1. An Introduction to Threat and Error Management 1

2. Discussing Threat and Error Management (TEM) in the Operational Environment Use some of the findings of NOSS to highlight areas for improvement What we will look at 3

3. What is Threat and Error Management 17 It’s not Rocket Science

4. Assumptions of Human Factors Training Humans have limitations in their performance 5 Error is inevitable

5. “To err is human” 6

6. Threats in the Operational Environment What is a “Threat” 8 TEM Definition: An event or error that occurs outside the influence of the controller, but which requires his or her attention and management if safety margins are to be maintained An indication of something coming; a menace or likely cause of harm

7. Threats Threat Error Threat 9

8. Threats (Aerodrome Environment) Weather Maintenance Restricted Airspace Visitors Runway crossings Comsfailure/ sticking mic Shift handovers Similar call signs Non-standard local procedures Heavy traffic Unfamiliar pilots Automation eventsMissed approaches Runway inspections System malfunctions Distractions Pilots and Other Controllers

9. Methods to Identify Threats Just because you deal with a situation every day doesn’t mean that its not a Threat 13

10. Methods to Identify Threats Just because you deal with a situation every day doesn’t mean that its not a Threat 13

11. NOSS / TEM Methodology Threats Errors Undesired States

12. Threat= Incorrect readback (pilot) Threat Management=Nil Error= Hearback Error (ATC) Error Management= Nil U/S= Aircraft climbing/ descending to altitude other than expected U/S Management= Nil Outcome= Loss of separation / Air Safety Incident Methods to Assess a Threats Impact 15

13. Barriers to Monitoring Threats Distractions Interruptions Preoccupations DIP’s 16 DIP’s should always trigger a red flag

14. Method to Monitor Threats Strategies to Reduce DIPs - Recognize conversation is a powerful distracter Recognize heads-down work greatly reduces your ability to monitor Minimize conflicts between tasks Avoid focusing on a single task for too long Assign responsibility Treat DIPs as RED FLAGS

15. Understand the difference between Error Management versus Error Avoidance 7

16. What is an Error An action or inaction that leads to deviation from one’s intention or procedural requirements.

17. What is an Error An action or inaction that leads to deviation from one’s intention or procedural requirements.

18. Types of Errors ProceduralCommunicationProficiencyDecision Intentional Non- compliance

19. Errors and Violations You make an error when your action deviates from your intention, or when your intention is inappropriate An error is not intentional The effect of errors can be accounted for within the system VIOLATIONS You commit a violation when you intentionally deviate from a regulation or from a procedure A violation is originally intentional but can become routine ER ORS R Errors and Violations

20. Error Management 76% of 165 errors had inconsequential outcomes 22% led to an undesired state 2% led to additional error Total 40 errors mismanaged Error Management 76% of 165 errors had inconsequential outcomes 22% led to an undesired state 2% led to additional error Total 40 errors mismanaged Threat Prevalence 100% of observations had at least one threat Total 363 threats observed Threat Prevalence 100% of observations had at least one threat Total 363 threats observed Threat to Error Linkage 44% of 165 errors were linked to mismanaged threat 56% of errors were not Threat to Error Linkage 44% of 165 errors were linked to mismanaged threat 56% of errors were not Threat Management 82% of 362 threats were effectively managed 18% were mismanaged Total 65 threats mismanaged Threat Management 82% of 362 threats were effectively managed 18% were mismanaged Total 65 threats mismanaged Threats - Undesired State Linkage 7% of threats were linked to undesired states 63% of 40 undesired states were linked to threats Threats - Undesired State Linkage 7% of threats were linked to undesired states 63% of 40 undesired states were linked to threats Error Prevalence 81% of observations had at least one error 19% were error free Total 165 errors were observed Error Prevalence 81% of observations had at least one error 19% were error free Total 165 errors were observed Detected Error Outcomes 74% of errors that were detected were inconsequential 22% were linked to undesired states 4% were linked to additional error Detected Error Outcomes 74% of errors that were detected were inconsequential 22% were linked to undesired states 4% were linked to additional error Undesired State Prevalence and Management 45% of observations had US Total 40 USs 100% of 40 US were inconsequential Undesired State Prevalence and Management 45% of observations had US Total 40 USs 100% of 40 US were inconsequential Error Response 13% of 165 errors were detected by the observed controller 20% were detected by another party 67% went undetected or were ignored Error Response 13% of 165 errors were detected by the observed controller 20% were detected by another party 67% went undetected or were ignored Undetected Error Outcomes 76% of errors that were detected were inconsequential 22% were linked to undesired states 2% were linked to additional error Undetected Error Outcomes 76% of errors that were detected were inconsequential 22% were linked to undesired states 2% were linked to additional error Total 63 observations 41% Airborne -Readback errors -Failure to respond -Parachuting near BDY 35% ANSP -Distractions,conversation -Incorrect co-ordination 23% Environmental -WX deviations -Low / poor visibility Overall R/T comms produced the most threats and occurred on 70% of Obs 67%of errors went undetected or were ignored

21. Threat Indexes Sectors AAWNCHOHBAY/RANNAK/KAI/STH Percentage of all (140) NOSS Observations 17%14% 13%18%24% Percentage of Airborne threats accounted for by each Sector Group 22% 13%14%12%17%22% Number of Airborne threats per observation 3.3 2.52.72.42.52.4 R/T Communication threats per observation 1.71.6 1.11.31.2 Pilot/Aircraft Performance threats per observation 0.90.40.60.70.50.6 Traffic threats per observation 0.70.5 0.60.70.6 Percentage of Airborne threats that were consequential 16%15%23% 29% 22%16% Number of consequential Airborne threats per observation 0.540.360.63 0.72 0.540.38 Most frequent Airborne threat Incomplete readback Pilot failure to respond to call Next most frequent Airborne threat Pilot failure to respond to call Incorrect readback Pilot failure to respond to call Training flight or flight crew failure to report Parachute activity Number of standard pilot requests per observation 3.44.33.7 6.76.1 2.7 2008 NOSS Findings

22. Airways and the Airlines MeYou The TEM Partnership

23. Summing it all up