developing an effective team approach to threat and error management in an aviation orgnization

8/7/2019 Developing an Effective Team Approach to Threat and Error Management in an Aviation Orgnization

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Avia6120 Essay Allan BradleyTrimester Two, 2010 Task 6 C 313 5319

ASSIGNMENT COVER SHEET (Use as the first page of your assignment)

Student DetailsFamily Name: BradleyGiven Name: AllanStudent Number: c 313 5319

Course DetailsCourse Name: Crew Resource ManagementCourse Code: Avia6120

Assignment DetailsTask Number : 6Task Title: Essay: CRM/TEM Training

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DECLARATION:I have read and understand the University of Newcastles Policy for the Prevention and Detection of Plagiarism Main Policy Document, which is located at:http://www.newcastle.edu.au/policy/academic/general/plagiarism.htm

I declare that, to the best of my knowledge and belief, this assignment is my own work, all sources havebeen properly acknowledged, and the assignment contains no plagiarism. This assignment or any partthereof has not previously been submitted for assessment at this or any other University .

I acknowledge that the assessor of this assignment may, for the purpose of assessing this assignment: Reproduce this assessment item and provide a copy to another member of the Faculty;and/or Communicate a copy of this assessment item to a plagiarism checking service (which maythen retain a copy of the item on its database for the purpose of future plagiarism checking). Submit the assessment item to other forms of plagiarism checking

By attaching this cover sheet I am affirming the above declaration.Allan Bradley

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An effective team approach to threat and error management is the aim of CRM training. Howcan this be best achieved and monitored? Refer to relevant literature on the topic.

Developing an Effective Team Approach to Threat and Error Management In AnAviation Organization

By Allan Bradley

AbstractCrew Resource Management (CRM) training has developed in response to acknowledgementby the aviation industry that human factors contribute to more than half of all aviationaccidents and incidents. In the thirty years since CRM courses have existed, they have evolvedthrough six generations to the current Threat and Error Management (TEM) model. CRM hasexpanded from its original client base of flight deck crew, to the great majority of aviationindustry personnel. In doing so, recognition of factors such as they types of cultures in whichpeople work has to be taken into consideration. The use of Line Operations Safety Audits(LOSA) was developed to provide a real time, objective and contextual record of how crewsmanaged threats and errors on a flight deck. Use of data obtained from LOSA can be used toimprove not only the way flight crews manage threats and errors, but also help develop a just,safety culture within the organization.

IntroductionDuring World War Two, Allied bomber pilots flying from England to Africa were regularlyissued flight plans which routed them due south over the Atlantic Ocean for several hoursbefore turning east, heading for Africas west coast. Beaty (1995) reveals some bombers lostduring these flights were reported to have reached the point where they should have turned left(east) for Africa, but instead turned right (west) for the mid-Atlantic. Eventually these aircraftwould have run out of fuel and ditched mid ocean. Several aircraft that survived the flight onlydid so because at the turning point, when the navigator reported that it was time to turn left, thecaptain turned right and refused to listen to his crews exhortations to alter course. Eventuallythese crews overpowered their captain and turned the aircraft around. Subsequent debriefingrevealed that the captain just got bloody minded and refused to listen to anyone, regardless of how much sense they made. Beaty (1995) offers other examples of aircraft accidents causedby captains making decisions that defied logic, but it was apparent that these erroneousdecisions could not be explained as one off, freak events. There were too many to ignore.There were human factors in aviation incidents and accidents that needed understanding andmitigating.

Human Factors (HF) in aviation has now developed into a serious field of academic researchand Hawkins (1987) explains that in 1978, KLM (Royal Dutch Airlines) provided the firstHuman Factors Awareness Course. HF has since developed several branches of studyincluding one identified by Ruffell Smith (1979) and labeled by Lauber (1980) as (originally)Cockpit Resource Management, now Crew Resource Management (CRM). As Hawkins(1987) explains, CRM can be thought of as the management and utilization of all the people,

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equipment and information available to the aircraft. Since then, CRM has evolved through sixgenerations. The current (sixth) generation is termed Threat and Error Management (TEM).

