threat and error management. what is tem? “defensive flying”

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.

ICAO made LOSA the central focus of flight safety and human factors programmes.

TEM and LOSA recognised Worldwide.

TEM Philosophy

Three basic concepts:- Anticipation- Recognition- Recovery

Recover first, analyse the cause later.

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.

What is a latent Threat?

A threat that is not directly obvious to flight crew. A threat that is not directly obvious to flight crew.

Equipment design.Equipment design.

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

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.

Flight Crew Errors

Can be divided into three types: Aircraft Handling Procedural Communication Errors.

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

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.

A Decision MUST be made

Identify the Threats?

TEM Application

T Terrain W Weather O Operational P Plan

TWO-P

Terrain old Terrain new Weather good Weather bad Operational in Operational out

TWO-P

Assessing threats does not make them go away.

A threat briefing must contain effective strategies.

There must be a plan.

Levels of Situational Awareness

Level One: Perceive Level Two: Comprehension Level Three: Projection

Understand

Notice

Think

Ahead

NUTA

The NUTA/TEM Links

Situation Awareness

Threat Management

Notice

Understand

Think Ahead

Mitigate

Trap

Avoid

Countermeasures

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

What is an Unexpected Threat?

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

threat.

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