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Intro to Threat & Error Management. Welcome. Time. Accident Causal Factors Over Time. Human Causes. Machine Causes. The Tip of the Iceberg. The Tip of the Iceberg. What is happening here?. What is CRM?.

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Intro to Threat & Error Management


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    Presentation Transcript
    1. Intro to Threat & Error Management Welcome

    2. Time Accident Causal Factors Over Time Human Causes Machine Causes

    3. The Tip of the Iceberg

    4. The Tip of the Iceberg What is happening here?

    5. What is CRM? • Effective use of all resources, to achieve the highest possible level of safety and efficiency. • (Transport Canada)

    6. RESIST THREATS HARDWARE & SOFTWARE THAT EXISTSBEFORE THE HUMAN ENTERS Strategies RESOLVE WHAT THE HUMAN BRINGS TOTHESYSTEM Continental Airlines ERRORS Resist Resolve CONSEQUENCE

    7. What’s a Threat? • Anything that increases operational complexity

    8. Example Threats Passenger Events Distractions ATC Cabin Crew Terrain Weather Similar Call Sign Maintenance Time Pressures Ground Crew Flight Diversion Heavy Traffic System Malfunction Unfamiliar Airport Missed Approach Automation Event

    9. What’s the Threat?

    10. ICAO

    11. Northwest Airlines Undesired Aircraft State Trap: Managing Error Avoid Error: Managing Threats

    12. Layered System of Defenses Undesired Aircraft State Threats

    13. TEM Toolkit

    14. Case Study What we did at NWA

    15. What we did at NWA Recurrent Training CBT

    16. What we did at NWA Instructor Briefing Guides

    17. What we did at NWA Briefing Room Posters

    18. What we did at NWA • 7-hole cards to all • 5500 pilots • Mailbox • Briefing Rooms • Jumpseat Handout • Lounges 7-hole cards

    19. Video Training & Scenario What we did at NWA

    20. Integrating Threat & Error Management • Flight Standards • Line checks to reinforce threat recognition, error avoidance and management • Flight Operations • Review/revise SOPs and policies • Safety • Error reporting system (ASAP) for data • Safety Programs (HF, FOQA) • Ongoing QA Audits • Training • Threat recognition & error avoidance and management • Captain Leadership • Focus on technical and procedural excellence

    21. More Info… WATS www.cfidarren.com

    22. Thanks Darren Smith www.cfidarren.com 813-503-3322