Aviation authorities in many countries now mandate that companies have, as an integral part of their structure a Safety Management System (SMS). The role of the SMS is to use tools suchas CRM and TEM to establish robust defences to ensure that errors do not result in incidentsor accidents (CASA 2004). Maurino (2000) explains that until the year 2000, human factorshad been concentrated on the Flight Deck, but since then the idea has expanded to includeground, security, ramp operations and cabin safety staff. As part of this effort, ICAOencourages the implementation of Standards and Recommended Practices (SARPS) asdescribed in ICAO documents 8168 and 4444.

The Flight Safety Foundation (2010) reports that between 1990 and 1994 there were 1.32serious airliner accidents per million departures. By the end of the century, the number of serious airliner accidents had dropped to 1.06 per million departures. In the ten years since, thenumber of serious airliner accidents has dropped to 0.55 per million departures. Learmount(2010) suggests that this almost halving of the accident rate can be attributed to several factorsincluding: rapid development of computer and communication technology making gatheringand sharing data quicker and easier, development of systems such as Enhanced GroundProximity Warning Systems (EGPWS) and Traffic Collision and Avoidance Systems (TCAS),and establishment of organizations such as The US Commercial Aviation Safety Team (CAST)whose task is to identify safety priorities and create an action plan. The implementation in1999 of ICAOs Universal Safety Oversight Audit Programme also held member statesindividually accountable for aviation safety oversight in their country.

While technological advances must have contributed to aviation safety, it is recognized that60% of large jet transport accidents have flight crew errors as a causal factor (Duke 1991).Therefore, to significantly reduce the number of aircraft accidents, work had to be done toidentify and mitigate flight crew errors.

By the beginning of this century, CRM was evolving through its third and fourth generation.By the year 2000, CRM was moving out of the Flight Deck into the cabin and beyond.Helmreich and Foushee (2010) suggest that the behaviours that exemplified effective CRMwere being identified and highlighted. Acceptance and implementation of CRM training is, asa result of ICAO or State mandate, or by voluntarily embracing of its principles, becoming thenorm in the aviation industry. As CRM moves out of the Flight Deck, the size and complexityof the team increases and identifying ways to achieve and monitor an effective team approachto threat and error management needs to be considered.

The TeamShortly after Lauber (1980) first used the term Cockpit Resource Management, it was quicklyrealized that CRM was relevant beyond the cockpit and CRM became Crew ResourceManagement. Cabin Crew were the first team members outside the cockpit to be included inCRM. The importance of Cabin Crew as a resource was highlighted when they werent usedduring a B737400 accident in Kegworth, England in 1989. The Department of Transport

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(1990) noted that attempts by cabin crew to inform the Captain of their observations regardingthe remaining engine were summarily dismissed. The same report noted the role of Air TrafficControl who, in their attempts to help, became distractions to the pilots. Although it isconjecture, it could be argued that if the Captain had listened to the Cabin Crew, or if ATC hadnot been a constant source of distraction, the accident might have been averted. Utilization of all available resources was not optimized. As CRM evolved it began to include morepersonnel. It became apparent that hazards and errors can occur at all levels of anorganization, from the cockpit or the shop floor right through to the boardroom. Seeminglyminor errors or hazards in one area can combine with others to result in an incident or accident. (Reason, J. 2000). It therefore follows that any effort to identify and mitigate or negate threats and errors must include as many members of the aviation community aspossible. While ideally this would include everyone involved in aviation, on a more practicallevel, it should include everyone within an aviation organization and other organizations theydeal with. An example would be an airline dealing with other organizations such as ATC,caterers, refuellers, cleaners, security and so on.

