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TEM as an Analytical Tool Bert Ruitenberg Bert Ruitenberg Flight Safety and Human Factors – ICAO First ICAO Global Symposium on TEM & NOSS in ATC Luxembourg.

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Presentation on theme: "TEM as an Analytical Tool Bert Ruitenberg Bert Ruitenberg Flight Safety and Human Factors – ICAO First ICAO Global Symposium on TEM & NOSS in ATC Luxembourg."— Presentation transcript:

1 TEM as an Analytical Tool Bert Ruitenberg Bert Ruitenberg Flight Safety and Human Factors – ICAO First ICAO Global Symposium on TEM & NOSS in ATC Luxembourg 9 – 10 November 2005

2 Presentation Overview The TEM Framework explained Definitions Examples TEM Case Study Ueberlingen mid-air collision Integrated Threat Analysis The Added Value of TEM

3 TEM Terminology for ATC l Threats: Events or errors that occur beyond the influence of the air traffic controller, increase operational complexity, and which must be managed to maintain the margins of safety l Errors: Actions or inactions by the air traffic controller that lead to deviations from organisational or controller intentions or expectations l Undesired States: operational conditions where an unintended traffic situation results in a reduction in margins of safety

4 Threats (TWR) Weather Maintenance Airspacerestrictions Visitors Runway crossings Comsfailure/ sticking mike Shift hand-over Near-identical callsigns call signs Missed approaches Busy traffic Unfamiliarcrews Unfamiliar crews System design errorsNon-standard local procedures Runway inspections Systemmalfunctions Distraction VFR traffic Military traffic Photo flights Banner towing Pilots

5 Threats (Radar) Weather Maintenance Airspacerestrictions Visitors Military traffic Comsfailure/ sticking mike Shift hand-over Near-identical callsigns call signs Differences in equipment (a/c) Busy traffic Co-ordination other sectors System design errors Non-standardprocedures Diversions Systemmalfunctions Distraction VFR traffic Unfamiliar crews Photo flights Parajumping Pilots

6 Error Categories Equipment handling error Making incorrect inputs to the automated system; incorrect placement of strips Procedural error Wrong separation minimum applied (e.g. wake turbulence) Communication error Misinterpretation; wrong information given

7 Undesired States l Unique to monitoring normal operations l Transient in nature – exists for limited time only l "When the traffic is not doing what you want it to do" l An Undesired State is often the first indication to a controller that an earlier threat or error was not adequately managed

8 Undesired States - Examples On the ground: Aircraft continuing taxiing when/where it should stop; aircraft stopping when/where it should continue taxiing Aircraft entering a taxiway that it shouldnt use; aircraft not entering a taxiway that it should use In the air: Aircraft not turning when it should; aircraft turning when it should not; aircraft turning in direction other than planned Aircraft climbing/descending to another flight level/altitude than it should; aircraft not climbing or descending to the flight level/altitude where it should

9 TEM Terminology - Example l Wrong readback by pilot Climbing FL150 l Not detected by controller l A/c climbing to other level than expected l Loss of separation (?) l Threat l Error l Undesired State l Outcome

10 How it Works Threats Errors Undesired States Outcome Threat Management Error Management Undesired State Management NOSSIndices

11 Presentation Overview The TEM Framework explained Definitions Examples TEM Case Study Ueberlingen mid-air collision Integrated Threat Analysis The Added Value of TEM

12 Case Study: Ueberlingen Mid-air l July 1st 2002; Tupolev 154 and Boeing 757 l One aircraft descending to comply with ATC instruction l One aircraft descending in response to TCAS Resolution Advisory l Airspace delegated by Germany to Zürich ACC, Switzerland l Maintenance on automated ATC system Zürich ACC l Maintenance on voice communication system between Zürich ACC and other ATC facilities

13 Ueberlingen Threats l No information to controller about scheduled maintenance l Maintenance scheduled for multiple systems at the same time l ATC system available in "degraded mode" only with reduced functionality l No training provided for working with system in "degraded mode" l Delayed and unexpected flight to regional airport had to be handled l To handle the flight to the regional airport a second working position had to be opened l Technical failure in back-up telephone system that had to be used to coordinate with the regional airport l Single person nightshift culture l Simultaneous and blocked R/T transmissions If there had been no mid-air the same Threats still would have existed

14 How it Works Threats Errors Undesired States Outcome Threat Management Error Management Undesired State Management NOSSIndices

15 Presentation Overview The TEM Framework explained Definitions Examples TEM Case Study Ueberlingen mid-air collision Integrated Threat Analysis The Added Value of TEM

16 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

17 Threats – ITA

18 Environmental Threats – ITA

19 Airline Threats – ITA

20 Flight Crew Errors – ITA

21 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

22 Conclusion l Controllers, pilots and other aviation professionals have intuitively been familiar with Threats (and Errors, and Undesired States) throughout their careers – the TEM framework provides a structured way to look at them l The TEM framework adds a valuable dimension to the analysis of safety data


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