1. ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005
Threat and Error Management Training for Air Traffic Control Officers Greg Down

2. Presentation Overview
Background
Overview of TEM Training
Benefits
Review

3. NAV CANADA TEM Background
In 2001, visited Continental Airlines and University of Texas to research the application of TEM in ATS
Participated in Continental’s TEM Training and experienced first hand the impact and value of this training

4. Continental Airlines TEM Training
A consistent and operationally focused perspective on Threats and Errors in the operational environment
TEM was (and still is) consistently applied throughout the organisation:
Training (Initial and Recurrent)
Simulator ‘Checks’
Auditing (FOQA & LOSA)
Dispatch, Ramp
Use of data-driven information made great impact on pilots (B777 captain & newspaper)

5. NAV CANADA TEM Training
Delivered in 2001 to all operational staff (ATCOs and FSSs) and Line Management
Included FAA Video “Collision Course”
Opportunity to discuss experiences through the TEM “lens”
Well received by staff and management

6. TEM Training Overview What is the TEM Framework? What is a Threat?
What is an Error?
What is an Undesired State?
Strategies for Managing Threats and Errors

7. What is the TEM Framework?
A safety management framework:
to enhance aviation safety and efficiency
through an operationally relevant and highly intuitive framework
to better understand and manage system and human performance in operational contexts

8. TEM Framework Threats Threat Management Errors Errors Undesired States
Error Management
Undesired States
Show and discuss model
Can use your own pre-drawn if you want.
Can show OAK departure video clip
Note: Reword tower clearance to “Change departure to the Oakland 5” (So clip will work!)
Can talk about it as a Umbrella or shield. Use an example or story to show how this works (How we saw people use it)
Undesired State
Management
Outcome

9. What is a Threat? Events or conditions which occur:
beyond the influence of the air traffic controller;
increase a situation’s complexity; and
must be managed to maintain the margins of safety.

10. “It’s a Beautiful Day in the Neighbourhood…”
The Ideal Shift
Overstaffed
All aircraft on radar
All systems operational
Beautiful VFR Weather
Happy, supportive supervisor
Pilots are attentive and responsive
Co-workers are pleasant and supportive

11. “It’s a Beautiful Day in the Neighbourhood…”
A More Typical Shift
Short staffed
Non-radar aircraft
Maintenance on critical systems
IFR / Marginal VFR Weather
Not-so-supportive supervisor
Pilots - slow to respond to instructions
Co-workers - demanding and create workload

12. Threats (Aerodrome Environment)
Distractions
Runway crossings
Comm. failure/
stuck mike
Visitors
Shift change
Weather
Similar call signs
Maintenance
Non-standard procedures
Airspace
restrictions
Runway inspections
Heavy traffic
System
malfunctions
Unfamiliar crews
Automation events
Missed approaches

13. Threats (Radar Environment)
Distractions
Military activities
Comm. failure/
‘Stuck’ mike
Visitors
Shift change
Weather
Maintenance
Similar call signs
Non-standard local procedures
Airspace
restrictions
Heavy traffic
Diversions
Co-ordination
other sectors
System
malfunctions
Automation events
Differing equipment

14. What is a Threat?
Threat
Error
Threat

15. What is Threat Management?
The process of detecting and responding to threats with countermeasures to maintain safety margins.

16. Tools to Teach About Threats
Discussion of Common Threats
Promote use of the phrase
“RED FLAGS”
“DIPs” – Distractions Interruptions Preoccupations

17. What does Error mean in TEM?
Actions or inactions by air traffic controllers that lead to deviations from organizational or air traffic controller intentions or expectations.

18. Examples of Error Incomplete Briefing Full Readback Not Obtained
Wrong Call Sign Used
Non-Standard Phraseology
Incorrect information passed

19. What is Error Management?
The process of detecting and responding to errors with countermeasures that mitigate the probability and / or severity of further errors or undesired states.

20. What about Error Prevention or Error Avoidance?
We cannot PREVENT all errors
Nor can we AVOID all errors
We can MANAGE errors

21. Managing Errors Follow procedures Use proper phraseology
Continuously monitor traffic
Clarify / challenge inconsistencies

22. What is an Undesired State?
Operational conditions where an
unintended traffic situation results
in a reduction in margins of safety.
‘Transitional’ safety phase between normal operations and an outcome
Indicator that earlier Threats and / or Errors were not adequately managed

23. Undesired State Examples
Aircraft climbing / descending to altitude beyond its clearance
Aircraft deviating from assigned heading / track / route
Incomplete coordination
Inaccurate flight info on the radar screen
Not using appropriate indicators when crossing vehicles across an active runway

24. Undesired States are NOT ‘Outcomes’?
an Outcome is an ‘end state’
Incident
Operational Error
Operating Irregularity
Accident
Once an Outcome has occurred, normal operations cannot be recovered
Undesired States can be effectively managed and normal operations regained

25. Goals of TEM Discover, assess and manage threats
Enhance the detection and management of error
Improve resistance to errors
Diagnose factors that may create threats and errors

26. TEM Framework Threats Threat Management Errors Errors Undesired States
Error Management
Undesired States
Show and discuss model
Can use your own pre-drawn if you want.
Can show OAK departure video clip
Note: Reword tower clearance to “Change departure to the Oakland 5” (So clip will work!)
Can talk about it as a Umbrella or shield. Use an example or story to show how this works (How we saw people use it)
Undesired State
Management
Outcome

27. Strategies to Improve Safety Margins
Identify ‘Threats’ in Operation and reduce or eliminate before they lead to error or consequence
Promote use of ‘common language’ to focus attention on safety issues (RED FLAGS)
Make errors ‘visible’ so that they can be easily identified and managed

28. Strategies to Improve Safety Margins
Make it ‘safe’ to report errors (‘just / error tolerant’ culture)
Treat errors as a feedback mechanism for learning and continuous improvement
Errors are EXPECTED and WILL occur. HOW they are MANAGED is what is important

29. Challenges to TEM Training
Tendency to focus to be on Errors rather than Threats
Can devolve into a debate over Risk vs. Hazard vs. Threat contextual meanings if not managed
Can appear overly simplistic to those who are accustomed to more elaborate frameworks

30. Benefits Of TEM Training
TEM is intuitive
Gives structure to what controllers already do on a daily basis
Simple, robust operational ‘Lens’ to view the operational environment
Identifies external factors that impact the operation
‘See’ factors that effect safety in a new way
‘Common language’
Can facilitate rapid identification and communication of factors that could impact operations (Red Flags)

31. Benefits Of TEM Training
Consistent with Safety Management Systems
Can be deployed independently or to reinforce existing SMSs
Promotes movement toward ‘Just Culture’
improved reporting of safety concerns through focus on external factors rather than individuals
Creates foundation for improved safety data collection
programs such as NOSS
Illuminates that ATCOs are effective Threat Managers

32. Presentation Review Background Overview of TEM Training Benefits

33. TEM Promotes an Effective Safety Culture
An organization’s safety culture can be defined by the extent to which it is:
Informed
Wary
Just
Flexible
Learning 33

34. ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005
Threat and Error Management Training for Air Traffic Control Officers Greg Down