DEA CRM TRAINING

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Threat Error Management (TEM) Workshop
3rd IATA ICAO LOSA TEM Conference September
13-14, 2005 Kuala Lumpur, Malaysia
Captain Don Gunther Managing Director Human
Factors Safety
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TEM Workshop Agenda

• Developing a TEM program
• LOSA
• TEM and an Automation Policy
• TEM applied outside of Flight Operations
• TEM applied to incident and accident analysis
• TEM as an integral part of a Safety Management
  System (SMS)

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Flight Operations TEM Training
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Why are we still doing CRM training?
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We Need to Continuously ImproveAviation
Safety1965 - 2004

Airplanes in service
Departures 2004 17.5 Million
19,077
2004
Hull loss accidentsper year
Accident Rate / Million Departure
Millions of departures
Hull loss accident rate
1965
1975
1985
1995
2005
2015
Year
Boeing 2004 Statistical Data May 2005
6
Accidents by Primary Cause1994 - 2003
Number of accidents
Percentage of total accidents with known causes
10
20
30
40
50
60
70
Primary Factor
Total
62
1994 -2003
84 19 16 7 5 5
Flight crew Airplane Weather Miscellaneous/othe
r Maintenance Airport/ATC
66
1991 -2000
69.1
1959 -1995
14
12
5
4
4
Total with knowncauses Unknown or
awaiting reports Total
136 50 186

• Excludes
• Sabotage
• Military action

Boeing 2003 Statistical Data May 2004
7
Accidents by Primary CauseHull Loss Accidents
Worldwide Commercial Jet Fleet 1995 through 2004
-
0
10
20
30
40
50
60
70
80
Flight Crew
75
56
23
Airplane
17
17
Weather
13
Misc./Other
8
6
5
4
Maintenance
Airport/Air Traffic Control
5
4
Total with known causes
133
Unknown or awaiting reports
44
As determined by the investigating authority,
percent of accidents with known causes.
Total
177
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Safety Culture

• Aviation Week Article on Healthy Organizations
• Investing the time and money needed to get at
  the root cause of a problem takes total
  commitment at the most senior levels of a company
  or organization. In most organizational
  settings, communicators learn early in life how
  bad news can impact their leaders. If the news
  is valued and the communicator is protected,
  there is a real chance information can and will
  routinely flow upward in time for proper action
  to be taken.

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The Safety Change ProgramTailored to
Continental

• To properly target change we need current
  operational data, specifically for Continental,
  which is unique due to its
• History Culture
• Areas of operation (CMI, polar routes, etc.)
• Philosophy

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Line Observation Safety Audit (LOSA)
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Normal Performance
FAA
Check Airmen
LOSA 1
LOSA 2
Angel
Normal
Perfect

• Distance between Perfect and Normal
  performance varies as a function of culture,
  training, etc.

• LOSA enables us to get as closer to normal
  performance than was previously possible.

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The Continental LOSA Process

• 1st year
• LOSA and data analysis followed by course
  development
• 2nd 3rd years
• Training course for all crewmembers, Check Airmen
  training and imbedding of TEM into courseware,
  policy procedures, etc.
• 4th year
• Preparation for next LOSA and targeting areas to
  be measured and new areas to be emphasized.

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Line Observation Safety AuditLOSA 1996
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Error Managements early focus was
Managing crew error
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Line Observation Safety AuditLOSA 2000
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LOSA 1996 vs. 2000

• A 70 reduction in Checklist errors
• A 60 reduction in unstable approaches (confirmed
  by FOQA data)
• Overall improvement in crew performance
• Still a need for improvement in Leadership skills

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Threat and Error Management
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Threats
"A threat is anything external to the crew that
increases operation complexity and, if not
managed properly, can decrease the safety
margins."

• Threats
• Do not equal errors
• Increase error potential
• Threats Red Flags

RED FLAG
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THREATS
Influences that can lead to crew error
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Threat and Error Management
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Threat Management

• Strategies/Countermeasures
• (Industry, Corporate and/or Personal)
• To reduce the number of errors
• To improve the error management process by
  increasing the awareness of potential errors

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Threat and Error Management
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Error

• Actions or inactions by the flight crew that lead
  to deviations from organizational or flightcrew
  intentions or expectations

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Error Management

• Actions taken to deal with errors committed by
  either
• Detecting and correcting them, or by
• Containing and reducing the severity

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Error Management
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Error Management
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RESISTANCE
HARDWARE SOFTWARE THAT EXISTS BEFORE THE HUMAN
ENTERS
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Error Management
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RESOLVE
WHAT THE HUMAN BRINGS TO THE SYSTEM
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Threat and Error Management
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NASA Guidelines
Monitoring Crosschecking
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NASA Guidelines

• Positively delegate flying and monitoring duties
• Monitoring is as important as flying
• Flying pilot does not become involved with
  secondary tasks
• When conflict arises-resolve with outside source
• When in doubt-must express!

