threat and error management training for air traffic control officers greg down icao global tem...
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Threat and Error Management Trainingfor Air Traffic Control Officers
Greg Down
ICAO Global TEM & NOSS Symposium EUROCONTROL IANS
LuxembourgNovember 9, 2005
Presentation Overview
• Background• Overview of TEM Training• Benefits• Review
NAV CANADATEM Background
• In 2001, visited Continental Airlines and University of Texas to research the application of TEM in ATS
• Participated in Continental’s TEM Training and experienced first hand the impact and value of this training
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
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
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
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
TEM FrameworkThreats
Errors
Undesired States
OutcomeOutcome
Threat Management
Error Management
Undesired StateManagement
Errors
What is a Threat?
Events or conditions which occur:• beyond the influence of the air traffic
controller;• increase a situation’s complexity; and• must be managed to maintain
the margins of safety.
“It’s 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
“It’s 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
Threats Threats (Aerodrome Environment)(Aerodrome Environment)
Weather
Maintenance
Airspacerestrictions
Visitors
Runway crossings Comm. failure/stuck mike
Shift change
Similar call signs
Non-standard procedures
Heavy traffic
Unfamiliar crews
Automation events Missed approaches
Runway inspections
System malfunctions
Distractions
Threats Threats (Radar Environment)(Radar Environment)
Weather
Maintenance
Airspacerestrictions
Visitors
Military activities Comm. failure/‘Stuck’ mike
Shift change
Similar call signs
Non-standard local procedures
Heavy traffic
Co-ordinationother sectors
Automation events Differing equipment
Diversions
System malfunctions
Distractions
Threat Error
Threat
What is a Threat?
What is Threat Management?
The process of detecting and responding to threats with countermeasures to maintain safety margins.
Tools to Teach About Threats
• Discussion of Common Threats• Promote use of the phrase
“RED FLAGS”• “DIPs” – Distractions
InterruptionsPreoccupations
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.
Examples of Error
•Incomplete Briefing•Full Readback Not Obtained•Wrong Call Sign Used•Non-Standard Phraseology•Incorrect information passed
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.
What about Error Preventionor Error Avoidance?
We cannot PREVENT all errors
Nor can we AVOID all errors
We can MANAGE errors
Managing Errors
• Follow procedures• Use proper phraseology• Continuously monitor traffic• Clarify / challenge inconsistencies
What is an Undesired State?
Operational conditions where anunintended traffic situation resultsin 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
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
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
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
TEM FrameworkThreats
Errors
Undesired States
OutcomeOutcome
Threat Management
Error Management
Undesired StateManagement
Errors
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
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
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
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)
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
Presentation Review
• Background• Overview of TEM Training• Benefits• Review
TEM Promotes an Effective Safety Culture
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An organization’s safety culture can be defined by the extent to which it is:
• Informed
• Wary
• Just
• Flexible
• Learning
Threat and Error Management Trainingfor Air Traffic Control Officers
Greg Down
ICAO Global TEM & NOSS Symposium EUROCONTROL IANS
LuxembourgNovember 9, 2005