Captain Don Gunther Managing Director Human Factors & Safety Threat & Error Management (TEM) Workshop 3 rd IATA –ICAO LOSA & TEM Conference September 13-14,

Captain Don GuntherManaging Director Human Factors & Safety

““Threat & Error Threat & Error Management (TEM) Management (TEM)

Workshop”Workshop”

““Threat & Error Threat & Error Management (TEM) Management (TEM)

Workshop”Workshop”

3rd IATA –ICAOLOSA & TEM Conference

September 13-14, 2005Kuala Lumpur, Malaysia

3rd IATA –ICAOLOSA & TEM Conference

September 13-14, 2005Kuala Lumpur, Malaysia

Continental Airlines, Sept. 2005Continental Airlines, Sept. 2005

TEM Workshop Agenda

Developing a TEM program• LOSA

TEM and an Automation Policy TEM applied outside of Flight

Operations TEM applied to incident and accident

analysis TEM as an integral part of a Safety

Management System (SMS)

Flight OperationsTEM Training

Flight OperationsTEM Training


Why are we still doing CRM training?


1965 1975 1985 1995 2005 2015

Year

Hull loss accidentsper year

Hull loss accident rate

Airplanes in service

Millions of departures

25,400

2015

Business as usual

19,077

2004

Ac

cid

en

t R

ate

/ M

illi

on

De

pa

rtu

re

Our Goal

Departures 2004

17.5 Million

438

1960

We Need to Continuously ImproveAviation Safety

1965 - 2004

Boeing 2004 Statistical Data – May 2005


Accidents by Primary Cause1994 - 2003

Primary Factor

Flight crew

Airplane

Weather

Miscellaneous/other

Maintenance

Airport/ATC

Total with knowncauses

Unknown or awaitingreports

Total

84

19

16

7

5

5

136

50

186

Number of accidents

Total 10 20 30 40 50 60 70

Percentage of total accidents with known causes

Excludes: Sabotage Military action

62%

14%

12%

5%

4%

4%

Boeing 2003 Statistical Data – May 2004

66%69.1%

1994 -2003

1991 -2000

1959 -1995


Accidents by Primary CauseHull Loss Accidents – Worldwide Commercial Jet Fleet –

1995 through 2004-

56%

17%

13%

6%

4%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Flight Crew

Airplane

Weather

Misc./Other

Maintenance

Airport/Air Traffic Control

Total with known causes

Unknown or awaiting reports

Total

75

23

17

8

5

5

133

44

177 *As determined by the investigating authority, percent of accidents with known causes.

4%


Aviation Week Article on Healthy Organizations

“Investing the time and money needed to get at the root cause of a problem takes total commitment at the most senior levels of a company or organization. In most organizational settings, communicators learn early in life how bad news can impact their leaders. If the news is valued and the communicator is If the news is valued and the communicator is protected, there is a real chance information can and protected, there is a real chance information can and will routinely flow upward in time for proper action to will routinely flow upward in time for proper action to be takenbe taken.”

Safety Culture


The Safety Change Program“Tailored to Continental”“Tailored to Continental”

To properly target change we need current operational data, specifically for Continental, which is unique due to its…• History & Culture• Areas of operation (CMI, polar routes, etc.)• Philosophy

Line Observation Safety Audit(LOSA)

Line Observation Safety Audit(LOSA)


“Normal” Performance

Angel Normal

FAA CheckAirmen LOSA 1 LOSA 2

• Distance between “Perfect” and “Normal performance varies as a function of culture, training, etc.

• LOSA enables us to get as closer to normal performance than was previously possible.

Perfect


The Continental LOSA Process

1st year • LOSA and data analysis followed by course

development

2nd & 3rd years • Training course for all crewmembers, Check Airmen

training and imbedding of TEM into courseware, policy & procedures, etc.

4th year • Preparation for next LOSA and targeting areas to be

measured and new areas to be emphasized.


