Threat and Error Management
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Transcript Threat and Error Management
Threat and Error
Management
What is TEM?
“Defensive flying”
ICAO and FAA
In 2000, LOSA baseline results showed that error
management had been incorporated into everyday
operations.
Improved checklist usage and a 70% reduction in
non-stabilised approaches.
ICAO made LOSA the central focus of flight safety
and human factors programmes.
TEM and LOSA recognised Worldwide.
TEM Philosophy
Three basic concepts:
- Anticipation
- Recognition
- Recovery
Recover first, analyse the cause later.
Threats
May be internal or external.
They are not caused by the crew.
They increase the operational complexity of a flight.
Require crew attention and management if safety
margins are to be maintained.
What is a latent Threat?
A threat that is not directly obvious to flight crew.
Equipment design.
Threat Management - GPS
Threats & errors
- Poor standardisation of
GPS receivers
- Poor integration with AP
- Mis-interpretation of HSI
Management
Obtain training &
practice (VMC) with
make & model
Use HDG mode when
changing any detail
In non-integ. cockpit,
double-check mode
Errors
Error is a crew action or inaction that leads to a deviation from
crew or organisational intentions or expectations.
Put simply: threats come “at” the crew, while errors come “from”
the crew.
An Error that is detected and effectively managed has no
adverse impact on the flight.
An error that is not detected cannot be managed.
Flight Crew Errors
Can be divided into three types:
Aircraft Handling
Procedural
Communication Errors.
Consequence of Error
The very same error can have
completely different
consequences, depending on the
factors involved.
Error : setting the flaps correctly
for landing is forgotten.
- Aircraft type and performance
- Actual landing weight
- Runway length and
obstructions ahead
Undesired Aircraft State (UAS)
A UAS is defined as a position, speed, attitude or
configuration of an aircraft that:
- Results from flight crew error, actions or inaction
- Clearly reduces safety margins
UAS can be managed effectively or mismanaged,
leading to an additional error, UAS, an incident or
accident.
A Decision MUST be made
Identify the Threats?
TEM Application
T
W
O
P
Terrain
Weather
Operational
Plan
TWO-P
Terrain old
Terrain new
Weather good
Weather bad
Operational in
Operational out
TWO-P
Assessing threats does not
make them go away.
A threat briefing must
contain effective strategies.
There must be a plan.
Levels of Situational Awareness
Level One:
Level Two:
Level Three:
Perceive
Comprehension
Projection
Notice
Understand
Think
Ahead
NUTA
The NUTA/TEM Links
Notice
Mitigate
Understand
Trap
Think Ahead
Avoid
Situation
Awareness
Threat
Management
Countermeasures
Anticipation builds vigilance.
Recognition leads to recovery.
Recover first, analyse causes later.
Planning.
Execution.
Review or modify.
What is an Unexpected Threat?
Just because you
deal with a situation
everyday does not
mean that it is not a
threat.
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