Threat and error management

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Threat and error management model

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. [1]

Contents

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. [2] 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. [3] However, an evaluation method was needed to identify threats and errors during flight operations and to add information to existing TEM data. [4] [5] A Line Operations Safety Audit (LOSA) serves this purpose and involves the identification and collection of safety-related information on crew performance, environmental conditions, and operational complexity by a highly trained observer. [5] [6] 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.

Importance of TEM

Threat and error management is an important element in the training of competent pilots that can effectively manage in-flight challenges. [1] 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. [4] 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. [7] Candidates who are shortlisted during selection and training processes must demonstrate analytical and coordination capabilities. [8] Possessing these nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.

Components of TEM

The following components are methods that help provide data for the TEM.

LOSA observation training

Training for LOSA experts includes two sessions: education in procedural protocols, and TEM concepts and classifications. [9] 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" 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. [10]

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: [9]

Planning and execution of performance

TaskTask DescriptionCommentsRating
Monitor cross-checkActive monitoring of crewsSituational awareness maintainedOutstanding
SOP briefingCarried out necessary briefingsThorough understanding of procedures
Contingency ManagementCommunicate strategiesGood management of threats and errors.
Identified ThreatsManagedMismanaged*Frequency (N)
Air Traffic Control17219
Airline Operational Pressure909
Weather6612

Frequency is the total number of threats that occurred and is denoted by N.

Categories of the LOSA

LOSA identifies three main categories that must be recorded:

Safety change process

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. [15] 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. [15] There are several steps involved in conducting SCP: [15]

Safety Change Process (SCP) model
1. Collect safety issues (LOSA expert)2. Conduct detailed analysis of Risks/data3. Identify improvement strategies
8. Revise any changesSafety Change Process4. Risk Analysis
7. Observe the impact of changes6. Apply changes to operations5. Funding of changes

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. [15] 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. [15] A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.

See also

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References

  1. 1 2 3 Dekker, Sidney; Lundström, Johan (May 2007). "From Threat and Error Management (TEM) to Resilience". Journal of Human Factors and Aerospace Safety: 1. Retrieved 6 October 2015.
  2. Maurino, Dan (18 April 2005). "Threat and Error Management (TEM)" (PDF). Coordinator, Flight Safety and Human Factors Programme - ICAO. Canadian Aviation Safety Seminar (CASS): 1. Retrieved 6 October 2015.
  3. Banks, Ian. "Threat & Error Management (TEM) SafeSkies Presentation" (PDF). Retrieved 19 October 2015.
  4. 1 2 Thomas, Matthew (2004). "Predictors of Threat and Error Management: Identification of Core Nontechnical Skills and Implications for Training Systems Design". The International Journal of Aviation Psychology. 14 (2): 207–231. doi:10.1207/s15327108ijap1402_6. S2CID   15271960 . Retrieved 24 October 2015.
  5. 1 2 Earl, Laurie; Murray, Patrick; Bates, Paul (2011). "Line Operations Safety Audit (LOSA) for the management of safety in single pilot operations (LOSA:SP) in Australia and New Zealand". Aeronautica (Griffith University Aerospace Strategic Study Centre) (1): 2.
  6. Thomas, Matthew (2003). "Operational Fidelity in Simulation-Based Training: The Use of Data from Threat and Error Management Analysis in Instructional Systems Design" (PDF). Proceedings of SimTecT2003: Simulation Conference: 2. Retrieved 19 October 2015.
  7. Thomas, Matthew; Petrilli, Renee (Jan 2006). "Crew Familiarity: Operational Experience, NonTechnical Performance, and Error Management" (PDF). Aviation, Space, and Environmental Medicine. 77 (1). Retrieved 25 October 2015.
  8. Sexton, J. Bryan; Thomas, Eric; Helmreich, Robert (March 2000). "Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys". British Medical Journal. 320 (7273): 745–749. doi:10.1136/bmj.320.7237.745. PMC   27316 . PMID   10720356 . Retrieved 25 October 2015.
  9. 1 2 3 4 Earl, Laurie; Bates, Paul; Murray, Patrick; Glendon, Ian; Creed, Peter (2012). "Developing a Single-Pilot Line Operations Safety Audit: An Aviation Pilot Study". Aviation Psychology and Applied Human Factors. 2: 49–61. doi:10.1027/2192-0923/a000027. hdl: 10072/49214 . Retrieved 24 October 2015.
  10. Leva, M.C.; et al. (August 2008). "The advancement of a new human factors report – 'The Unique Report' – facilitating flight crew auditing of performance/operations as part of an airline's safety management system". Ergonomics. 53 (2): 164–183. doi:10.1080/00140130903437131. PMID   20099172. S2CID   32462406.
  11. 1 2 Edward; et al. (February 2015). "National Aeronautics and Space Administration threat and error model applied to pediatric cardiac surgery: Error cycles precede 85% of patient deaths". The Journal of Thoracic and Cardiovascular Surgery. 149 (2): 496–507.e4. doi: 10.1016/j.jtcvs.2014.10.058 . PMID   25726875.
  12. Kearns, Suzanne; Sutton, Jennifer (April 2013). "Hangar Talk Survey: Using Stories as a Naturalistic Method of Informing Threat and Error Management Training". Human Factors. 55 (2): 267–77. doi:10.1177/0018720812452127. PMID   23691823. S2CID   19549684.
  13. Thomas, Matthew; Ferguson, Sally (July 2010). "Prior Sleep, Prior Wake, and Crew Performance During Normal Flight Operations". Aviation, Space, and Environmental Medicine. 81 (7): 665–70. doi:10.3357/ASEM.2711.2010. PMID   20597246.
  14. Drury, Arthur; Ferguson, Sally; Thomas, Matthew (August 2011). "Restricted sleep and negative affective states in commercial pilots during short haul operations". Accident Analysis and Prevention. 45: 80–84. doi:10.1016/j.aap.2011.09.031. PMID   22239937.
  15. 1 2 3 4 5 "Line Operations Safety Audit (LOSA)" (PDF). ICAO Journal (First Edition): 25–29. 2002. Retrieved 18 November 2015.