2TEM Workshop Agenda Developing a TEM program LOSATEM and an Automation PolicyTEM applied outside of Flight OperationsTEM applied to incident and accident analysisTEM as an integral part of a Safety Management System (SMS)
4Why are we still doing CRM training? Ask and facilitate this questionHow are we doing on the line?Are we doing a good job? Can we do better?
5We Need to Continuously Improve Aviation Safety 1965 - 2004 Airplanes in serviceDepartures 200417.5 Million25,4002015Business as usual19,07743819602004Hull loss accidents per yearAccident Rate / Million DepartureOur goal is to reduce the accident rateOur GoalMillions of departuresHull loss accident rate196519751985199520052015YearBoeing 2004 Statistical Data – May 2005
6Accidents by Primary Cause 1994 - 2003 Number of accidentsPercentage of total accidents with known causesPrimary FactorTotal1020304050607062%Flight crewAirplaneWeatherMiscellaneous/otherMaintenanceAirport/ATC8419167566%69.1%14%12%5%4%4%Total with known causesUnknown or awaitingreportsTotal13650186Excludes:SabotageMilitary actionBoeing 2003 Statistical Data – May 2004
7Accidents by Primary Cause Hull Loss Accidents – Worldwide Commercial Jet Fleet – 1995 through 2004 -0%10%20%30%40%50%60%70%80%Flight Crew7556%Airplane2317%Weather1713%Misc./Other86%Maintenance54%Airport/Air Traffic Control54%Total with known causes133Unknown or awaiting reports44*As determined by the investigating authority, percent of accidents with known causes.Total177
8Aviation Week Article on Healthy Organizations Safety CultureAviation 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 protected, there is a real chance information can and will routinely flow upward in time for proper action to be taken.”
9The Safety Change Program “Tailored to Continental” To properly target change we need current operational data, specifically for Continental, which is unique due to its…History & CultureAreas of operation (CMI, polar routes, etc.)Philosophy
11“Normal” Performance FAA LOSA 1 LOSA 2 Perfect Angel Normal CheckAirmenLOSA 1LOSA 2PerfectAngelNormalDistance 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.
12The Continental LOSA Process 1st yearLOSA and data analysis followed by course development2nd & 3rd yearsTraining course for all crewmembers, Check Airmen training and imbedding of TEM into courseware, policy & procedures, etc.4th yearPreparation for next LOSA and targeting areas to be measured and new areas to be emphasized.
14Error Management’s early focus was: Managing crew errorAs we discussed earlier the focus of our first EM class was to “manage crew error”And while we still need to continue this focus, we also need to expand our awareness of things that affect us on the flightdeck
16LOSA 1996 vs. 2000 A 70% reduction in Checklist errors A 60% reduction in unstable approaches (confirmed by FOQA data)Overall improvement in crew performanceStill a need for improvement in Leadership skills
18Threats Threats Threats = Red Flags Do not equal errors "A threat is anything external to the crew that increases operation complexity and, if not managed properly, can decrease the safety margins."ThreatsDo not equal errorsIncrease error potentialThreats = Red FlagsREDFLAGThis is our introduction to the RED FLAG concept. It is important to build recognition here. Many more Red Flags will be shown in the discussion of AA1420.Also important to note here that, as the slide states, “a threat does not equal an error”. It only allows for the potential to commit an error. However, a threat should be perceived as a Red Flag to the crew, and even talked about amongst themselves as such.Take one of the threats previously listed by the group and use as an example of how the threat could have become an error or not an error.
19Influences that can lead to crew error THREATSInfluences that can lead to crew errorWeatherMaintenanceGround CrewCabin CrewPassenger eventsATCTerrainSimilar call signTime pressuresHeavy trafficUnfamiliar airportAutomation eventMissed approachFlight diversionSystem malfunctionDistractionsSlide will appear with the cockpit and title only.ONE MOUSE CLICK will start the animation and automatically show many of the LOSA observer threats.This is a good opportunity to compare the list that the class developed with those that were specifically looked for on the observations. This list is not exhaustive are there any others?
21Strategies/Countermeasures Threat ManagementStrategies/Countermeasures(Industry, Corporate and/or Personal)To reduce the number of errorsTo improve the error management process by increasing the awareness of potential errors
22Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS
23ErrorActions or inactions by the flight crew that lead to deviations from organizational or flightcrew intentions or expectations
24Error Management Actions taken to deal with errors committed by either Detecting and correcting them, or byContaining and reducing the severity
25Error Management ERRORS CONSEQUENCE Resist Resolve Review of Error Management: Use this slide to start a discussion of the previous course. Asking these questions in other classes such as Upgrade has is general produced the following. Few remember much of the specifics of EM. They remember something about errors and the fact that we cannot avoid them totally. Recall of the resist and resolve tools is sketchy at best.Do a review as necessary to bring them up to speed, but keep it short!Use pre-made chart as a center for your discussion.Possible questions:What do you remember from our previous course?How is it working? Has admitting we make mistakes changed your approach any?How do you resist errors?What are some of the resist tools? See next slideHow do you resolve error that have occurred in your cockpit?What are some of the resolve tools? See the slide after thatAdditions questions to keep the discussion going.How do you use these tools?How have you seen these tools abused?
26HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS Error ManagementRESISTHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERSResistResolveCONSEQUENCEERRORS
27HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS RESISTANCEHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERSGPWSTCASTRAININGMANUALSSOP’sCHECKLISTSAUTOMATIONATCAsk the question; what are some resist tool?Write a few of the answers on the pre-made chart (Use dry ease marker)Field a few responses and then click again to bring up rest of responses.
28Error Management RESIST ERRORS CONSEQUENCE RESOLVE Resist Resolve HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERSResistResolveCONSEQUENCEERRORSRESOLVEWHAT THE HUMAN BRINGS TO THE SYSTEM
29RESOLVE PROFICIENCY VIGILANCE EXPERIENCE ASSERTIVENESS LEADERSHIP WHAT THE HUMAN BRINGS TO THE SYSTEMPROFICIENCYVIGILANCEASSERTIVENESSMONITORING & CROSSCHECKINGDECISION MAKINGEXPERIENCELEADERSHIPSIT. ASSESSMENTCHECKLIST DISCIPLINESame thing for Resolve tools
30Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS
31Monitoring & Crosschecking NASA GuidelinesMonitoring & Crosschecking
32NASA Guidelines Positively delegate flying and monitoring duties Monitoring is as important as flyingFlying pilot does not become involved with secondary tasksWhen conflict arises-resolve with outside sourceWhen in doubt-must express!
33Monitoring and Crosschecking Pilot Monitoring(PM)Take ActionCrosschecking StepsExpress Your ViewError Resolved
34Monitoring and Crosschecking Pilot Monitoring(PM)Take ActionCrosschecking StepsExpress Your ViewError Resolved
35Monitoring and Crosschecking Pilot Monitoring(PM)Take ActionCrosschecking StepsExpress Your ViewError Resolved
36Monitoring and Crosschecking (PM)Take ActionCrosschecking StepsSolutionProblemExpress Your ViewError Resolved
37“Look in the mirror first” Case Studies“Look in the mirror first”
38How to improve “Threat” Identification? “Get it on the Radar!” TEM “the challenge”How to improve“Threat”Identification?“Get it on the Radar!”REDFLAGThis is our introduction to the RED FLAG concept. It is important to build recognition here. Many more Red Flags will be shown in the discussion of AA1420.Also important to note here that, as the slide states, “a threat does not equal an error”. It only allows for the potential to commit an error. However, a threat should be perceived as a Red Flag to the crew, and even talked about amongst themselves as such.Take one of the threats previously listed by the group and use as an example of how the threat could have become an error or not an error.
39DistractionsExplain to the class that after takeoff a duck impacted the windshield and entered the cockpit killing the captain.The discussion can be started by asking the question “why did this accident happen?” Typical answer bird hit the windshield.OK, why was it able to penetrate the cockpit?Windshield heat was off.That is on most checklist, “why do you think it was off?”The chain of events for this accident started when a flight attendant came into the cockpit while the cockpit crew was running the “Receiving Aircraft” checklist at the gate. The crew allowed the flight attendant to interrupt the checklist, then picked up the checklist one item after “windshield heat”.The total flight time from the first event in the chain until back on the ground was less than 30. The reading of the checklist was recorded by the CVR.
41DECISION-MAKING “Plan, Review, Monitor & Modify” The purpose of this module is to review decision making both in the tactical (reactive) stage when time is often very limited and during the strategic (proactive) stage which allows more time to better manage threats and thus ensure better performance. Looking at the tire tracks leads one to wonder what in the decision making process that led to this event.
42Decision Making Strategic Perceive Situation Develop Plan Share Plan Execute PlanMonitor ResultsWhat we really do.So lets look at these two aspects.Most of the time we: Situation Assessment -- Look for what we recognize or have seen before then select a course of action, usually something we have tried before. Then if that doesn’t work we’ll start over with a more involved process.So let’s look at these steps.
43Select a Course of Action Decision MakingStrategicTacticalPerceive SituationDevelop PlanShare PlanExecute PlanMonitor ResultsSituation AssessmentSelect a Course of ActionWhat we really do.So lets look at these two aspects.Most of the time we: Situation Assessment -- Look for what we recognize or have seen before then select a course of action, usually something we have tried before. Then if that doesn’t work we’ll start over with a more involved process.So let’s look at these steps.
44Situation AssessmentThe Nature of the ThreatsRISKTIME
45Leadership What have you seen? Introduce the topic of flightdeck leadershipBuild a verbal bridge from what the participants have said earlier, such as in Good Crew discussion, in AA 1420 or in the DM discussions on the topic of leadership.Then go into questions on the next slideWho was providing the leadership in American 1420 or in our FOQA events?Is leadership important in our cockpit?If there is no leadership what fills the void?
46Threat and Error Management “Training”THREATSStrategiesResistResolveCONSEQUENCEERRORS
47TEM TRAINING CLASS Ideal class size 15-20 The value of the introductionOpening questionFacilitation trainingLine pilotsFollow-on Check Airmen training
48Crew Resource Management Effective Crew Resource Management is the bedrock of Threat and ErrorManagement.
