Airbus 16th Human Factors Symposium

Threat Recognition and Error Management (TREM)

Singapore, 8-10 October, 2002

Customer Services

Airbus 16th Human Factors Symposium

Presented by

Joey M. ANCA Jr Mike MYLAN

Singapore Airlines

Threat Recognition and Error Management (TREM)

Singapore, 8-10 October, 2002

Customer Services

Threat Recognition and Error Management (TREM) Contents The Evolution of Crew Resource Management (CRM) Threat Recognition & Error Management (TREM) Tools from Ground Up: An Organisational Strategy Building a Culture of Safety TREM in Singapore Airlines

16th Human Factors Symposium - Singapore 2002

The Evolution of CRM A Quick Heads Up

25 years of CRM with key issues that need to be addressed:
CRM

regulation of CRM into the Business of airline

Integration

operations
CRM

Evaluation and its relevance to shaping skills to minimize human error

Have we indeed given the pilot the TOOLS for better flightdeck error management? Have we made the necessary link between CRM and the business?
4 16th Human Factors Symposium - Singapore 2002

The Evolution of CRM

6th Generation CRM
LOSA TREM

SCIENCE & TECHNOLOGY (TOOLING

4th-5th Generation CRM

KAL Guam

DISCIPLINE
FOQA/QAR Incident Reporting/CHIRP/ASRS LOFT Development UAL 232 Sioux City

1st-3rd Generation CRM

UAL Everglades AF90 Potomac Behavioural Markers CRM
5 16th Human Factors Symposium - Singapore 2002

CONCEPT

CRM Instructors Behavioural Indicators

1st-5th Generation CRM Instructor (Aspirin to Ecstasy) CRM Zealot--one sided, either Management or Line; The I or Experience Syndrome of teaching: Been there, Done that; Uses psychobabble to impress learning; Inability to deal with classroom issues and its relationship to fleet or flying school concerns; Views CRM as the magic potion; CRM is localised as a teambuilding technique Increases pilot independence with other flightcrew (cabin crew, mechanics etc)-the Right Stuff or Clipper Captain attitude Very Charismatic and well-liked

6th Generation CRM Instructor (Antibiotic) CRM Helper--sees that CRM is just one of a host of error prevention strategies; Focus of error management is building an error tolerant crew or pilot Veers away from behaviour and focuses on systems approaches to safety Becomes a potent aid to flight operations administration Concerned with long-term solutions which may not deliver initial positive results Upholds Captains Authority but only after seeking information from crew members Uses a Just approach to things-respected for views but sometimes feared because of the truth.

16th Human Factors Symposium - Singapore 2002

Error Management An Organisational Strategy

Engineer Pilot Cabin Crew Station Manager

Organisation ATC Environment Team Workplace

Events
anomaly incident accident

16th Human Factors Symposium - Singapore 2002

TREM A Preventive Tool

Overt Threats: Organisational , Team, Individual, Environmental, External, Overt Threats: Organisational , Team, Individual, Environmental, Aircraft External, Aircraft

Threat Management

THREAT

Latent Threats: National, Organisational, Professional cultures; Regulatory System CRM Skill Countermeasures: Team Management,

RESPONSE

Planning, Task Execution, Task Review and Modification

Crew Error(s)

Error Management

OUTCOME

New Error

Inciden t

Undesired Aircraft State

8 16th Human Factors Symposium - Singapore 2002

Inconsequential

Safe Flight

The Safety and Service Culture Context

Actively Listening to Staff Chronic Unease about Safety Instilling Greater Customer Satisfaction

Just Culture

Safety & Service Culture Learning Culture

Informed Culture

*Red denotes SSE area of influence. 9 16th Human Factors Symposium - Singapore 2002

The Safety and Service Culture Context

Proactive Investigation Focused on Error Avoidance, Trapping, Mitigation IInvestigation and Discipline Process I

Just Culture

Safety Culture Informed Culture

Active Event Reporting System Incident Knowledge Base CConfidential Incident Reporting FFDAP/ Aviation Quality Database

CCRM Flight Ops CCRM beyond Flight Ops LLOSA

Learning Culture
Listening to the Troops Chronic Unease about Safety

*Red denotes SSE area of influence. 10 16th Human Factors Symposium - Singapore 2002