Threat and Error ManagementMaurino (2005) defines threats as events or errors that occur beyond the influence of the flightcrew, increase operational complexity, and which must be managed to maintain margins of safety. Helmreich, Klinect and Wilhelm (1999) suggest threats can be classified as expected,unexpected or external errors. An example of an expected threat could be high terrainsurrounding an airfield. The terrain is well documented and procedures developed to mitigatethis threat. An example of an unexpected threat could be an in-flight aircraft systemmalfunction. In this situation the pilots must use their knowledge and skill to achieve asuccessful outcome. An external threat could be a hidden or latent system shortcoming such asan electronic flight instrument that becomes unreadable in bright sunlight. Maurino (2005)prefers to classify threats as either environmental or organizational. Regardless of how a threatis classified, a measure of the effectiveness of a team is their ability to anticipate and manage athreat.

Maurino (2005) defines errors as actions or inactions by the flight crew that lead to deviationsfrom organizational or flight crew intentions or expectations. Helmreich et al. (1999) havecategorized errors into five types and offer three possible responses to any error. One responseto an error that the error is trapped, that is, identified and managed before it is of anyconsequence. Another response is that an error could be exacerbated because although it isdetected, the flight crews actions lead to an undesirable outcome. Finally the flight crew couldfail to respond to the error at all. Outcomes to these three responses are listed asinconsequential, undesired aircraft state and additional error.

When it comes to threat and error management (TEM), Gunther (2003) proposes that threatsand errors are initially handled by strategies such as corporate culture, SOPs and personallydeveloped techniques. If these strategies fail, the threat or error is resisted by hardware andsoftware such as GPWS and TCAS. It is only when the resistance is defeated that humans arecalled upon to resolve the threat or error. In the examples of threats listed above, anticipatingand managing high terrain could include using full power takeoffs and terrain avoidance

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departure and arrival procedures. Anticipating and managing in-flight malfunctions could beachieved by Abnormal Procedures Checklists. For the example of an unreadable flightinstrument, good CRM that utilizes the other crew members instruments could be a strategy tomanage the threat. Errors can be avoided or resolved by crew members by being proficient intheir job, being vigilant, monitoring and challenging, exercising leadership skills and takingadvantage of previous experience (Gunther 2003).

As Gunther (2003) says because flying is our business, threats must be identified andreduced/eliminated while errors must be avoided and managed.

CultureSincere efforts to reduce threats or errors may mean changes being made within anorganization both structurally, such as reorganizing departments, and in the way personnelinteract, such as modifying Power Distance gradients. Helmreich (2003) notes that resistanceto such changes can be due to cultural issues. Helmreich and Merritt (1988) identify threecultures types influencing flight crew. These cultures are national, organizational andprofessional.

The national culture in which an organization and individual exists will inevitably exertinfluence in the workplace. While Lonner (1980) identifies seven psychological universalscommon to all cultures, Hofstede (1983) identified four cultural dimensions which varybetween nations. While little can be done by an organization to change a national culture, itshould be cognizant of the effect national culture has on the way threats and errors aremanaged and develop appropriate strategies. If a national culture places great value in safework practices, then the organization should reward and encourage this. If the national cultureis otherwise, it should develop strategies to modify such norms within the organization.

An organizations culture will have a major effect on how threats and errors and managed. Thehighest levels of management must be committed to installing and visibly supporting a systemwhich exists to minimize or negate threats and errors. If they are not, any attempt bysubordinate officers to install such a system will not be taken seriously by co workers. Asenior management which does not take safety seriously, will create a culture that suggestssafety isnt important and this will permeate through all ranks. Numerous organizationsincluding CASA (2004), ICAO-IATA (2003) confirm this.

Professional culture is well described by Helmreich (2002) and acknowledges that individualprofessions have norms, patterns of behaviour and other characteristics which make their profession unique. Sometimes a professional culture can be a positive influence for improvingsafety, such as refusing to accept incomplete or substandard work. Alternatively a professionalculture might not be such a positive influence, for instance supporting an attitude of near enough is good enough.

If all three aspects of culture; national. organizational and professional work together toencourage and support safe work practices and then a Safety Culture can establish itself withinthe organization. At the airline I work for efforts are ongoing to create an effective safety

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culture. Last week I attended an in-house workshop where it was stressed that the companyssafety culture needed to be seen as a just culture. Characteristics of a just culture include:accepting that safety is everyones responsibility, any staff member can report threats anderrors free from fear of reprisal, confidentiality of reporting is respected, there is mutual trustbetween a reporter and the person to whom they report, and acceptance by everyone thatmistakes happen but it is everyones responsibility to try to minimize them (RBA 2010).