49Feedback to the pilots is essential for continued program success. NewsletterFeedback to the pilots is essential for continued program success.
50The Role of the Check Airman in Threat & Error Management
52To REALLY make a mess of things, you need a computer! To ERR is HumanTo REALLY make a mess of things, you need a computer!
53Verbalize Verify Monitor The Continental AirlinesAutomation PolicyVerbalize Verify Monitor
54To help “Get it on the RADAR” TEM“the challenge”Improve “Threat & Error” identification by usingTo help “Get it on the RADAR”Verbalize, Verify, Monitor
55Verbalize, Verify, Monitor Threat and Error ManagementAUTOMATIONTHREATSStrategiesVerbalize, Verify, MonitorERRORSHardware & Software that exists before the human enters`ResistResistResolveWhat the human brings to the systemResolveCONSEQUENCE
58Influences that can lead to agent error ThreatsInfluences that can lead to agent errorPassenger eventsDistractionsLate BagsCabin CrewWeatherRamp slopeMaintenanceLate Gate ChangeNew AgentTime pressuresHeavy trafficFlight diversionSystem malfunctionUnfamiliar gateFlight CrewLate Cargo
60Why Ramp LOSA? The first step in managing threats is to collect data Precursors (Threats) are identified and evaluatedCountermeasures (Strategies) are developed, communicated throughout the organization, and then implemented in the system
61Identified Threats Threats can be prioritized according to The probability of an incident or accident occurring and then byThe severity of an incident or accident that may occur if the “threat” is mismanaged
62Threat Management The objective of “Threat Management” is to Obtain an understanding of how to assess the various risk levels of the threats and toGain an insight on logical approaches (strategies) to deal them
67Incident Example Aircraft taxiing toward the gate 757 parked at adjacent gateCatering truck parked properly within the adjacent gate clearance zoneArrival gate has an auxiliary J-line, requires 2 marshallers and clearance zones overlapPre-arrival briefing not doneWing-walker had less than 30 days on job & unfamiliar with these gatesNew wing-walker panicked and failed to give the STOP signal when he saw the wing was going to strike the catering truckDamage to wing and catering truck
73Threats 757 parked at adjacent gate Catering truck Arrival gate has an auxiliary J-line, requires 2 marshallers and clearance zones overlapWing-walker had less than 30 days on job & unfamiliar with these gates
74Threat Management 1. Identify the Threat 1. Was the threat managed or mismanaged? How?126.96.36.199.4.4.
75Threat Management 1. 757 parked at adjacent gate 1. Managed 2. Catering truck2. Managed3. Arrival gate… auxiliary J-line… clearance zones overlap3. Mismanaged – clearance zone not properly marked (latent)4. Wing-walker had less than 30 days on job & unfamiliar with gates4. Mismanaged – Crew brief not accomplished
77Errors 1. Pre-arrival briefing not accomplished 2. Catering truck parked in clearance zone3. Wing-walker did not give stop signal4.
78Error Management 1. Identify the Error 1. Was the error managed or mismanaged? How?188.8.131.52.4.4.
79Error Management 1. Pre-arrival briefing not accomplished 1. Mismanaged – Awareness of threat not established2. Catering truck parked in over-lapping clearance zone2. Mismanaged – improper markings not detected (T3)3. Wing-walker did not give stop signal3. Mismanaged – (latent?) training/ crew brief (E1)4.4.
80Undesired State Management List how the Undesired State was managed or mismanaged.
81Undesired State Management ManagedPost mishap procedures followedPAX, fuel spill, etcEtc.Mismanaged…
82Prevention Strategies List initial corrective actions at the present time and any proposed actions.Crew BriefsTrainingAuditing procedures/policy
83TEM an integral part of a Safety Management System (SMS)
84Continental Airlines Safety Management System (SMS)
85SMS Documents and Training IATA & ICAOSMS Documents and Training
86SMS Essential Prerequisites A comprehensive corporate approach to safety,An effective organization for delivering safety, andSystems to achieve safety oversight.
87Developing the Continental Safety Management System (SMS) Safety statement from CEOCorporate Safety PolicyAdd SMS description and Corporate Safety Policy to the Safety manualEstablish the Corporate Safety Review BoardBegin development of the Safety Action Team within each divisionAudit the remainder of the Continental SMS
88Corporate Safety Review Board (CSRB) AccountabilityThe CSRB is chaired by the CEOMembershipCSRB 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.
89Safety Action Team (SAT) AccountabilitySATs are responsible to the Corporate Safety Review Board and the chair is determined by the appropriate (Sr/Exec) VP.MembershipSAT 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 ReferenceAs 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.
91Flight Operations Safety Action Team (SAT) Develop the process by which safety data and crew performance and behavior data fromFOQA, LOSA, ASAP, CASIS, Line Checks,… are analyzed bySafety, Flight Operations, Inflight, Flight Standards & Training, FAA and ALPA Safety in order to facilitate change.
92To have an effective SMS… Safety & Operational Efficiencyneed to be combined into aCorporate “Safety Culture”
93GoalBecome 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
94Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS