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Threat and error management

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Threat and error management (TEM) is a safety concept that aims to maintain safety margins by training pilots and flight crews with ability to detect and respond to events that are likely to cause damage to flight operations.[1] TEM is a diagnostic tool that measures the complexities of operational context and records the human performance in that context.[2] TEM also includes technical and environmental issues as well as Crew Resource Management issues.

In 1994, TEM Model was developed by the psychologists at University of Texas based on the investigation of accidents of high capacity Regular Public Transport (RPT) airlines.[3] The model primarily focuses on how to effectively manage the undesired occurrences. The model assumes that an undocumented and mismanaged errors or threats are linked to flight crew errors, which add more complexities in operational context and causes negative impact on crew performance. TEM Model should be constantly updated and reflect changing operational issues that pilots and crew members face daily.

LOSA (Line Operations Safety Audit) is a part of the TEM Model endorsed by ICAO. It is a safety measure process in which highly-trained expert identifies and collects safety related information about crew performance, environmental conditions, and operational complexity.[4] For example, LOSA expert collects information about the crew's certain responses and behaviors when a threat or error occurs during normal operation.[5]

Importance of TEM

Threat and error management is a crucial element in human factors engineering in aviation industry. There has been many strategies (e.g. training, teamwork, reallocating workload) that were focused on improving stress, fatigue, and error. According to Thomas (2004), flight crew training stressed the importance of operational procedures and technical knowledge and there has been less emphasis on nontechnical skills, which became isolated from the real-world operational contexts.[6] It is not well-acknowledged that there exists a barrier to effectively designing and managing a TEM system. According to Thomas and Petrilli (2006), a crew's nontechnical knowledge helps more in managing errors effectively than crew's familiarization of operations through experience.[7] Pilots who are selected from selection and training processes must be able to show analytical and coordination abilities.[8] Understanding nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.

LOSA

Line operation safety audit (LOSA) is a strategy that aims to develop measures for threats and errors in operational context. Under LOSA, an expert is employed to collect data about potential threats, errors, and communicates how these obstacles can be managed or removed.[9] The experts of LOSA observe and record the behaviors of flight crews but do not evaluate the performance.[10] Specific activities include the following: a) record visible threats b) identify error types, crew's responses, and specific outcomes c) use CRM behavioral markers to rate crew.[11]

Observation training

Training for LOSA expert includes two sessions: education in procedural protocol and TEM concepts and classifications.[9] A LOSA trainee is taught to find data first and code them later. In these two training sessions, a crew who receives the education must exhibit "LOSA Etiquette"; a crew must be able to notify the pilot as to why he or she was not able to detect an error or threat occurred after a flight. The pilot's responsibilities include his or her opinions on what safety issues could have had an adverse impact on their operations during the flight. A LOSA trainee then must record the specific responses from the pilot and code TEM performance after. Subsequent training involves testing exercises, demonstrating the mastery of safety skills and concepts, and a trial run.

Observers will finally record a pilot's overall response on a 4-point Likert Scale: 1) poor 2) marginal 3) good and 4) outstanding. This information will be quantified and will be presented as a table. For example, a following format may be used:[9]

Planning and execution of performance

Task Task Description Comments Rating
Monitor cross-check Active monitoring of crews Situational awareness maintained Outstanding
SOP briefing Carried out necessary briefings Thorough understanding of procedures
Contingency Management Communicate strategies Good management of threats and errors.
Identified Threats Managed Mismanaged *Frequency (N)
Air Traffic Control 17 2 19
Airline Operational Pressure 9 0 9
Weather 6 6 12

Frequency is the total number of threats occurred. Denoted by N.

Categories of TEM model

LOSA identifies three main categories of TEM model:

  • Threats are external factors or errors[9] that are outside the influence of flight crews. These increase the complexity of the normal operation because these can occur unexpectedly; pilots and flight crews may not be able to plan and fully investigate the cause of a threat if an unexpected threat occurs during the flight. Examples of threats are weather, terrain, aircraft malfunctions, and other external errors related to a personnel in charge of flight operations other than cockpit members. Non-standard care, decision strategy error, procedural error, protocol deviations are only few examples of other external factors.[10] A LOSA expert, who is seated on the jump seat,[12] must record such threats and categorize the findings under minor or major threats. A research on crew performance with TEM model discovered that a captain who had 6 hour less sleep on the day before regular flight schedule carried out poorer threat management.[13] Moreover, First Officers experienced frustration and crews experienced increased HEA (Heightened Emotional Acitivity) due to restricted sleep. An understanding of the HEA as a major part of TEM model is important during normal flight operation.[14]
  • Errors are caused by human action or inaction and increase the likelihood of adverse event.[10] In simple words, the errors come from crew judgment and communication problems. The difference between an error and a threat is that an error can be quickly identified with a careful attention and crew members are able to find a prompt solution to the error. Therefore, the impact of an error can be reduced quickly if that error is managed properly. Examples of errors include procedural errors (mistakes or inadequacy of attention towards a task at hand), and violation of SOP (intentional or unintentional adherence to standard operating procedures). Although crew members are encouraged not to be afraid of admitting their own mistakes, they must be able to self-criticize themselves since this learning process will help them understand the potential dangers that could have affected other crew members.[1]
  • Unintended States are aircraft configurations or circumstances that are caused by either human errors or by external factors.[9] The management of unintended states are vital since these can result in a severe aircraft accident. For example, navigation problems on the cockpit display may lead a pilot to make incorrect decision. Responding to this decision may cause fatal injuries to passengers and crew members on board.

