operational threat and error management ver 11

7/29/2019 Operational Threat and Error Management Ver 11

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Copyright D. Gurney Sept 2006

Threatand

Error Management

Flight crew guide to managing error

Human Factors Tool Kit

This presentation provides information and guidance to help improve decision making. It is intended to enhance the reader's awareness but it shall not supersede the applicable regulations or

airline's operational documentation; should any deviation appear between this presentation and the airlines AFM / (M)MEL / FCOM / QRH / FCTM, the latter shall prevail at all times.


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Threat and Error Management

Introduction

This visual guide provides practical guidance to aid crews in managing the

hazards in everyday operations. Threat and error management is a central

safety activity for both organisations and individuals.

There are four sections:

1. Introduction

2. Threats and Error Avoidance

3. Error detection

4. Response

The guide may be used for self study or as part of a formal training presentation.

The speaker notes provide additional information.

Threat Management is the opportunity to manage your future.

Error Management is the necessity to manage your past.

Speakers notes provide additional information, they can be selected by clicking the right mouse button in Slideshow View, select Screen, select Speakers notes.

This presentation can be printed in the notes format to provide a personal reference document.


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Operational Threat and Error Management

TEM- a central safety process

Threat and Error Management(TEM) defends against operational threats and errors,

which if incorrectly managed can lead to undesired states. The process involves

recognising and cancelling the effects of threats, avoiding, trapping, or

mitigating the result of errors and managing the outcome.

Priorities:

Deal with any undesired state, take immediate corrective action

Threat recognition and avoidance - good situation awarenessCancelling the effects - awareness and decision making

Avoiding and trapping errors - plan, do, check

Managing and mitigate - use all resources

Golden rules

1. Fly the aircraft take immediate corrective action2. Navigate maintain situation awareness

3. Communicate - decision making

4. Manage - use all resources

An Undesired State is often the first indication of an earlier threat or error

that was not satisfactorily managed


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Any condition or situation that reduces safety.

Undesired states reduce margins of safety and may lead to hazardous situations in daily

operation; - flight near Cbs, new taxi patterns.

They represent aircraft or operational deviations from the normal standard at edge of the safety

envelope; - an un stabilised approach, failure to go around.

Undesired states are often the last stage before an incident or accident; - EGPWS Pull Up.

Undesired .

States

Undesired Stateas close to an accident as you ever want to get

Threats

Other

peoples errorsS

E

L

H

L

Managing

a safe

operation

Your errors

Errors

slip, lapse, mistake


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S

E

L

H

L

Threats- come from beyond your influence

Threats are events or errors that increase operational difficulty and must be

managed to maintain safety.

Threats may be minor or isolated issues, but are of particular significance

when they occur in combinations or in high risk situations.

Hardware: design,

displays, location of

controls

Software: regulations,

manuals, checklists,

publications, SOPs

Liveware: crews,

ATC, dispatch,

maintenance

management

Environment: working

conditions visibility,

weather, turbulence,

terrain.

Threat Situation threats - mainly physical items

Organisational threats - other peoples error

Self induced threats - commence with your error

Origin


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Erroran unexpected outcome

Errors are actions or inactions which result in an unintended outcome. Errors

reduce the margin of safety and can lead to undesired states.

Most situations contain opportunities for error and error provoking items. You, or other people

are always part of the situation and therefore subject to error.

S

E

L

H

LBias, belief, CRM

Miscommunication.

Illusion, preconception

Situation awareness.

Mistake, haste

misunderstanding.

Liveware,You: Inattention.

Situation awareness.

Knowledge, experience,attitudes and judgement.

Misinterpretation, slip, rush,

lapse, failure to use, no

feedback.

Error Origin

Good plan - made a mess of it; inattention, distraction

Poor plan - did not understand the situationBad habits - no SOP, poor discipline


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Anticipating threats and errors

Activities in a Safety Management System (SMS) must proactively seek out threats

and opportunities for error.

Management officers and pilots, instructors, andcheckers must provide guidance for avoiding

and resolving threats and errors, and then

minimise the resultant effects with;

Rules

Procedures

Training and Checking

Reporting and Incident analysis

Operating crew have to manage residual risks and the situational threats or opportunities for

error encountered in daily operation; this requires -

Preparation, Planning, Briefing

Gaining and maintaining situation awareness

Vigilance, Scanning and Questioning Task and Workload sharing

Teamwork, Communication

Checking and Monitoring

Following SOPs

Debriefing

A mistake is just another way of doing something


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Threats- Recognition and Cancelling their effect

Threat recognition requires good situation awareness and attention.

Obvious threats within the operating environment i.e. terrain, weather, ATC.

Other threats may not be so easy to see and may require special attention: Operational aspects; dispatch, cabin, passengers, paperwork

Distraction; system faults, warnings or unusual indications

Human performance; time pressure, fatigue, stress

Beware of multiple or threat combinations as

the adverse effects can develop rapidly.

Wet runway and tailwind or crosswind

Non precision approach, no DME

IFR, terrain, system fault

Cancelling the effect of threats involves choosing a course of action.

This involves awareness, decision making, checking, and monitoring.

