operational threat and error management ver 11
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Copyright D. Gurney Sept 2006
Threatand
Error Management
Flight crew guide to managing error
Human Factors Tool Kit
This presentation provides information and guidance to help improve decision making. It is intended to enhance the reader's awareness but it shall not supersede the applicable regulations or
airline's operational documentation; should any deviation appear between this presentation and the airlines AFM / (M)MEL / FCOM / QRH / FCTM, the latter shall prevail at all times.
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Threat and Error Management
Introduction
This visual guide provides practical guidance to aid crews in managing the
hazards in everyday operations. Threat and error management is a central
safety activity for both organisations and individuals.
There are four sections:
1. Introduction
2. Threats and Error Avoidance
3. Error detection
4. Response
The guide may be used for self study or as part of a formal training presentation.
The speaker notes provide additional information.
Threat Management is the opportunity to manage your future.
Error Management is the necessity to manage your past.
Speakers notes provide additional information, they can be selected by clicking the right mouse button in Slideshow View, select Screen, select Speakers notes.
This presentation can be printed in the notes format to provide a personal reference document.
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Operational Threat and Error Management
TEM- a central safety process
Threat and Error Management(TEM) defends against operational threats and errors,
which if incorrectly managed can lead to undesired states. The process involves
recognising and cancelling the effects of threats, avoiding, trapping, or
mitigating the result of errors and managing the outcome.
Priorities:
Deal with any undesired state, take immediate corrective action
Threat recognition and avoidance - good situation awarenessCancelling the effects - awareness and decision making
Avoiding and trapping errors - plan, do, check
Managing and mitigate - use all resources
Golden rules
1. Fly the aircraft take immediate corrective action2. Navigate maintain situation awareness
3. Communicate - decision making
4. Manage - use all resources
An Undesired State is often the first indication of an earlier threat or error
that was not satisfactorily managed
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Operational Threat and Error Management
Any condition or situation that reduces safety.
Undesired states reduce margins of safety and may lead to hazardous situations in daily
operation; - flight near Cbs, new taxi patterns.
They represent aircraft or operational deviations from the normal standard at edge of the safety
envelope; - an un stabilised approach, failure to go around.
Undesired states are often the last stage before an incident or accident; - EGPWS Pull Up.
Undesired .
States
Undesired Stateas close to an accident as you ever want to get
Threats
Other
peoples errorsS
E
L
H
L
Managing
a safe
operation
Your errors
Errors
slip, lapse, mistake
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Operational Threat and Error Management
S
E
L
H
L
Threats- come from beyond your influence
Threats are events or errors that increase operational difficulty and must be
managed to maintain safety.
Threats may be minor or isolated issues, but are of particular significance
when they occur in combinations or in high risk situations.
Hardware: design,
displays, location of
controls
Software: regulations,
manuals, checklists,
publications, SOPs
Liveware: crews,
ATC, dispatch,
maintenance
management
Environment: working
conditions visibility,
weather, turbulence,
terrain.
Threat Situation threats - mainly physical items
Organisational threats - other peoples error
Self induced threats - commence with your error
Origin
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Operational Threat and Error Management
Erroran unexpected outcome
Errors are actions or inactions which result in an unintended outcome. Errors
reduce the margin of safety and can lead to undesired states.
Most situations contain opportunities for error and error provoking items. You, or other people
are always part of the situation and therefore subject to error.
S
E
L
H
LBias, belief, CRM
Miscommunication.
Illusion, preconception
Situation awareness.
Mistake, haste
misunderstanding.
Liveware,You: Inattention.
Situation awareness.
Knowledge, experience,attitudes and judgement.
Misinterpretation, slip, rush,
lapse, failure to use, no
feedback.
Error Origin
Good plan - made a mess of it; inattention, distraction
Poor plan - did not understand the situationBad habits - no SOP, poor discipline
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Operational Threat and Error Management
Anticipating threats and errors
Activities in a Safety Management System (SMS) must proactively seek out threats
and opportunities for error.
