In aviation safety, threat and error management (TEM) is an overarching safety management approach that assumes that pilots will naturally make mistakes and encounter risky situations during flight operations. Rather than try to avoid these threats and errors, its primary focus is on teaching pilots to manage these issues so they do not impair safety. Its goal is to maintain safety margins by training pilots and flight crews to detect and respond to events that are likely to cause damage (threats) as well as mistakes that are most likely to be made (errors) during flight operations.
TEM allows crews to measure the complexities of a specific organization's context — meaning that the threats and errors encountered by pilots will vary depending upon the type of flight operation — and record human performance in that context. TEM also considers technical (e.g. mechanical) and environmental issues, and incorporates strategies from Crew Resource Management to teach pilots to manage threats and errors.
The TEM framework was developed in 1994 by psychologists at University of Texas based on the investigation of accidents of high capacity Regular Public Transport (RPT) airlines. — on crew performance, environmental conditions, and operational complexity — by a highly trained observer. LOSA data is used to assess the effectiveness of an organization's training program and to find out how trained procedures are being implemented in day-to-day flights.However, an evaluation method was needed to identify threats and errors during flight operations and to add information to existing TEM data. A Line Operations Safety Audit (LOSA) serves this purpose and involves the identification and collection of safety-related information
Threat and error management is an important element in the training of competent pilots that can effectively manage in-flight challenges.Many strategies have been developed (e.g. training, teamwork, reallocating workload) that were focused on improving on stress, fatigue, and error. Flight crew training stressed the importance of operational procedures and technical knowledge, with less emphasis placed on nontechnical skills, which became isolated from the real-world operational contexts. Safety training, including TEM, is important because a crew's nontechnical (safety) knowledge helps more in managing errors effectively than crews' familiarization with operations through experience. Candidates who are shortlisted during selection and training processes must demonstrate analytical and coordination capabilities. Possessing these nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.
The following components are methods that help provide data for the TEM.
Training for LOSA experts includes two sessions: education in procedural protocols, and TEM concepts and classifications. — ability to notify the pilot as to why he or she was not able to detect an error or threat after a flight. The pilot's responsibilities include his or her opinions on what safety issues could have had an adverse impact on their operations. A LOSA trainee must then record the specific responses of the pilot and thereafter code performance using behavioral markers. The order of the recording is as follows: a) record visible threats; b) identify error types, crew's responses, and specific outcomes; and c) use CRM behavioral markers to rate crew.A LOSA trainee is taught to find data first and then code them later for both sessions, during which a crew member must exhibit "LOSA Etiquette"
Observers will finally record a pilot's overall response on a 4-point Likert scale: 1) poor, 2) marginal, 3) good, and 4) outstanding. The data are then quantified and tabulated as exemplified by the following format:
Planning and execution of performance
|Monitor cross-check||Active monitoring of crews||Situational awareness maintained||Outstanding|
|SOP briefing||Carried out necessary briefings||Thorough understanding of procedures|
|Contingency Management||Communicate strategies||Good management of threats and errors.|
|Identified Threats||Managed||Mismanaged||*Frequency (N)|
|Air Traffic Control||17||2||19|
|Airline Operational Pressure||9||0||9|
Frequency is the total number of threats that occurred and is denoted by N.
LOSA identifies three main categories that must be recorded:
Safety change process (SCP), which is part of LOSA, is a formal mechanism that airlines can use to identify active and latent threats to flight operations.It is a guideline that communicates in detail what is an imminent threat to current operations or who is causing the threat. In the past, SCP data were based on investigation of accidents or incidents, experiences, and intuitions but nowadays SCP focuses more on the precursors to accidents. There are several steps involved in conducting SCP:
|Safety Change Process (SCP) model|
An unnamed airline conducted base-line observations from 1996 to 1998 using the defined SCP and LOSA data to improve its organization's safety culture and the results were positive. The crew error-trapping rate was significantly increased to 55%, meaning that crews were able to detect about 55% of the errors they caused.A 40% reduction in errors related to checklist performance and a 62% reduction in unstabilized approaches (tailstrikes, controlled flight into terrain, runway excursions, etc.) were observed. A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.
