Threat and Error Management Flashcards
What is the ICAo definition of Threat and Error Management?
“The threat and error framework is a conceptual model that assists in understanding from an operational perspective, the inter-relationship between safety and human being performance in dynamic and challenging operational contexts”
What are the three ways to manage or mitigate an error?
Planning Countermeasures
Execution Countermeasures
Review Countermeasures
What are some examples of planning countermeasures?
- Preflight check
- Through planning
- Briefings (preflight, TC-TWO)
- Backup plans
- IMSAFE
- Communication of plan to others
What are some examples of execution countermeasures?
- Monitoring
- Cross checking
- KDP’s
- Aircraft safety systems (TAA, TAWS, GPWS
- SOP’s
- Checklists
- Prioritising
What are some examples of review countermeasures?
- Evaluating and modifying plans as flight progresses
- Self Reporting
- Reporting
- Additional training, advice, questioning
What is the goal of TEM?
Managing threats and errors to avoid an undesired state of flight
What are the categorisations of threats?
External (Environmental/ Organisational) Internal Expected Unexpected Latent
What are some examples of external threats?
4 Environmental
7 Organisational
Environmental
- Weather (minima/ density/ temp)
- Traffic
- Terrain/ Obstacles
- Runway surface/ length/ condition
Organisational
- Maintenance
- Organisational pressures
- Cabin events
- Ground handing error
- Systematic error
- Training deficiencies
- Hardware design
What are some examples of internal threats? (7)
Stress Fatigue Distraction Complacency Over/ Under confidence Hazardous behaviours Lack of currency
What are some behaviours that are effective for TEM?
- Self auditing
- Professionalism
- Appropriate attitude
- Chronic Unease (not complacent)
- Actively managing situational awareness
What are some characteristics/ causes of an undesired aircraft state?
- Pilot induced or from external point
- Reduces margins of safety
- Can be a precursor to disaster
- Requires immediate action to return to normal
- State should be dealt with before trying to determine the cause
- Most common outcome is a reportable occurrence
What is the definition of an error?
Flight crew action or inaction that leads to a deviation from crew or organisational intentions or expectations that reduces safety margins and increases the probability of adverse operational events on the ground and in flight
What are the three categories of pilot errors?
- Procedural
- Handling
- Communication
What are some examples of handling errors?
- Aircraft mishandling (airspeed, altitude, vertical speed etc.)
- Incorrect systems, radio or instrument usage
- Incorrect navigation
- Incorrect use of automation
- Inaccurate flight planning
- Incorrect performance calculations
What are some examples of procedural errors?
-Checklist errors
-SOP violation
-Briefings and callouts missed
Incorrect documentation
-Incorrect application of MEL or QRH items
What are some examples of communication errors?
Crew to Crew
Crew to External
What are the 5 Error management strategies?
Error Prevention Error Reduction Error Detection Error Recovery Error Tolerance
What are the characteristics and examples of error recovery?
- To prevent the error completely
- It is almost exclusively design based solutions
- Only possible in specific situations
- FADEC is used to start engine to prevent damage or timing errors
What are the characteristics and examples of error reduction?
- Aims to minimise the magnitude and likelihood of an error
- Good ergonomics (flap and gear lever)
- Sterile cockpit
- Checklists designed to reduce the chances of slips or lapses
What are the characteristics and examples of error detection?
- Aim is to make errors apparent as fast and as clearly as possible
- Enables a timely and suitable recovery
- Detections are done by the person commenting the error, the system, cued by the environment, or another person
- Performance calculations will change colour when outside of reasonable range, remove before flight tags, cross checking, location of flags (or lack of them)
What are the characteristics and examples of error recovery?
- Make the system easy to return to a safe state after an error is made
- Automatic pull up when EGPWS alerts go off
- Stick pusher in a stall
What are the characteristics and examples of error tolerance?
- Conservative operation margins will ensure that small errors do not engage the safety of flight
- Conservative envelope in W&B or in performance calculations.
What are some methods of reducing slips and lapses?
- Controlling factors likely to cause a slip or lapse
- Standardising procedures
- Functions are designed with good tactile feedback k
- Checklists and sterile cockpit principals
Detection, recovery and tolerance to slips and lapses can be done how?
- Aircraft provides immediate, good quality feedback on actions and crew are trained to respond to those responses
- Pilot monitoring must know how to effectively monitor the flight in different phases
- Unlocking movements of some controls can be long enough to allow the error to be detected and prevent the action
- Airbus have fly-by-wire to prevent any control input that put the aircraft outside the safe flight envelope
Violation management can be done how?
- Create channels for people to discuss difficulties and solutions
- Analyse current violations and asses potential for future violations
- Create a good leadership and planning culture
- Make people aware of the risks and responsibilities of their job and explain how things can reduce the overall margins of safety
- Any violations should prompt change as no organisation can operate safely with widespread disregard for the rules
What are the potential responses to an error?
Trap
Exacerbate
Fail to respond
What are the potential outcomes to an error response?
Recovery to safe flight
Additional Error
Accident/ Incident