The effect of threats can be reduced by: Changing the plan.

Using of alternative procedures.

Checking and monitoring the progress of the new plan.

Comparing planned activities with standard operating procedures.

See the Visual Guides on Critical Thinking and Situation Awareness


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Threats manage the result

Management includes the ability to identify, understand,

and to project consequences into future activity.

Threat management involves evaluating plans or options and choosing suitable

course of action to maintain the safety of flight.

Ask questions about your assessment of the situation and your choice of action

Continuously assess and balance the risks involved with the choice of action

Check your immediate objective; is this the safest , thus the best option

Check your understanding of the planned actions think ahead

Have you used all resources and information

Confirm the action gave the expected resultMonitor the progress of the chosen option

Seek an alternative view of the situation

Compare with the planned objective

See the Visual Guides on Situation Awareness and Decision Making


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The most important aspect of TEM is to understand that errors always occur.

Everyone makes errors; errors are part of normal behaviour.

Human error is the single largest cause of incidents and accidents in aviation.

Human error appears in many forms and severity, but most are detectable.

Human error can be managed by avoiding, trapping, or containing the result.

Error - action or inaction with an unintended outcome

Slip - failure of attention

Lapse - failure of memory

Mistake - misapplication of a good rule

application of a bad rule

or no ready made solution available

You must manage:-Yourself, attention, stress and haste

Time, disruption, workload; monitoring

Knowledge, situation awareness, planning

Managing error- to err is human

to err is human

Violation: An intentional action deviating from rules and procedures,

either by habit or as provoked by the situation.

C i ht D G S t 2006


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Error avoidance requires good situation awareness. Awareness involves a mental

model and monitoring progress against a plan; plans help us to avoid error.

You must create a plan; if not you could select an incorrect course of action.

Any plan can be affected by the situation, but all plans can be changed.

Prepare a briefing; structure it along the flight path - Visualise mental waypoints.

What should happen; when. What are the limits; why?

Allocate tasks - workload management:

Who will action these tasks; when, and how?Consider likely threats and opportunities for error - ask what if

How are these best avoided; who checks these hazards, and when.

Error Avoidance, plan ahead

Planning is a skill requiring experience and knowledge.

A skill can be improved with practice; make plans and

prepare briefings for every flight phase - self brief. Experience is gained from every plan and briefing.

Knowledge is improved by briefing and debriefing.

Stay ahead of the airplane

Consider what if

Cop right D G rne Sept 2006


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Attention -directing your thoughts

Insufficient cues, competing demands

Attention, Vigilance and Comprehension

Pre attentionCommunication

Teamwork, Support

Self monitoring

Cross monitoring

Communication

SOPs, Task management

Check the plan and briefing, use SOPs

Self monitor, focus and maintain attention

Scan plane, path, people; identify the unusual

Decision making, beware stress attention narrowing reduced working memory

Beware concurrent task demands, time pressurecontrolling distraction

The path to adverse incidents is paved with false assumptionsProf James Reason

Good plan; plan goes wrong made a mess of it

Good plan; plan goes wrong forgot something

Poor plan; did not understand the situationBad habit; deviation from procedure

Copyright D Gurney Sept 2006


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Manage yourself

Self knowledge enables you to control how you think; controlling your thoughts

enables you to stay in control of the situation and reduce error.

Ask questions of yourself:

Check the reasons for your decisions and intended actions.

Monitor your performance:

Check the results of your thoughts and actions, your workload.

Switch on your thinking, be proactive:

Scan the situation, now and future - Plane, Path, People.

Review the risks from existing threats:

Cross check with the plan and briefings, are these as expected.

The absence of accidents does not mean there are no hazards.

Questions for managing the mind.

What should I be thinking about now.

Why do I think this is safe.

When will this happen.How do I achieve this.

Who will assist me.

It is not who is right, its what is right

Self monitoring requires self awareness

Detect adverse mental states such as distraction, lack of

attention, or rushing,

Stay inside your comfort zone your mental

and physical limits, follow SOPs

Copyright D Gurney Sept 2006


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Use the plan monitoring, error trapping

Monitoring is a comparison of the plan or procedure against flight progress or

actions to identify error.

Briefings and procedures are the initial plans for monitoring and checking

A briefing is the flight plan for the mind, it defines the boundaries of a safe operation.

Briefings enable a shared mental model, but check that everyone has the correct mental model.

Cross check your understanding of the current situation

Take time to assess the situation, compare it with the planScan the Plane, Path, People:

Aviate, Navigate, Communicate.

Identify and highlight:

Anything unusual or non standard,

out of limit or abnormal values.

Expect threats and errors:

Maintain vigilance and attention,

monitor yourself, check you actions and

avoid risky alternatives.

Plane

Path

People

check,

scan and

recheck

If the plan is not working - change the plan !

If something doesnt look or feel right, then it probably isnt right.



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A good plan- poor execution - forgot

Sometimes good plans fail due to errors in carrying them out - a loss of situation

awareness or misinterpretation of the situation.

