Presentation is loading. Please wait.

Presentation is loading. Please wait.

Captain Don Gunther Managing Director Human Factors & Safety Threat & Error Management (TEM) Workshop 3 rd IATA –ICAO LOSA & TEM Conference September 13-14,

Similar presentations


Presentation on theme: "Captain Don Gunther Managing Director Human Factors & Safety Threat & Error Management (TEM) Workshop 3 rd IATA –ICAO LOSA & TEM Conference September 13-14,"— Presentation transcript:

1 Captain Don Gunther Managing Director Human Factors & Safety Threat & Error Management (TEM) Workshop 3 rd IATA –ICAO LOSA & TEM Conference September 13-14, 2005 Kuala Lumpur, Malaysia 3 rd IATA –ICAO LOSA & TEM Conference September 13-14, 2005 Kuala Lumpur, Malaysia

2 Continental Airlines, Sept 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)

3 Flight Operations TEM Training Flight Operations TEM Training

4 Continental Airlines, Sept Why are we still doing CRM training?

5 Continental Airlines, Sept Year Hull loss accidents per year Hull loss accident rate Airplanes in service Millions of departures 25, Business as usual 19, Accident Rate / Million Departure Our Goal Departures Million We Need to Continuously Improve Aviation Safety Boeing 2004 Statistical Data – May 2005

6 Continental Airlines, Sept Accidents by Primary Cause Primary Factor Flight crew Airplane Weather Miscellaneous/other Maintenance Airport/ATC Total with known causes Unknown or awaiting reports Total Number of accidents Total Percentage of total accidents with known causes Excludes: Sabotage Military action 62% 14% 12% 5% 4% Boeing 2003 Statistical Data – May % 69.1%

7 Continental Airlines, Sept Accidents by Primary Cause Hull Loss Accidents – Worldwide Commercial Jet Fleet – 1995 through % 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 *As determined by the investigating authority, percent of accidents with known causes. 4%

8 Continental Airlines, Sept Aviation Week Article on Healthy Organizations 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 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. Safety Culture

9 Continental Airlines, Sept Tailored to Continental The 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 & Culture Areas of operation (CMI, polar routes, etc.) Philosophy

10 Line Observation Safety Audit (LOSA) Line Observation Safety Audit (LOSA)

11 Continental Airlines, Sept Normal Performance Angel Normal FAA Check Airmen LOSA 1LOSA 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

12 Continental Airlines, Sept The Continental LOSA Process 1 st year LOSA and data analysis followed by course development 2 nd & 3 rd years Training course for all crewmembers, Check Airmen training and imbedding of TEM into courseware, policy & procedures, etc. 4 th year Preparation for next LOSA and targeting areas to be measured and new areas to be emphasized.

13 Continental Airlines, Sept Line Observation Safety Audit LOSA 1996

14 Continental Airlines, Sept Error Managements early focus was: crew error Managing crew error

15 Continental Airlines, Sept Line Observation Safety Audit LOSA 2000

16 Continental Airlines, Sept LOSA 1996 vs 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

17 Continental Airlines, Sept Threat and Error Management

18 Continental Airlines, Sept 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."

19 Continental Airlines, Sept THREATS Influences that can lead to crew error Weather Maintenance Ground Crew Cabin Crew Passenger events ATC Terrain Similar call sign Time pressures Heavy traffic Unfamiliar airport Automation eventMissed approach Flight diversion System malfunction Distractions

20 Continental Airlines, Sept Threat and Error Management

21 Continental Airlines, Sept 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

22 Continental Airlines, Sept Threat and Error Management

23 Continental Airlines, Sept Error Actions or inactions by the flight crew that lead to deviations from organizational or flightcrew intentions or expectations

24 Continental Airlines, Sept Error Management Actions taken to deal with errors committed by either Detecting and correcting them, or by Containing and reducing the severity

25 Continental Airlines, Sept Error Management

26 Continental Airlines, Sept RESIST HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS Error Management

27 Continental Airlines, Sept RESISTANCE HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS GPWS TCAS TRAINING MANUALS SOPsSOPs CHECKLISTSCHECKLISTS AUTOMATION ATC

