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Cabin Crew
Threat and Error Management Carolyn Vaughan - Principal Human Factors
27th November 2014
Asiana Flight 214 – San Francisco, July 2013
1L
2L
3L 3R
1R
4L 4R
FC told to Initiated
after hearing 2L’s
commands
Fire outside
Slide inflated
inside, created
bottleneck of
pax to 2L
Slide inflated
inside trapping
2x CC
Initiated evac after
seeing fire at 2R
Main Exit point
CC injured, door
opened by pax Briefly lost
consciousness
Door wouldn’t open,
CC redirected pax to
3R
Door torn from
frame, slide inflated
inside cabin
Severe damage.
Slide would not have
worked due
maintenance error
2R
Real accidents are not as
black and white as EPs!
Procedures v Threat and Error Management
• How do procedures and Threat and Error Management work together?
• Have we got the right emphasis?
• Will our crew be willing to think outside the box if needed?
Risk assessed procedures
v
Risk evaluation on the day
Threat and Error Management Toolbox
The Non Technical strategies and tools that you learn in Human Factors are your tools to help you:
Avoid / Prevent
Detect
Manage
Threats and Errors in the operation.
TEM Strategies are also embedded into procedures and practices.
Communication
Leadership and
Managerial Skills Teamwork
Decision Making Situational
Awareness
Structure of Topics
Fatigue
Stress
Distractions
and
Interruptions
Design
Culture Technology
Threat & Error Management
•Avoid / Prevent
•Identify
•Manage / Recover
Threat & Error Management Model
TEM Stages
AVOID Threats
PREVENT
Errors
IDENTIFY Threats and Errors
MANAGE and RECOVER from Threats and Errors
• Normal Procedures Training
• Briefings and communication between crew
• Silent Review
• Maintaining a shared or connected mental model
• Reporting
• Anticipating potential threats
AVOID PREVENT
• Allocating attention and managing distractions
• Cue recognition – What information is important?
• Recognising an action or situation as a threat or error
IDENTIFY
• Know the objective and put a strategy in place to meet it
• New objective New strategy
• Use all available resources
• Effective decision making methods that consider risk
• Awareness of factors affecting or limiting performance
• Evaluation loop
MANAGE and RECOVER
Underlying beliefs for Threat and Error Management to work
• Identifying and managing threats is a core part of
the Cabin Crew role.
- They may be expected (anticipated) or unexpected
(unanticipated)
• Errors should not be punished, but rather
expected and managed.
- Managing errors is part of the Cabin Crew role
• Cabin Crew are an integral part of the System.
- What I do matters! It’s up to me!
Behaviour for effective TEM
• Preparation, Anticipation, Communication
• If it is not possible to follow an exact procedure, follow the intent of the procedure
• Chronic unease – not complacent
• Actively managing and maintaining situational awareness
Attitudes towards Threat and Error Management
Sometimes errors happen, fortunately the crew caught it
and managed it effectively.
They managed to catch it before anyone was hurt but why
didn’t they avoid the situation altogether?
OR
