Intro to Threat & Error Management

Welcome

Accident Causal Factors Over Time Human Causes Machine Causes Time

The Tip of the Iceberg

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)

Continental Airlines

RESIST HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS RESOLVE WHAT THE HUMAN BRINGS TO THE SYSTEM

What’s a Threat?

Anything that increases operational complexity

Example Threats

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

What’s the Threat?

ICAO

Northwest Airlines

Undesired Aircraft State Trap: Managing Error Avoid Error: Managing Threats

Layered System of Defenses

Threats

TEM Toolkit

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

What we did at NWA Video Training & Scenario

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

Thanks Darren Smith www.cfidarren.com

813-503-3322