Transcript PowerPoint Presentation - Flight Safety Foundation

Flight Safety Foundation
CAC Workshop Oct. 17, 2007
Durwood Heinrich, Ph.D.
A Threat & Error
Management Model
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Some Definitions
THREATS



Threats are events that occur outside the
influence of the flight crew, but which require
crew attention and management if safety margins
are to be maintained
Threats increase the complexity of the operation
and weaken barriers against error
Observable Threats
– Known
• e. g., Thunderstorms, delays
– Unexpected
• e. g., Engine failure on take off
Threats = Red Flags!
Heinrich 2007
Fortunately, not all events become accidents…
Accident
1
Serious incident
10
Significant event
30
Routine occurrence
Statistical event
200
600
…but events/occurrences can lead to incidents and accidents
Flight Safety Foundation, 2006; Adapted with permission.
Latent Threats
Latent Threats – factors residing in the system,
organization or individual that increase risk.
 Latent threats are not directly observable at
the ‘sharp end’ of operations
 Latent threats are usually uncovered by
analysis of aggregate data such as confidential
incident reports, e.g.,
Equipment design issues
 Optical illusions
 Air traffic system design
 Training philosophy and practices
 Organizational culture (positive or negative)

Heinrich 2007
Typical Latent Errors










Poor planning or scheduling
Inadequate design/poor equipment
Improper allocation/lack of resources
Flawed procedures
Defective communications
Training deficiencies
Inadequate selection procedures
Inspection and oversight flaws
Neglect of known hazards
Lack of motivation
Note that these are all management problems!
Flight Safety Foundation, 2006; Adapted with permission.
ERRORS

Errors are actions or inactions by the flight crew
that lead to deviations from intention or expectation
 Traditional thinking focused on eliminating error in
the cockpit, i.e., Zero Error!
 Contemporary thinking acknowledges that error is a
part of life, i.e., humans make mistakes!
 Intentional non-compliance is not an error
 Types of errors:
Flight handling errors (e.g., unintentional speed deviation)
 Procedural errors (e.g., performing checklist items from memory)
 Communications errors (e.g., missed ATC call)

Heinrich 2007
Pilots are human…
and humans make errors!
(Note: this does not mean that errors are OK!)
Primary Causes of Aircraft Accidents *
Percentage of Total Accidents with Known Causes
Primary Factor
10
20
30
40
50
60
70
Flight Crew
Airplane
Maintenance
Weather
Airport/ATC
Other
Excludes:
• Sabotage
• Military Action
• Turbulence Injury
• Evacuation Injury
• Servicing Injury
The Crew usually makes the last mistake!
* Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.
Error Outcomes
Exacerbate
Miss Errors
Errors
Mitigate
Trap Errors
Errors
* Helmreich, 1998
Strategies/Countermeasures
Strategies/Countermeasures are employed…
 to
reduce the number of threats and
errors, and
 to increase the awareness of potential
threats and errors
Errors must be recognized and corrected
before negative consequences occur!
Focus on managing your future!
Heinrich 2007
Safeguards
Safeguards are the hardware & software that
serve as additional barriers to problems*:




GPWS
TCAS
EVS
MANUALS




SOPs
CHECKLISTS
AUTOMATION
ATC
*Note: Because these are also developed by humans, the potential
still exists for latent defects and errors.
Heinrich 2007
Awareness, Anticipation
Awareness and anticipation are important
characteristics of effective CRM and TEM
 Awareness includes






Search
Perception
Spatial orientation
Knowledge of mission goals
Anticipation includes



Projection/forecasting
Planning
Threat awareness
Heinrich 2007
Desired OUTCOMES
or Undesired CONSEQUENCES ?
Successful Threat and Error Management results in
outcomes that are desirable, i.e., safe flight
 Consequences of errors that are not corrected or
not contained can result in an undesired aircraft
state (UAS)
 An undesired aircraft state is an aircraft deviation or
incorrect configuration associated with a clear
reduction in safety margins

Heinrich 2007
TEM Principles
TEM Principles
The objective of Threat and Error
Management (TEM) …



to obtain an understanding of how to
assess the various risk levels of threats
to gain an insight on logical approaches
(strategies) to deal with them, and
to reduce human error in dynamic daily
operations.
Heinrich 2007
TEM Principles
TEM is central to all safety processes and
provides defences against hazards in
operational situations; it involves…
 Identifying hazards to safety, i.e., threats,
errors, or undesired states (deviations)
 Assessing the risks of these hazards (the
consequence of accepting hazards)
 Avoiding or trapping threats and errors
 Containing the end result (mitigation)
Heinrich 2007
Important TEM Concepts
TEM Concepts




