the university of texas at austin threat and error management model robert helmreich capt. bruce...
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The University of Texas at Austin
Threat and Error Management Model
Robert Helmreich Capt. Bruce Tesmer
University of Texas Continental Airlines
ATA CRM Conference
Comair, Cincinnati
September 21,1999
The University of Texas at Austin
Applying TEMM to a ‘pilot error’ incident:
Landing at the wrong airport
Aerospace Crew Research Project
Aerospace Crew Research Project
Aerospace Crew Research Project
The Flight Scenario Houston to Corpus Christi second leg of the first day
of a trip that began in Newark Captain was PF from Newark, FO to CRP Captain was highly experienced check airman
conducting IOE CRP ATIS “..good, 6,000 broken 10 miles, wind 010,
10kts. Expect loc app to Rwy 31.” Descent started early expecting VORTAC vectors to
Rwy 31 localizer. ….. On autopilot until intercepting final approach course
After CRP Vortac, App Cont. gives vectors to, and clearance for intercepting localizer and “Cleared Approach.Rwy 31 Localizer”
Aerospace Crew Research Project
The Scenario – continued Turning final, the Capt sees the airport and reports to
tower “Runway in sight.” Crew has slowed and configured early to allow time
to reach landing configuration and be stable by 500’ AGL. They are surprised runway so close.
A normal landing was completed but runway shorter than expected. Landing completed with 500’ remaining
There was no terminal, only hangers. Crew taxis off Rwy and realizes they are not at CRP
The call Tower which knows they have landed at Cabaniss
External External ThreatsThreats
Known Threats
•First day as crew•IOE being given•1st leg in 737-300 round dial, 2nd in 737-500 EFIS•1st EFIS leg for FO•FO only exposure to EFIS in Level 5 device•FO’s 1st trip to CRP•Capt had not been to CRP in 3 years & had never landed to North at CRP
Unexpected Threats
•ATIS doesn’t mention 2000’ scattered cloud layer. Doesn’t warn about location of Cabaniss Field•A/C on autopilot, has problem intercepting localizer•Scattered 2,000’ cloud layer blocks fwd vision but allows ground contact for 5 miles
ExternalError
•ATC had localizer set to Rwy 13 for previous A/C doing training
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Crew Error
Latent Systemic Threats Regulatory: Cabniss Field located 6nm on Corpus localizerRegulatory: no ATIS warning about Cabaniss on weekendRegulatory: chart depiction hard to readRegulatory: Cabaniss field layout looks like CRPRegulatory: MSAW warning for Cabniss disabledRegulatory: runway alignment (31) same as CorpusNavy: allows racing events except special days (Mothers’ Day)System: information on other near approaches to Cabaniss existed, but not availableOrganizational: no mention of Cabaniss on10-7 page in manual Professional: operational and professional pressure to make landing
Proficiency
Crew lacked knowledge about Cabaniss location
Fail to Respond
Undesired StateAdditional Error
Error Types
Error Responses
Error Outcomes
Procedural
Crew briefed and were flying ILS approach, did
not check DME to confirm FAF
Fail to Respond
Undesired StateAdditional Error
Error Types
Error Responses
Error Outcomes
Decision Error
Crew high & fast when lined up for Cabaniss but
stable at 500’ chose riskier decision
Fail to Respond
Undesired StateApproach tp
wrong airport
Error Types
Error Responses
Incident
Undesired Aircraft State
Outcomes
Fail to Respond
Error Outcomes
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Threat and Error Totals
ExternalThreats•Expected•Unknown
External Error
Threat Recognition and Error Avoidance Behaviors -
System -- Organizational -- Professional
Latent Systemic Threats
MitigateExacerbate
Fail to Respond
IncidentAdditional ErrorRecovery
InconsequentialUndesired Aircraft State
Intentional Noncompliance-Procedural
CommunicationProficiency
Operational Decision
Fail to Respond
Additional ErrorOutcomesOutcomes
ExternalExternalThreatsThreats
ActionAction
ErrorError
ActionsActions
ActionsActions
FinalFinalOutcomeOutcome
Aerospace Crew Research Project
ExternalThreats
•Expected -6 •Unknown -3
External Error1
Threat Recognition and Error Avoidance Behaviors - 2
System -- Organizational -- Professional
10 Latent Systemic Threats
MitigateExacerbate
1 Fail to Respond
1Incident
Additional ErrorRecovery
InconsequentialUndesired Aircraft State
Intentional Noncompliance1 -Procedural
Communication1 Proficiency
1- Operational Decision
3- Fail to Respond
Additional ErrorOutcomesOutcomes
ExternalExternalThreatsThreats
ActionAction
ErrorError
ActionsActions
ActionsActions
FinalFinalOutcomeOutcome
Aerospace Crew Research Project
Conclusion A short flight with a highly competent captain became
very complex because of numerous latent systemic threats
These were compounded by external threat and error and crew errors
Any of a number of actions could have broken the incident sequence
Aerospace Crew Research Project
About Latent Threats Latent threats are highly variable. They can
– exist for a long time– be based on tradition ‘We’ve always done it this way.’– be associated with new technology– fail to appear as threats or seem to be based on good
decisions– be difficult to resolve because corrective actions cross too
many jurisdictions and no entity takes responsibility for corrective action
– are often known by some but not communicated to others– frequently involve ‘local knowledge’
Latent threats don’t show up in training
Aerospace Crew Research Project
The Future The identification of Latent Systemic Threats is
essential to safety Application of the model points to training needs and
to latent threats that need to be modified Safety, CRM, Training and Flight Ops need to
coordinate to address threat and error management
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CRM Countermeasures
Aerospace Crew Research Project
CRM Countermeasures Possible
External Threat and error Mental models Mental model check Cockpit Communication error
Situation was high threat but not fully recognized
Aerospace Crew Research Project
Conclusions Crew faced a variety of external threats and error Crew recognized and managed several threats Latent Systemic Threats played a critical role
– They can be addressed in CRM if identified CRM countermeasures were available for error management Mental models of ATC and Crew were understandable but led to
misinterpretation of actions– A ‘Mental Model Check’ could have served as the critical
countermeasure