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Monitoring and Crosschecking
Pilot Monitoring (PM)
Take Action
Crosschecking Steps
Express Your View
Error Resolved
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Monitoring and Crosschecking
Pilot Monitoring (PM)
Take Action
Crosschecking Steps
Express Your View
Error Resolved
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Monitoring and Crosschecking
Pilot Monitoring (PM)
Take Action
Crosschecking Steps
Express Your View
Error Resolved
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Monitoring and Crosschecking
(PM)
Take Action
Crosschecking Steps
Express Your View
Error Resolved
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Case Studies
Look in the mirror first
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TEMthe challenge

• How to improve
• Threat
• Identification?
• Get it on the Radar!

RED FLAG
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Distractions

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Threat and Error Management
LOW VISIBILITY TAXI
DE - ICING
WRONG TURN
Decision Making Leadership
ALTITUDE DEVIATION
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DECISION-MAKINGPlan, Review, Monitor Modify
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Decision Making
Strategic

• Perceive Situation
• Develop Plan
• Share Plan
• Execute Plan
• Monitor Results

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Decision Making
Strategic
Tactical

• Perceive Situation
• Develop Plan
• Share Plan
• Execute Plan
• Monitor Results

Situation Assessment
Select a Course of Action
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Situation Assessment
The Nature of the Threats
RISK
TIME
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Leadership
What have you seen?
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Threat and Error Management Training
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TEM TRAINING CLASS

• Ideal class size 15-20
• The value of the introduction
• Opening question
• Facilitation training
• Line pilots
• Follow-on Check Airmen training

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Crew Resource Management Effective Crew Resource
Management is the bedrock of Threat and
Error Management.
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Newsletter

• Feedback to the pilots is essential for continued
  program success.

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The Role of the Check Airman in Threat Error
Management
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TEM Automation
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To ERR is Human

• To REALLY make a mess of things, you need a
  computer!

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Verbalize VerifyMonitor

• The Continental Airlines
• Automation Policy

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TEM the challenge

• Improve Threat Error identification by using
• To help Get it on the RADAR

Verbalize, Verify, Monitor
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Threat and Error Management
AUTOMATION
Verbalize, Verify, Monitor
ERRORS
Resist
Resolve
CONSEQUENCE
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TEM Training outside of Flight Operations
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Maintenance Threat Error Management (MTEM)
Food Services Threat Error Management Field
Services Threat Error Management
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Threats
Influences that can lead to agent error
Passenger events
Distractions
Late Bags
Cabin Crew
Weather
Ramp slope
Late Gate Change
Maintenance
Time pressures
New Agent
Flight diversion
Heavy traffic
System malfunction
Unfamiliar gate
Flight Crew
Late Cargo
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Ramp LOSA
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Why Ramp LOSA?

• The first step in managing threats is to collect
  data
• Precursors (Threats) are identified and
  evaluated
• Countermeasures (Strategies) are developed,
  communicated throughout the organization, and
  then implemented in the system

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Identified Threats

• Threats can be prioritized according to
• The probability of an incident or accident
  occurring and then by
• The severity of an incident or accident that may
  occur if the threat is mismanaged

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Threat Management

• The objective of Threat Management is to
• Obtain an understanding of how to assess the
  various risk levels of the threats and to
• Gain an insight on logical approaches
  (strategies) to deal them

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TEM applied to Incident Accident Analysis
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TEM Toolkitfor Incident Accident (IA)Analysis
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IATA Safety Advisory CommitteeIncident
Accident analysis
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IATA Safety Advisory CommitteeIncident
Accident analysis
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Incident Example

• Aircraft taxiing toward the gate
• 757 parked at adjacent gate
• Catering truck parked properly within the
  adjacent gate clearance zone
• Arrival gate has an auxiliary J-line, requires 2
  marshallers and clearance zones overlap
• Pre-arrival briefing not done
• Wing-walker had less than 30 days on job
  unfamiliar with these gates
• New wing-walker panicked and failed to give the
  STOP signal when he saw the wing was going to
  strike the catering truck
• Damage to wing and catering truck

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Diagram of incident
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Diagram of incident
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Diagram of incident
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Threat and Error Management (TEM)
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Threats

• 1. List of the Threats
• 2.
• 3.
• 4.
• 5.
• 6.
• 7.
• 8.