The “mission” (i.e., safe, effective
mission/objective) may be a flight, an aircraft
repair, a trip plan, or even an ops manual or
company procedure…
… i.e., TEM can be applied to all aviation
organizational entities.
The crew is only one resource to the “operator” or
“systems manager” who must make accurate and
timely decisions for successful results.
The operator is only as effective as the
information he or she receives from all resources
(The TEAM).
Heinrich 2007
TEM Concepts




Individuals are humans, and humans (all
humans!) make mistakes.
The aviation mission or objective is dynamic.
TEM is not a sequential system! Because all
organizational entities are made up of individuals,
threats (hopefully with innovative threat
solutions!) and human error (with error
resolutions!) are introduced throughout the
timeline of the particular “mission.”
External threats also continuously occur and must
be dealt with utilizing all appropriate resources
available.
Heinrich 2007
Accurate Decision-Making
The primary key to a successful mission outcome
is accurate decision-making by the individual or
individuals who are “steering the ship.”
Accurate Decision-Making = Successful Outcome!
 In the operational setting, the operator is only as
effective as the information (not data!) he or she
receives through proper teamwork and resource
management.
 The operator is the final authority regarding the
safety of the mission; e.g., a pilot can always
elect to abandon a dangerous approach.

Heinrich 2007
A Case Study
Case Study
G-III Fatal Accident, Aspen, March 2001
The Accident:
On March 29, 2001, about 1902 MST, a
Gulfstream III, N303GA, owned by
Airbourne Charter, Inc., and operated by
Avjet Corporation of Burbank, California,
crashed while on final approach to
runway 15 at Aspen-Pitkin County
Airport (ASE), Aspen, CO. The charter
flight had departed Los Angeles
International Airport (LAX) about 1711
with 2 pilots, 1 flight attendant, and 15
passengers. The airplane crashed into
sloping terrain about 2,400 feet short of
the runway threshold. All of the
passengers and crewmembers were
killed, and the airplane was destroyed.
The flight was being operated on an IFR
flight plan under CFR Part 135.
Case Study
G-III Fatal Accident, Aspen, March 2001
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent
Threats
External
Threats &
Errors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Crew
Errors
TRM/CRM
Behaviors
CRM
Outcomes
Behaviors
Outcomes
Latent Threats:
(Factors residing in the system, organization or
individual
Decision-making,
SA, that increase risk )
Threat recognition,
Error avoidance,
Safe Flight
Safeguards,
 Company management
Countermeasures
 Organization management
Organizational

Resources
Violations,
Communication,
Procedural,
Proficiency,
Decision  SOPs

System
Policies
 Procedures
 Techniques
Error-management

Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
failtoOperators
respond)

Inconsequential
Professional
Crew
 Team

Recovery to
Safe Flight
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Latent Threats
Organizational
System
Professional
What are some of the Latent Threats in the
Aspen Accident?
 ?
 ?
 ?
 ?
Latent Threats
Organizational
System
Professional
Some of the Latent Threats in the Aspen Accident

The March 27, 2001, NOTAM regarding the nighttime
restriction on the VOR/DME-C approach was vaguely worded
and ineffectively distributed:
The NOTAM stated, “circling NA at night,” but the intended meaning
was to prohibit the entire approach procedure at night.
 Pilots might have inferred that an approach without a circle-to-land
maneuver to runway 15 was still authorized.
 If the FAA had worded the first NOTAM more clearly, it might have
made more of an impression on the first officer when he received the
preflight briefing from the Automated Flight Service Station and might
have affected the conduct of the flight.
 The local controller could not notify the flight crew of the NOTAM
because Denver Center had not sent a copy to the ASE tower.