Inattention; incorrect action or thought

Distraction; failure or inability to remember

Misinterpretation illusion; time & workload

Haste stress

SOPs

Checklists Review and evaluation, monitoring

Airmanship - diligence

Predictive proactive reactiveGood plan; plan goes wrong made a mess of it

Good plan; plan goes wrong forgot something

Poor plan; did not understand the situation

Bad habit; deviation from procedure

SOPs, Task management

Time criticality, level of threat, risk assessment



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py g y p


Error trapping

Proactive Scan, general awareness, systematic check. Anything

unusual divergence from the norm the plan

Audit, Scan, Attention, Vigilance and Comprehension



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Avoidance manage the situation and SA

Controlling behaviour

TIME

TIME

Self monitoringRisk assessment




Bad Habits- violations

Violations are intentional actions or inactions, which violate known rules,

procedures or norms. The fundamental difference between errors and violations

is that violations are deliberate, whereas errors are not. In other words,

committing a violation is a conscious decision, whereas errors occur irrespective

ofones will to avoid them.

There are known factors that increase the probability of committing violations:

Expectation that rules will have to be bent to get the work done

Powerfulness: Feeling that skills and experience justify deviating from the standardprocedures

Opportunities for short cuts and other ways of doing things in a seemingly better way

Poor planning and preparation, putting the person in situations where it is necessary to

improvise and solve problems on the fly as they arise.

Bad habits - no SOP, poor discipline




Good Habits-an attitude of mind

Risk assessment




SOPs- Controlling and containing error




Error Response Priorities& Workload

Stay in control - mitigation

Managing normal operations

Assess time available and risk

Think ahead, plan and recheck

Decision making, prioritise

Use the safest option

Monitor, check

Debrief

Undesired state management Containing the result




Conclusions -Hazard response

Provide means of escape and rescue

Contain and eliminate hazards

Interpose safety barriers between hazards and losses

Restore system to safe state in off-normal conditions

Provide alarms when danger is imminent

Give clear guidance on safe operation

Create understanding of hazards



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Summary

Avoidance - PPPP Error Avoidance1 Avoid committing errors

Manage operational complexity2 Threat Management

Manage their own errors3 Error Management

Undesired Aircraft StateManagement

4 Manage induced aircraft deviations

A mixture of 'hard' and 'soft' defences.

Defences-in-depthNot forgetting to be afraid



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Recognise threats, avoid errors

Scan plane, path, people; identify the unusual

Thoughtful decision making, careful actions

Self monitor, focus and maintain attention

Check the plan and briefing, use SOPs

Cancel the effect of threats, trap errors

Procedures, monitoring, checklists

Planning and preparation, briefing

Task and workload reduction

Teamwork, communication

Manage threats, mitigate the effects of error

Assess time available and risk

Think ahead, prioritise

Use the safest option

Monitor, recheck

Debrief

TEM- Manage


Outside boxes external influences = Threats


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Intellectual

Sense of

Justice

IntellectualHumility

IntellectualIntegrity

IntellectualConfidence in

Reason

?S

E

L

H

L

Outside boxes, external influences = Threats

Links = sources ofError/ error paths

Spaces in between = Undesired States



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Errors

HFACS Principles

Principle 1: Aviation is similar in nature to other complex productive systems.

Principle 2: Human errors are inevitable within such a system.

Principle 3: Blaming an error on the decision maker is like blaming a mechanical

failure on the hardware.

Principle 4: An accident, no matter how minor, is a failure of the system.

Principle 5: Accident investigation and error prevention go hand-in-hand

Longer time scales Strategic, proactive

Management: checks and audits, data monitoring, SMS

Operational: planning, briefing, Situation awareness, thinking ahead

Shorter time scales Tactical, reactive

Operational: Situation awareness, monitoring, check against plan, risk assessment,

judgment, decision making



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Situation

The first and most important item of TEM is to accept that errors occur;

everyone suffers error. Errors are part of your normal behaviour.

Origins of error:

First

Nor

activi

Familiar task

or situation

No conscious

thought

Skill based

error - action

Rules

procedures

experience

wrong rule;

misapplied

correct rule

Unfamiliar

situation or

task

Incorrect

diagnosis

Rule based

error - procedural

Knowledge based

error - thinking



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The structure of an accident

In general incidents and accidents result from of a combination of latent factors -

preconditions, and unsafe acts. Situations when the holes line up.

Threats in everyday situations contribute to many of the preconditions; many threats result

in unsafe acts.

Errors dominate the unsafe acts, which consist of intended and unintended actions.

Defensive barriers

Safety Management

Threat and Error Management

Hazards

Situationthreats

Undesired

states

Potential incidentor accident

Latent Conditions

Unsafe Acts

Errors, mistakes, slips,lapses. Violations



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Error- Attention, Thinking, and Discipline

.

Attention failure

Memory failure

Thinking failure

Good plan, plan goes wrong

made a mess of it

Poor plan, did not understand

the situation

Bad habitDeviation from procedure

Good plan, plan goes wrong

forgot something

Inattention

Haste, Stress

Insufficient cues

Competing demands

Insufficient knowledge

experience, or data

Insufficient

understanding of the

risk or consequences

Violation

Situation Error contributors

operational threat and error management ver 11

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