1. Error

2. Error Chain Ambiguity Fixation or preoccupation
Confusion or an empty feeling
No one flying the aircraft
No one looking out of the window
Use of an undocumented procedure
Violating limitations or minimum operating standards
Unresolved discrepancies
Failure to meet targets
Departure from standard operating procedure
Incomplete communications

3. Threat & Error Management

4. Session Objective By the end of this session you will be able to:
Define the types of threat and error and determine a process to managing them
In order to recognise and manage threat and error in your own flight operations

5. TEM Concept
The concept of considering the performance of flight crews in terms of a model of TEM was proposed and developed by UTHFRP
Later discussions on the evolution of CRM, TEM described as the 6th gen of CRM. This led to some organisations substituting TEM for CRM training
More appropriate to regard TEM as element of CRM.

6. Definition of a threats
A threat may be defined as:
Any situation, event, or circumstance that occurs outside the influence of the flight crew and which may affect the safety of an operation
Threats require crew attention and management if safety margins are to be maintained
The concept of considering the performance of flight crews in terms of Threat and Error Management models was proposed and developed by the University of Texas Human Factors Research Project (UTHFRP).
In some later discussions on the evolution of CRM the ‘sixth generation’ of CRM was described as ‘threat and error management’. This led to some organisations and airlines substituting TEM for CRM training.
However it is more appropriate to regard TEM as an element within CRM.
CRM provides a range of tools and countermeasures which may be used in trapping and mitigating threats and errors.
Defining Threats
A threat may be defined as:
Any situation, event, or circumstance that occurs outside the influence of the flight crew and which may affect the safety of an operation.
Threats require crew attention and management if safety margins are to be maintained

7. Types of Threats Observable Threats Latent Threats
1) Known e.g. strong crosswind
2) Unexpected e.g. engine failure after take off
Latent Threats
Factors residing in the system, organisation or individual that increase risk & are not directly observable in operations
Equipment design issues - Optical illusions - Air traffic system design - Training philosophy and practices - Organisational culture
Observable Threats
We can have 2 types of observable threats – Known or Unexpected. Can you give a couple of examples of each?
Known e.g. strong crosswind, wet runway
Unexpected e.g. engine failure after take off, TCAS alert
Latent Threats
Latent threats are factors residing in the system, organisation or individual that increase risk. Latent threats are not directly observable in operations. They may be uncovered by analysis of aggregate data such as confidential incident reports and include the following (ask students to give an example of each):
Equipment design issues (side sticks not coupled, Kegworth B737 instruments)
Optical illusions (Auto Kinetic, Black Hole, Velocity & height etc)
Air traffic system design (leading to 2 aircraft at same height, runway incursions etc)
Training philosophy and practices (Air Florida not applying full pwr, Dryden 2 sets of manuals)
Organisational culture (low cost operators, Dryden)

8. Phoenix Media Footage of Car Chase – 27th July 2007
1 police helicopter plus 5 local news helicopters (different TV stations)
Police pursuit of criminals
Pilots' responsibility to perform reporting and visual tracking duties
No formal procedures for pilots to follow regarding the conduct of these ops
Any Threats Present?

10. Any threats in your operation?
Terrain
Weather
Aircraft
ATC errors
Pressure to perform
Fatigue
Schedules
Culture (own / differing cultures)
Others????

11. Combating threats
How will you as an individual and/or team combat the threats you have identified?
Training, proficiency & experience
SOPs’
Vigilance & maintaining a good S/A
Monitoring & cross checking
Communication
Workload management
Effective leadership

12. Managing threats Avoid - Trap – Mitigate
Maintain a high degree of situational awareness
Notice – understand - think ahead
Imagine what could be, confront what can be, contain what is now!
The effects of threats occur in the future and so may be trapped or mitigated by planning ahead
Threats are not errors, but they increase the potential for error.

13. Defining Errors An error may be defined as:
A consequence of human involvement which causes deviation from crew or organisational intentions or expectations. Errors may occur either in the presence or absence of threats.

14. We may identify five types of error
1) Intentional non-compliance errors or violations of SOPs or regulations
2) Procedural errors in which the intention is correct but the execution flawed
3) Communication errors that occur when information is incorrectly transmitted or interpreted
4) Proficiency errors
5) Operational decision errors in which crews make a discretionary decision that unnecessarily increases risk
We may identify five types of error:
Intentional non-compliance errors - or violations of SOPs or regulations.
Examples include omitting required briefings or checklists
Procedural errors - in which the intention is correct but the execution flawed.
These include the usual slips, lapses, and mistakes such as incorrect data entries or flying the wrong heading
Communication errors - that occur when information is incorrectly transmitted or interpreted.
Examples include incorrect read back to ATC or communicating wrong course to the other pilot
Proficiency errors - that indicate a lack of knowledge or stick and rudder skill; and
Operational decision errors – the crew make a discretionary decision that unnecessarily increases risk.
Examples include extreme manoeuvres on approach, choosing to fly into adverse weather, or over-reliance on automation.

15. Increasing Risk
Risk can also be increased by errors made outside the cockpit, e.g. by ATC, maintenance & dispatch.
In addition, crews themselves may err in the absence of any external precipitating factor.
However:
External threats are countered by the defences provided by CRM skills.
If the CRM defences are successful, error is managed and there is recovery to a safe flight.
If the defences are breached, they may result in additional crew error or an incident or accident.
Risk can also be increased by errors made outside the cockpit, for example, by ATC, maintenance, and dispatch.
External threats are countered by the defences provided by CRM skills. When successful, these lead to a safe flight.
In addition, crews themselves may err in the absence of any external precipitating factor.
Again CRM skills stand as the last line of defence.
If the CRM defences are successful, error is managed and there is recovery to a safe flight.
If the defences are breached, they may result in additional crew error or an incident or accident

16. A Model of Error Management
Crew error has been implicated in around two-thirds of air accidents.
Errors; are consequence of an action or inaction and they reduce the margin of safety and increase the probability of accidents or incidents
We mentioned earlier there were five error types
1 Intentional non-compliance errors - Eg omitting required briefings or checklists
2. Procedural errors – eg. incorrect data entries or flying the wrong heading
3. Communication errors – eg. incorrect read back to ATC
4. Proficiency errors - that indicate a lack of knowledge or stick and rudder skill
5. Operational decision errors - crew makes a decision that unnecessarily increases risk
If we look at this study which was taken from Line Operations Safety Audits we find that from one of the error types there will be one of 3 responses.
1. Trap - The error is detected and managed before it becomes consequential or leads to additional error
2. Exacerbate - The error is detected but the crew’s action or inaction leads to a negative outcome
3. Fail to respond - The crew fails to react to the error either because it is undetected or is ignored.
We then have the outcome of this action. There are three possible outcomes:
1. Inconsequential - The error has no effect on the safe completion of the flight.
2. Undesired aircraft state - The error results in the aircraft being in a condition that increases risk. This includes incorrect vertical or lateral navigation, unstable approaches, low fuel state, and hard or otherwise improper landings.
3. Additional error - The response to error, as we have noted, can result in an additional error that again initiates the cycle of response
Let’s look at the undesired aircraft state scenario. This which may be defined as:
An aircraft deviation or incorrect configuration associated with a clear reduction in safety margins
and may include:
Incorrect position
Incorrect speed
Incorrect heading
Incorrect configuration
Undesired aircraft states can be mitigated, exacerbated, or ignored.
For example, recognising an unstable approach and going-around would mitigate the situation.
Crew actions may exacerbate the situation, increasing the severity of the state and the level of risk.
Just as with error response, there can also be a failure to respond to the situation.
There are three possible resolutions of the undesired aircraft state:
Recovery - indicating that the risk has been eliminated
Additional error - where the actions initiate a new cycle of error and management
Incident or accident

17. LOSA Data - Threats
External threats & flight crew errors are pervasive in normal flight ops but differ in their frequency and type across airlines
The average number of threats/flight was 3.7
66% of threats were environmental (wx, airport conditions, ATC, terrain)
33% of threats were airline (ground, ramp, dispatch, cabin, operational pressure)
The descent/approach/landing phase of flight contained the most threats, errors, and consequential outcomes
29% of flights had a threat that was mismanaged and led to some form of crew error

18. LOSA Data - Errors 75% of flights had 1 or more errors
The average number of errors/flight was 2.6
Handling errors – 36% of all errors. Most common – unintentional speed deviation
Procedural errors – 52% of all errors. Most common – checklist from memory
Communications errors – 12% of all errors. Most common – missed ATC call
Mainly flight crews failed to respond to errors after they were committed. A significant amount turned into undesired aircraft states, however crews were successful in mitigating the consequences

19. Session Objective By the end of this session you will be able to:
Define the types of threat and error and determine a process to managing them
In order to recognise and manage threat and error in your own flight operations