Line Observation Safety AuditLine Observation Safety AuditLOSA 1996LOSA 1996


Error Management’s early focus was:

Managing crew errorcrew error


Line Observation Safety AuditLOSA 2000


LOSA 1996 vs. 2000

A 70% reduction in Checklist errors A 60% reduction in unstable

approaches (confirmed by FOQA data) Overall improvement in crew

performance Still a need for improvement in

Leadership skills


Threat and Error ManagementThreat and Error Management


Threats

Threats • Do not equal errors• Increase error potential

Threats = Red Flags

"A threat is anything external to the crew that increases operation complexity and, if not managed

properly, can decrease the safety margins."

"A threat is anything external to the crew that increases operation complexity and, if not managed

properly, can decrease the safety margins."


THREATS

Influences that can lead to crew error

Weather

Maintenance

Ground Crew

Cabin Crew

Passenger eventsATC

Terrain

Similar call sign

Time pressures

Heavy traffic

Unfamiliar airport

Automation event Missed approach

Flight diversion

System malfunction

Distractions




Threat Management

Strategies/Countermeasures (Industry, Corporate and/or Personal)

• To reduce the number of errors

• To improve the error management process by increasing the awareness of potential errors




Error

Actions or inactions by the flight crew that lead to deviations from organizational or flightcrew intentions or expectations


Error Management

Actions taken to deal with errors committed by either

Detecting and correcting them, or by

Containing and reducing the severity


Error Management


RESISTRESISTHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS

Error Management


RESISTANCERESISTANCE

HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERSHUMAN ENTERS

•GPWS

•TCAS

•TRAINING

•MANUALS

•SOP’s SOP’s

•CHECKLISTSCHECKLISTS

•AUTOMATION

•ATC


RESISTRESISTHARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS

RESOLVERESOLVEWHAT THE HUMAN BRINGS TOWHAT THE HUMAN BRINGS TO THETHE SYSTEMSYSTEM

Error Management


RESOLVE

WHAT THE HUMAN BRINGS TO THE SYSTEMWHAT THE HUMAN BRINGS TO THE SYSTEM

• PROFICIENCY

• VIGILANCE

• ASSERTIVENESS

• MONITORING &

CROSSCHECKING

• DECISION MAKING

• EXPERIENCE

• LEADERSHIP

• SIT. ASSESSMENT

• CHECKLIST DISCIPLINE




NASA Guidelines

Monitoring & CrosscheckingMonitoring & Crosschecking


NASA Guidelines

Positively delegate flying and monitoringmonitoring duties

MonitoringMonitoring is as important as flying

Flying pilot does not become involved with secondary tasks

When conflict arises-resolve with outside source

When in doubt-must express!


Error ResolvedError Resolved

Monitoring and Crosschecking

Pilot Monitoring(PM)


Express Your ViewExpress

Your View

Take ActionTake ActionCrosschecking

StepsCrosschecking

Steps







Your View


StepsCrosschecking

Steps







Your View


StepsCrosschecking

Steps




(PM)(PM)

Crosschecking Steps

Crosschecking Steps


Your View

Take ActionTake Action


Case Studies““Look in the mirror first”Look in the mirror first”


TEM“the challenge”

How to improve How to improve

““Threat”Threat”

Identification?

““Get it on the Radar!”Get it on the Radar!”


Distractions


LOW VISIBILITY TAXI

DE - ICING

ALTITUDE DEVIATION

WRONG TURN

Threat and Error Management

Decision MakingDecision Making&&

LeadershipLeadership


DECISION-MAKING“Plan, Review, Monitor & Modify”


Perceive Situation

Develop Plan

Share Plan

Execute Plan

Monitor Results

Decision Making

Strategic


Perceive Situation

Develop Plan

Share Plan

Execute Plan

Monitor Results

Decision Making

Situation AssessmentSelect a Course of Action

StrategicTactical


Situation Assessment

The The Nature of the ThreatsNature of the Threats


Leadership

What have you seen?


Threat and Error ManagementThreat and Error Management““Training”Training”


TEM TRAINING CLASS

Ideal class size 15-20 The value of the introduction

• Opening question

Facilitation training• Line pilots

Follow-on Check Airmen training


Crew Resource ManagementCrew Resource Management

Effective Crew Resource Management is the bedrock of Threat and Error

Management.


NewsletterFeedback to the pilots is essential for continued

program success.


The Role of the Check Airman inThe Role of the Check Airman inThreat & Error ManagementThreat & Error Management

TEM &

Automation

TEM &

Automation


To ERR is Human

To REALLY make a mess of To REALLY make a mess of things, you need a computer!things, you need a computer!

Verbalize Verify

Monitor

The Continental Airlines The Continental Airlines

Automation PolicyAutomation Policy


TEMTEM““the challenge”the challenge”

Improve “Improve “Threat & ErrorThreat & Error” ” identification by usingidentification by using

To help “Get it on the To help “Get it on the RADARRADAR””

Verbalize, Verify, Monitor



What the human brings to the system

Hardware & Software that exists before the human enters

`

Verbalize, Verify, Monitor

TEM Trainingoutside of

Flight Operations

TEM Trainingoutside of

Flight Operations


Maintenance Threat & Error Management (MTEM)

Food Services Threat & Error Management

Field Services Threat & Error Management


Influences that can lead to agent error

Weather

Maintenance

New Agent

Cabin Crew

Passenger eventsLate Bags

Time pressures

Heavy traffic

Unfamiliar gate

Flight Crew

Flight diversion

System malfunction

DistractionsDistractions

Threats

Ramp slope

Late Gate Change

Late Cargo


Ramp LOSA


Why Ramp LOSA?

The first step in managing threats is to collect data• Precursors (Threats) are identified and

evaluated• Countermeasures (Strategies) are developed,

communicated throughout the organization, and then implemented in the system


Identified Threats

Threats can be prioritized according to• The probability of an incident or accident

occurring and then by• The severity of an incident or accident that may

occur if the “threat” is mismanaged


Threat Management

• The objective of “Threat Management” is to• Obtain an understanding of how to assess the

various risk levels of the threats and to• Gain an insight on logical approaches

(strategies) to deal them

TEM applied toIncident & Accident

Analysis

TEM applied toIncident & Accident

Analysis


TEM Toolkitfor

Incident & Accident (IA)Analysis


IATA Safety Advisory CommitteeIATA Safety Advisory CommitteeIncident & Accident analysisIncident & Accident analysis


IATA Safety Advisory CommitteeIncident & Accident analysis

THREAT AND ERROR MANAGEMENT (TEM): ANALYTICAL TOOLKIT

Introduction The TEM Analytical toolkit has been developed for Manager’s to facilitate presenting and sharing events and lessons learned. The toolkit is comprised of this document, explaining the TEM concept, and the presentation template.

Background Threat and Error Management (TEM) is proposed as a useful tool to analyse incidents and occurrences. Using this model naturally leads to prevention strategies, remedial actions and countermeasures. The model helps to reinforce positive strategies and highlights areas and issues that need to be addressed. It also helps to keep the focus on the relevant lessons learned from the event, moving away from the who and what and towards understanding the WHY.


Incident Example

Aircraft taxiing toward the gate 757 parked at adjacent gate Catering truck parked properly within the adjacent

gate clearance zone Arrival gate has an auxiliary J-line, requires 2

marshallers and clearance zones overlap Pre-arrival briefing not done Wing-walker had less than 30 days on job &

unfamiliar with these gates New wing-walker panicked and failed to give the

STOP signal when he saw the wing was going to strike the catering truck

Damage to wing and catering truck


Diagram of incident


Diagram of incident


Diagram of incident


Threat and Error Management (TEM)


Threats

1. List of the Threats2. 3.4.5.6.7.8.


Threats

1. 757 parked at adjacent gate2. Catering truck3. Arrival gate has an auxiliary J-line, requires 2

marshallers and clearance zones overlap4. Wing-walker had less than 30 days on job &

unfamiliar with these gates


Threat Management

1. Identify the Threat 1. Was the threat managed or mismanaged? How?

3.