Management officers and pilots, instructors, andcheckers must provide guidance for avoiding
and resolving threats and errors, and then
minimise the resultant effects with;
Rules
Procedures
Training and Checking
Reporting and Incident analysis
Operating crew have to manage residual risks and the situational threats or opportunities for
error encountered in daily operation; this requires -
Preparation, Planning, Briefing
Gaining and maintaining situation awareness
Vigilance, Scanning and Questioning Task and Workload sharing
Teamwork, Communication
Checking and Monitoring
Following SOPs
Debriefing
A mistake is just another way of doing something
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Threats- Recognition and Cancelling their effect
Threat recognition requires good situation awareness and attention.
Obvious threats within the operating environment i.e. terrain, weather, ATC.
Other threats may not be so easy to see and may require special attention: Operational aspects; dispatch, cabin, passengers, paperwork
Distraction; system faults, warnings or unusual indications
Human performance; time pressure, fatigue, stress
Beware of multiple or threat combinations as
the adverse effects can develop rapidly.
Wet runway and tailwind or crosswind
Non precision approach, no DME
IFR, terrain, system fault
Cancelling the effect of threats involves choosing a course of action.
This involves awareness, decision making, checking, and monitoring.
The effect of threats can be reduced by: Changing the plan.
Using of alternative procedures.
Checking and monitoring the progress of the new plan.
Comparing planned activities with standard operating procedures.
See the Visual Guides on Critical Thinking and Situation Awareness
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Threats manage the result
Management includes the ability to identify, understand,
and to project consequences into future activity.
Threat management involves evaluating plans or options and choosing suitable
course of action to maintain the safety of flight.
Ask questions about your assessment of the situation and your choice of action
Continuously assess and balance the risks involved with the choice of action
Check your immediate objective; is this the safest , thus the best option
Check your understanding of the planned actions think ahead
Have you used all resources and information
Confirm the action gave the expected resultMonitor the progress of the chosen option
Seek an alternative view of the situation
Compare with the planned objective
See the Visual Guides on Situation Awareness and Decision Making
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Operational Threat and Error Management
The most important aspect of TEM is to understand that errors always occur.
Everyone makes errors; errors are part of normal behaviour.
Human error is the single largest cause of incidents and accidents in aviation.
Human error appears in many forms and severity, but most are detectable.
Human error can be managed by avoiding, trapping, or containing the result.
Error - action or inaction with an unintended outcome
Slip - failure of attention
Lapse - failure of memory
Mistake - misapplication of a good rule
application of a bad rule
or no ready made solution available
You must manage:-Yourself, attention, stress and haste
Time, disruption, workload; monitoring
Knowledge, situation awareness, planning
Managing error- to err is human
to err is human
Violation: An intentional action deviating from rules and procedures,
either by habit or as provoked by the situation.
C i ht D G S t 2006
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Operational Threat and Error Management
Error avoidance requires good situation awareness. Awareness involves a mental
model and monitoring progress against a plan; plans help us to avoid error.
You must create a plan; if not you could select an incorrect course of action.
Any plan can be affected by the situation, but all plans can be changed.
Prepare a briefing; structure it along the flight path - Visualise mental waypoints.
What should happen; when. What are the limits; why?
Allocate tasks - workload management:
Who will action these tasks; when, and how?Consider likely threats and opportunities for error - ask what if
How are these best avoided; who checks these hazards, and when.
Error Avoidance, plan ahead
Planning is a skill requiring experience and knowledge.
A skill can be improved with practice; make plans and
prepare briefings for every flight phase - self brief. Experience is gained from every plan and briefing.
Knowledge is improved by briefing and debriefing.
