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An Introduction to. Threat and Error Management. 1. What we will look at. 3. What is Threat and Error Management. It’s not Rocket Science. 17. Assumptions of Human Factors Training. Humans have limitations in their performance. Error is inevitable. 5. “To err is human”. 6.

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An Introduction to

Threat and Error Management

1



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What is Threat and Error Management

It’s not

Rocket

Science

17


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Assumptions of Human Factors Training

  • Humans have limitations in their performance

  • Error is inevitable

5



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Threats in the Operational Environment

What is a “Threat”

An indication of something coming; a menace or likely cause of harm

TEM Definition: An event or error that occurs outside the influence of the controller, but which requires his or her attention and management if safety margins are to be maintained

8


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Error

Threat

Threat

Threats

9


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Threats (Aerodrome Environment)

Comsfailure/

sticking mic

Distractions

Runway crossings

Visitors

Shift handovers

Weather

Similar call signs

Pilots and

Other Controllers

Maintenance

Non-standard local procedures

Restricted

Airspace

Runway inspections

Heavy traffic

System

malfunctions

Unfamiliar pilots

Automation events

Missed approaches


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Methods to Identify Threats

Just because you deal with a situation every day doesn’t mean that its not a Threat

13


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Methods to Identify Threats

Just because you deal with a situation every day doesn’t mean that its not a Threat

13


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NOSS / TEM Methodology

Threats

Errors

Undesired

States


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Methods to Assess a Threats Impact

  • Threat= Incorrect readback (pilot)

  • Threat Management=Nil

  • Error= Hearback Error (ATC)

  • Error Management= Nil

  • U/S= Aircraft climbing/ descending to altitude other than expected

  • U/S Management= Nil

  • Outcome= Loss of separation / Air Safety Incident

15


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DIP’s

Barriers to Monitoring Threats

  • Distractions

  • Interruptions

  • Preoccupations

DIP’s should always trigger a red flag

16


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Method to Monitor Threats

Strategies to Reduce DIPs -

  • Recognize conversation is a powerful distracter

  • Recognize heads-down work greatly reduces your ability to monitor

  • Minimize conflicts between tasks

  • Avoid focusing on a single task for too long

  • Assign responsibility

  • Treat DIPs as RED FLAGS


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Understand the difference between

Error Managementversus

Error Avoidance

7


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What is an Error

An action or inaction that leads to deviation from one’s intention or procedural requirements.


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What is an Error

An action or inaction that leads to deviation from one’s intention or procedural requirements.



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ER ORS

R

Errors and Violations

Errors and Violations

VIOLATIONS

  • You make an error when your action deviates from your intention, or when your intention is inappropriate

  • An error is not intentional

  • The effect of errors can be accounted for within the system

  • You commit a violation when you intentionally deviate from a regulation or from a procedure

  • A violation is originally intentional but can become routine


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67%of errors went undetected or were ignored

41% Airborne -Readback errors

-Failure to respond

-Parachuting near BDY

35% ANSP -Distractions,conversation

-Incorrect co-ordination

23% Environmental -WX deviations

-Low / poor visibility

Overall R/T comms produced the most threats and occurred on 70% of Obs

Threat Prevalence

100% of observations had at least one threat

Total 363 threats observed

Threat Management

82% of 362 threats were effectively managed

18% were mismanaged

Total 65 threats mismanaged

Threats - Undesired State Linkage

7% of threats were linked to undesired states

63% of 40 undesired states were linked to threats

Threat to Error Linkage

44% of 165 errors were linked to mismanaged threat

56% of errors were not

Total 63 observations

Error Prevalence

81% of observations had at least one error

19% were error free

Total 165 errors were observed

Error Management

76% of 165 errors had inconsequential outcomes

22% led to an undesired state

2% led to additional error

Total 40 errors mismanaged

Detected Error Outcomes

74% of errors that were detected were inconsequential

22% were linked to undesired states

4% were linked to additional error

Undesired State

Prevalence

and Management

45% of observations had US

Total 40 USs

100% of 40 US were inconsequential

Error Response

13% of 165 errors were detected by the observed controller

20% were detected by another party

67% went undetected or were ignored

Undetected Error Outcomes

76% of errors that were detected were inconsequential

22% were linked to undesired states

2% were linked to additional error





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