Safety change process

Safety change process (SCP) is a part of LOSA and it is a formal mechanism that airlines can use to identify active and latent threats to flight operations.[15] It is a guideline that clearly communicates in detail what is an imminent threat to current operation or who is causing the threats. In the past, SCP data were based on investigation of accidents or incidents, experiences, and intuitions but nowadays SCP focuses more on the precursors of accidents.[15] There are several steps involved in conducting SCP[15]:

Safety Change Process (SCP) Model
1. Collect safety issues (LOSA expert)2. Conduct detailed analysis of Risks/data3. Identify improvement strategies
8. Revise any changesSafety Change Process4. Risk Analysis
7. Observe the impact of changes6. Apply changes to operations5. Funding of changes

An anonymous airline conducted a base-line observations from 1996 to 1998 using the defined SCP and LOSA data to improve its organization's safety culture and the results were positive. A crew error-trapping rate was significantly increased to 55%, meaning that crews were able to detect about 55% of the errors they caused.[15] A 40% reduction in errors related to checklist performance and 62% reduction in unstabilized approaches (tailstrike, controlled flight into terrain, and runway excursions etc) were observed.[15] A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.

See also

References

  1. ^ a b Dekker, Sidney; Lundström, Johan (May 2007). "From Threat and Error Management (TEM) to Resilience". Journal of Human Factors and Aerospace Safety: 1. {{cite journal}}: |access-date= requires |url= (help)
  2. ^ Maurino, Dan (18 April 2005). "Threat and Error Management (TEM)". Coordinator, Flight safety and Human Factors Programme - ICAO. Canadian Aviation Safety Seminar (CASS): 1. {{cite journal}}: |access-date= requires |url= (help)
  3. ^ Banks, Ian. "Threat & Error Management (TEM) SafeSkies Presentation". {{cite web}}: |access-date= requires |url= (help); Missing or empty |url= (help)
  4. ^ Earl, Laurie; Murray, Patrick; Bates, Paul (2011). "Line Operations Safety Audit (LOSA) for the management of safety in single pilot operations (LOSA:SP) in Australia and New Zealand". Aeronautica (Griffith University Aerospace Strategic Study Centre) (1): 2.
  5. ^ Thomas, Matthew (2003). "Operational Fidelity in Simulation-Based Training: The Use of Data from Threat and Error Management Analysis in Instructional Systems Design". Proceedings of SimTecT2003: Simulation Conference: 2. {{cite journal}}: |access-date= requires |url= (help)
  6. ^ Thomas, Matthew (2004). "Predictors of Threat and Error Management: Identification of Core Nontechnical Skills and Implications for Training Systems Design". The International Journal of Aviation Psychology. 14 (2). {{cite journal}}: |access-date= requires |url= (help)
  7. ^ Thomas, Matthew; Petrilli, Renee (Jan 2006). "Crew Familiarity: Operational Experience, NonTechnical Performance, and Error Management". Aviation, Space, and Environmental Medicine. 77 (1). {{cite journal}}: |access-date= requires |url= (help)
  8. ^ Sexton, J. Bryan; Thomas, Eric; Helmreich, Robert (March 2000). "Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys". British Medical Journal. 320 (7273): 745–749. {{cite journal}}: |access-date= requires |url= (help)
  9. ^ a b c d e Earl, Laurie; Bates, Paul; Murray, Patrick; Glendon, Ian; Creed, Peter (2012). "Developing a Single-Pilot Line Operations Safety Audit: An Aviation Pilot Study". Aviation Psychology and Applied Human Factors. 2: 49–61. {{cite journal}}: |access-date= requires |url= (help)
  10. ^ a b c Edward; et al. (February 2015). "National Aeronautics and Space Administration threat and error model applied to pediatric cardiac surgery: Error cycles precede 85% of patient deaths". The Journal of Thoracic and Cardiovascular Surgery. 149 (2). {{cite journal}}: |access-date= requires |url= (help); Explicit use of et al. in: |last1= (help)
  11. ^ Leva, M.C.; et al. (August 2008). "The advancement of a new human factors report – 'The Unique Report' – facilitating flight crew auditing of performance/operations as part of an airline's safety management system". Ergonomics. 53 (2): 164–183. {{cite journal}}: |access-date= requires |url= (help); Explicit use of et al. in: |last1= (help)
  12. ^ Kearns, Suzanne; Sutton, Jennifer (April 2013). "Hangar Talk Survey: Using Stories as a Naturalistic Method of Informing Threat and Error Management Training". Human Factors. 55 (2). {{cite journal}}: |access-date= requires |url= (help)
  13. ^ Thomas, Matthew; Ferguson, Sally (July 2010). "Prior Sleep, Prior Wake, and Crew Performance During Normal Flight Operations". Aviation, Space, and Environmental Medicine. 81 (7). {{cite journal}}: |access-date= requires |url= (help)
  14. ^ Drury, Arthur; Ferguson, Sally; Thomas, Matthew (August 2011). "Restricted sleep and negative affective states in commercial pilots during short haul operations". Accident Analysis and Prevention. 45: 80–84. {{cite journal}}: |access-date= requires |url= (help)
  15. ^ a b c d e "Line Operations Safety Audit (LOSA)". ICAO Journal (First Edition): 25–29. 2002. {{cite journal}}: |access-date= requires |url= (help)
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