Stay ahead of the airplane
Consider what if
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Operational Threat and Error Management
Attention -directing your thoughts
Insufficient cues, competing demands
Attention, Vigilance and Comprehension
Pre attentionCommunication
Teamwork, Support
Self monitoring
Cross monitoring
Communication
SOPs, Task management
Check the plan and briefing, use SOPs
Self monitor, focus and maintain attention
Scan plane, path, people; identify the unusual
Decision making, beware stress attention narrowing reduced working memory
Beware concurrent task demands, time pressurecontrolling distraction
The path to adverse incidents is paved with false assumptionsProf James Reason
Good plan; plan goes wrong made a mess of it
Good plan; plan goes wrong forgot something
Poor plan; did not understand the situationBad habit; deviation from procedure
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Operational Threat and Error Management
Manage yourself
Self knowledge enables you to control how you think; controlling your thoughts
enables you to stay in control of the situation and reduce error.
Ask questions of yourself:
Check the reasons for your decisions and intended actions.
Monitor your performance:
Check the results of your thoughts and actions, your workload.
Switch on your thinking, be proactive:
Scan the situation, now and future - Plane, Path, People.
Review the risks from existing threats:
Cross check with the plan and briefings, are these as expected.
The absence of accidents does not mean there are no hazards.
Questions for managing the mind.
What should I be thinking about now.
Why do I think this is safe.
When will this happen.How do I achieve this.
Who will assist me.
It is not who is right, its what is right
Self monitoring requires self awareness
Detect adverse mental states such as distraction, lack of
attention, or rushing,
Stay inside your comfort zone your mental
and physical limits, follow SOPs
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Operational Threat and Error Management
Use the plan monitoring, error trapping
Monitoring is a comparison of the plan or procedure against flight progress or
actions to identify error.
Briefings and procedures are the initial plans for monitoring and checking
A briefing is the flight plan for the mind, it defines the boundaries of a safe operation.
Briefings enable a shared mental model, but check that everyone has the correct mental model.
Cross check your understanding of the current situation
Take time to assess the situation, compare it with the planScan the Plane, Path, People:
Aviate, Navigate, Communicate.
Identify and highlight:
Anything unusual or non standard,
out of limit or abnormal values.
Expect threats and errors:
Maintain vigilance and attention,
monitor yourself, check you actions and
avoid risky alternatives.
Plane
Path
People
check,
scan and
recheck
If the plan is not working - change the plan !
If something doesnt look or feel right, then it probably isnt right.
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A good plan- poor execution - forgot
Sometimes good plans fail due to errors in carrying them out - a loss of situation
awareness or misinterpretation of the situation.
Inattention; incorrect action or thought
Distraction; failure or inability to remember
Misinterpretation illusion; time & workload
Haste stress
SOPs
Checklists Review and evaluation, monitoring
Airmanship - diligence
Predictive proactive reactiveGood plan; plan goes wrong made a mess of it
Good plan; plan goes wrong forgot something
Poor plan; did not understand the situation
Bad habit; deviation from procedure
SOPs, Task management
Time criticality, level of threat, risk assessment
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py g y p
Operational Threat and Error Management
Error trapping
Proactive Scan, general awareness, systematic check. Anything
unusual divergence from the norm the plan
Audit, Scan, Attention, Vigilance and Comprehension
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Avoidance manage the situation and SA
Controlling behaviour
TIME
TIME
Self monitoringRisk assessment
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Bad Habits- violations
Violations are intentional actions or inactions, which violate known rules,
procedures or norms. The fundamental difference between errors and violations
is that violations are deliberate, whereas errors are not. In other words,
committing a violation is a conscious decision, whereas errors occur irrespective
ofones will to avoid them.
There are known factors that increase the probability of committing violations:
Expectation that rules will have to be bent to get the work done
Powerfulness: Feeling that skills and experience justify deviating from the standardprocedures
Opportunities for short cuts and other ways of doing things in a seemingly better way
Poor planning and preparation, putting the person in situations where it is necessary to
improvise and solve problems on the fly as they arise.