Aviation safety is the study and practice of managing risks in aviation. This includes preventing aviation accidents and incidents through research, educating air travel personnel, passengers and the general public, as well as the design of aircraft and aviation infrastructure. The aviation industry is subject to significant regulation and oversight.
Crew resource management or cockpit resource management (CRM) is a set of training procedures for use in environments where human error can have devastating effects. CRM is primarily used for improving aviation safety and focuses on interpersonal communication, leadership, and decision making in aircraft cockpits. Its founder is David Beaty, a former Royal Air Force and a BOAC pilot who wrote "The Human Factor in Aircraft Accidents" (1969). Despite the considerable development of electronic aids since then, many principles he developed continue to prove effective.
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Gulf Air Flight 072 (GF072/GFA072) was a scheduled international passenger flight from Cairo International Airport in Egypt to Bahrain International Airport in Bahrain, operated by Gulf Air. On 23 August 2000 at 19:30 Arabia Standard Time (UTC+3), the Airbus A320 crashed minutes after executing a go-around upon failed attempt to land on Runway 12. The flight crew suffered from spatial disorientation during the go-around and crashed into the shallow waters of the Persian Gulf 5 km from the airport. All 143 people on board the aircraft were killed.
United Airlines Flight 173 was a scheduled flight from John F. Kennedy International Airport in New York City to Portland International Airport in Portland, Oregon, with a scheduled stop in Denver, Colorado. On December 28, 1978, the aircraft flying this route ran out of fuel while troubleshooting a landing gear problem and crashed in a suburban Portland neighborhood near NE 157th Avenue and East Burnside Street, killing 10 on board.
Maintenance resource management (MRM) training is an aircraft maintenance variant on crew resource management (CRM). Although the term MRM was used for several years following CRM's introduction, the first governmental guidance for standardized MRM training and its team-based safety approach, appeared when the FAA (U.S.) issued Advisory Circular 120-72, Maintenance Resource Management Training in September, 2000.
Single-pilot resource management (SRM) is defined as the art and science of managing all the resources available to a single-pilot to ensure that the successful outcome of the flight is never in doubt. SRM includes the concepts of Aeronautical Decision Making (ADM), Risk Management (RM), Task Management (TM), Automation Management (AM), Controlled Flight Into Terrain (CFIT) Awareness, and Situational Awareness (SA). SRM training helps the pilot maintain situational awareness by managing the automation and associated aircraft control and navigation tasks. This enables the pilot to accurately assess and manage risk and make accurate and timely decisions.
Maritime resource management (MRM) or bridge resource management (BRM) is a set of human factors and soft skills training aimed at the maritime industry. The MRM training programme was launched in 1993 – at that time under the name bridge resource management – and aims at preventing accidents at sea caused by human error.
The Academy of Technical Training is a privately owned institution which provides training programs in aviation security and safety, air traffic control, and management of aircraft accidents. The curriculum and courses are accredited and certified by the General Civil Aviation Authority.
Aviation accident analysis is performed to determine the cause of errors once an accident has happened. In the modern aviation industry, it is also used to analyze a database of past accidents in order to prevent an accident from happening. Many models have been used not only for the accident investigation but also for educational purpose.
Pilot decision making, also known as aeronautical decision making (ADM), is a process that aviators perform to effectively handle troublesome situations that are encountered. Pilot decision-making is applied in almost every stage of the flight as it considers weather, air spaces, airport conditions, ETA and so forth. During the flight, employers pressure pilots regarding time and fuel restrictions since a pilots’ performance directly affects the company’s revenue and brand image. This pressure often hinders a pilot's decision-making process leading to dangerous situations as 50% to 90% of aviation accidents are the result of pilot error.
Culture can affect aviation safety through its effect on how the flight crew deals with difficult situations; cultures with lower power distances and higher levels of individuality can result in better aviation safety outcomes. In higher power cultures subordinates are less likely to question their superiors. The crash of Korean Air Flight 801 in 1997 was attributed to the pilot's decision to land despite the junior officer's disagreement, while the crash of Avianca Flight 52 was caused by the failure to communicate critical low-fuel data between pilots and controllers, and by the failure of the controllers to ask the pilots if they were declaring an emergency and assist the pilots in landing the aircraft. The crashes have been blamed on aspects of the national cultures of the crews.
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