cabin crew threat and error management - pacdeff · • cabin crew are an integral part of the...

Cabin Crew

Threat and Error ManagementCarolyn Vaughan

Principal Adviser Human Factors

Example of Positive Cabin Crew TEMSan Francisco, July 2013

1L

2L

3L 3R

1R

4L 4R

FC told to Initiated

after hearing 2L’s

commands

Fire outside

Slide inflated

inside, created

bottleneck of

pax to 2L

Slide inflated

inside trapping

2x CC

Initiated evac after

seeing fire at 2R

Main Exit point

CC injured, door

opened by paxBriefly lost

consciousness

Door wouldn’t open,

CC redirected pax to

3R

Door torn from

frame, slide inflated

inside cabin

Severe damage.

Slide would not have

worked due

maintenance error

2R

Procedures v Threat and Error Management

• How do procedures and Threat and Error Management work together?

• Have we got the right emphasis?

• Will our crew be willing to think outside the box if needed?

Risk assessed procedures

v

Risk evaluation on the day

Real accidents are not as

black and white as EPs!

Threat and Error Management Toolbox

The Non Technical strategies and tools that you learn in Human Factors are your tools to help you:

Avoid / Prevent

Detect

Manage

Threats and Errors in the operation.

TEM Strategies are also embedded into procedures and practices.

Communication

Leadership and Managerial Skills

Teamwork

Decision MakingSituational Awareness

Structure of Topics

Fatigue

Stress

Distractions and

Interruptions

Design

CultureTechnology

Threat & Error Management•Avoid / Prevent

•Identify•Manage / Recover

Threat & Error Management Model

TEM Stages

AVOIDThreats

PREVENTErrors

IDENTIFYThreats and Errors

MANAGE and RECOVERfrom Threats and Errors

• Normal Procedures Training

• Briefings and communication between crew

• Silent Review

• Maintaining a shared or connected mental model

• Reporting

• Anticipating potential threats

AVOID PREVENT

• Allocating attention and managing distractions

• Cue recognition

• Recognising an action or situation as a threat or error

IDENTIFY

• Know the objective and put a strategy in place to meet it

• New objective New strategy

• Use all available resources

• Effective decision making methods that consider risk

• Awareness of factors affecting or limiting performance

• Evaluation loop

MANAGE and RECOVER

Underlying beliefs for Threat and Error Management to work

• Managing threats is a core part of the Cabin Crew

role.

- They may be expected (anticipated) or unexpected

(unanticipated)

• Errors should not be punished, but rather

expected and managed.

- Managing errors is part of the Cabin Crew role

• Cabin Crew are an integral part of the System.

- What I do matters! It’s up to me!

Behaviour for effective TEM

• Preparation, Anticipation, Communication

• If it is not possible to follow an exact procedure, follow the intent of the procedure

• Chronic unease – not complacent

• Actively managing and maintaining situational awareness

Attitudes towards Threat and Error Management

Sometimes errors happen, fortunately the crew caught it

and managed it effectively.

They managed to catch it before anyone was hurt but they

should have avoided the situation in the first place