Line Operations Safety AuditsEven with a determined and sincere desire within an organization to develop and improve ajust and effective safety culture, some staff may be engaging in unsafe practices or makingdecisions which erode safety without being aware of it. There are already some devicesavailable to the aviation industry which can highlight problem areas. Gunther (2003) lists someas: accident and incident reports, Quick Access Recorder (QAR) downloads for FlightOperations Quality Assurance (FOQA), regulatory mandates or rule changes, and regular simulator assessments of pilots. The issue with all of these tools is that they are backwardlooking and do not necessarily allow a context for a situation. All of the tools listed explainwhat happened. None of them explain what is happening. Maurino (1998) explains thataccident investigations rarely provide data which can be applied in future training and whilethey can tell us what went wrong, they give little or no opportunity to identify what pilots doright. Furthermore, accident investigation reports often identify procedures or systems thatfailed, but rarely have the ability to report human conditions such as confusion, forgetfulness,distraction or fatigue, which may be a result of training errors, flawed technology humaninterfaces, poorly designed procedures, corporate pressures or a poor safety culture. In order togive real time data which can be constructively used in the future to improve flight safety, theLine Operations Safety Audit (LOSA) was developed.

LOSA is a tool for helping to develop an effective safety culture within the aviation industry.FAA Advisory Circular 120-90 (2006) describes LOSA as a formal process that requiresexpert and highly trained observers to ride the jumpseat during regularly scheduled flights tocollect safety-related data on environmental conditions, operational complexity and flightcrewperformance. Confidential data collection and non-jeopardy assurance for pilots arefundamental to the process.

Escuer (2003) stresses that for any LOSA to succeed, pilots involved must be confident thatany data gathered during a flight will be confidential and not used as evidence for punitiveaction by the company. Trust between the pilots and the LOSA observers in the confidentialityof any data gathered is essential.

The FAA Advisory Circular 120-90 (2006) explains in detail the process for planning andconducting a LOSA and then goes on to summarize the ten operating characteristics of LOSA.The unique characteristic of LOSA which makes it so useful is the trained observer. Theobserver is able to identify threats which would otherwise remain unnoticed such as overloadedradio frequencies or regularly missed callouts or checklists. The observer can not only identifythreats and errors, but also record how the crew manage them. If a LOSA identifies threatsoccurring, errors or violations committed or normalization of deviance from Standard

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Operating Procedures (SOPs) then an organization with an effective safety culture should takeaction to improve safety. Any changes made should, as the FAA AC says be action-focusedand data driven. As well as being able to identify threats and errors, LOSA can also identifypositive behaviours such as techniques pilots have developed to manage regular threats or frequent errors. Kriechbaum and Alai. (2003) note that by conducting a LOSA, a snapshot of the current situation within an organization can be developed, improvements can then bedeveloped and implemented. Further LOSA in the future will provide data to identify if anychanges have been beneficial and if further changes are needed.

ConclusionFor more than sixty years the aviation industry has been aware that regardless of the reliability,intelligence, simplicity or complexity of any equipment, the human component must also beconsidered. Humans do not always behave logically or rationally and they can make errors.Evidence confirms that more than half of all aircraft accidents and incidents have human errorsas a causal factor. Developing systems and techniques to cope with the human component in asystem has been an ongoing field of research.

Efforts by the aviation industry to make flight crews aware of human factors and developstrategies to cope with them have been present for more than thirty years. Originally thecourses were provided solely for flight deck crew (pilots, flight engineers and in some cases,navigators and radio operators) however it soon became apparent that the team membersbeyond the Flight Deck needed to be included in human factors awareness and copingstrategies. The result was the development of Crew Resource Management (CRM) which hasas a basic premise, the management and utilization of all the people, equipment andinformation available to the aircraft (Hawkins 1987).

