Presentation on theme: "TEM & LOSA: The State of Affairs"— Presentation transcript:
1 TEM & LOSA: The State of Affairs Captain Dan MaurinoFlight Safety and Human Factors – ICAOThird IATA/ICAO LOSA/TEM ConferenceKuala Lumpur, Malaysia13 – 14 September 2005111
2 The Big Safety Data Picture Forensic systems – FailuresAccident investigationMajor incident investigationProactive systems – Routine operational eventsElectronic safety data acquisition systems (FOQA)Voluntary self-reporting systems (ASAP)Direct observation safety data acquisition systems (LOSA & NOSS)Reactive systems – AnomaliesMandatory reporting systems (CAA’s)Voluntary reporting systems (ASRS/BASIS)
3 LOSA [NOSS] & TEM: Clarifying a Relationship TEM = Framework – What we look forThe features in operational context – ThreatsWhat people do – ErrorsThe results of the features in operational context and of what people do – Undesired statesLOSA [NOSS] =Tool(s) – How we collect what we look forThe Ten Operating Characteristics
4 TEM Framework – Expanding Role Monitoring normal operations (LOSA & NOSS)Training – Flight & Cabin Crew/ATCO (ICAO, IATA, Airlines and ATS providers)Safety management data analysisIntegrated Threat Analysis (ITA) – ICAO & IATACabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATAResearch and development (UT & Boeing)Rule-making – ICAO provisionsThis is our introduction to the RED FLAG concept. It is important to build recognition here. Many more Red Flags will be shown in the discussion of AA1420.Also important to note here that, as the slide states, “a threat does not equal an error”. It only allows for the potential to commit an error. However, a threat should be perceived as a Red Flag to the crew, and even talked about amongst themselves as such.Take one of the threats previously listed by the group and use as an example of how the threat could have become an error or not an error.
5 FCLT/P – State Letter AN 12/1.1-05/62 Annex 1 – Personnel LicensingKnowledge requirementsHuman performance including principles of threat and error managementOperational procedures – Application of threat and error management to operational performanceSkills requirementsRecognize and manage threats and errors
6 FCLT/P – Multi-Crew Pilot License (MPL) Competency units, competency elements and performance criteria1) apply threat and error management (TEM) principles;2) perform aeroplane ground operations;3) perform take-off;4) perform climb;5) perform cruise6) perform descent;7) perform approach;8) perform landing; and9) perform after landing and aeroplane post-flight operations.Note .— The application of threat and error management principles is a specific competency unit that is to be integrated with each of the other competency units for training and testing purposes.
7 FCLT/P – MPL Competency Unit 2 – Perform aeroplane ground operations Competency element: Line up checks completedATC call to give clearance interrupts checklist (threat)Crew skips pitot heat checklist item (error)Aircraft is lined up for take off roll with pitot heat off (undesired aircraft state)Performance criteria: Example TEM countermeasuresKeep finger in checklist item until check list is re-startedStart checklist all over again after clearance read backRequest ATC to hold clearance until checklist completed
8 FCLT/P – Annex 6, Operation of Aircraft Chapter 9. Aeroplane Flight Crew9.3 Flight crew member training programmes9.3.1 An operator shall establish and maintain a ground and flight training programme, approved by the State of the operator…The training programme shall also include…training in knowledge and skills related to human performance and threat and error management…The training programme shall be given on a recurrent basis…
9 Aligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and IIIAnnex 11 – Air Traffic ServicesAnnex 14 – AerodromesA basic safety management “template”Two basic conceptsSafety programme – StatesSafety management system – OperatorsThe ICAO Safety Management Manual (Doc xxxx)LOSANOSS
10 TEM – Aggregate Safety Analysis AccidentsADREPIncidentsSTEADESNormal OpsArchieIntegrated Threat Analysis (ITA) – A Joint ICAO/IATA ProjectCase study: TEM analysis – Runway excursions34 ADREP narratives36 STEADES narrativesThe “bridge” between ADREP/STEADES & Archie: UASLong landingsFloated landingsOff centre-line landings164 LOSA narratives
16 Clearing the Air – LOSA Is not the same as IATA’s IOSA Is not the same as Airbus’ LOASIs not the same as the JAA’s NOTECHSIs not an evaluation of CRMIs not the sixth generation CRMIs not a research toolIs not culturally incompatibleLOSA [NOSS] is a safety management data collection tool[s] that generates safety management data otherwise not available
17 Clearing the Air (II) – TEM & CRM “…TEM is an overarching safety concept with multiple applications in aviation; while CRM is exclusively a training intervention. The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example as an additional module – within existing CRM programmes. This is because TEM countermeasures build in part – although not exclusively – upon CRM skills. The combination of TEM concepts with CRM skills thus introduces the opportunity to present the utilization of CRM skills by flight crews anchored in the operational environment, from an operational perspective. It is emphasized that TEM training does not replace CRM training, but rather complements and enhances it.”