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Threat and Error Management: Diagnosing Safety Before a System Breakdown

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1. Reactive - improvement to system defenses in order to prevent a particular ... 5. Lavatory smoke alarm during cruise. 6. Weather and heavy traffic on arrival ... – PowerPoint PPT presentation

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Title: Threat and Error Management: Diagnosing Safety Before a System Breakdown


1
Threat and Error Management Diagnosing Safety
Before a System Breakdown
  • James Klinect
  • The University of Texas at Austin
  • February 18, 1999

2
Three Organizational Approaches to Safety
  • 1. Reactive - improvement to system defenses in
    order to prevent a particular breakdown (incident
    or accident) from reoccurring
  • 2. Proactive - diagnose weaknesses in system
    defenses that have the potentiality to lead to
    future breakdowns
  • 3. Reactive and Proactive - The optimal
    organizational safety approach

3
Reactive Sources of Data
  • Data collected after a system breakdown
  • Accident reports - too rare (1.5 PMD accident
    rate)
  • Voluntary incident reporting - causes and
    outcomes
  • Same as ASRS but the reports are collected
    in-house
  • Air Safety Awareness Partnership (ASAP) - 3500
    reports per year

4
Requirements for a Successful Reporting System
  • 1. Trust
  • 2. Non-punitive policy toward flightcrew error
  • 3. Confidentiality
  • 4. Managerial commitment to take action
  • 5. Feedback information to the line

5
Surveying Incident Reporting Roadblocks
6
Voluntary Incident Reporting Limitations
  • Reports can be skewed - incomplete data about the
    event (ex., procedural violations)
  • Retrospective - Only provides post-hoc data on
    failed system or crew performance

7
Proactive Safety Approach
A proactive safety approach is an informed
approach
8
Why Threats and Error?
  • Threats and errors reduce the margin of safety
    and increase the probability of incidents or
    accidents
  • Threats and errors are inevitable and can only
    hope to reduce their impact by managing their
    consequences
  • The quality of threat and error management is a
    better indicator of system safety because it is
    more robust than incident or accident reports

9
Proactive Data Sources
  • Data collected before a system breakdown
  • Performance evaluations - crew competency
  • DFDR (FOQA) - flight instrument parameters
  • Surveys - attitudes, perceptions, and suggestions
  • Line Operations Safety Audit (LOSA) - crew
    performance during normal flight operations

10
Line Operations Safety Audit
  • Systematic observations of crew performance
  • Team of observers from the airline and U.T.
  • Non-jeopardy
  • Union supported
  • Measures
  • SOP compliance
  • CRM behavioral markers and crew performance
  • Threat management - external threat types and
    behavior
  • Error management - error types and behavior
  • Informal feedback from the crews about flight
    operations and training

11
The LOSA Error Database
  • 1. International Major - 59 crews on 91 flights
  • International and domestic flights - South
    Pacific and Pacific Rim
  • 2. U.S. Major - 65 crews on 102 flights
  • Only international flights - Central and South
    America
  • 3. U.S. Regional - 60 crews on 121 flights
  • Experienced Captains with inexperienced First
    Officers (less than 4 years in aviation and less
    than one year in position)

12
Threat Management
13
The Rain of Threats
14
Threats
Threats increase the level of risk to safety
  • External Events
  • Adverse weather
  • ATC command
  • Terrain
  • Aircraft systems malfunction
  • Maintenance event
  • Dispatch event
  • Ground handling event
  • Cabin event
  • Airport conditions
  • Operational pressure
  • External Errors
  • Maintenance error
  • Dispatch error
  • ATC error
  • Ground crew error
  • Cabin crew error

15
A Heavy Rain of Threat
  • On one flight observation,
  • 1. Late arriving aircraft
  • 2. Inconsistent fuel slips
  • 3. Weight restriction on departure
  • 4. Weather and heavy traffic on takeoff
  • 5. Lavatory smoke alarm during cruise
  • 6. Weather and heavy traffic on arrival
  • 7. ATC instructed a runway change in late final

16
Threat Results
  • 72 of the flights had at least one or more
    threats
  • From 0 to 10 external threats per flight
  • Averaged 2 threats per flight

17
Threats by Phase of Flight
Threats most frequently occur during preflight
and approach
18
Most Common Threats
  • 1. Adverse weather - 20 of all flights
  • 2. Aircraft malfunctions - 12
  • 3. ATC event - 10
  • 4. External errors (ATC, Maintenance, Cabin,
    Dispatch, and Ground Crew) - 8
  • 5. Operational pressures - 8

19
Threat Recognition and Error Avoidance Behaviors
  • Behaviors that crews used to recognize threats
    and avoid error
  • 1. Active Captain leadership
  • 2. Vigilance
  • 3. Operational plans clearly stated and
    acknowledged
  • 4. Staying ahead of the curve
  • 5. Following SOP

20
Error Management
21
The Other Piece Flightcrew Errors
22
Flightcrew Errors
  • Can be triggered by an external threat or occur
    in isolation
  • Flightcrew error - the action or inaction that
    leads to a deviation from crew intentions or
    expectations

