Threat And Error Management

Question 1

34.52.2 The role of human error in aviation accidents

Answer 1

More than 75% of accidents in aviation have a human element or factor as their main cause rather than a mechanical breakdown or failure

Question 2

34.52.4 The degree to which human error can be eliminated

Answer 2

Human error can never be completely avoided no matter how much training is provided and how many warnings are put in the operational documentation

Question 3

34.52.6/46.52.2 The main types of threats which could potentially affect a safe flight (4)

Answer 3

External threats – not caused by crew, increase the operational complexity of the flight and require crew attention and management if safety margins are to be maintained

• Internal threats – the flight crew themselves
• Latent threat – not obvious to the crew and could lie dormant (vague policies, poor culture)
• Overt/Active threat – these bite immediately and can include environmental factors, organisational or the crew themselves

Question 4

34.52.8/46.52.4 Describe threat management (a/b/c) recognising, avoiding and mitigating the effects of threats

Answer 4

Recognising: Identify potential threats
•e.g. TCTWOS, ABRIEFS

• Avoiding: Identify current threats that are developing and avoid them– maintain S.A.
• Mitigating: Identify errors that have occurred and limit the damage

Question 5

34.52.10/46.52.6 Identify examples of overt/active threats (6)

Answer 5

Exist on the day of the flight, can be anticipated or unexpected, generally observable factors:
●Fatigue
●Recency
●Weather
●New airfield
●Competence
●Shortened turn around

Question 6

34.52.12/46.52.8 Identify examples of latent threats (5)

Answer 6

Develop behind the scenes, tend to be contributing factors to an incident/accident:

●Equipment design
●Visual illusions
●Aircraft malfunction
●Risk taking culture
●Vague policies/procedures

Question 7

34.52.14/46.52.10 Methods and means for detecting error in the aviation system

Answer 7

Hard safegaurds – A/C Design, autopilot, TCAS, EGPWS
•Safety reporting
•Cross checking – Multi Crew
•Use of checklists

Question 8

34.52.16/46.52.12 Error avoidance techniques

Answer 8

Soft safegaurds – Breifings, SOP’s and checklists, standards. (eg. stable gate – if the a/c is not configured correctly and/or on speed/slope you must go around)

•Crew is the last line of defence!

Question 9

•34.52.18/46.52.14 How incipient errors can be trapped after they have been committed

Answer 9

Recognition leads to recovery – don’t be complacent

•Recover first, analyse the cause later

Question 10

34.52.2046.52.16 How can the consequences of errors be mitigated

Answer 10

Command leadership, crew assertiveness, and technical knowledge are essential

•Don’t allow the aircraft to enter an undesired state

• Use CRM to ensure the error is recovered
• Teamwork
• Leadership
• Responsibility

Question 11

34.52.22/46.52.18 How CRM countermeasures assist the management of threat and error

Answer 11

Workload management – everyone has a role

• Shared mental model
• They ensure things are checked and verified by the crew
• Communication – information shared

Question 12

34.52.24 The basic elements of the Reason model

Answer 12

The Swiss Cheese model addresses the causal sequence of human failures that lead to an error or accident

• Most accidents can be traced to one or more of four layers of failure:
• Organisational influences, unsafe supervision, preconditions for unsafe acts and the unsafe acts themselves

Question 13

34.52.26/46.52.20 Identify examples of a latent failure/error (professional culture, organisational, vague policies)

Answer 13

Develop behind the scenes and contribute to the combination of system weaknesses that lead to an accident

• Professional Culture – risk taking culture and macho attitudes
• Organisational – safety rules and operating procedures not considered important
• Vague Policies – do not clearly describe what actions are required and when.

Question 14

34.52.28/46.52.22 Identify examples of an active failure/error

Answer 14

Also known as Unsafe Acts (swiss cheese)
•Primary cause of the accident
•e.g. Raising flaps instead of landing gear
•Any mismanaged threat

Question 15

34.52.30 Describe slips, lapses, mistakes and violations

Answer 15

Slips
can be thought of as actions not carried out as intended or planned, e.g. “finger trouble” when dialing in a frequency

•Lapses
are missed actions and omissions, i.e. when somebody has failed to do something due to lapses of memory and/or attention or because they have forgotten something, e.g. forgetting to lower the undercarriage on landing.

•Mistakes
are a specific type of error brought about by a faulty plan/intention, i.e. somebody did something believing it to be correct when it was, in fact, wrong, e.g. switching off the wrong engine.

Violations
sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are deliberate illegal actions, i.e. somebody did something knowing it to be against the rules (e.g. deliberately failing to follow proper procedures).

Question 16

The elements in a safety culture CBAAIJ

Answer 16

Commitment 
Behaviour
Awareness
Adaptability
Information
Justness

Question 17

34.54.4/46.54.4 Reporting mechanisms to rectify safety problems

Answer 17

Should be done by way of a systematic and comprehensive reporting system made up of a confidential reporting system and a non-punitive environment (wont go out of the way to punish)

Question 18

34.54.6/46.54.6 The core concept of an organisational culture

Answer 18

Ideally - safety behaviour is fully integrated into everything the organisation does

• The value system associated with safety and safe working is fully internalised as beliefs, almost to the point of invisibility
• Starts from the top, moving downwards
• “The way things are done around here”.

