Transcript Chapter 4 Threat and Error Management

Ramp Resource Management Training
Version 1.0
Threat and Error Management
Nationaal
LuchtRuimtevaartlaboratorium – National Aerospace Laboratory NLR
Developed
for ECAST
by en
NLR/NLR-ATSI
Topics
 Safety regulations
 Teamwork





Team dynamics
Leadership
Communication
Team situational awareness
Cultural, ethnic and educational differences
 Threat and error management
 Human performance



Stress
Fatigue
Alcohol, medicines and drugs
Developed for ECAST by NLR/NLR-ATSI
2
Threat and error management
• How many errors do you make each shift?
• How many errors are made during a shift?
• How many accidents occur each shift?
Developed for ECAST by NLR/NLR-ATSI
3
CASE: Towing
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
4
Towing
Setting the scene:
 XYZ Airline operates from Terminal at Any Airport
 Crew consists of two ground support agents from a
service provider
 Crew is towing a fuelled B737-900 from remote parking
to gate 71
 Weather is clear, sunny, temperature 1 °C, wind is
westerly at 29 km/h with gusts to 45 km/h
 There are several icy patches on the ramp where aircraft
have previously been di-iced with water/glycol
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
5
Towing
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
6
Towing
 Suddenly, without warning, the tractor jackknifes under
the aircraft nose, turning approximately 135 degrees
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
7
Towing
Light
Bracket
Sheared
off
Buckled frame
Antenna
Struck and
Torn from
Mount
Witness
marks
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
8
Towing
 Driver:

More than 7 years experience

Trained on the equipment approximately 6 months before

Worked 1 hour before the accident
 Agent 2:

1 to 2 years experience

Trained on the equipment approximately 6 months before

Worked 1 hour before the accident
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
9
Towing
 What are your thoughts on this?

Errors?

Equipment failure?

Airport layout?
 Why do you think so?
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Developed for ECAST by NLR/NLR-ATSI
10
Threat and Error management
Di
str
ac
W
ea
s
th
e
r
n
tio
e
Fu
ls
pi
Ma i n
ll
Sta
ff
sh
o rt
ag
Flight
crew
e
Ground
engineer
tena
n
m
Da
Cabin
crew
t
igh
cr e
w
Flight
dispatch
ce
Colleagues
e
Fl
Security
Baggage
transport
ag
in
Cab
cr e w
Supervisor
Fueller
Injury
Malfunctions
k
Security chec
bagg
Late
age
t
en
Catering
Airport
authority
o
sh
rta
ge
Passenger
handling
Unr
Cleaning
Passenger
Airline
representative transport
Fli
g
ht
div
uly
e rs
pas
se n
ger
s
ion
La
te
ca
Eq
m
uip
Gate ch
ange
rg
o
Developed for ECAST by NLR/NLR-ATSI
11
Threat and error management
 What are expected and unexpected threats?
 What are internal, external and environmental threats?
 Did you ever experience threats and how did you deal
with those threats?
Developed for ECAST by NLR/NLR-ATSI
12
Threat and Error management

Identify the threat: weather forecast, planning, equipment status

Assess the risk: severity, probability and exposure

Prepare: notify team members, request wing walkers, lock loose equipment

Monitor the threat: recognize distractions, interruptions and preoccupation
Developed for ECAST by NLR/NLR-ATSI
13
Situational awareness
Look around before you start shit
Developed for ECAST by NLR/NLR-ATSI
14
Threat and error management
Stupid! vs Consequences of
normal human activity
Developed for ECAST by NLR/NLR-ATSI
15
Threat and error management
Human Error Low Tech
Developed for ECAST by NLR/NLR-ATSI
16
Threat and error management
Human Error High Tech
Developed for ECAST by NLR/NLR-ATSI
17
Threat and error management
Different reactions to errors:
Ignored : forgetting to place cones or parking of Ground
Service Equipment within the aircraft movement zone
Exacerbated: the combination of a not fully opened cargo door
and an inattentive high loader operator increases the risk of
aircraft and equipment damage
Trapped: this requires team situation awareness and an active
attitude from team members to trap and correct errors – not
only their own, but also errors made by fellow workers
Report errors to learn and prevent!!!
Developed for ECAST by NLR/NLR-ATSI
18
I could have saved a life that day
I could have saved a life that day, but I chose to look the other way.
It wasn’t that I didn’t care, I had the time, and I was there.
But I didn’t want to seem a fool, or argue over a safety rule.
I knew he’d done the job before, if I pulled him up, he might get sore.
The chances didn’t seem that bad, I’ve done the same, he knew I had.
So I shook my head and walked on by, he knew the risks as well as I.
He took the chance, I closed an eye, and with that act, I let him die.
I could have saved a life that day, but I chose to look the other way.
Now every time I see his wife, I’ll know I should have saved his life.
That guilt is something I must bear, but it isn’t something you need to share.
If you see a risk that others take, that puts their health or life at stake.
The question asked, or thing you say, could help them live another day.
If you see a risk and walk away, then hope you never have to say,
I could have saved a life that day, but I chose to look the other way.
Developed for ECAST by NLR/NLR-ATSI
Written by Brian McMillan
19
Threat and Error management
Threats
Identify, assess, prepare & monitor
Errors
Trap & correct
Undesired
state
Emergency action
Consequences
Developed for ECAST by NLR/NLR-ATSI
20