Threat and Error Management

What is TEM?  “Defensive flying”

ICAO and FAA  In 2000, LOSA baseline results showed that error management had been incorporated into everyday operations.  Improved checklist usage and a 70% reduction in non-stabilised approaches.  ICAO made LOSA the central focus of flight safety and human factors programmes.  TEM and LOSA recognised Worldwide.

TEM Philosophy  Three basic concepts: -Anticipation -Recognition -Recovery  Recover first, analyse the cause later.

Threats  May be internal or external.  They are not caused by the crew.  They increase the operational complexity of a flight.  Require crew attention and management if safety margins are to be maintained.

What is a latent Threat? A threat that is not directly obvious to flight crew. A threat that is not directly obvious to flight crew. Equipment design. Equipment design.

Threat Management - GPS  Threats & errors -Poor standardisation of GPS receivers -Poor integration with AP -Mis-interpretation of HSI Management Obtain training & practice (VMC) with make & model Use HDG mode when changing any detail In non-integ. cockpit, double-check mode

Errors  Error is a crew action or inaction that leads to a deviation from crew or organisational intentions or expectations.  Put simply: threats come “at” the crew, while errors come “from” the crew.  An Error that is detected and effectively managed has no adverse impact on the flight.  An error that is not detected cannot be managed.

Flight Crew Errors Can be divided into three types:  Aircraft Handling  Procedural  Communication Errors.

Consequence of Error  The very same error can have completely different consequences, depending on the factors involved.  Error : setting the flaps correctly for landing is forgotten. -Aircraft type and performance -Actual landing weight -Runway length and obstructions ahead

Undesired Aircraft State (UAS)  A UAS is defined as a position, speed, attitude or configuration of an aircraft that: -Results from flight crew error, actions or inaction -Clearly reduces safety margins  UAS can be managed effectively or mismanaged, leading to an additional error, UAS, an incident or accident.

 A Decision MUST be made

Identify the Threats?

TEM Application  TTerrain  WWeather  OOperational  PPlan

TWO-P  Terrain old  Terrain new  Weather good  Weather bad  Operational in  Operational out

TWO-P  Assessing threats does not make them go away.  A threat briefing must contain effective strategies.  There must be a plan.

Levels of Situational Awareness  Level One:Perceive  Level Two:Comprehension  Level Three:Projection Understand Notice Think Ahead NUTA

The NUTA/TEM Links Situation Awareness Threat Management NoticeUnderstandThink AheadMitigateTrapAvoid

Countermeasures  Anticipation builds vigilance.  Recognition leads to recovery.  Recover first, analyse causes later.  Planning.  Execution.  Review or modify.

What is an Unexpected Threat?

Just because you deal with a situation everyday does not mean that it is not a threat.

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