Operational Threat and Error Management Ver 11

Copyright D.
Gurney Sept 2006
Human Factors Tool Kit
Threat
and
Error Management
Flight crew guide to managing error
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.
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.
Copyright D. Gurney Sept 2006
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 awareness Cancelling the effects - awareness and decision making Avoiding and trapping errors - plan, do, check Managing and mitigate - use all resources
Golden rules
Fly the aircraft take immediate corrective action 2. Navigate maintain situation awareness 3. Communicate - decision making 4. Manage - use all resources
1.
An Undesired State is often the first indication of an earlier threat or error that was not satisfactorily managed
Operational Threat and Error Management
Undesired State
as close to an accident as you ever want to get
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.
Threats
H
Other peoples errors
Errors slip, lapse, mistake Your errors
S
.
L E
L
Managing
Undesired
a safe
operation
States
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.
Threat
Origin
Situation threats - mainly physical items Organisational threats - other peoples error Self induced threats - commence with your error
Software: regulations,
manuals, checklists, publications, SOPs
H S L E L
Hardware: design, displays, location of controls
Environment: working conditions visibility, weather, turbulence, terrain.
Liveware: crews, ATC, dispatch, maintenance management
Error an 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.
Liveware, You: Inattention. Situation awareness. Knowledge, experience, attitudes and judgement.
Error Origin Good plan - made a mess of it; inattention, distraction Poor plan - did not understand the situation Bad habits - no SOP, poor discipline
Misinterpretation, slip, rush, lapse, failure to use, no feedback.
H S L E L
Mistake, haste misunderstanding.
Illusion, preconception Situation awareness.
Bias, belief, CRM Miscommunication.
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, and
checkers 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
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
Threats manage the result

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 result Monitor the progress of the chosen option Seek an alternative view of the situation Compare with the planned objective
Management includes the ability to identify, understand, and to project consequences into future activity.
See the Visual Guides on Situation Awareness and Decision Making
Managing error - to err is human

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 to err is human or no ready made solution available You must manage:Yourself, attention, stress and haste Time, disruption, workload; monitoring Knowledge, situation awareness, planning Violation: An intentional action deviating from rules and procedures, either by habit or as provoked by the situation.
Error Avoidance, plan ahead

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.
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
Attention - directing your thoughts

Insufficient cues, competing demands Attention, Vigilance and Comprehension Pre attention Communication 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 pressure controlling distraction
Good plan; plan goes wrong made a mess of it Good plan; plan goes wrong forgot something Poor plan; did not understand the situation
The path to adverse incidents is paved with false assumptions

Prof James Reason
Bad habit; deviationOperational Threat and Error Management from procedure
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. 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.
Self monitoring requires self awareness Detect adverse mental states such as distraction, lack of The attention, or rushing, absence of accidents does not mean there are no hazards. Stay inside your comfort zone your mental It is not who is right, its what is right and physical limits, follow SOPs
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 plan Scan 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.
check, scan and recheck
Plane
Path People
If something doesnt look or feel right, then it probably isnt right.
If the plan is not working - change the plan !

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
SOPs, Task management Time criticality, level of threat, risk assessment
Predictive proactive reactive Good 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
Error trapping
Proactive Scan, general awareness, systematic check. Anything
unusual divergence from the norm the plan Audit, Scan, Attention, Vigilance and Comprehension
Avoidance manage the situation and SA

Controlling behaviour
TIME
TIME
Self monitoring Risk 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
of ones 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 standard
procedures 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
Summary
Avoidance - PPPP
1 Avoid committing errors Error Avoidance 2 Manage operational complexity Threat Management
Manage their own errors
Error Management
Manage induced aircraft deviations
Undesired Aircraft State Management
A mixture of 'hard' and 'soft' defences. Defences-in-depth Not forgetting to be afraid
TEM - Manage
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
Outside boxes, external influences = Threats Links = sources of Error / error paths Spaces in between = Undesired States
Intellectual Confidence in Reason
Intellectual Sense of Justice
? L
Intellectual Integrity
Intellectual Humility
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
First
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:
Skill based error - action No conscious thought Rule based error - procedural wrong rule; misapplied correct rule
Situation Familiar task or situation
Rules procedures experience
Unfamiliar situation or task
Incorrect diagnosis
Knowledge based error - thinking
Norm activi
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 Situation threats
Undesired
Latent Conditions Unsafe Acts
Errors, mistakes, slips, lapses. Violations
states
Potential incident or accident
Error - Attention, Thinking, and Discipline

.
Situation
Good plan, plan goes wrong made a mess of it
Good plan, plan goes wrong forgot something
Error contributors
Inattention Haste, Stress
Attention failure
Insufficient cues Competing demands
Memory failure
Poor plan, did not understand the situation
Insufficient knowledge experience, or data
Thinking failure
Bad habit Deviation from procedure
Insufficient understanding of the risk or consequences
Violation

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Copyright D.

Gurney Sept 2006

Human Factors Tool Kit

Threat and Error Management

Copyright D. Gurney Sept 2006

TEM - a central safety process

Copyright D. Gurney Sept 2006

Errors slip, lapse, mistake Your errors

Copyright D. Gurney Sept 2006

Threats - come from beyond your influence

manuals, checklists, publications, SOPs

Hardware: design, displays, location of controls

Environment: working conditions visibility, weather, turbulence, terrain.

Liveware: crews, ATC, dispatch, maintenance management