Error

1. Error

2. Error Chain • Ambiguity • Fixation or preoccupation • Confusion or an empty feeling • No one flying the aircraft • No one looking out of the window • Use of an undocumented procedure • Violating limitations or minimum operating standards • Unresolved discrepancies • Failure to meet targets • Departure from standard operating procedure • Incomplete communications

3. Threat & Error Management

4. Session Objective • By the end of this session you will be able to: • Define the types of threat and error and determine a process to managing them • In order to recognise and manage threat and error in your own flight operations

5. TEM Concept • The concept of considering the performance of flight crews in terms of a model of TEM was proposed and developed by UTHFRP • Later discussions on the evolution of CRM, TEM described as the 6th gen of CRM. This led to some organisations substituting TEM for CRM training • More appropriate to regard TEM as element of CRM.

6. Definition of a threats • A threat may be defined as: • Any situation, event, or circumstance that occurs outside the influence of the flight crew and which may affect the safety of an operation • Threats require crew attention and management if safety margins are to be maintained

7. Types of Threats • Observable Threats • 1) Known e.g. strong crosswind • 2) Unexpected e.g. engine failure after take off • Latent Threats • Factors residing in the system, organisation or individual that increase risk & are not directly observable in operations • Equipment design issues - Optical illusions - Air traffic system design - Training philosophy and practices - Organisational culture

8. Phoenix Media Footage of Car Chase – 27th July 2007 • 1 police helicopter plus 5 local news helicopters (different TV stations) • Police pursuit of criminals • Pilots' responsibility to perform reporting and visual tracking duties • No formal procedures for pilots to follow regarding the conduct of these ops • Any Threats Present?

10. Any threats in your operation? • Terrain • Weather • Aircraft • ATC errors • Pressure to perform • Fatigue • Schedules • Culture (own / differing cultures) • Others????

11. Combating threats • How will you as an individual and/or team combat the threats you have identified? • Training, proficiency & experience • SOPs’ • Vigilance & maintaining a good S/A • Monitoring & cross checking • Communication • Workload management • Effective leadership

12. Managing threats • Avoid - Trap – Mitigate • Maintain a high degree of situational awareness • Notice – understand - think ahead • Imagine what could be, confront what can be, contain what is now! • The effects of threats occur in the future and so may be trapped or mitigated by planning ahead • Threats are not errors, but they increase the potential for error.

13. Defining Errors • An error may be defined as: • A consequence of human involvement which causes deviation from crew or organisational intentions or expectations. Errors may occur either in the presence or absence of threats.

14. We may identify five types of error • 1) Intentional non-compliance errors or violations of SOPs or regulations • 2) Procedural errors in which the intention is correct but the execution flawed • 3) Communication errors that occur when information is incorrectly transmitted or interpreted • 4) Proficiency errors • 5) Operational decision errors in which crews make a discretionary decision that unnecessarily increases risk

15. Increasing Risk • Risk can also be increased by errors made outside the cockpit, e.g. by ATC, maintenance & dispatch. • In addition, crews themselves may err in the absence of any external precipitating factor. • However: • External threats are countered by the defences provided by CRM skills. • If the CRM defences are successful, error is managed and there is recovery to a safe flight. • If the defences are breached, they may result in additional crew error or an incident or accident.

16. A Model of Error Management

17. LOSA Data - Threats • External threats & flight crew errors are pervasive in normal flight ops but differ in their frequency and type across airlines • The average number of threats/flight was 3.7 • 66% of threats were environmental (wx, airport conditions, ATC, terrain) • 33% of threats were airline (ground, ramp, dispatch, cabin, operational pressure) • The descent/approach/landing phase of flight contained the most threats, errors, and consequential outcomes • 29% of flights had a threat that was mismanaged and led to some form of crew error

18. LOSA Data - Errors • 75% of flights had 1 or more errors • The average number of errors/flight was 2.6 • Handling errors – 36% of all errors. Most common – unintentional speed deviation • Procedural errors – 52% of all errors. Most common – checklist from memory • Communications errors – 12% of all errors. Most common – missed ATC call • Mainly flight crews failed to respond to errors after they were committed. A significant amount turned into undesired aircraft states, however crews were successful in mitigating the consequences

19. Session Objective • By the end of this session you will be able to: • Define the types of threat and error and determine a process to managing them • In order to recognise and manage threat and error in your own flight operations