28 Continental Airlines, Sept RESIST HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS RESOLVE WHAT THE HUMAN BRINGS TO THE SYSTEM Error Management

29 Continental Airlines, Sept RESOLVE WHAT THE HUMAN BRINGS TO THE SYSTEM PROFICIENCY VIGILANCE ASSERTIVENESS MONITORING & CROSSCHECKING DECISION MAKING EXPERIENCE LEADERSHIP SIT. ASSESSMENT CHECKLIST DISCIPLINE

30 Continental Airlines, Sept Threat and Error Management

31 Continental Airlines, Sept NASA Guidelines Monitoring & Crosschecking

32 Continental Airlines, Sept NASA Guidelines monitoring Positively delegate flying and monitoring duties Monitoring Monitoring 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!

33 Continental Airlines, Sept Error Resolved Monitoring and Crosschecking Pilot Monitoring (PM) Pilot Monitoring (PM) Express Your View Take Action Crosschecking Steps

34 Continental Airlines, Sept Error Resolved Monitoring and Crosschecking Pilot Monitoring (PM) Pilot Monitoring (PM) Express Your View Take Action Crosschecking Steps

35 Continental Airlines, Sept Error Resolved Monitoring and Crosschecking Pilot Monitoring (PM) Pilot Monitoring (PM) Express Your View Take Action Crosschecking Steps

36 Continental Airlines, Sept Error Resolved Monitoring and Crosschecking (PM) Crosschecking Steps Express Your View Take Action

37 Continental Airlines, Sept Case Studies Look in the mirror first

38 Continental Airlines, Sept TEM the challenge How to improve Threat Identification? Get it on the Radar!

39 Continental Airlines, Sept Distractions

40 Continental Airlines, Sept LOW VISIBILITY TAXI DE - ICING ALTITUDE DEVIATION WRONG TURN Threat and Error Management Decision Making &Leadership

41 Continental Airlines, Sept DECISION-MAKING Plan, Review, Monitor & Modify

42 Continental Airlines, Sept Perceive Situation Develop Plan Share Plan Execute Plan Monitor Results Decision Making Strategic

43 Continental Airlines, Sept Perceive Situation Develop Plan Share Plan Execute Plan Monitor Results Decision Making Situation Assessment Select a Course of Action Strategic Tactical

44 Continental Airlines, Sept Situation Assessment The Nature of the Threats

45 Continental Airlines, Sept Leadership What have you seen?

46 Continental Airlines, Sept Threat and Error Management Training

47 Continental Airlines, Sept TEM TRAINING CLASS Ideal class size The value of the introduction Opening question Facilitation training Line pilots Follow-on Check Airmen training

48 Continental Airlines, Sept Crew Resource Management Effective Crew Resource Management is the bedrock of Threat and Error Management.

49 Continental Airlines, Sept Newsletter Feedback to the pilots is essential for continued program success.

50 Continental Airlines, Sept The Role of the Check Airman in Threat & Error Management

51 TEM & Automation TEM & Automation

52 Continental Airlines, Sept To ERR is Human To REALLY make a mess of things, you need a computer!

53 Verbalize Verify Monitor The Continental Airlines Automation Policy

54 Continental Airlines, Sept TEM the challenge Improve Threat & Error identification by using To help Get it on the RADAR Verbalize, Verify, Monitor

55 Continental Airlines, Sept Threat and Error Management What the human brings to the system Hardware & Software that exists before the human enters ` Verbalize, Verify, Monitor

56 TEM Training outside of Flight Operations TEM Training outside of Flight Operations

57 Continental Airlines, Sept Maintenance Threat & Error Management (MTEM) Food Services Threat & Error Management Field Services Threat & Error Management

58 Continental Airlines, Sept Influences that can lead to agent error Weather Maintenance New Agent Cabin Crew Passenger events Late Bags Time pressures Heavy traffic Unfamiliar gate Flight Crew Flight diversion System malfunction Distractions Threats Ramp slope Late Gate Change Late Cargo

