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Threat and Error Management: the LCC and IATA Experience
Joey Anca IATA
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Overview Regional and International Aviation- the Good News and Bad News The Future in Aviation Redefining SAFETY Experience with Low Cost Carriers Threat and Error Management (TEM) Tools CRM in the Countermeasure Context TEM as a Framwork Take Away and the Culture of Safety
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World Aviation: Bad News & Good News
Air Transport is a USD 400 Billion Industry IATA combined Fuel Bill for 2005 is USD83 Billion, equal to the GNP of New Zealand Winners and Losers: North America USD 9B Africa USD 150M Latin America Europe USD 1.4B Asia USD 2.6B Middle East USD 100M Safety: 1.8 Billion flew in 2004; 428 Fatalities (similar to 1945 figures where 9 million people traveled by air World Aviation: Bad News & Good News Global Turmoil driven by: Fuel Costs Legacy vs Low Cost Carriers Imbalanced Taxation by Governments Bisignani, G (2005) State of the Air Transport Industry. IATA.
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Asia-Pacific: Bad News, Good News
High Growth Markets attracting rapid foreign investments (China, India, Middle East) Asia Pacific Airlines reported US$ 5B profits (2004) India to require trained staff each year over next 5 years Demand for pilots to exceed factor of three in next 5 years; Salary bill for pilots up by 30-40% India placed orders of 190 aircraft in last Paris Air Show; number expected to escalate to aircraft by 2010 Regional Issues driven by: Fuel Costs Airline Restructuring Inadequate Regulatory Systems Harbison, Peter (2005). Indian Subcontinent & Middle East Aviation & Tourism Summit
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Corpus of Experience in this Report
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Future Transformation: the Jetsons
Affordability of Micro Jets to a larger segment of Entrepreneurs Increased Capability of distal and agile Air Traffic Control Increased vulnerability of Situational Awareness Devolution of Safety Management Systems to micro users Need for Global Equipage harmonization to counteract present differentiation The Future is Scary Baker, D (2005) NGATS FAA Swinburne University of Technology
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Redefining Safety
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Redefining Safety for an Organisation to Reflect Reality
Latent Conditions Redefining Safety for an Organisation to Reflect Reality Safety (Middle English, saufte) The state of being safe from undergoing or causing hurt, injury or loss A billiard shot made with no attempt to score or so as to leave the balls in an unfavorable position for the opponent The problem is…a state of safety does not exist 100% of the Time Threats Violation Error
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Safety is a Measure of Organisational Resistance to RISK.
Latent Conditions SAFETY Safety is a Measure of Organisational Resistance to RISK. Safety (Middle English, saufte) Dynamic protections from mishaps Interventions for system integrity and compliance Creative “buffering” for latent conditions …instead of a harm-free STATE, Risk Violation Error
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Threat and Error Management Tools
Restating (CRM) as the Countermeasures to threats, errors and undesired equipage states Reinforcing Threat and Error Management (TEM) as a framework
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The Riddle of the 5 Daughters
Mary’s Parents had 5 Daughters Their names were: Mara Mare Mari Maro… What is the name of the fifth daughter?
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6th Generation? The Summits of CRM 5th Generation- Error Management
Ubiquity of Human Error Manage Errors by Avoidance/Trapping/Mitigation The Summits of CRM 4th Generation-Integrated CRM CRM embedded in procedures/checklists Specialized topics eg. Automation Performance based CRM 3rd Generation-Advanced CRM CRM Integration with technical training/performance Instructor CRM Training Included Dispatchers, Flight Attendants, Engineers 2nd Generation- Crew Resource Management Error Chain & Accident Causality Teambuilding Games Situational Awareness and Stress Management Concepts Cluster Knowledge (Decision Making, Briefing, etc) 1st Generation- Cockpit Resource Management Business Management orientation Interpersonal Relationships/ Leadership Styles Psychobabble language distant from Pilots The “Unassertive” Co-pilot
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Applying the Riddle to Generations of CRM
The next generation is not about a new form of CRM It is about using TEM as a Framework and CRM as a training countermeasure tool—Maru does not exist, but Mary does It is about going back to the foundation of flying operations—the management of operational threats and errors
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Threat and Error Management (TEM)
TEM training is both a framework of CRM as well as a detour back to CRM Beginnings—a training tool to manage Human Error The TEM Model—outlines propagation and breach of Human Error (Threat-Error-Undesired Equipage State-Incident) Appropriately positions CRM as a set of Countermeasures in managing Threats and Errors
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The IATA TEM Program Positions TEM as a context of CRM
CRM Skill Training as the set of countermeasures to manage threats and errors Includes a Train-the-Trainer component to critique the delivery of CRM Programs suited to local conditions