Heinrich 2007
Latent Threats
Organizational
System
Professional
Some of the Latent Threats in the Aspen Accident

Company Standard Operating Procedures
Manual incomplete:
 No sterile cockpit procedure
 No procedure/restrictions regarding the use of
cockpit observers (jump seat)
 No guidance regarding weather minimums for
mountain operation
Heinrich 2007
What would have happened if the
Organization…






…Utilized Corporate Flight Operations Quality
Assurance (C-FOQA) to uncover latent threats
and dangerous procedures/techniques?
Had an effective Safety Management System
and Incident Reporting System?
Conducted Line Operational Safety Audits
(LOSA)?
Conducted confidential surveys?
Regularly performed training evaluations?
Redesigned policies, procedures, tasks, and
equipment?
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Crew
Errors
TRM/CRM
Behaviors
Outcomes
Unexpected External
Threats/Events/Risks




Latent threats
System
failures
Decision-making,
SA,
WX/ Environmental
Threat recognition, changes
Error avoidance,
Safe Flight
Other dynamics
Safeguards,
Countermeasures
Expected External
CRM
Outcomes
Behaviors
Threats
Events that occur
outside the influence
of the flight crew, but
which require crew
attention and
management if safety
margins are to be
maintained.
Violations,
Threats/Events/Risks
Communication,
Procedural,
 Destination
issues
 Proficiency,
Terrain
Decision


Recovery to
Safe Flight
Environmental problems
Inconsequential
Logistics
Error-management
Behaviors
External
Error
(avoid, trap, contain,
mitigate, exacerbate,
 ATC errors
fail to respond)
 Other aircraft
Undesired
aircraft
state


Additional
error
Communication issues
Time pressures
Undesired state
management
behaviors
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
External
Threats & Errors
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
What are some of the External Threats &
Errors in the Aspen Accident?
 ?
 ?
 ?
 ?
External
Threats & Errors
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Some of the External Threats and Errors
 The Flight Crew was under pressure to land at ASE
 Because of the flight’s delayed departure from LAX and the
landing curfew at ASE, the crew could attempt only one approach
before having to divert to the alternate.
 The charter customer had a strong desire to land at ASE, and his
communications before and during the flight most likely
heightened the pressure on the flight crew.
 The presence of a passenger on the jumpseat, especially if it
were the charter customer, most likely further heightened the
pressure on the flight crew to land.
 Darkness, reduced visibility, and light snow showers significantly
degraded the flight crew’s ability to see and safely avoid terrain.
Heinrich 2007
In the Dynamic environment…
What would have happened if…



…The organization had advised the
passengers of the need to arrive on time
because of the night curfew at Aspen?
The flight attendant had recognized the
potential problems associated with
allowing passengers to occupy the
jumpseat, especially in adverse
conditions?
The crew had advised the jumpseat
passenger of an organization sterile
cockpit rule?
Safe Flight
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Organizational
System
Professional
Crew
Errors
Unexpected
Events/Risks
Actions
or
inactions by
Expected
the flight
crew
Events/Risks
that lead to
deviations
External
from intention
Error
or expectation
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Crew Errors *
 Non-compliance
Decision-making, SA,
 Communication
Threat recognition,
(violation)
Error avoidance,
Safeguards,
Countermeasures
Violations,
Communication,
Procedural,
Proficiency,
Decision



Safe Flight
Procedural
Proficiency
Poor or uninformed decision
* All humans
make mistakes!
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Recovery to
Safe Flight
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Crew Errors







Violations,
Communication,
Procedural,
Proficiency,
Decision
What are some of the Crew Errors in the
Aspen Accident?
?
?
?
?
?
?
?
Crew Errors
Violations,
Communication,
Procedural,
Proficiency,
Decision
Some of the Crew Errors

Procedural errors & deviations during Final Approach Segment:
 Crossed step-down fixes below minimum specified altitudes
 Descended below the MDA, even though aircraft maneuvers and
comments on CVR indicated neither pilot had established or maintained
visual contact with the runway or its environment.
 Contrary to manufacturer’s procedures, the captain deployed spoilers
after gear and final flap extension and set power to 55% N2 rather than
64% N2
 When the aircraft was 1.4 miles from the runway (21 sec before impact),
captain asked, “where’s it at?” but did not abandon the approach, even
though he had not identified, or had lost sight of, the runway.
 Radar data and CVR comments indicated that, until the aircraft began
turning left about 10 sec. before impact, the crew probably did not have
the runway or its environment in sight.
Heinrich 2007
Crew Errors
Violations,
Communication,
Procedural,
Proficiency,
Decision
Some of the Crew Errors (continued)