2.

4. 4.

3.

2.


Threat Management

1. 757 parked at adjacent gate

1. Managed

3. Mismanaged – clearance zone not properly marked (latent)

2. Managed

4. Mismanaged – Crew brief not accomplished

4. Wing-walker had less than 30 days on job & unfamiliar with gates

3. Arrival gate… auxiliary J-line… clearance zones overlap

2. Catering truck


Errors

1. List of the Errors2.3.4.5.6.7.8.


Errors

1. Pre-arrival briefing not accomplished2. Catering truck parked in clearance zone3. Wing-walker did not give stop signal4.


Error Management

1. Identify the Error 1. Was the error managed or mismanaged? How?

4.

3.

2.

3.

2.

4.


Error Management

1. Pre-arrival briefing not accomplished

1. Mismanaged – Awareness of threat not established

4.

3. Wing-walker did not give stop signal

2. Catering truck parked in over-lapping clearance zone

3. Mismanaged – (latent?) training/ crew brief (E1)

2. Mismanaged – improper markings not detected (T3)

4.


Undesired State Management

List how the Undesired State was managed or mismanaged.


Undesired State Management

Managed• Post mishap procedures followed• PAX, fuel spill, etc• Etc.

Mismanaged…


Prevention Strategies

List initial corrective actions at the present time and any proposed actions.• Crew Briefs• Training• Auditing procedures/policy

TEM an integral part of a Safety Management System

(SMS)

TEM an integral part of a Safety Management System

(SMS)


Continental AirlinesSafety Management System

(SMS)


IATA & ICAO

SMS Documents and Training


SMS Essential Prerequisites

A comprehensive corporate approach to safety,

An effective organization for delivering safety, and

Systems to achieve safety oversight.


Developing the ContinentalSafety Management System (SMS)

Safety statement from CEO Corporate Safety Policy

• Add SMS description and Corporate Safety Policy to the Safety manual

Establish the Corporate Safety Review Board• Begin development of the Safety Action Team

within each division

Audit the remainder of the Continental SMS


Corporate Safety Review Board (CSRB)

Accountability

The CSRB is chaired by the CEO

Membership

CSRB membership comprises the CEO, (Sr/Exec) VPs of Flight Operations, Field Services, Tech Ops and Marketing (heads of the ‘functional areas’). The Director of Safety will attend the CSRB as the facilitator.


Safety Action Team (SAT)

Accountability SATs are responsible to the Corporate Safety Review Board and the

chair is determined by the appropriate (Sr/Exec) VP. Membership

SAT membership will normally be drawn from directors, managers, supervisors and staff, from within the appropriate functional area and when appropriate the FAA and labor.

Terms of Reference As a minimum each SAT is responsible for the following: To oversee operational safety within the functional area. To ensure that any necessary corrective action is taken in a timely

manner. To report to and accept strategic direction from the Corporate Safety

Review Board via the appropriate Exec/Sr VP.


Continental SMS

Corporate Safety Review BoardCSRB

Flight OperationsSafety Action Team

Tech OpsSafety Action Team

Field ServicesSafety Action Team

Director of Safety

Mkt/RsvSafety Action Team


Flight OperationsSafety Action Team (SAT)

Develop the process by which safety data and Develop the process by which safety data and crew performance and behavior data fromcrew performance and behavior data from

FOQA, LOSA, ASAP, CASIS, Line Checks,… FOQA, LOSA, ASAP, CASIS, Line Checks,… are analyzed by are analyzed by

Safety, Flight Operations, Inflight, Flight Safety, Flight Operations, Inflight, Flight Standards & Training, FAA and ALPA Safety Standards & Training, FAA and ALPA Safety in order to facilitate change.in order to facilitate change.


To have an effective SMS…

Safety & Operational Efficiency

need to be combined into a

Corporate “Safety CultureSafety Culture”


Goal

Become a better Threat Manager – actively identify threats in your operation

“Threat Management is managing your future.”

“Error Management is managing your past”

Continue building a Safety Culture by encouraging open, honest communications