An important consideration when dealing with people is the culture in which they live andwork. National, organizational and professional cultures all influence personnel. Culture can bean obstacle to good CRM, for example a national culture which encourages high Power Distance (PD) gradients across a flight deck thus inhibiting a First Officer from challenging aCaptain. National culture may also enhance CRM if it encourages attention to detail andadherence to procedures. An organization may have a culture which encourages safe practicessuch as assertiveness from junior staff when they notice threats or errors within theorganization. Alternatively, an organizations culture might be so profit driven, that safepractices are not considered as important as a balance sheet with no red ink. Professionalpersonnel such as flight crew may also have a culture of their own. In a positive light, aprofessional culture may hold high standards of work in high esteem. Alternatively it mightimpose a negative influence such as belittling attempts to upgrade or improve procedures.Whichever cultural aspect is considered, because people are involved, CRM skills are animportant tool that can be used to help manage threats and errors.

CRM has evolved over the years and is now thought to be in its sixth generation which isidentified as Threat and Error Management (TEM). Threats are considered to be events or errors that occur beyond the influence of the flight crew, increase operational complexity, andwhich must be managed to maintain margins of safety Maurino (2005). Errors are considered

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to be actions or inactions by the flight crew that lead to deviations from organizational or flight crew intentions or expectations Maurino (2005). Initial countermeasures to threats anderrors are strategies already developed such as a corporate safety culture and SOPs. If thesestrategies are defeated, then the threat or error is resisted by hardware or software such asEGPWS or TCAS. It is only when strategies and resistance have been overcome that the flightcrew are called upon to resolve the situation using techniques such as vigilance, monitoringand challenging, assertiveness and leadership skills. As Gunther (2003) says because flying isour business, threats must be identified and reduced/eliminated while errors must be avoidedand managed.

Some of the issues that must be addressed when considering TEM are; knowing what threatsand errors are actually occurring, why they are occurring and how they are being resolved.Accident and Incident reports or Flight Data Recorder downloads only offer an after theevent perspective and do not give much opportunity for context. In an attempt to overcomethese shortcomings, the Line Operations Safety Audit (LOSA) was developed. During aLOSA, an independent, objective observer sits on the Flight Deck jumpseat recording threatsand errors as they occur and how the flight crew manages them. The advantage of a LOSA isthat it can give a real time analyses of what is happening and why. It can identify what thepilots get wrong (ignore or miss threats, commit violations, make errors) but just as important,it can also identify what the pilots get right. By conducting LOSA on a regular basis,

The data obtained from LOSA can then be used to make changes for the better. Weaknessescan be identified and strengthened, faults corrected and good ideas incorporated. Strategiescan be improved or put in place, levels of resistance can be enhanced and the ability of humansto resolve threats or errors developed. Cultural issues can be addressed in such a way as todevelop a just, safety culture within the organization. In this way an effective team approach tothreat and error management can be achieved and monitored.

References

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Hawkins, F., (1993) Human factors in flight , Aldershot, U.K. Ashgate

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http://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-90/$FILE/AC%20120-90.pdfhttp://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-90/$FILE/AC%20120-90.pdfhttp://www.flightglobal.com/articles/article.aspx?liArticleID=336920&printerFriendlyhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-90/$FILE/AC%20120-90.pdfhttp://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-90/$FILE/AC%20120-90.pdfhttp://www.flightglobal.com/articles/article.aspx?liArticleID=336920&printerFriendlyhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://www.icao.int/anb/humanfactors/icaojournalist.htm


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Submitted 12:52 BSTThursday 05 August 2010

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http://www.icao.int/cgi/goto_anb.pl?soahttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://flightsafety.org/archives-and-resources/threat-and-error-management-temhttp://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19790006598_1979006598.pdfhttp://www.icao.int/cgi/goto_anb.pl?soahttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://www.icao.int/anb/humanfactors/icaojournalist.htmhttp://flightsafety.org/archives-and-resources/threat-and-error-management-temhttp://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19790006598_1979006598.pdf

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