Poor Crew Coordination/CRM:
 Captain failed to discuss the instrument approach procedure, the
missed approach procedure, and other required elements during
his approach briefing because he anticipated using a visual
approach.
 The first officer never challenged the captain even though he
crossed step-down fixes below minimum specified altitudes.
 The captain and the first officer failed to make required instrument
approach callouts, and the first officer did not call out required
course, fix, & altimeter information.
 The crew failed to discuss a missed approach after receiving a third
report of a missed approach to the airport and a report of
deteriorating visibility in the direction of the approach course.
Heinrich 2007
In the Dynamic environment…
What would have happened if…




…The first office would have challenged the
captain about missing stepdown altitudes?
The crew would have briefed and planned on
an instrument approach, especially after
hearing that three other aircraft had executed
the missed approach procedure?
The crew would have abandoned their
obsession with finding visual landmarks?
The crew would have altered their thinking
from “landing unless…” to “go around
unless…” ?
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
TRM/CRM Behaviors
CRM
Outcomes
Behaviors
Organizational
 Decision-making – must have “information” from all Team resources (integration)
System
 Situation Awareness and “Projection” in a very dynamic environment
Professional




Threat recognition
Decision-making, SA,
Error avoidance
Unexpected
Threat recognition,
Safeguards
– hardware and software
that serve asSafe
additional
barriers to problems
Events/Risks
Error avoidance,
Flight
Countermeasures – increase awareness
Safeguards,and reduce number of threats/errors
Expected
Events/Risks






Avoid
Trap
External
Contain Error
Mitigate
Exacerbate
Fail to respond
Countermeasures
Error
Management Behaviors
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Undesired
Behaviors
aircraft
(trap, contain,
state
mitigate, exacerbate,
fail to respond)
immediate
action before negative
Undesired state
management
behaviors
Undesired State Management Behaviors



Errors/deviations require
consequences occur!
Additional error can lead to an incident or accidentAdditional
Additional
error
Note: Pilots can always elect to abandon a dangerous approach or phase oferror
flight!
Incident
Accident
* Adapted from Helmreich, 2003
TRM/CRM
Behaviors
Decision-making, SA,
Threat recognition,
Error avoidance ,
Safeguards,
Countermeasures
Error-management
Behaviors (+/-)
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired state
management
Behaviors (+/-)
What are some of the TRM/CRM Behaviors in the Aspen Accident?
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Error-management
Behaviors (+/-)
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired state
management
Behaviors (+/-)
?
?
?
?
TRM/CRM
Behaviors
Decision-making, SA,
Threat recognition,
Error avoidance ,
Safeguards,
Countermeasures
Error-management
Behaviors (+/-)
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired state
management
Behaviors (+/-)
Some TRM/CRM Behaviors
Captain and another Avjet captain discussed nighttime landing
restriction at ASE.
 Captain asked controller whether the pilot of N527JA was practicing or
had actually missed.
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures

Error-management
Behaviors (+/-)
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)

When airplane is at 10,400 feet, captain states, “Okay...I'm breaking
out," and asks local controller, about 5 seconds later, whether runway
lights are all way up. The controller indicates, “Affirmative they're on
high." First officer says, “Okay you can go...ten thousand two hundred
[the MDA].”
Undesired state
management
Behaviors (+/-)

Descended below MDA, even though aircraft maneuvers and comments
on CVR indicated neither pilot had established or maintained visual
contact with the runway or its environment.
Heinrich 2007
In the Dynamic environment…
What would have happened if…



…The crew had expected to execute a missed
approach after hearing that the Challenger
ahead (N527JA) had executed the missed
approach?
The crew had realized that when they were
“breaking out” that they were not in a
position to land when they were unable to see
the runway lights?
The crew had executed a missed approach
when they reached the MDA missedapproach point and were unable to see the
runway or its environment?
Missed
Approach!
Safe Flight
Missed
Approach!
Safe Flight
Missed
Approach!
Safe Flight
Heinrich 2007
External
Latent
Crew
TRM/CRM
Safe Flight
Threats
&
Threats
Errors
Behaviors
 Effective
ErrorsDM, SA, threat recognition, error
avoidance
Organizational
 Appropriate application of T&E strategies
System
result in desirable outcomes
Professional
Decision-making, SA,
Inconsequential Outcome
Unexpected
Threat recognition,
 Management
(i.e.,
Events/Risks of threats & errors
Error avoidance,
avoiding, trapping, containing) results
in little
Safeguards,
or no adverse consequences Countermeasures
Expected
Events/Risks
Violations,State
Undesired Aircraft
Communication,
 Aircraft deviation or incorrect configuration
Procedural,
associated
with a clearProficiency,
reduction in safety
External
margins
Error
Decision
Outcomes
CRM
Outcomes
Behaviors
Safe Flight
Recovery to
Safe Flight
Inconsequential
Recovery to SafeError-management
Flight
 Effective undesired state management
Behaviors
behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Additional Error
 Additional error(s) requires further error
management behaviors
 Exacerbation or failure to respond can result
in an incident or accident
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Safe Flight
Outcomes
Inconsequential
Undesired
aircraft
state
Additional
error
Recovery to
Safe Flight
Incident
Accident
What are some of the Crew CRM Behaviors and subsequent Outcomes in
the Aspen Accident?
Safe Flight

