Title: Threat and Error Management Training for Air Traffic Control Officers Greg Down
1Threat and Error Management Trainingfor Air
Traffic Control Officers Greg Down
ICAO Global TEM NOSS Symposium EUROCONTROL
IANSLuxembourgNovember 9, 2005
2Presentation Overview
- Background
- Overview of TEM Training
- Benefits
- Review
3NAV 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
4Continental 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
5NAV 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
6TEM 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
7What 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
8TEM Framework
Threats
Threat Management
Errors
Errors
Error Management
Undesired States
Undesired State Management
Outcome
9What 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
12Threats (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
13Threats (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
14What is a Threat?
15What is Threat Management?
- The process of detecting and responding to
threats with countermeasures to maintain safety
margins.
16Tools to Teach About Threats
- Discussion of Common Threats
- Promote use of the phrase
- RED FLAGS
- DIPs Distractions Interruptions Preoccupa
tions
17What 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.
18Examples of Error
- Incomplete Briefing
- Full Readback Not Obtained
- Wrong Call Sign Used
- Non-Standard Phraseology
- Incorrect information passed
19What 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.
20What about Error Preventionor Error Avoidance?
- We cannot PREVENT all errors
- Nor can we AVOID all errors
- We can MANAGE errors
21Managing Errors
- Follow procedures
- Use proper phraseology
- Continuously monitor traffic
- Clarify / challenge inconsistencies
22What 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
23Undesired 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
24Undesired 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
25Goals 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
26TEM Framework
Threats
Threat Management
Errors
Errors
Error Management
Undesired States
Undesired State Management
Outcome
27Strategies 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
28Strategies 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
29Challenges 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
30Benefits 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)
31Benefits 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
32Presentation Review
- Background
- Overview of TEM Training
- Benefits
- Review
33TEM 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
34Threat and Error Management Trainingfor Air
Traffic Control Officers Greg Down
ICAO Global TEM NOSS Symposium EUROCONTROL
IANSLuxembourgNovember 9, 2005