The Transcending Customer Service & TREM Education Program

TREM SAFE Program
Pilots

Engineering & Maintenance

TCS-OASIS TREM

Cabin Crew

Station Managers

11

16th Human Factors Symposium - Singapore 2002

A Culture of Safety Model: Overlapping Sleeves of Protection

Greater Vulnerability
Maturing Culture Values and Beliefs Compatibility throughout Layers of Sleeves Less Incidence of Non-protected Areas Predicting Vulnerability is a Way of Life

Sleeves Always in Motion

Decreasing Loyalty to the Company and Business Units engaged in SelfProtectionist affairs rather than Collective Wins Leaders are more concerned about Selfpreservation Safety information resides with a critical few

Individual

Team Workplace Organisation

Greater Protection
12 16th Human Factors Symposium - Singapore 2002

Context of CRM Integration (Areas of Influence)

Practical Application

Flight Operations

Joint Tech-Cabin CRM embedded in SEP

Ramp Operations

Integrated CRM

Cabin Crew
Maintenance Resource Management (MRM)

Customer Service Officers

Engineering

13

16th Human Factors Symposium - Singapore 2002

Building in the Business: Excellent Service + Error Free Product)

The Customers Line of Sight

Load, taxi, Takeoff unload

Initial climb Climb

Cruise

Final Initial Descent approachapproach Landing

CIQ/Baggag e

Flaps retracted
Ring Reservat ions

Home
Service Recovery

Nav fix Outer marker

Check-In

Our Line of Sight

ERRORS?

Service Error Free Product

14

16th Human Factors Symposium - Singapore 2002

Errors and Performance

In a tolerant system, when errors are detected ...

They are corrected

Behavior is readapted:

- Margins are increased - Attention level is raised - Monitoring is improved

Short term performance is adapted Long term performance is improved (learning)

15 16th Human Factors Symposium - Singapore 2002 Slide c/o Dedale Asia Pacific

LOSA and the SIA Safety Agenda

Quality Assurance FDAP Flight Ops Quality Management Flight Safety Pilots Flight Safety Champions

Safety, Efficiency, Reliability

Investigation Management System & Individual Learning Process IDP Discipline

Safety Information System CHFIRPS Incident Reporting Voyage Reports

LOSA Regular Audits Executive Feedback

16 16th Human Factors Symposium - Singapore 2002

The New ICON of Intent

Violation + Intent = Death and Destruction

17 16th Human Factors Symposium - Singapore 2002

Threat and Error Management

Threats & Errors

Threats / Errors detected and managed Inconsequential

Successful flight

Threats / Errors not detected / managed

Undesired aircraft state managed

Undesired aircraft state

Undesired aircraft state not managed

Slide c/o Dedale Asia Pacific

ACCIDENT/ INCIDENT

18

16th Human Factors Symposium - Singapore 2002

Violations Matter

40% of accidents in the global fatal accident database had violations

Flight Safety Foundation Report

Those who violate make twice as many other errors as those who do not Their errors are twice as likely to be consequential
Helmreich: US LOSA data

19

16th Human Factors Symposium - Singapore 2002

Slide c/o Dedale Asia Pacific

Learning From Errors

What happened?
Forgetting to... Seeing / hearing what was expected Slip

Why?
Time pressure Distraction Inattention

What did you learn?

Manage time Prioritise tasks Use check list

Highly experienced/ What if my expectation Too much anticipation is incorrect? Routine errors More attention More monitoring What may be different? Make it simple Stick to SOP

Wrong reasoning

Inadequate knowledge

20

16th Human Factors Symposium - Singapore 2002

Slide c/o Dedale Asia Pacific

Threat Recognition and Error Management (TREM) Conclusion

Have we provided more tools than theory to address

operational reality?

What are the opportunities to build TREM as an integral

component of airline business?

Thinking Pilot + Thinking Crew = Error Tolerant Operation?

A Culture of Safety: Where is the balance between

investing on the Hearts and Mind vv. Shaping the Environment?

TREM is focused on the CEO of the Aircraft. What else

can be done to focus on the CEO of the airline?
21 16th Human Factors Symposium - Singapore 2002