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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Time Accident Causal Factors Over Time Human Causes Machine Causes
The Tip of the Iceberg What is happening here?
What is CRM? • Effective use of all resources, to achieve the highest possible level of safety and efficiency. • (Transport Canada)
RESIST THREATS HARDWARE & SOFTWARE THAT EXISTSBEFORE THE HUMAN ENTERS Strategies RESOLVE WHAT THE HUMAN BRINGS TOTHESYSTEM Continental Airlines ERRORS Resist Resolve CONSEQUENCE
What’s a Threat? • Anything that increases operational complexity
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
Northwest Airlines Undesired Aircraft State Trap: Managing Error Avoid Error: Managing Threats
Layered System of Defenses Undesired Aircraft State Threats
Case Study What we did at NWA
What we did at NWA Recurrent Training CBT
What we did at NWA Instructor Briefing Guides
What we did at NWA Briefing Room Posters
What we did at NWA • 7-hole cards to all • 5500 pilots • Mailbox • Briefing Rooms • Jumpseat Handout • Lounges 7-hole cards
Video Training & Scenario What we did at NWA
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
More Info… WATS www.cfidarren.com
Thanks Darren Smith www.cfidarren.com 813-503-3322