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
what the swiss cheese model
Model of how accidents occur
There is no single cause of an accident but occurs as culmination of multiple factors and a series of unsafe acts
Trajectory from highest level in the system (organization) all the way to the incident.
*Each barrier has potential to stop an accident, unless it passes thru a hole.
*In theory, you should be able to put the holes out of line to avoid an accident
what does ‘4 - 7’ links mean in the swiss cheese model
A single factor or act can prevent an accident
you have up to 7 opportunities to stop an accident
What are the barriers/layers in the swiss cheese model
In an atypical conditions:
1) the cheese layer is the barrier
2) the arrow thruough the holes is “The trajectory of error”
4) 3) It starts with
Organization –> unsafe supervision –> preconditions for unsafe acts –>unsafe acts
*the idea is to establish the root cause of an accident and identify at which point in the barrier it occured
what’s UAS
undersired aircraft state
Position, condition or attitude of aircraft can arise from errors and result in significant reduction in safety margins and might resolution or minor or major issues of life/airframe.
safety culture - vital for a SMS (safety management system)
a culture with an organization formed with shared beliefs, values, and attitudes and describes how safety is managed within
it offers non-punitive approach to error reporting
Safety culture includes
Just culture:atmosphere of trust but also a clear line between what is or isn’t acceptable.
**informed culture:
**those who manage the system are knowledgable and informed, collects data , etc
**reporting culture:
**allows people to report their errors without punishment
**flexible culture :
**can reconfigure themselves depending on the tempo or certain dangers
**learning culture:
**
possess willingness to draw right conculusions from it’s Safety information system and will to implement reforms
factors promoting safety culture
leadership
commitment
good examples
why is risk management important
it’s important part of decision making hence, when clubbed with following good precedures, the risk is reduced
what does risk management mean for a pilot
managing risk is a balance between completing a task versus the prospect of harm, damanage or loss while doing so
whether a risk is small or big to accept depends on
judegment
Risk is
The chance that a situation or consequence will cause a hazard that can cause harm, loss or injury
risk arises every time a person is in the presence of a hazard
when an error chain starts to come together, the risk starts building.
Error is a source of risk (and occupies the largest share of the total)
if there is uncertainty about a situation, it’s likely risky
Therefore, risk is the value judgment based upon the hazard. You measure the degree of hard agaisnt that of exposure. The morenyou have to lose, the less risk you take
hazard is:
event, circumstand or condition that potentially can cause harm or damanage to people, aircraft, equipment, structures
what is the easa requirement for an Acceptable level of safety
10 (-6) = remote probability
ex: losing of one hull every 10 years
There are 4 approaches to risk management
Zero risk: no risk of an accident that may have harmful consequences
de minimis: riks minimised to ‘Remote probability 10(-6)’ or ‘Extreme probablity 10(-8)’ == acceptable safety targets
comparitive risk: comparing risk to other types of exposure such as carying a patient with spinal injury
As low as is reasonably practicable: where additional controls are not economically or reasonably practicable - organization issues such as staff turnover, inexperienced pilot needing supervision, cash flow issues,
Residual risk
what remians when all mitigating procedures are applied - risk is usually minimised by applying such mitigating procedures.
This is why training is important, or working with two crew members minimum
what is the goal of someone who operates a safety management system
Identify hazards
identify all risk associated
identify the level of each risk
apply rules or design SOPs to minimize risk (and monitor)
There are 2 types of risk
External (objective) - risk of an accident in the current situation if no changes were made to the flight path or operational system
Internal (subjective) - risk that reflects the inability of hte crew to implement decisions due to knowledge and time. Risk increases as the deadline to make the decision appraoches.
risk factor
is anything that may in crease the likelyhood of an accident occuring
how is a risk assessed
based on subjective perception and evaluation of situational factors
The difference between what’s perceived and actual risk deped on the amount of control you think you have and familiarity
risk is = probablity mutiplied by consequences of what you are proposing to do and your exposure
You have 4 choices to tackle risk
TEAM
Transfer
Eliminate (don’t do the job)
Accept (depend on risk tolerance)
Mitigate (reduce)
In the last step, to metigate:
**ARS
**
Avoidance (if risk exceeds gain)
Reduction (reduce consequences/don’t take riks often)
Segregation (isolate the effects of the risk, build some redundancies)
murphey’s law
if there is more than one outcome for task, and one of these outcomes will result in disaster, then somebody will do it that way anyways
anything that could go wrong will eventually go wrong.
what’s an error chain
one error that happend had caused another error to happen that would not have otherwise happened if it weren’t for the first error
planning and anticipation pros and cons
**Pros:
**saves time and reduces workload in flight
improves quality of decision making esp during high workload
**Cons:
**
-Rigid plans can make you overlook better solutions in unexpected situations
-might select unsuitable actions which have been planned in advance
what is error management strategies x5
Error preventions: Avoid the error
Error detection: detect the error as soon and clear as possible
Error recovery: it’ll be simple to reset the system back to safe state (after the occurance of error)
error tolerance: minimize the effect of the error by making a system that is as tolerant as possible towards error
error reduction: reduce probability of error occurance and minimize the extent of the erro
Human reliability is changing…
human error is now considered inevitable
what is low error tolerance
means a situation is risky and must be very careful to not produce error
best thing is to constatnly complying with cross over verifcations procedures
what is cognitive errors
cognitive distortions are habituatl thought patterns that cause people to view reality inaccurately or negatively
types of cognitive errors
Polarised thinking: view things in one extreme or the other (no option in between). You are an angel or pure evil
overgeneralisation: knowledge gained from one event is generalized to every possible similar future event
catastrophising: assuming the worst all the time.
personalisation:taking things personally which aren’t connected to him/her
mind reading: assuming you know what others are thinking
mental filtering: choosing to ignore positives and focusing on negatives
discounting positives: ignoring positives and assuming it’s luck (not skills, etc)
emotional reasoning: thinking ones emotions are facts
labelling: reducing someone or you to a single negative aspect of personality
In TEM, threates are dividied into 2 categories
threats happen beyond hte influence of the flight crew (so human behaviour is not a category)
Organizational
Environmental
Procedural errors
SOPs: failure to cross verify automation inputs is a procedural error
another example: call outs that are omitted or incorrect
weight/balance/fuel info incorrect on forms
omitted briefing
counter measures in TEM
ACAS
TAWS
SOPS
checklists
briefings
training
callouts
personal strategies and tactics
Crew/planning/execution and reviews
