intro to threat & error management

Intro to Threat & Intro to Threat & Error ManagementError Management

Welcome

Accident Causal Factors Over Time

Human Causes

Machine Causes

Time

The Tip of the Iceberg

The Tip of the Iceberg

What is happening here?

What is CRM?

Effective use of all Effective use of all resources, to achieve the resources, to achieve the highest possible level of highest possible level of safety and efficiency. safety and efficiency.

(Transport Canada)(Transport Canada)

RESISTHARDWARE & SOFTWARE THAT

EXISTS BEFORE THE HUMAN ENTERS

RESOLVEWHAT THE HUMAN BRINGS TO THE SYSTEM

Continental Airlines

What’s a Threat?

Anything that Anything that increases increases

operational operational complexitycomplexity

Weather

MaintenanceMaintenance

Ground Crew

Cabin Crew

Passenger EventsPassenger EventsATC

Terrain

Similar Call Sign

Time Pressures

Heavy Traffic

Unfamiliar Airport

Automation EventAutomation Event

Missed Approach

Flight DiversionFlight Diversion

System MalfunctionSystem Malfunction

DistractionsDistractions

Example Threats

What’s the Threat?

ICAO

Northwest Airlines

UndesiredAircraft State

Trap:Managing Error

Avoid Error:Managing Threats

Threats

Layered System of Defenses

Undesired

Aircraft

State

TEM Toolkit

Case Study

What we did at NWA

What we did at NWA

Recurrent Training CBT

What we did at NWA

Instructor Briefing Guides

What we did at NWA

Briefing Room Posters

What we did at NWA

7-hole cards to all

5500 pilots

• Mailbox

• Briefing Rooms

• Jumpseat Handout

• Lounges

7-hole cards

Video Training & Scenario

What we did at NWA

Integrating Threat & Error Management

Flight StandardsLine checks to reinforce threat recognition, error avoidance and

management

Flight OperationsReview/revise SOPs and policies

SafetyError reporting system (ASAP) for dataSafety Programs (HF, FOQA)Ongoing QA Audits

TrainingThreat recognition & error avoidance and managementCaptain LeadershipFocus on technical and procedural excellence

More Info…

WATS

Thanks

Darren Smithwww.cfidarren.com

813-503-3322