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Threat and Error Management: the LCC and IATA Experience Joey Anca IATA.

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Presentation on theme: "Threat and Error Management: the LCC and IATA Experience Joey Anca IATA."— Presentation transcript:

1 Threat and Error Management: the LCC and IATA Experience Joey Anca IATA

2 Overview Regional and International Aviation- the Good News and Bad News The Future in Aviation Redefining SAFETY Experience with Low Cost Carriers Threat and Error Management (TEM) Tools CRM in the Countermeasure Context TEM as a Framwork Take Away and the Culture of Safety

3 World Aviation: Bad News & Good News Bisignani, G (2005) State of the Air Transport Industry. IATA. Global Turmoil driven by: Fuel Costs Legacy vs Low Cost Carriers Imbalanced Taxation by Governments Air Transport is a USD 400 Billion Industry IATA combined Fuel Bill for 2005 is USD83 Billion, equal to the GNP of New Zealand Winners and Losers: North America USD 9B Africa USD 150M Latin America Europe USD 1.4B Asia USD 2.6B Middle East USD 100M Safety: 1.8 Billion flew in 2004; 428 Fatalities (similar to 1945 figures where 9 million people traveled by air

4 Asia-Pacific: Bad News, Good News Harbison, Peter (2005). Indian Subcontinent & Middle East Aviation & Tourism Summit Regional Issues driven by: Fuel Costs Airline Restructuring Inadequate Regulatory Systems High Growth Markets attracting rapid foreign investments (China, India, Middle East) Asia Pacific Airlines reported US$ 5B profits (2004) India to require trained staff each year over next 5 years Demand for pilots to exceed factor of three in next 5 years; Salary bill for pilots up by 30-40% India placed orders of 190 aircraft in last Paris Air Show; number expected to escalate to aircraft by 2010

5 Corpus of Experience in this Report

6 Future Transformation: the Jetsons Affordability of Micro Jets to a larger segment of Entrepreneurs Increased Capability of distal and agile Air Traffic Control Increased vulnerability of Situational Awareness Devolution of Safety Management Systems to micro users Need for Global Equipage harmonization to counteract present differentiation The Future is Scary Baker, D (2005) NGATS FAA

7 Redefining Safety

8 Redefining Safety for an Organisation to Reflect Reality Safety (Middle English, saufte ) 1.The state of being safe from undergoing or causing hurt, injury or loss 2.A billiard shot made with no attempt to score or so as to leave the balls in an unfavorable position for the opponent Violation Error Threats Latent Conditions The problem is…a state of safety does not exist 100% of the Time

9 Violation Error Risk Latent Conditions SAFETY Safety is a Measure of Organisational Resistance to RISK. Safety (Middle English, saufte ) Dynamic protections from mishaps Interventions for system integrity and compliance Creative buffering for latent conditions …instead of a harm-free STATE,

10 Threat and Error Management Tools Restating (CRM) as the Countermeasures to threats, errors and undesired equipage states Reinforcing Threat and Error Management (TEM) as a framework

11 The Riddle of the 5 Daughters Marys Parents had 5 Daughters Their names were: Mara Mare Mari Maro… What is the name of the fifth daughter?

12 The Summits of CRM 1 st Generation- Cockpit Resource Management Business Management orientation Interpersonal Relationships/ Leadership Styles Psychobabble language distant from Pilots The Unassertive Co-pilot 2 nd Generation- Crew Resource Management Error Chain & Accident Causality Teambuilding Games Situational Awareness and Stress Management Concepts Cluster Knowledge (Decision Making, Briefing, etc) 3 rd Generation- Advanced CRM CRM Integration with technical training/performance Instructor CRM Training Included Dispatchers, Flight Attendants, Engineers 4 th Generation- Integrated CRM CRM embedded in procedures/checklists Specialized topics eg. Automation Performance based CRM 5 th Generation- Error Management Ubiquity of Human Error Manage Errors by Avoidance/Trapping/Mitigation 6 th Generation ?

13 Applying the Riddle to Generations of CRM The next generation is not about a new form of CRM It is about using TEM as a Framework and CRM as a training countermeasure toolMaru does not exist, but Mary does It is about going back to the foundation of flying operations the management of operational threats and errors

14 Threat and Error Management (TEM) TEM training is both a framework of CRM as well as a detour back to CRM Beginningsa training tool to manage Human Error The TEM Modeloutlines propagation and breach of Human Error (Threat-Error-Undesired Equipage State-Incident) Appropriately positions CRM as a set of Countermeasures in managing Threats and Errors

15 The IATA TEM Program Positions TEM as a context of CRM CRM Skill Training as the set of countermeasures to manage threats and errors Includes a Train-the-Trainer component to critique the delivery of CRM Programs suited to local conditions

16 Latent Threats National, Organizational, Professional Culture Standards and Policies Regulations Overt Threats Environment Factors Organizational Factors Individual, Team, Crew Factors Equipage Factors Threat © Bombala, M Capt (2004) IATA Threats: Elements and Conditions that are outside the Crews Control

17 Error Types Communication Intentional Non-Compliance (Violation) Procedural Lapse Proficiency Faulty Decisions & Judgment Crew Error © Bombala, M Capt (2004) IATA Crew Error: Mismanagement of Threats Most errors are inconsequential

18 Equipage is not where it is supposed to be because of threats or mismanaged threats Undesired Equipage Undesired EquipageState © Bombala, M Capt (2004) IATA Undesired State

19 Incident-Accident Result of mismanaged threat and/or error the tip of the iceberg © Bombala, M Capt (2004) IATA Incident or Accident

20 Managing Threats and Errors: the TEM Solution Ensure competency training on CRM Countermeasures Countermeasures Error Avoidance Threat Management Error Management Undesired Equipage State Management

21 Threat Crew Error Undesired Equipage Undesired Equipage State State Incident Error Avoidance Team Climate Planning © Bombala, M Capt (2004) IATA CRM Countermeasure 1

22 Threat Crew Error Undesired UndesiredEquipage State State Incident Error Avoidance Threat Management Team Climate Planning Review /Modify © Bombala, M Capt (2004) IATA CRM Countermeasure 2

23 Threat Crew Error Undesired Undesired Equipage Equipage State State Incident Error Avoidance Threat Management Error Management Team Climate Execution © Bombala, M Capt (2004) IATA CRM Countermeasure 3

24 Threat Crew Error Incident Error Avoidance Threat Management Error Management Undesired Undesired Equipage State Undesired Equipage State Management Team Climate Review / Modify © Bombala, M Capt (2004) IATA CRM Countermeasure 4

25 Threat Threat Crew Error Crew Error Undesired Equipage Undesired Equipage State State Incident Error Avoidance Error Avoidance Threat Management Error Management Undesired Equipage State Management Threat and Error Management Framework CRM Countermeasure Competencies Team Climate Planning Execution Review /Modify

26 TEM and A Culture of Safety

27 A Culture of Safety Change Model © Anca, JM (2000)

28 Take Away Questions we should ask: The CEO Regulator Crew Union Human Resources Head

29 The Questions to Your CEO: Overlapping Sleeves of Protection Individual Team Workplace Organisation Increasing Protection Increasing Vulnerability Sleeves in Perpetual Motion Maturing Culture: are your Values and Beliefs Compatible? Vulnerability: Can you Predict your Next Accident? Staff Loyalty: Collective SUCCESS or Individual Wins? Are Your Leaders more concerned about THEIR Self- preservation? Safety Information: is it Meaningful to a critical few or is it OWNED by ALL? © Anca, JM (2000)

30 A Prologue Discretion is the better half of Valor. Thank You.

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