59 Continental Airlines, Sept Ramp LOSA

60 Continental Airlines, Sept 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

61 Continental Airlines, Sept 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

62 Continental Airlines, Sept 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

63 TEM applied to Incident & Accident Analysis TEM applied to Incident & Accident Analysis

64 Continental Airlines, Sept TEM Toolkit for Incident & Accident (IA) Analysis

65 Continental Airlines, Sept IATA Safety Advisory Committee Incident & Accident analysis

66 Continental Airlines, Sept IATA Safety Advisory Committee Incident & Accident analysis

67 Continental Airlines, Sept 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

68 Continental Airlines, Sept Diagram of incident

69 Continental Airlines, Sept Diagram of incident

70 Continental Airlines, Sept Diagram of incident

71 Continental Airlines, Sept Threat and Error Management (TEM)

72 Continental Airlines, Sept Threats 1. List of the Threats

73 Continental Airlines, Sept Threats parked at adjacent gate 2.Catering truck 3.Arrival gate has an auxiliary J-line, requires 2 marshallers and clearance zones overlap 4.Wing-walker had less than 30 days on job & unfamiliar with these gates

74 Continental Airlines, Sept Threat Management 1. Identify the Threat1. Was the threat managed or mismanaged? How?

75 Continental Airlines, Sept Threat Management 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

76 Continental Airlines, Sept Errors 1. List of the Errors

77 Continental Airlines, Sept Errors 1. Pre-arrival briefing not accomplished 2.Catering truck parked in clearance zone 3. Wing-walker did not give stop signal 4.

78 Continental Airlines, Sept Error Management 1. Identify the Error 1. Was the error managed or mismanaged? How?

79 Continental Airlines, Sept Error Management 1. Pre-arrival briefing not accomplished 1. Mismanaged – Awareness of threat not established 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.

80 Continental Airlines, Sept Undesired State Management List how the Undesired State was managed or mismanaged.

81 Continental Airlines, Sept Undesired State Management Managed Post mishap procedures followed PAX, fuel spill, etc Etc. Mismanaged…

82 Continental Airlines, Sept Prevention Strategies List initial corrective actions at the present time and any proposed actions. Crew Briefs Training Auditing procedures/policy

83 TEM an integral part of a Safety Management System (SMS) TEM an integral part of a Safety Management System (SMS)

84 Continental Airlines, Sept Continental Airlines Safety Management System (SMS)

85 Continental Airlines, Sept IATA & ICAO SMS Documents and Training

86 Continental Airlines, Sept SMS Essential Prerequisites A comprehensive corporate approach to safety, An effective organization for delivering safety, and Systems to achieve safety oversight.

87 Continental Airlines, Sept Developing the Continental Safety 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

88 Continental Airlines, Sept 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.

89 Continental Airlines, Sept 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.

90 Continental Airlines, Sept Continental SMS Corporate Safety Review Board CSRB Flight Operations Safety Action Team Tech Ops Safety Action Team Field Services Safety Action Team Director of Safety Mkt/Rsv Safety Action Team

91 Continental Airlines, Sept Flight Operations Safety Action Team (SAT) Develop the process by which safety data and crew performance and behavior data from FOQA, LOSA, ASAP, CASIS, Line Checks,… are analyzed by FOQA, LOSA, ASAP, CASIS, Line Checks,… are analyzed by Safety, Flight Operations, Inflight, Flight Standards & Training, FAA and ALPA Safety in order to facilitate change. Safety, Flight Operations, Inflight, Flight Standards & Training, FAA and ALPA Safety in order to facilitate change.

92 Continental Airlines, Sept To have an effective SMS… Safety & Operational Efficiency need to be combined into a Safety Culture Corporate Safety Culture

93 Continental Airlines, Sept 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

94 Continental Airlines, Sept Threat and Error Management


Download ppt "Captain Don Gunther Managing Director Human Factors & Safety Threat & Error Management (TEM) Workshop 3 rd IATA –ICAO LOSA & TEM Conference September 13-14,"

Similar presentations


Ads by Google