Bad habits - no SOP, poor discipline
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Good Habits-an attitude of mind
Risk assessment
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SOPs- Controlling and containing error
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Error Response Priorities& Workload
Stay in control - mitigation
Managing normal operations
Assess time available and risk
Think ahead, plan and recheck
Decision making, prioritise
Use the safest option
Monitor, check
Debrief
Undesired state management Containing the result
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Conclusions -Hazard response
Provide means of escape and rescue
Contain and eliminate hazards
Interpose safety barriers between hazards and losses
Restore system to safe state in off-normal conditions
Provide alarms when danger is imminent
Give clear guidance on safe operation
Create understanding of hazards
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Operational Threat and Error Management
Summary
Avoidance - PPPP Error Avoidance1 Avoid committing errors
Manage operational complexity2 Threat Management
Manage their own errors3 Error Management
Undesired Aircraft StateManagement
4 Manage induced aircraft deviations
A mixture of 'hard' and 'soft' defences.
Defences-in-depthNot forgetting to be afraid
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Operational Threat and Error Management
Recognise threats, avoid errors
Scan plane, path, people; identify the unusual
Thoughtful decision making, careful actions
Self monitor, focus and maintain attention
Check the plan and briefing, use SOPs
Cancel the effect of threats, trap errors
Procedures, monitoring, checklists
Planning and preparation, briefing
Task and workload reduction
Teamwork, communication
Manage threats, mitigate the effects of error
Assess time available and risk
Think ahead, prioritise
Use the safest option
Monitor, recheck
Debrief
TEM- Manage
Copyright D. Gurney Sept 2006
Outside boxes external influences = Threats
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Operational Threat and Error Management
Intellectual
Sense of
Justice
IntellectualHumility
IntellectualIntegrity
IntellectualConfidence in
Reason
?S
E
L
H
L
Outside boxes, external influences = Threats
Links = sources ofError/ error paths
Spaces in between = Undesired States
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Operational Threat and Error Management
Errors
HFACS Principles
Principle 1: Aviation is similar in nature to other complex productive systems.
Principle 2: Human errors are inevitable within such a system.
Principle 3: Blaming an error on the decision maker is like blaming a mechanical
failure on the hardware.
Principle 4: An accident, no matter how minor, is a failure of the system.
Principle 5: Accident investigation and error prevention go hand-in-hand
Longer time scales Strategic, proactive
Management: checks and audits, data monitoring, SMS
Operational: planning, briefing, Situation awareness, thinking ahead
Shorter time scales Tactical, reactive
Operational: Situation awareness, monitoring, check against plan, risk assessment,
judgment, decision making
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Operational Threat and Error Management
Situation
The first and most important item of TEM is to accept that errors occur;
everyone suffers error. Errors are part of your normal behaviour.
Origins of error:
First
Nor
activi
Familiar task
or situation
No conscious
thought
Skill based
error - action
Rules
procedures
experience
wrong rule;
misapplied
correct rule
Unfamiliar
situation or
task
Incorrect
diagnosis
Rule based
error - procedural
Knowledge based
error - thinking
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Operational Threat and Error Management
The structure of an accident
In general incidents and accidents result from of a combination of latent factors -
preconditions, and unsafe acts. Situations when the holes line up.
Threats in everyday situations contribute to many of the preconditions; many threats result
in unsafe acts.
Errors dominate the unsafe acts, which consist of intended and unintended actions.
Defensive barriers
Safety Management
Threat and Error Management
Hazards
Situationthreats
Undesired
states
Potential incidentor accident
Latent Conditions
Unsafe Acts
Errors, mistakes, slips,lapses. Violations
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Error- Attention, Thinking, and Discipline
.
Attention failure
Memory failure
Thinking failure
Good plan, plan goes wrong
made a mess of it
Poor plan, did not understand
the situation
Bad habitDeviation from procedure
Good plan, plan goes wrong
forgot something
Inattention
Haste, Stress
Insufficient cues
Competing demands
Insufficient knowledge
experience, or data
Insufficient
understanding of the
risk or consequences
Violation
Situation Error contributors