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Threats: Elements and Conditions that are outside the Crew’s Control
Latent Threats National, Organizational, Professional Culture Standards and Policies Regulations Overt Threats Environment Factors Organizational Factors Individual, Team, Crew Factors Equipage Factors Threats: Elements and Conditions that are outside the Crew’s Control Overt= obvious © Bombala, M Capt (2004) IATA Swinburne University of Technology
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Crew Error: Mismanagement of Threats
Error Types Communication Intentional Non-Compliance (Violation) Procedural Lapse Proficiency Faulty Decisions & Judgment Crew Error Crew Error: Mismanagement of Threats Give examples of each error group. Most errors are inconsequential because other defenses catch it, margin of safety allows for it or just plain luck. You cannot pick which ones will be! Most errors are inconsequential © Bombala, M Capt (2004) IATA Swinburne University of Technology
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Threat Crew Error Undesired Equipage State Equipage is not where it is supposed to be because of threats or mismanaged threats Undesired State © Bombala, M Capt (2004) IATA Swinburne University of Technology
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Result of mismanaged threat and/or error “the tip of the iceberg”
Crew Error Undesired Equipage State Incident or Accident Incident- Accident Result of mismanaged threat and/or error “the tip of the iceberg” © Bombala, M Capt (2004) IATA Swinburne University of Technology
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Managing Threats and Errors: the TEM Solution
Ensure competency training on CRM Countermeasures Countermeasures Error Avoidance Threat Management Error Management Undesired Equipage State Management The following CRM skills represent some, but not all of the types that can be utilized. After introducing each skill set, insert the suggestions from the “what makes a safe pilot” or “CRM is...” Swinburne University of Technology
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CRM Countermeasure 1 Threat Team Climate Planning Crew Error Incident
Error Avoidance Threat Team Climate Planning Crew Error Undesired Equipage State Your own skills you take on the line proficiency, leadership, communication Along with the defense layers in put place by manufacturer, company, regulator All assist in prevention of crew error Incident CRM Countermeasure 1 © Bombala, M Capt (2004) IATA Swinburne University of Technology
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CRM Countermeasure 2 Threat Team Climate Planning Review /Modify
Error Avoidance Threat Threat Management Team Climate Planning Review /Modify Crew Error Undesired Equipage State Your own skills you take on the line proficiency, leadership, communication Along with the defense layers in put place by manufacturer, company, regulator All assist in prevention of crew error Incident CRM Countermeasure 2 © Bombala, M Capt (2004) IATA Swinburne University of Technology
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CRM Countermeasure 3 Threat Crew Error Team Climate Execution Incident
Error Avoidance Threat Threat Management Crew Error Error Management Team Climate Execution Undesired Equipage State Your own skills you take on the line proficiency, leadership, communication Along with the defense layers in put place by manufacturer, company, regulator All assist in prevention of crew error Incident CRM Countermeasure 3 © Bombala, M Capt (2004) IATA Swinburne University of Technology
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CRM Countermeasure 4 Threat Crew Error Undesired Equipage State
Error Avoidance Threat Threat Management Crew Error Error Management Undesired Equipage State Undesired Equipage State Management Team Climate Review / Modify Your own skills you take on the line proficiency, leadership, communication Along with the defense layers in put place by manufacturer, company, regulator All assist in prevention of crew error Incident CRM Countermeasure 4 © Bombala, M Capt (2004) IATA Swinburne University of Technology
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Threat and Error Management Framework CRM Countermeasure Competencies
Error Avoidance Threat Threat Management Crew Error Error Management Team Climate Planning Execution Review /Modify Undesired Equipage State Undesired Equipage State Management Have a pre-drawn flipchart of this to be posted. Threat and Error Management Framework CRM Countermeasure Competencies Incident Swinburne University of Technology
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TEM and A Culture of Safety
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A Culture of Safety Change Model
© Anca, JM (2000)
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Take Away Questions we should ask: The CEO Regulator Crew Union
Human Resources Head
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The Questions to Your CEO: Overlapping Sleeves of Protection
Individual Increasing Vulnerability Sleeves in Perpetual Motion Staff Loyalty: Collective SUCCESS or Individual Wins? Are Your Leaders more concerned about THEIR Self-preservation? Safety Information: is it Meaningful to a critical few or is it OWNED by ALL? Maturing Culture: are your Values and Beliefs Compatible? Vulnerability: Can you Predict your Next Accident? Team Workplace Increasing Protection Organisation © Anca, JM (2000)
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A Prologue Discretion is the better half of Valor. Thank You.
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