicates, “Affirmative they're on high." First officer says, “Okay you can go...ten thousand two hundred [the MDA].” Descended below MDA, even though aircraft maneuvers and comments on CVR indicated neither pilot had established or maintained visual contact with the runway or its environment. Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) Heinrich 2007

Time Out!

…The crew had expected to execute a missed approach after hearing that the Challenger ahead (N527JA) had executed the missed approach? The crew had realized that when they were “breaking out” that they were not in a position to land when they were unable to see the runway lights? The crew had executed a missed approach when they reached the MDA missed- approach point and were unable to see the runway or its environment? Missed Approach! Safe Flight Missed Approach! Safe Flight Missed Approach! Safe Flight Heinrich 2007

External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Safe Flight Effective DM, SA, threat recognition, error avoidance Appropriate application of T&E strategies result in desirable outcomes Outcomes Outcomes Organizational System Professional Inconsequential Outcome Management of threats & errors (i.e., avoiding, trapping, containing) results in little or no adverse consequences Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Undesired Aircraft State Aircraft deviation or incorrect configuration associated with a clear reduction in safety margins Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Recovery to Safe Flight Effective undesired state management behaviors Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional Error Additional error(s) requires further error management behaviors Exacerbation or failure to respond can result in an incident or accident Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

Outcomes Safe Flight Undesired aircraft state Incident Accident Inconsequential Additional error Recovery to Safe Flight What are some of the Crew CRM Behaviors and subsequent Outcomes in the Aspen Accident? ? Safe Flight Inconsequential Recovery to Safe Flight Additional error Undesired aircraft state Accident

Crew CRM Behaviors and subsequent Outcomes
Safe Flight Undesired aircraft state Incident Accident Inconsequential Additional error Recovery to Safe Flight Crew CRM Behaviors and subsequent Outcomes Flight crew properly certificated & qualified; aircraft properly certified, equipped, & maintained; the first officer obtained a weather briefing Crew crossed the FAF 100’ low, descended 300’ below the next stepdown, and crossed the 9.5 DME fix 900’ low At about 1901:53, the captain added max power (less than a second before impact) Determination to continue with the original plan of action despite the presence of cues suggesting the need for a modified course of action High descent rate (GPWS sink rate alerts) & excessive bank angle near ground Descent below MDA without visual contact with the runway or environment Safe Flight Inconsequential Recovery to Safe Flight Additional error Undesired aircraft state Accident Heinrich 2007

Time Out!

The crew had received general TEM training? TEM training had been integrated into formal simulator training? The organization had a non-punitive approach to error? The crew had applied CRM training? Active sharing of concerns & ideas Limitations of human performance Threat and error recognition Error avoidance Error management strategies The crew had learned and practiced techniques to apply in specific situations? Safe Flight Safe Flight Safe Flight Safe Flight Safe Flight Heinrich 2007

Gulfstream III - Aspen, Colorado March 2001
* Eighteen Fatalities NTSB Findings Procedural Errors Poor Crew Coordination Time Pressures Passenger Expectations IN THE EARLY EVENING HOURS OF MARCH , A GULFSTREAM III CARRYING CRASHED INTO A SLOPING HILLSIDE DURING AN INSTRUMENT APPROACH TO THE ASPEN, COLORADO AIRPORT. FIFTEEN PASSENGERS AND THREE CREWMEMBERS WERE KILLED. IN ITS INVESTIGATION, THE NATIONAL TRANSPORTATION SAFETY BOARD FOUND THAT THE FLIGHT CREW: (1) MADE NUMEROUS PROCEDURAL ERRORS DURING ITS INSTRUMENT APPROACH; (2) DEMONSTRATED POOR CREW COORDINATION; (3) ENDURED SIGNIFICANT TIME PRESSURE FROM A RAPIDLY APPROACHING NIGHT CURFEW AND A DEMANDING PASSENGER.

The Error Chain Effect in a Dynamic Environment
External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Errors Additional error “Oh, really!” YES PAX to FA: “Can I ride on the jumpseat?” Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Additional error No sterile cockpit FA to PAX: “Would anyone like to ride on the jumpseat?” No! Captain: “Please, flight issues only!” Safe Flight Additional error First officer hesitant to challenge captain Threat & Error Management First officer: “You’re too low! Let’s miss!” Safe Flight Additional error Captain determined to land Captain: “3 MAs! Let’s plan for MA!” Safe Flight Safe Flight Heinrich 2007

External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Errors Additional error “Oh, really!” YES PAX to FA: “Can I ride on the jumpseat?” Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Additional error No sterile cockpit FA to PAX: “Would anyone like to ride on the jumpseat?” No! Captain: “Please, flight issues only!” Safe Flight Additional error First officer hesitant to challenge captain Threat & Error Management First officer: “You’re too low! Let’s miss!” Safe Flight Additional error Captain determined to land Captain: “3 MAs! Let’s plan for MA!” Safe Flight Safe Flight Incident Accident Heinrich 2007

External Threats & Errors Latent Threats Crew Errors TRM/CRM Behaviors CRM Behaviors Outcomes Errors Additional error “Oh, really!” YES PAX to FA: “Can I ride on the jumpseat?” Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Additional error No sterile cockpit FA to PAX: “Would anyone like to ride on the jumpseat?” No! Captain: “Please, flight issues only!” Safe Flight Additional error First officer hesitant to challenge captain Threat & Error Management First officer: “You’re too low! Let’s miss!” Safe Flight Additional error Captain determined to land Captain: “3 MAs! Let’s plan for MA!” Safe Flight Safe Flight Heinrich 2007

for Business Aviation Questions? Salutation. Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph.D.