Question 19

34.54.8/46.54.8 The ways in which organisational culture affects performance

Answer 19

Organisational culture can be either weak or strong.

•A strong culture is one where the culture is
accepted by employees, this can have many benefits from increased safety to improved financial performance.

•A weak culture will still have some safety values, but employees do not strongly embrace them, and as a result there is little or no effect on the organisation.

Question 20

34.54.10/46.54.2 The principles of Safety Management System (SMS) in air operations (7)

Answer 20

Policy Objectives e.g. Personnel appointments & responsibilities, Emergency response planning

• Risk Management e.g. Reporting & investigation, Risk Assessment & Mitigation
• Safety Assurance e.g. Monitoring & Measuring, Management of change, Improvement of SMS

•Safety Promotion e.g. Training & Education,
Communication.

DAMP - drug and alcohol programme

Fatigue risk management - FRMS

Environment (hazardous substances)

Question 21

34.54.12/46.54.10 What is meant by harassment, its effects on employees and how it should be dealt with should it arise in the workplace

Answer 21

Harassment is any unwelcome comment, conduct or gesture that is insulting, intimidating, humiliating, malicious, degrading or offensive. It may be repeated or an isolated incident.

• Its likely to affect staff morale, creativity and productivity and create an unhealthy workplace culture.
• The employer should take the complaint seriously, respond promptly using published policies and procedure, check it has stopped.

Question 22

34.54.14/46.54.12 What is meant by stereotypes and stereotypical behaviour within organisations and give examples of where such behaviour may have a negative impact on safety

Answer 22

Commercial aviation continues to be dominated by masculine values and practices.

• Dealing with sexism and adapting to the masculine culture continues to influence the attitudes of female pilots, especially toward gender and equal opportunities
• This can cause female pilots to experience difficulties and distress.

Question 23

46.54.14 Inertia of large organisations with respect to safety messages

Answer 23

An organisations desire to move up the ladder and introduce a more effective safety system may be hampered by inertia, particularly if it is a large organisation.

•It is characterised by an inability to make decisions, an overload of reports and analysis with no apparent reason, a stop and start approach to executing tactics as strategy changes year on year or an inability to execute what appear to be robust strategies e.g. a safety system.

Question 24

34.54.16/46.54.16 Key reasons for safety reporting in aviation

Answer 24

By sharing knowledge and experience by way or a comprehensive and systematic reporting system, occurrence of incidents can be prevented, or more realistically, be significantly reduced

Question 25

34.54.18 The rationale for mandatory reporting of incidents as required by part 12

Answer 25

12.1 Purpose (a) Subject to paragraph (b), this Part prescribes rules for the— (1) notification, investigation, and reporting of accidents and incidents; and (2) preservation of aircraft, aircraft contents, and aircraft records following an accident or serious incident; and (3) preservation of records relating to an accident, facility malfunction incident, an airspace incident, or a promulgated information incident; and (4) reporting of aircraft operating and statistical data.

Question 26

34.54.20 /46.54.18 The relevance of internal hazard reporting

Answer 26

Contributes to the improvement of flight safety by ensuring that relevant information on safety is reported, stored, protected and disseminated.

•The sole objective is the prevention of accidents and incidents and not to attribute blame or liability.

Question 27

34.54.22/46.54.20 The key elements of the Just Culture approach to the management of errors, reporting, and the use of disciplinary sanctions under this approach

Answer 27

In a just culture errors and unsafe acts will not be punished if the error was unintentional. Those who act recklessly or take deliberate or unjustifiable risks will however be subject to disciplinary action.

Question 28

34.54.24/26 Distinguish between normal error, at risk (negligent) behaviour and high culpability (reckless) behaviour

Answer 28

Human Error: Where the person inadvertently carries out an error, which may/or may not have caused an undesirable outcome

• At-Risk behaviour (negligent): Action is intentional; the action increases the risk of an accident; the person does not recognise the risk
• High Culpability behaviour (reckless): A conscious disregard of a substantial and unjustifiable risk (wilful intent)

Question 29

34.54.28 Attributes of at risk behaviour

Answer 29

Where people behave in a manner that increases risk, they either fail to recognise the risk involved, or they think the risk is justified.

Question 30

34.54.30/46.54.22 Concepts of risk creep and risk tolerance and their application within an aviation organisation

Answer 30

Risk tolerance is defined as the extent to which a person or organisation choose to risk experiencing a less favourable outcome in the pursuit of a more favourable outcome

•Risk creep is the slow building up of risk until there is a sudden realisation, perhaps brought about by a serious incident or accident that things have gone to far

Question 31

34.54.32 The role of punitive sanction

Answer 31

Punitive sanctions are disciplinary consequences imposed on someone who is in violation of a law or regulation. Such sanction could be a fine, but also imprisonment

•This is for serious wilful violations