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What is an Undesired State?

What is an Undesired State?. A condition that clearly reduces safety margins resulting from an operator’s actions. Undesired state ≠ accident/incident. Examples: Unstabilized approach Unsecured galley cart during landing Engine access panel not secured before aircraft dispatch.

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What is an Undesired State?

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  1. What is an Undesired State? A condition that clearly reduces safety margins resulting from an operator’s actions. • Undesired state ≠ accident/incident • Examples: • Unstabilized approach • Unsecured galley cart during landing • Engine access panel not secured before aircraft dispatch * Must be managed or an accident or incident becomes more likely

  2. Putting TEM to Work Training Hazard Identification Maintenance QA Incident Analysis

  3. Hazard Identification and Mitigation: A Real-Life Example • Objective • Winter Ramp Operations • Aircraft towing operations • Personal Safety • Aircraft damage prevention • Meeting • Aviation Maintenance Technicians • Line Service Technicians • Pilot • Managers

  4. SMS: Hazard Identification

  5. “Brainstorming” with TEM • Identify expected and unexpected threats. • Tell me how to manage those threats. • What can we do if an error occurs? • What if we reach an undesired state? • MMMM

  6. What did we discover? • Threats • Expected • Snow, ice, cold, snow banks, plow trucks, • Ramp slope, de-ice fluid • Tug jack-knife • Unexpected • Increased time pressure • Snowy tires outside – wet slippery inside • Jet blast – blowing ice chunks • Flight attendant – baggage cart

  7. Insights • Threat Management • Winter driving techniques • “Make ‘em wait” • Error Management • Monitoring • Tug Operation • Personal well-being • Route planning • Undesired States • Jack-knifing tug

  8. Positive Safety Culture • Open Communication • Personal Commitment • Shared Values

  9. Validation • TEM model provided a helpful framework to guide the analysis. • Common language aided the discussion. • Other Comments: • “Raised common awareness” • “Usable results more quickly” • “Educational and fun”

  10. Conclusion • Easy to understand • Accessible to front-line personnel • Low-tech • Inexpensive • Broad cross-functional application • Supports a positive safety culture

  11. Threat and Error Management A SMS Tool You Can Use To Learn More About TEM: Go to www.flightsafety.org Peter N. Stein Air Charter Safety Foundation Symposium Washington, D.C. February 20, 2008

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