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Threat and Error Management

Threat and Error Management. What is TEM?. “Defensive flying”. ICAO and FAA. In 2000, LOSA baseline results showed that error management had been incorporated into everyday operations. Improved checklist usage and a 70% reduction in non-stabilised approaches.

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Threat and Error Management

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  1. Threat and Error Management

  2. What is TEM? • “Defensive flying”

  3. ICAO and FAA • In 2000, LOSA baseline results showed that error management had been incorporated into everyday operations. • Improved checklist usage and a 70% reduction in non-stabilised approaches. • ICAO made LOSA the central focus of flight safety and human factors programmes. • TEM and LOSA recognised Worldwide.

  4. TEM Philosophy • Three basic concepts: • Anticipation • Recognition • Recovery • Recover first, analyse the cause later.

  5. Threats • May be internal or external. • They are not caused by the crew. • They increase the operational complexity of a flight. • Require crew attention and management if safety margins are to be maintained.

  6. What is a latent Threat? A threat that is not directly obvious to flight crew. Equipment design.

  7. Threat Management - GPS • Threats & errors • Poor standardisation of GPS receivers • Poor integration with AP • Mis-interpretation of HSI Management Obtain training & practice (VMC) with make & model Use HDG mode when changing any detail In non-integ. cockpit, double-check mode

  8. Errors • Error is a crew action or inaction that leads to a deviation from crew or organisational intentions or expectations. • Put simply: threats come “at” the crew, while errors come “from” the crew. • An Error that is detected and effectively managed has no adverse impact on the flight. • An error that is not detected cannot be managed.

  9. Flight Crew Errors Can be divided into three types: • Aircraft Handling • Procedural • Communication Errors.

  10. Consequence of Error • The very same error can have completely different consequences, depending on the factors involved. • Error : setting the flaps correctly for landing is forgotten. • Aircraft type and performance • Actual landing weight • Runway length and obstructions ahead

  11. Undesired Aircraft State (UAS) • A UAS is defined as a position, speed, attitude or configuration of an aircraft that: • Results from flight crew error, actions or inaction • Clearly reduces safety margins • UAS can be managed effectively or mismanaged, leading to an additional error, UAS, an incident or accident.

  12. A Decision MUST be made

  13. Identify the Threats?

  14. TEM Application • T Terrain • W Weather • O Operational • P Plan

  15. TWO-P • Terrain old • Terrain new • Weather good • Weather bad • Operational in • Operational out

  16. TWO-P • Assessing threats does not make them go away. • A threat briefing must contain effective strategies. • There must be a plan.

  17. Levels of Situational Awareness Notice • Level One: Perceive • Level Two: Comprehension • Level Three: Projection Understand Think Ahead NUTA

  18. Situation Awareness Threat Management Notice Understand Think Ahead Mitigate Trap Avoid The NUTA/TEM Links

  19. Countermeasures • Anticipation builds vigilance. • Recognition leads to recovery. • Recover first, analyse causes later. • Planning. • Execution. • Review or modify.

  20. What is an Unexpected Threat?

  21. Just because you deal with a situation everyday does not mean that it is not a threat.

  22. Discussion Time

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