Threat and management error Flashcards
why undersand error?
for error prevention and protection
what is Threat and Error management framework
conceptual understanding, from an operational sense, the inter relationship between safety and human performance (experience & habits) in a dynamic and challenging operational
contexts
it detects and responds to threats and errors so that the** outcome doesn’t involve **further errors, threats or undersided states
What is a threat
Events or hazards that may have a negative impact on the safety of the flight and clan lead to pilot error
1)**can be outside the pilot’s control ** (need situational awareness to avoid)
2)increase the operational complexity of the flight
3) requires attention from crew and management (ie additional resources)
Notes:
- Threats can be anticipated (bad weather)
- Threats can be unexpected (ex: engine failure)
- Threates can be latent (ex: cockpit design)
- how one is perceived is
- the basis of any stress experienced
- the knowledge and experience of the pilot (young pilot vs experienced pilot)
The accepted progression
unamanged threats -> error -> undersired state of aircraft->incident/accident
these events that must be managed to maintain or indresae safety margins
propsective memory failure
symptom of humans not being good at remembering tasks that have been deffered to the future
you were on checklist, then got interrupted and forgot to go back to it or forgot elements of it
counter measures
Divided into 2 parts:
Hard/systemic:
Regulations and legislative control
System design
procedures/sops, checklist
training
Soft resources (attitude of crew)
CREW
communication, leadership, crew participation, briefing, etc..
PLANNING
briefing, checklist, preparation preflight, managing anticipated and not anticipated threats, contingency management, workload assignment
EXECUTION
monitoring/cross-check, scanning, workload management, automation management
REVIEW
evalution/modification of exiting plans, feeback, investigations, inquiry, assertiveness
Types of threats
External:
Environment
bad weather, aerordrome conditions, traffic, terrain
organizational
pressure from management, maintenance, aircraft malfunction
these threats can be dormant and require special operating conditoins to cause effect.
Ex: not updating expired charts/not correcting
**Internal: **
Other
stress, fatigue, overload, distraction, not following protocol and checklists
**Anticipated threats **- can be managed with preplanning
Unanticipated threats - can be managed with skills and knowledge
what is error - icao definition
An action or inaction by a flight crew that leads to deviations from organisational or crew intentions or expectations
sometimes occurs due to a threat that’s mismanaged
reduce safety margins
increase propability of adverse operational events on the ground and during the flight (ie. can lead to an Undesired Aircraft state)
a system is vulnerable when..
it allows eroors to affect it
a system is tolerant when..
when consequence of an error doesn’t jeapordize it
what is the ration of errors after ‘methodological training’ vs during repetitive tasks
methodological training - 1 error in 1000 tasks
repetitive tasks - 1 error in 100 tasks
typeos of errors
Latent
* errors that go unoticed or their consequence lie dormant because they are difficult to foresee (like an error in gps database)
* To prevent it, it should be made visible in the Safety management system
* Sometimes the error occurs but the consequence appears much later (ex: management cutbacks that due to economical downturn, error occurs at pre-flight/taxi out, but the consequence appears during take off or departure)
* can be producted by the front liners but also the system
Active
* happen immediate and can be easily rectified - so fewer/lower consequences
* happen at the human/system interface level
* happens to pilots/ATC staff (front liners)
Procedural
* failure to follow procedures. looking at what is to be achieved (prior intentions) and how it will be achieved (intentions in action)
composed of slips, lapses, violations and mistakes
what is a slip
difference bewteen intended action and those that were actually executed (execution failure) - it doesn’t satisfy the operator’s intent
(inserting wrong gps coordinataes - inappropriate action into a sequence that was otherwise good)
mostly found in Skill based modes
mistake/fault
mismatch between prior intention and the intended consequences (planning failure - planned actions that are incorrect)
ex: you diagnose soemthing wrong/incorrect knowledge
ie. you turn off wrong engine because you misdiagnosed.
ex: pilot doesn’t fuel enough as he check that the weather is good but when faced with headwind, he almost ran out. Eror is incomplete knowledge of the situation.
mostly found in Rule or Knowledge based modes
lapse/omission
omission of one or two steps from a sequence (ie missing action items from check list) -
majority of crashes are caused by what type of errors
Mistakes (decion making processes where planned action is incorrect)
followed by error in execution
followed by perception
what’s a violation
it’s a deliverate deviation from rules and procedures (even if unintentional)
Not taking taking a checklist, doing a checklist by memory instead of reading it
types of violations
Routine: violoations that eventually become normal practice
Situational: occur due to time pressure, workload, inadequate tools, etc
Optimizing: breaking the rules for the sake of it
Exceptional:you had no option (normal rules don’t apply)
Type of errors pilots do
reversion
reverting back to old known procedure instead of following a new specified one (due to lack of learning of the new procedure)
social error
When pilot doesn’t coperate with team, ignorance towards feedback, etc
procedural errors: when you do something inccorectly or in different order (ie checkist item out of sequence
no compliance errors - failure to follow official guidelines
faulty comm - wrong readback to ATC
lack of profiency - airmanship. TEM skills
Decision making - These errors improve practice and situational awareness.
Economic error: caused due to financial matters
egnronaumic error: error caused due to the design of machine not fitting with the human
knowledge error:
lack of knowledge and operational experience
ways to allow for better error detection
improve man machine interface
develop systems for checking the consistency of situations
compliance with cross over reduance procedures by crew (cross monitor)
what is error management
counter measures against a bad decision
- Avoid the error –> anticipate / plan contingency
- detect & trap before they are significant –> Recognize/monitory/cross check/workload management
- Error recovery –>metigation/challenge/modify actions
*it accepts a mistake that happens
*adopts non punitive approach to minimise the effects (ie anonymous reports)
*remove the human from th3e system altogether