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Threats

• 757 parked at adjacent gate
• Catering truck
• Arrival gate has an auxiliary J-line, requires 2
  marshallers and clearance zones overlap
• Wing-walker had less than 30 days on job
  unfamiliar with these gates

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Threat Management

• 1. Identify the Threat

• 1. Was the threat managed or mismanaged? How?

2.
2.
3.
3.
4.
4.
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Threat Management

• 1. 757 parked at adjacent gate

• 1. Managed

2. Managed
2. Catering truck
3. Mismanaged clearance zone not properly
marked (latent)
3. Arrival gate auxiliary J-line clearance
zones overlap
4. Wing-walker had less than 30 days on job
unfamiliar with gates
4. Mismanaged Crew brief not accomplished
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Errors

• 1. List of the Errors
• 2.
• 3.
• 4.
• 5.
• 6.
• 7.
• 8.

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Errors

• 1. Pre-arrival briefing not accomplished
• 2. Catering truck parked in clearance zone
• 3. Wing-walker did not give stop signal
• 4.

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Error Management

• 1. Was the error managed or mismanaged? How?

• 1. Identify the Error

2.
2.
3.
3.
4.
4.
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Error Management

• 1. Mismanaged Awareness of threat not
  established

• 1. Pre-arrival briefing not accomplished

2. Catering truck parked in over-lapping
clearance zone
2. Mismanaged improper markings not detected
(T3)
3. Wing-walker did not give stop signal
3. Mismanaged (latent?) training/ crew brief
(E1)
4.
4.
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Undesired State Management

• List how the Undesired State was managed or
  mismanaged.

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Undesired State Management

• Managed
• Post mishap procedures followed
• PAX, fuel spill, etc
• Etc.
• Mismanaged

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Prevention Strategies

• List initial corrective actions at the present
  time and any proposed actions.
• Crew Briefs
• Training
• Auditing procedures/policy

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TEM an integral part of a Safety Management
System (SMS)
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Continental AirlinesSafety Management
System(SMS)
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IATA ICAO SMS Documents and Training
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SMS Essential Prerequisites

• A comprehensive corporate approach to safety,
• An effective organization for delivering safety,
  and
• Systems to achieve safety oversight.

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Developing the ContinentalSafety Management
System (SMS)

• Safety statement from CEO
• Corporate Safety Policy
• Add SMS description and Corporate Safety Policy
  to the Safety manual
• Establish the Corporate Safety Review Board
• Begin development of the Safety Action Team
  within each division
• Audit the remainder of the Continental SMS

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Corporate Safety Review Board (CSRB)

• Accountability
• The CSRB is chaired by the CEO
• Membership
• CSRB membership comprises the CEO, (Sr/Exec)
  VPs of Flight Operations, Field Services, Tech
  Ops and Marketing (heads of the functional
  areas). The Director of Safety will attend the
  CSRB as the facilitator.

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Safety Action Team (SAT)

• Accountability
• SATs are responsible to the Corporate Safety
  Review Board and the chair is determined by the
  appropriate (Sr/Exec) VP.
• Membership
• SAT membership will normally be drawn from
  directors, managers, supervisors and staff, from
  within the appropriate functional area and when
  appropriate the FAA and labor.
• Terms of Reference
• As a minimum each SAT is responsible for the
  following
• To oversee operational safety within the
  functional area.
• To ensure that any necessary corrective action is
  taken in a timely manner.
• To report to and accept strategic direction from
  the Corporate Safety Review Board via the
  appropriate Exec/Sr VP.

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Continental SMS
Corporate Safety Review Board CSRB
Director of Safety
Flight Operations Safety Action Team
Tech Ops Safety Action Team
Field Services Safety Action Team
Mkt/Rsv Safety Action Team
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Flight OperationsSafety Action Team (SAT)

• Develop the process by which safety data and
  crew performance and behavior data from
• FOQA, LOSA, ASAP, CASIS, Line Checks, are
  analyzed by
• Safety, Flight Operations, Inflight, Flight
  Standards Training, FAA and ALPA Safety in
  order to facilitate change.

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To have an effective SMS
Safety Operational Efficiency need to be
combined into a Corporate Safety Culture
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Goal

• Become a better Threat Manager actively
  identify threats in your operation
• Threat Management is managing your future.
• Error Management is managing your past
• Continue building a Safety Culture by encouraging
  open, honest communications

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Threat and Error Management