Presentation is loading. Please wait.

Presentation is loading. Please wait.

Threat and Error Management Training for Air Traffic Control Officers Greg Down ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9,

Similar presentations


Presentation on theme: "Threat and Error Management Training for Air Traffic Control Officers Greg Down ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9,"— Presentation transcript:

1 Threat and Error Management Training for Air Traffic Control Officers Greg Down ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005

2 Presentation Overview Background Overview of TEM Training Benefits Review

3 NAV CANADA TEM Background In 2001, visited Continental Airlines and University of Texas to research the application of TEM in ATS Participated in Continentals TEM Training and experienced first hand the impact and value of this training

4 Continental Airlines TEM Training A consistent and operationally focused perspective on Threats and Errors in the operational environment TEM was (and still is) consistently applied throughout the organisation: –Training (Initial and Recurrent) –Simulator Checks –Auditing (FOQA & LOSA) –Dispatch, Ramp

5 NAV CANADA TEM Training Delivered in 2001 to all operational staff (ATCOs and FSSs) and Line Management Included FAA Video Collision Course Opportunity to discuss experiences through the TEM lens Well received by staff and management

6 TEM Training Overview What is the TEM Framework? What is a Threat? What is an Error? What is an Undesired State? Strategies for Managing Threats and Errors

7 What is the TEM Framework? A safety management framework: to enhance aviation safety and efficiency through an operationally relevant and highly intuitive framework to better understand and manage system and human performance in operational contexts

8 TEM Framework Threats Errors Undesired States Outcome Threat Management Error Management Undesired State Management Errors

9 What is a Threat? Events or conditions which occur: beyond the influence of the air traffic controller; increase a situations complexity; and must be managed to maintain the margins of safety.

10 Its a Beautiful Day in the Neighbourhood… The Ideal Shift Overstaffed All aircraft on radar All systems operational Beautiful VFR Weather Happy, supportive supervisor Pilots are attentive and responsive Co-workers are pleasant and supportive

11 Its a Beautiful Day in the Neighbourhood… A More Typical Shift Short staffed Non-radar aircraft Maintenance on critical systems IFR / Marginal VFR Weather Not-so-supportive supervisor Pilots - slow to respond to instructions Co-workers - demanding and create workload

12 Threats (Aerodrome Environment) Weather Maintenance Airspace restrictions Visitors Runway crossings Comm. failure/ stuck mike Shift change Similar call signs Non-standard procedures Heavy traffic Unfamiliar crews Automation eventsMissed approaches Runway inspections System malfunctions Distractions

13 Threats (Radar Environment) Weather Maintenance Airspace restrictions Visitors Military activities Comm. failure/ Stuck mike Shift change Similar call signs Non-standard local procedures Heavy traffic Co-ordination other sectors Automation eventsDiffering equipment Diversions System malfunctions Distractions

14 Threat Error Threat What is a Threat?

15 What is Threat Management? The process of detecting and responding to threats with countermeasures to maintain safety margins.

16 Tools to Teach About Threats Discussion of Common Threats Promote use of the phrase RED FLAGS DIPs – Distractions Interruptions Preoccupations

17 What does Error mean in TEM? Actions or inactions by air traffic controllers that lead to deviations from organizational or air traffic controller intentions or expectations.

18 Examples of Error Incomplete Briefing Full Readback Not Obtained Wrong Call Sign Used Non-Standard Phraseology Incorrect information passed

19 What is Error Management? The process of detecting and responding to errors with countermeasures that mitigate the probability and / or severity of further errors or undesired states.

20 What about Error Prevention or Error Avoidance? We cannot PREVENT all errors Nor can we AVOID all errors We can MANAGE errors

21 Managing Errors Follow procedures Use proper phraseology Continuously monitor traffic Clarify / challenge inconsistencies

22 What is an Undesired State? Operational conditions where an unintended traffic situation results in a reduction in margins of safety. –Transitional safety phase between normal operations and an outcome –Indicator that earlier Threats and / or Errors were not adequately managed

23 Undesired State Examples Aircraft climbing / descending to altitude beyond its clearance Aircraft deviating from assigned heading / track / route Incomplete coordination Inaccurate flight info on the radar screen Not using appropriate indicators when crossing vehicles across an active runway

24 Undesired States are NOT Outcomes? an Outcome is an end state Incident Operational Error Operating Irregularity Accident Once an Outcome has occurred, normal operations cannot be recovered Undesired States can be effectively managed and normal operations regained

25 Goals of TEM Discover, assess and manage threats Enhance the detection and management of error Improve resistance to errors Diagnose factors that may create threats and errors

26 TEM Framework Threats Errors Undesired States Outcome Threat Management Error Management Undesired State Management Errors

27 Strategies to Improve Safety Margins Identify Threats in Operation and reduce or eliminate before they lead to error or consequence Promote use of common language to focus attention on safety issues (RED FLAGS) Make errors visible so that they can be easily identified and managed

28 Strategies to Improve Safety Margins Make it safe to report errors (just / error tolerant culture) Treat errors as a feedback mechanism for learning and continuous improvement Errors are EXPECTED and WILL occur. HOW they are MANAGED is what is important

29 Challenges to TEM Training Tendency to focus to be on Errors rather than Threats Can devolve into a debate over Risk vs. Hazard vs. Threat contextual meanings if not managed Can appear overly simplistic to those who are accustomed to more elaborate frameworks

30 Benefits Of TEM Training TEM is intuitive –Gives structure to what controllers already do on a daily basis Simple, robust operational Lens to view the operational environment –Identifies external factors that impact the operation –See factors that effect safety in a new way Common language –Can facilitate rapid identification and communication of factors that could impact operations (Red Flags)

31 Benefits Of TEM Training Consistent with Safety Management Systems –Can be deployed independently or to reinforce existing SMSs Promotes movement toward Just Culture –improved reporting of safety concerns through focus on external factors rather than individuals Creates foundation for improved safety data collection –programs such as NOSS Illuminates that ATCOs are effective Threat Managers

32 Presentation Review Background Overview of TEM Training Benefits Review

33 TEM Promotes an Effective Safety Culture 33 An organizations safety culture can be defined by the extent to which it is: Informed Wary Just Flexible Learning

34 Threat and Error Management Training for Air Traffic Control Officers Greg Down ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005


Download ppt "Threat and Error Management Training for Air Traffic Control Officers Greg Down ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9,"

Similar presentations


Ads by Google