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Threat and Error Management Training for Air Traffic Control Officers Greg Down

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Title: Threat and Error Management Training for Air Traffic Control Officers Greg Down


1
Threat and Error Management Trainingfor Air
Traffic Control Officers Greg Down
ICAO Global TEM NOSS Symposium EUROCONTROL
IANSLuxembourgNovember 9, 2005
2
Presentation Overview
  • Background
  • Overview of TEM Training
  • Benefits
  • Review

3
NAV CANADATEM Background
  • In 2001, visited Continental Airlines and
    University of Texas to research the application
    of TEM in ATS
  • Participated in Continentals TEM Training and
    experienced first hand the impact and value of
    this training

4
Continental AirlinesTEM Training
  • A consistent and operationally focused
    perspective on Threats and Errors in the
    operational environment
  • TEM was (and still is) consistently applied
    throughout the organisation
  • Training (Initial and Recurrent)
  • Simulator Checks
  • Auditing (FOQA LOSA)
  • Dispatch, Ramp

5
NAV CANADA TEM Training
  • Delivered in 2001 to all operational staff (ATCOs
    and FSSs) and Line Management
  • Included FAA Video Collision Course
  • Opportunity to discuss experiences through the
    TEM lens
  • Well received by staff and management

6
TEM Training Overview
What is the TEM Framework? What is a
Threat? What is an Error? What is an Undesired
State? Strategies for Managing Threats and Errors
7
What is the TEM Framework?
  • A safety management framework
  • to enhance aviation safety and efficiency
  • through an operationally relevant and highly
    intuitive framework
  • to better understand and manage system and human
    performance in operational contexts

8
TEM Framework
Threats
Threat Management
Errors
Errors
Error Management
Undesired States
Undesired State Management
Outcome
9
What is a Threat?
  • Events or conditions which occur
  • beyond the influence of the air traffic
    controller
  • increase a situations complexity and
  • must be managed to maintain the margins of
    safety.

10
Its a Beautiful Day in the Neighbourhood
The Ideal Shift
  • Overstaffed
  • All aircraft on radar
  • All systems operational
  • Beautiful VFR Weather
  • Happy, supportive supervisor
  • Pilots are attentive and responsive
  • Co-workers are pleasant and supportive

11
Its a Beautiful Day in the Neighbourhood
A More Typical Shift
  • Short staffed
  • Non-radar aircraft
  • Maintenance on critical systems
  • IFR / Marginal VFR Weather
  • Not-so-supportive supervisor
  • Pilots - slow to respond to instructions
  • Co-workers - demanding and create workload

12
Threats (Aerodrome Environment)
Distractions
Runway crossings
Comm. failure/ stuck mike
Visitors
Shift change
Weather
Similar call signs
Maintenance
Non-standard procedures
Airspace restrictions
Runway inspections
Heavy traffic
System malfunctions
Unfamiliar crews
Automation events
Missed approaches
13
Threats (Radar Environment)
Distractions
Military activities
Comm. failure/ Stuck mike
Visitors
Shift change
Weather
Similar call signs
Maintenance
Non-standard local procedures
Airspace restrictions
Heavy traffic
Diversions
Co-ordination other sectors
System malfunctions
Automation events
Differing equipment
14
What is a Threat?
15
What is Threat Management?
  • The process of detecting and responding to
    threats with countermeasures to maintain safety
    margins.

16
Tools to Teach About Threats
  • Discussion of Common Threats
  • Promote use of the phrase
  • RED FLAGS
  • DIPs Distractions Interruptions Preoccupa
    tions

17
What does Error mean in TEM?
  • Actions or inactions by air traffic
    controllers that lead to deviations from
    organizational or air traffic controller
    intentions or expectations.

18
Examples of Error
  • Incomplete Briefing
  • Full Readback Not Obtained
  • Wrong Call Sign Used
  • Non-Standard Phraseology
  • Incorrect information passed

19
What is Error Management?
  • The process of detecting and responding to
    errors with countermeasures that mitigate the
    probability and / or severity of further errors
    or undesired states.

20
What about Error Preventionor Error Avoidance?
  • We cannot PREVENT all errors
  • Nor can we AVOID all errors
  • We can MANAGE errors

21
Managing Errors
  • Follow procedures
  • Use proper phraseology
  • Continuously monitor traffic
  • Clarify / challenge inconsistencies

22
What is an Undesired State?
  • Operational conditions where an
  • unintended traffic situation results
  • in a reduction in margins of safety.
  • Transitional safety phase between normal
    operations and an outcome
  • Indicator that earlier Threats and / or Errors
    were not adequately managed

23
Undesired State Examples
  • Aircraft climbing / descending to altitude beyond
    its clearance
  • Aircraft deviating from assigned heading / track
    / route
  • Incomplete coordination
  • Inaccurate flight info on the radar screen
  • Not using appropriate indicators when crossing
    vehicles across an active runway

24
Undesired States are NOT Outcomes?
  • an Outcome is an end state
  • Incident
  • Operational Error
  • Operating Irregularity
  • Accident
  • Once an Outcome has occurred, normal operations
    cannot be recovered
  • Undesired States can be effectively managed and
    normal operations regained

25
Goals of TEM
Discover, assess and manage threats Enhance the
detection and management of error Improve
resistance to errors Diagnose factors that may
create threats and errors
26
TEM Framework
Threats
Threat Management
Errors
Errors
Error Management
Undesired States
Undesired State Management
Outcome
27
Strategies to Improve Safety Margins
  • Identify Threats in Operation and reduce or
    eliminate before they lead to error or
    consequence
  • Promote use of common language to focus
    attention on safety issues(RED FLAGS)
  • Make errors visible so that they can be easily
    identified and managed

28
Strategies to Improve Safety Margins
  • Make it safe to report errors (just / error
    tolerant culture)
  • Treat errors as a feedback mechanism for learning
    and continuous improvement
  • Errors are EXPECTED and WILL occur. HOW they are
    MANAGED is what is important

29
Challenges to TEM Training
  • Tendency to focus to be on Errors rather than
    Threats
  • Can devolve into a debate over Risk vs. Hazard
    vs. Threat contextual meanings if not managed
  • Can appear overly simplistic to those who are
    accustomed to more elaborate frameworks

30
Benefits Of TEM Training
  • TEM is intuitive
  • Gives structure to what controllers already do on
    a daily basis
  • Simple, robust operational Lens to view the
    operational environment
  • Identifies external factors that impact the
    operation
  • See factors that effect safety in a new way
  • Common language
  • Can facilitate rapid identification and
    communication of factors that could impact
    operations (Red Flags)

31
Benefits Of TEM Training
  • Consistent with Safety Management Systems
  • Can be deployed independently or to reinforce
    existing SMSs
  • Promotes movement toward Just Culture
  • improved reporting of safety concerns through
    focus on external factors rather than
    individuals
  • Creates foundation for improved safety data
    collection
  • programs such as NOSS
  • Illuminates that ATCOs are effective Threat
    Managers

32
Presentation Review
  • Background
  • Overview of TEM Training
  • Benefits
  • Review

33
TEM Promotes an Effective Safety Culture
  • An organizations safety culture can be
    defined by the extent to which it is
  • Informed
  • Wary
  • Just
  • Flexible
  • Learning

33
34
Threat and Error Management Trainingfor Air
Traffic Control Officers Greg Down
ICAO Global TEM NOSS Symposium EUROCONTROL
IANSLuxembourgNovember 9, 2005
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