23
A Model of Error Management
24
Intentional Noncompliance Procedural Communication
Proficiency Operational Decision
Error Types
25
Error Types
  • 1. Intentional Noncompliance - violations
  • ex.) Omitted required briefings
  • Performing checklists from memory
  • Failure to cross-verify settings
  • 2. Procedural - followed procedures but wrong
    execution
  • ex.) Lever and switch settings
  • Wrong altitude dialed
  • Wrong MCP mode executed

26
Error Types
  • 3. Communication - Misinterpretation or missing
    information or during an exchange
  • ex.) Wrong readbacks to ATC
  • Missed ATC calls
  • Wrong runway communicated
  • 4. Proficiency - lack of knowledge error
  • ex.) Lack of stick and rudder proficiency
  • Lack of knowledge with automation
  • Lack of knowledge with procedures

27
Error Types
  • 5. Operational Decision - discretionary decision
    not covered by procedures that unnecessarily
    increased risk
  • ex.) Over-reliance on automation
  • Unnecessary low maneuver on approach
  • Unnecessary navigation through adverse
    weather

28
Intentional Noncompliance Procedural Communication
Proficiency Operational Decision
Error Types
Trap Exacerbate Fail to Respond
Error Responses
29
Error Responses
  • Trap - error is detected and managed before it
    becomes consequential (undesired state or
    additional error)
  • Exacerbate - error is detected but the crews
    action or inaction becomes consequential
  • Fail to Respond - lack of a response to an error
    (undetected or ignored) that can either end up
    being inconsequential or consequential

30
Intentional Noncompliance Procedural Communication
Proficiency Operational Decision
Error Types
Trap Exacerbate Fail to Respond
Error Responses
Error Outcomes
Inconsequential
Undesired State
Additional Error
31
Undesired States
Undesired states are deviations from normal
flight that unnecessarily compromises safety
  • Lateral deviation - heading
  • Vertical deviation - altitude
  • Speed to high or low
  • Unstable approach
  • Near miss
  • Fuel level below minimums
  • Vertical deviation on the G.S.
  • Long landing
  • Hard landing
  • Landing off centerline
  • Wrong taxiway or ramp
  • Wrong runway
  • Wrong airport
  • Wrong country

32
Intentional Noncompliance Procedural Communication
Proficiency Operational Decision
Error Types
Trap Exacerbate Fail to Respond
Error Responses
Error Outcomes
Inconsequential
Undesired State
Additional Error
Undesired State Responses
Mitigate
Additional Error
33
Flightcrew Error Results
  • 72 of the crews committed at least one error
  • 65 of the flights had at least one error
  • From 0 to 14 errors per flight
  • Averaged 2 errors per flight
  • There were between and within-fleet differences

34
Errors by Phase of Flight
35
Error Frequencies and Consequences
36
Most Common Errors
  • 1. Automated systems errors (MCP and FMC) - 21
    of all flights
  • Failure to cross-verify settings
  • Wrong MCP or FMC settings
  • Other Intentional noncompliance errors
  • 2. Checklist errors - 20
  • Checklist performed from memory
  • Nonstandard checklist usage
  • Self-performed checklist
  • Procedural checklist errors

37
Most Common Errors
  • 3. Sterile cockpit violations - 10
  • 4. ATC errors - 6
  • Missed ATC calls
  • Omitted information (readbacks or call signs)
  • Accepting ATC instructions that unnecessarily
  • increased risk
  • Procedural ATC errors
  • 5. Briefing errors (omitted or incomplete) - 5

38
Error Management Results
39
Undesired State Results
  • Responses to Undesired States
  • 75 are mitigated
  • 9 lead to additional errors
  • 16 required no crew response
  • Most common undesired states
  • 1. Vertical deviations
  • 2. Speed too high
  • 3. Lateral deviations

40
Error Detection and Management Behaviors
  • Behaviors that crews used to detect and manage
    errors
  • 1. Active captain leadership
  • 2. Environment set for open communications
  • 3. Crew members asking questions and speaking up
  • 4. Vigilance
  • 5. Prioritization of tasks to manage workload

41
Between-Airline Differences
42
Violations as the Norm
  • One observer noted the following during the U.S.
    Regional audit on an IOE ride,
  • The Check Airman ran the entire taxi
    checklist by memory.
  • Organizations cannot allow violations to
    normalize
  • Why? - Crews that commit at least one intentional
    noncompliance error are more likely to commit
    other types of error than those without an
    intentional noncompliance error

43
Summary
44
Optimizing Safety Efforts
  • Organizational safety approaches need to be
    reactive and proactive
  • Incident reports provides useful data after a
    system breakdown, but only part of the answer
  • Safety efforts will be fully optimized when
    systems diagnose weaknesses before breakdowns
  • This requires ongoing line audits of normal
    flight operations that measures crew performance
    in threat and error management

45
Safety Roles in Improving System Defenses
  • Flight Standards
  • Line checks to reinforce threat recognition,
    error avoidance and management
  • Flight Operations
  • Review/revise SOPs and policies
  • Safety
  • Error reporting system (ASAP) for data
  • Ongoing line audits for different parts of the
    operation
  • Training
  • Threat recognition, error avoidance, and error
    management
  • Leadership
  • Focus on technical and procedural excellence

46
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