Threat and error management

Threat and error management is an important element in the training of competent pilots that can effectively manage in-flight challenges.{{cite book | last=Martin | first=Wayne L. | title=Crew Resource Management | chapter=Crew Resource Management and Individual Resilience | publisher=Elsevier | year=2019 | doi=10.1016/b978-0-12-812995-1.00007-5 | pages=207–226}} Many strategies have been developed (e.g. training, teamwork, reallocating workload) that were focused on improving on stress, fatigue, and error. Flight crew training stressed the importance of operational procedures and technical knowledge, with less emphasis placed on nontechnical skills, which became isolated from the real-world operational contexts.{{cite journal|last1=Thomas|first1=Matthew|title=Predictors of Threat and Error Management: Identification of Core Nontechnical Skills and Implications for Training Systems Design|journal=The International Journal of Aviation Psychology|date=2004|volume=14|issue=2|pages=207–231|doi=10.1207/s15327108ijap1402_6|s2cid=15271960|accessdate=24 October 2015|url=https://www.researchgate.net/publication/228977150}} Safety training, including TEM, is important because a crew's nontechnical (safety) knowledge helps more in managing errors effectively than crews' familiarization with operations through experience.{{cite journal|last1=Thomas|first1=Matthew|last2=Petrilli|first2=Renee|title=Crew Familiarity: Operational Experience, NonTechnical Performance, and Error Management|journal=Aviation, Space, and Environmental Medicine|date=Jan 2006|volume=77|issue=1|accessdate=25 October 2015|url=http://www.unisanet.unisa.edu.au/staff/matthewthomas/paper/thomas_familiarity.pdf}} Candidates who are shortlisted during selection and training processes must demonstrate analytical and coordination capabilities.{{cite journal|last1=Sexton|first1=J. Bryan|last2=Thomas|first2=Eric|last3=Helmreich|first3=Robert|title=Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys|journal=British Medical Journal|date=March 2000|volume=320|issue=7273|pages=745–749|doi=10.1136/bmj.320.7237.745|pmid=10720356|pmc=27316|url=}} Possessing these nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.

The following components are methods that help provide data for the TEM.

Training for LOSA experts includes two sessions: education in procedural protocols, and TEM concepts and classifications.{{cite journal|last1 = Earl|first1 = Laurie|last2 = Bates|first2 = Paul|last3 = Murray|first3 = Patrick|last4 = Glendon|first4 = Ian|last5 = Creed|first5 = Peter|title = Developing a Single-Pilot Line Operations Safety Audit: An Aviation Pilot Study|journal = Aviation Psychology and Applied Human Factors|date = 2012|volume = 2|pages = 49–61|accessdate = 24 October 2015|url = https://www.researchgate.net/publication/263917559|doi=10.1027/2192-0923/a000027|hdl = 10072/49214|hdl-access = free}} A LOSA trainee is taught to find data first and then code them later for both sessions, during which a crew member must exhibit "LOSA Etiquette" — ability to notify the pilot as to why he or she was not able to detect an error or threat after a flight. The pilot's responsibilities include his or her opinions on what safety issues could have had an adverse impact on their operations. A LOSA trainee must then record the specific responses of the pilot and thereafter code performance using behavioral markers. The order of the recording is as follows: a) record visible threats; b) identify error types, crew's responses, and specific outcomes; and c) use CRM behavioral markers to rate crew.{{cite journal|last1=Leva|display-authors=etal|first1=M.C.|title=The advancement of a new human factors report – 'The Unique Report' – facilitating flight crew auditing of performance/operations as part of an airline's safety management system|journal=Ergonomics|date=August 2008|volume=53|issue=2|pages=164–183|doi=10.1080/00140130903437131|pmid=20099172|s2cid=32462406}}

Observers will finally record a pilot's overall response on a 4-point Likert scale: 1) poor, 2) marginal, 3) good, and 4) outstanding. The data are then quantified and tabulated as exemplified by the following format:

Planning and execution of performance

Frequency is the total number of threats that occurred and is denoted by N.

LOSA identifies three main categories that must be recorded:

• Errors include procedural errors (mistakes or inadequacy of attention towards a task at hand), and violation of SOP (intentional or unintentional). Although crew members are encouraged not to be afraid of admitting their mistakes, they must be able to criticize themselves since the learning process helps them understand the potential danger presented other crew members.
• Undesired Aircraft States are aircraft configurations or circumstances that are caused either by human error or by external factors. The management of unintended states is vital since they can result in serious aircraft accidents. For example, navigation problems on the cockpit display may lead a pilot to make an incorrect decisions, potentially causing injuries or fatality to passengers and crew members alike.

Safety change process (SCP), which is part of LOSA, is a formal mechanism that airlines can use to identify active and latent threats to flight operations.{{cite journal|title=Line Operations Safety Audit (LOSA)|journal=ICAO Journal|date=2002|issue=First Edition|pages=25–29|accessdate=18 November 2015|url=http://www.skybrary.aero/bookshelf/books/2494.pdf}} It is a guideline that communicates in detail what is an imminent threat to current operations or who is causing the threat. In the past, SCP data were based on investigation of accidents or incidents, experiences, and intuitions but nowadays SCP focuses more on the precursors to accidents. There are several steps involved in conducting SCP:

{{chart top|Safety Change Process (SCP) model}}

{{chart/start|align=center}}

{{chart| | | | |Mea|-|Ana|-|Lis| |Mea=1. Collect safety issues (LOSA expert)|Ana=2. Conduct detailed analysis of Risks/data|Lis=3. Identify improvement strategies}}

{{chart| | | | | |!| | | | | | | |!| |}}

{{chart| | | | |Rem| |Safety Change Process| |Risk| |Rem=8. Revise any changes|Safety Change Process=Safety Change Process|Risk=4. Risk Analysis|}}

{{chart| | | | | |!| | | | | | | |!| |}}

{{chart| | | | |Time|-|Imp|-|Sel| |Time=7. Observe the impact of changes|Imp=6. Apply changes to operations|Sel=5. Funding of changes}}

{{chart/end}}

{{chart bottom}}

An unnamed airline conducted base-line observations from 1996 to 1998 using the defined SCP and LOSA data to improve its organization's safety culture and the results were positive. The crew error-trapping rate was significantly increased to 55%, meaning that crews were able to detect about 55% of the errors they caused. A 40% reduction in errors related to checklist performance and a 62% reduction in unstabilized approaches (tailstrikes, controlled flight into terrain, runway excursions, etc.) were observed. A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.

• Accident Classification
• Aviation safety
• Crew Resource Management
• Pilot Error
• Error Management
• The curse of expertise

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Category:Aviation safety

Category:Safety analysis