Backup Slides

TEM Take-Aways TEM does not replace CRM; rather, CRM is the foundation of an effective TEM program Keys to using TEM and the automated flightdeck: Identify automation threats Develop automation strategies Verbalize, verify, and monitor! Treat interruptions as “red flags” “What gets measured gets managed” Utilize check airmen, observers (LOSA), FOQA Record best practices Track progress Revise procedures and processes Heinrich 2007

TEM Take-Aways (continued)
Encourage good communication Make sure everyone is “on the same page” (good CRM!) Discourage the “Hint and Hope” syndrome (dropping a subtle hint, hoping the other person will get the message) Communicate anything that can reduce your ability to detect errors or anything that can increase your chance of making errors Statistically, better communication = fewer errors Follow SOPs: Crews who fail to follow SOPs are twice as likely to commit subsequent errors “Buy time” for your crew – pause to properly assess the situation, develop strategies, and make informed decisions Heinrich 2007

Organizations that have a proactive safety culture…
Understand that… …aviation professionals are human and therefore prone to error acceptance of vulnerability is the first step in taking responsibility and avoiding risk-taking behaviors detecting, reducing, and containing human errors are the most effective ways of improving safety it is important to have incident reporting programs that are confidential and non-punitive Now let’s look at organizations that have a proactive safety culture. These organizations recognize that aviation professionals are human and are therefore prone to error. They understand that acceptance of the tendency towards human error is the first step in taking responsibility and avoiding risk-taking behaviors. Proactive organizations also understand that risks associated with aviation can be mitigated by risk compensation strategies. When this is impossible, they find ways to provide or restore adequate margins of safety. Heinrich 2007

Understand that… … adherence to SOPs can greatly reduce the opportunities for accidents and incidents internal and external audits are critical to safety “health” risks can most times be mitigated by risk-compensation when risk compensation cannot be accomplished, alternatives must be found that provide adequate margins of safety Now let’s look at organizations that have a proactive safety culture. These organizations recognize that aviation professionals are human and are therefore prone to error. They understand that acceptance of the tendency towards human error is the first step in taking responsibility and avoiding risk-taking behaviors. Proactive organizations also understand that risks associated with aviation can be mitigated by risk compensation strategies. When this is impossible, they find ways to provide or restore adequate margins of safety. Heinrich 2007

Understand that… …safety is an attitude on and off the job safety can be proactively managed, i.e., all accidents and incidents can be prevented all operating exposures can be safeguarded; barriers must be erected and maximized safety comes from proper decision-making, usually a product of good CRM, MRM, or TRM safety should be continually recognized and re-enforced Organizations with proactive safety cultures also understand that safety is an attitude on and off the job. Safety doesn’t start when the employee “clocks in.” Safety has to be a way of life! Further, proactive organizations know that safety can be managed. In other words, they believe that all accidents and incidents can be avoided. In addition, all operating exposures can be safeguarded. Accordingly, appropriate safety barriers must be erected and maximized. Such organizations understand that safety is a product of proper decision-making and sound decision-making generally comes from effective CRM and MRM. Heinrich 2007

Understand that… …both management and employees are responsible for avoiding accidents and incidents employees must be trained and given the tools/resources to work safely – i.e., there should be no incentives to take short cuts or break the rules prevention of personal injuries is a product of caring, but it is also good business working safely and responsibly should be a condition of employment Organizations with a proactive safety program understand that it is the responsibility of both management and employees to assist in avoiding accidents and incidents – one group cannot function effectively without the other. Proactive organizations recognize that employees must be trained and given the tools to work safely. They must ensure that there are no incentives in place to take short cuts or break the rules. Such organizations understand that prevention of personal injuries is a product of management that cares but that it is also good business to safeguard the health and well-being of employees. Finally, proactive organizations make it understood that working safely and responsibly is a condition of employment. When safety rules are broken, employees responsible must be held accountable. Heinrich 2007

External Threats & Errors Latent Threats Crew Errors CRM Behaviors CRM Behaviors Outcomes Outcomes Organizational System Professional Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Unexpected Events/Risks Safe Flight Expected Events/Risks Violations, Communication, Procedural, Proficiency, Decision External Error Recovery to Safe Flight Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Threat & Error Management Undesired aircraft state Undesired state management behaviors Additional error Additional error Incident Accident * Adapted from Helmreich, 2003

for Business Aviation Questions? Salutation. Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph.D.

Threat and Error Management Flight Safety Foundation

Similar presentations

Presentation on theme: "Threat and Error Management Flight Safety Foundation"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Threat and Error Management Flight Safety Foundation

Similar presentations

Presentation on theme: "Threat and Error Management Flight Safety Foundation"— Presentation transcript:

Similar presentations

About project

Feedback