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TEM & LOSA: The State of Affairs TEM & LOSA: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Third.

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Presentation on theme: "TEM & LOSA: The State of Affairs TEM & LOSA: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Third."— Presentation transcript:

1 TEM & LOSA: The State of Affairs TEM & LOSA: The State of Affairs Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Third IATA/ICAO LOSA/TEM Conference Kuala Lumpur, Malaysia 13 – 14 September 2005

2 The Big Safety Data Picture Forensic systems – Failures Forensic systems – Failures Accident investigation Accident investigation Major incident investigation Major incident investigation Proactive systems – Routine operational events Proactive systems – Routine operational events Electronic safety data acquisition systems (FOQA) Electronic safety data acquisition systems (FOQA) Voluntary self-reporting systems (ASAP) Voluntary self-reporting systems (ASAP) Direct observation safety data acquisition systems (LOSA & NOSS) Direct observation safety data acquisition systems (LOSA & NOSS) Reactive systems – Anomalies Reactive systems – Anomalies Mandatory reporting systems (CAAs) Mandatory reporting systems (CAAs) Voluntary reporting systems (ASRS/BASIS) Voluntary reporting systems (ASRS/BASIS)

3 LOSA [NOSS] & TEM: Clarifying a Relationship The features in operational context – Threats The features in operational context – Threats What people do – Errors What people do – Errors The results of the features in operational context and of what people do – Undesired states The results of the features in operational context and of what people do – Undesired states TEM = Framework – What we look for TEM = Framework – What we look for LOSA [NOSS] =Tool(s) – How we collect what we look for LOSA [NOSS] =Tool(s) – How we collect what we look for The Ten Operating Characteristics The Ten Operating Characteristics

4 Monitoring normal operations (LOSA & NOSS) Monitoring normal operations (LOSA & NOSS) Training – Flight & Cabin Crew/ATCO (ICAO, IATA, Airlines and ATS providers) Training – Flight & Cabin Crew/ATCO (ICAO, IATA, Airlines and ATS providers) Safety management data analysis Safety management data analysis Integrated Threat Analysis (ITA) – ICAO & IATA Integrated Threat Analysis (ITA) – ICAO & IATA Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA Research and development (UT & Boeing) Research and development (UT & Boeing) Rule-making – ICAO provisions Rule-making – ICAO provisions TEM Framework – Expanding Role

5 FCLT/P – State Letter AN 12/1.1-05/62 Annex 1 – Personnel Licensing Knowledge requirements Knowledge requirements Human performance including principles of threat and error management Human performance including principles of threat and error management Operational procedures – Application of threat and error management to operational performance Operational procedures – Application of threat and error management to operational performance Skills requirements Skills requirements Recognize and manage threats and errors Recognize and manage threats and errors

6 FCLT/P – Multi-Crew Pilot License (MPL) Note. The application of threat and error management principles is a specific competency unit that is to be integrated with each of the other competency units for training and testing purposes. 1)apply threat and error management (TEM) principles; 2)perform aeroplane ground operations; 3)perform take-off; 4)perform climb; 5)perform cruise 6)perform descent; 7)perform approach; 8)perform landing; and 9)perform after landing and aeroplane post-flight operations. Competency units, competency elements and performance criteria

7 FCLT/P – MPL Competency Unit 2 – Perform aeroplane ground operations Competency element: Line up checks completed Competency element: Line up checks completed ATC call to give clearance interrupts checklist ( threat ) ATC call to give clearance interrupts checklist ( threat ) Crew skips pitot heat checklist item ( error ) Crew skips pitot heat checklist item ( error ) Aircraft is lined up for take off roll with pitot heat off ( undesired aircraft state ) Aircraft is lined up for take off roll with pitot heat off ( undesired aircraft state ) Performance criteria: Example TEM countermeasures Performance criteria: Example TEM countermeasures Keep finger in checklist item until check list is re-started Keep finger in checklist item until check list is re-started Start checklist all over again after clearance read back Start checklist all over again after clearance read back Request ATC to hold clearance until checklist completed Request ATC to hold clearance until checklist completed

8 FCLT/P – Annex 6, Operation of Aircraft Chapter 9. Aeroplane Flight Crew 9.3 Flight crew member training programmes 9.3.1An operator shall establish and maintain a ground and flight training programme, approved by the State of the operator…The training programme shall also include…training in knowledge and skills related to human performance and threat and error management…The training programme shall be given on a recurrent basis…

9 Aligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and III Annex 6 – Operation of Aircraft, Parts I and III Annex 11 – Air Traffic Services Annex 11 – Air Traffic Services Annex 14 – Aerodromes Annex 14 – Aerodromes A basic safety management template A basic safety management template Two basic concepts Two basic concepts Safety programme – States Safety programme – States Safety management system – Operators Safety management system – Operators The ICAO Safety Management Manual (Doc xxxx) The ICAO Safety Management Manual (Doc xxxx) LOSA LOSA NOSS NOSS

10 Normal Ops ArchieIncidentsSTEADESAccidentsADREP TEM – Aggregate Safety Analysis Integrated Threat Analysis (ITA) – A Joint ICAO/IATA Project Case study: TEM analysis – Runway excursions Case study: TEM analysis – Runway excursions 34 ADREP narratives 34 ADREP narratives 36 STEADES narratives 36 STEADES narratives Long landings Long landings Floated landings Floated landings Off centre-line landings Off centre-line landings The bridge between ADREP/STEADES & Archie : UAS The bridge between ADREP/STEADES & Archie : UAS 164 LOSA narratives 164 LOSA narratives

11 Threats – ITA

12 Environmental Threats – ITA

13 Airline Threats – ITA

14 Flight Crew Errors – ITA

15 Safety Management: Data, not Opinion Threat scenarios – Accidents & incidents Weather (heavy rain, TS, wind gusts, tailwind) Weather (heavy rain, TS, wind gusts, tailwind) A/C malfunctions, RTO A/C malfunctions, RTO Night operations Night operations Proficiency issues Proficiency issues Threat Scenarios – ITA ATC ATC Weather (heavy rain,TS, wind gusts, tailwind) Weather (heavy rain,TS, wind gusts, tailwind) Operational pressure Operational pressure A/C malfunctions, RTO A/C malfunctions, RTO Night operations Night operations Proficiency and procedural issues Proficiency and procedural issues

16 Clearing the Air – LOSA Is not the same as IATAs IOSA Is not the same as IATAs IOSA Is not the same as Airbus LOAS Is not the same as Airbus LOAS Is not the same as the JAAs NOTECHS Is not the same as the JAAs NOTECHS Is not an evaluation of CRM Is not an evaluation of CRM Is not the sixth generation CRM Is not the sixth generation CRM Is not a research tool Is not a research tool Is not culturally incompatible Is not culturally incompatible LOSA [NOSS] is a safety management data collection tool[s] that generates safety management data otherwise not available LOSA [NOSS] is a safety management data collection tool[s] that generates safety management data otherwise not available

17 Clearing the Air (II) – TEM & CRM …TEM is an overarching safety concept with multiple applications in aviation; while CRM is exclusively a training intervention. The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example as an additional module – within existing CRM programmes. This is because TEM countermeasures build in part – although not exclusively – upon CRM skills. The combination of TEM concepts with CRM skills thus introduces the opportunity to present the utilization of CRM skills by flight crews anchored in the operational environment, from an operational perspective. It is emphasized that TEM training does not replace CRM training, but rather complements and enhances it.

18 TEM & LOSA – Safety Management Tools FDA Voluntary Reporting Direct observations


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