?
Inconsequential

?
Recovery to
Safe Flight

?

?

?

?
Additional
error
Undesired
aircraft
state
Accident
Safe Flight
Outcomes
Inconsequential
Undesired
aircraft
state
Additional
error
Recovery to
Safe Flight
Incident
Accident
Crew CRM Behaviors and subsequent Outcomes
Safe Flight

Flight crew properly certificated & qualified; aircraft properly certified, equipped,
& maintained; the first officer obtained a weather briefing
Inconsequential

Crew crossed the FAF 100’ low, descended 300’ below the next stepdown, and
crossed the 9.5 DME fix 900’ low
Recovery to
Safe Flight

At about 1901:53, the captain added max power (less than a second before
impact)
Additional
error

Determination to continue with the original plan of action despite the presence
of cues suggesting the need for a modified course of action
Undesired
aircraft
state

High descent rate (GPWS sink rate alerts) & excessive bank angle near ground

Descent below MDA without visual contact with the runway or environment
Accident
Heinrich 2007
In the Dynamic environment…
What would have happened if…





The crew had received general TEM training?
TEM training had been integrated into formal simulator
training?
The organization had a non-punitive approach to error?
The crew had applied CRM training?
 Active sharing of concerns & ideas
 Limitations of human performance
 Threat and error recognition
 Error avoidance
 Error management strategies
The crew had learned and practiced techniques to
apply in specific situations?
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Safe Flight
Heinrich 2007
Gulfstream III - Aspen, Colorado
March 2001
* Eighteen Fatalities
NTSB Findings



