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Part 3 Crew Resource Management > Threat and Error Management > Flashcards

Threat and Error Management Flashcards

1
Q

What is the ICAo definition of Threat and Error Management?

A

“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”

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2
Q

What are the three ways to manage or mitigate an error?

A

Planning Countermeasures
Execution Countermeasures
Review Countermeasures

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3
Q

What are some examples of planning countermeasures?

A
  • Preflight check
  • Through planning
  • Briefings (preflight, TC-TWO)
  • Backup plans
  • IMSAFE
  • Communication of plan to others
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4
Q

What are some examples of execution countermeasures?

A
  • Monitoring
  • Cross checking
  • KDP’s
  • Aircraft safety systems (TAA, TAWS, GPWS
  • SOP’s
  • Checklists
  • Prioritising
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5
Q

What are some examples of review countermeasures?

A
  • Evaluating and modifying plans as flight progresses
  • Self Reporting
  • Reporting
  • Additional training, advice, questioning
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6
Q

What is the goal of TEM?

A

Managing threats and errors to avoid an undesired state of flight

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7
Q

What are the categorisations of threats?

A 
External (Environmental/ Organisational)
Internal
Expected
Unexpected
Latent
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8
Q

What are some examples of external threats?
4 Environmental
7 Organisational

A

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
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9
Q

What are some examples of internal threats? (7)

A 
Stress
Fatigue
Distraction
Complacency
Over/ Under confidence
Hazardous behaviours
Lack of currency
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10
Q

What are some behaviours that are effective for TEM?

A
  • Self auditing
  • Professionalism
  • Appropriate attitude
  • Chronic Unease (not complacent)
  • Actively managing situational awareness
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11
Q

What are some characteristics/ causes of an undesired aircraft state?

A
  • 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
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12
Q

What is the definition of an error?

A

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

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13
Q

What are the three categories of pilot errors?

A
  • Procedural
  • Handling
  • Communication
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14
Q

What are some examples of handling errors?

A
  • 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
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15
Q

What are some examples of procedural errors?

A

-Checklist errors
-SOP violation
-Briefings and callouts missed
Incorrect documentation
-Incorrect application of MEL or QRH items

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16
Q

What are some examples of communication errors?

A

Crew to Crew

Crew to External

17
Q

What are the 5 Error management strategies?

A 
Error Prevention
Error Reduction
Error Detection
Error Recovery
Error Tolerance
18
Q

What are the characteristics and examples of error recovery?

A
  • 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
19
Q

What are the characteristics and examples of error reduction?

A
  • 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
20
Q

What are the characteristics and examples of error detection?

A
  • 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)
21
Q

What are the characteristics and examples of error recovery?

A
  • 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
22
Q

What are the characteristics and examples of error tolerance?

A
  • Conservative operation margins will ensure that small errors do not engage the safety of flight
  • Conservative envelope in W&B or in performance calculations.
23
Q

What are some methods of reducing slips and lapses?

A
  • Controlling factors likely to cause a slip or lapse
  • Standardising procedures
  • Functions are designed with good tactile feedback k
  • Checklists and sterile cockpit principals
24
Q

Detection, recovery and tolerance to slips and lapses can be done how?

A
  • 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
25
Q

Violation management can be done how?

A
  • 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
26
Q

What are the potential responses to an error?

A

Trap
Exacerbate
Fail to respond

27
Q

What are the potential outcomes to an error response?

A

Recovery to safe flight
Additional Error
Accident/ Incident

Part 3 Crew Resource Management (11 decks)

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