Procedural Errors
Poor Crew Coordination
Time Pressures
 Passenger Expectations
Latent
Threats
External
Threats &
Errors
Crew
Errors
PAX to FA:
“Can I ride
on the
jumpseat?”
FA to PAX:
“Would anyone
like to ride on
the jumpseat?”
TRM/CRM
Behaviors
Errors
CRM
Behaviors
Additional
error
“Oh, really!”
YES
No!
Captain :
Reminds PAX
about 3 MAs
and Safety #1!
Safe Flight
Captain:
“Please,
flight issues
only!”
Safe Flight
First officer:
“You’re too low!
Let’s miss!”
Safe Flight
No sterile
cockpit
First officer
hesitant to
challenge
captain
Captain
determined
to land
Outcomes
Additional
error
Additional
error
Additional
error
Captain:
“3 MAs! Let’s
plan for MA!”
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
PAX to FA:
“Can I ride
on the
jumpseat?”
FA to PAX:
“Would anyone
like to ride on
the jumpseat?”
TRM/CRM
Behaviors
Errors
CRM
Behaviors
Additional
error
“Oh, really!”
YES
No!
Captain :
Reminds PAX
about 3 MAs
and Safety #1!
Safe Flight
Captain:
“Please,
flight issues
only!”
Safe Flight
First officer:
“You’re too low!
Let’s miss!”
Safe Flight
No sterile
cockpit
First officer
hesitant to
challenge
captain
Captain
determined
to land
Outcomes
Additional
error
Additional
error
Additional
error
Captain:
“3 MAs! Let’s
plan for MA!”
Safe Flight
Safe Flight
Incident
Accident
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
PAX to FA:
“Can I ride
on the
jumpseat?”
FA to PAX:
“Would anyone
like to ride on
the jumpseat?”
TRM/CRM
Behaviors
Errors
CRM
Behaviors
Additional
error
“Oh, really!”
YES
No!
Captain :
Reminds PAX
about 3 MAs
and Safety #1!
Safe Flight
Captain:
“Please,
flight issues
only!”
Safe Flight
First officer:
“You’re too low!
Let’s miss!”
Safe Flight
No sterile
cockpit
First officer
hesitant to
challenge
captain
Captain
determined
to land
Outcomes
Additional
error
Additional
error
Additional
error
Captain:
“3 MAs! Let’s
plan for MA!”
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
PAX to FA:
“Can I ride
on the
jumpseat?”
FA to PAX:
“Would anyone
like to ride on
the jumpseat?”
TRM/CRM
Behaviors
Errors
CRM
Behaviors
Additional
error
“Oh, really!”
YES
No!
Captain :
Reminds PAX
about 3 MAs
and Safety #1!
Safe Flight
Captain:
“Please,
flight issues
only!”
Safe Flight
First officer:
“You’re too low!
Let’s miss!”
Safe Flight
No sterile
cockpit
First officer
hesitant to
challenge
captain
Captain
determined
to land
Outcomes
Additional
error
Additional
error
Additional
error
Captain:
“3 MAs! Let’s
plan for MA!”
Safe Flight
Safe Flight
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
TRM/CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Questions?
Flight Safety Foundation
CAC Workshop Oct. 17, 2007
Durwood Heinrich, Ph.D.
Backup Slides
TEM Take-Aways
• TEM does not replace CRM; rather, CRM is the
foundation of an effective TEM program
• Keys to using TEM and the automated flightdeck:
– Identify automation threats
– Develop automation strategies
– Verbalize, verify, and monitor!
– Treat interruptions as “red flags”
• “What gets measured gets managed”
– Utilize check airmen, observers (LOSA), FOQA
– Record best practices
– Track progress
– Revise procedures and processes
Heinrich 2007
TEM Take-Aways (continued)
• Encourage good communication
– Make sure everyone is “on the same page” (good CRM!)
– Discourage the “Hint and Hope” syndrome (dropping a
subtle hint, hoping the other person will get the
message)
– Communicate anything that can reduce your ability to
detect errors or anything that can increase your chance
of making errors
– Statistically, better communication = fewer errors
• Follow SOPs:
– Crews who fail to follow SOPs are twice as likely to
commit subsequent errors
• “Buy time” for your crew – pause to properly
assess the situation, develop strategies, and
make informed decisions
Heinrich 2007
Organizations that have a proactive safety culture…
Understand that…
 …aviation professionals are human and
therefore prone to error
 acceptance of vulnerability is the first step in
taking responsibility and avoiding risk-taking
behaviors
 detecting, reducing, and containing human
errors are the most effective ways of
improving safety
 it is important to have incident reporting
programs that are confidential and nonpunitive
Heinrich 2007
Organizations that have a proactive safety culture…
Understand that…
 … adherence to SOPs can greatly reduce
the opportunities for accidents and
incidents
 internal and external audits are critical to
safety “health”
 risks can most times be mitigated by riskcompensation
 when risk compensation cannot be
accomplished, alternatives must be found
that provide adequate margins of safety
Heinrich 2007
Organizations that have a proactive safety culture…
Understand that…
 …safety is an attitude on and off the job
 safety can be proactively managed, i.e., all
accidents and incidents can be prevented
 all operating exposures can be safeguarded;
barriers must be erected and maximized
 safety comes from proper decision-making,
usually a product of good CRM, MRM, or TRM
 safety should be continually recognized and
re-enforced
Heinrich 2007
Organizations that have a proactive safety culture…
Understand that…
 …both management and employees are
responsible for avoiding accidents and
incidents
 employees must be trained and given the
tools/resources to work safely – i.e., there
should be no incentives to take short cuts or
break the rules
 prevention of personal injuries is a product of
caring, but it is also good business
 working safely and responsibly should be a
condition of employment
Heinrich 2007
Latent
Threats
External
Threats &
Errors
Crew
Errors
CRM
Behaviors
Outcomes
CRM
Outcomes
Behaviors
Organizational
System
Professional
Unexpected
Events/Risks
Expected
Events/Risks
External
Error
Decision-making, SA,
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures
Safe Flight
Violations,
Communication,
Procedural,
Proficiency,
Decision
Recovery to
Safe Flight
Inconsequential
Error-management
Behaviors
(avoid, trap, contain,
mitigate, exacerbate,
fail to respond)
Undesired
aircraft
state
Undesired state
management
behaviors
Additional
error
Additional
error
Incident
Accident
* Adapted from Helmreich, 2003
Questions?
Flight Safety Foundation
CAC Workshop Oct. 17, 2007
Durwood Heinrich, Ph.D.