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Customer Services

Threat Recognition and Error ManagementThreat Recognition and Error Management(TREM)(TREM)

Singapore, 8-10 October, 2002

Airbus 16th Human Factors Symposium

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Customer Services

Airbus 16th Human Factors Symposium

Threat Recognition and Error ManagementThreat Recognition and Error Management(TREM)(TREM)

Singapore, 8-10 October, 2002

Joey M. ANCA Jr

Mike MYLANSingapore Airlines

Presented by

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16th Human Factors Symposium - Singapore 200233

The Evolution of Crew Resource Management (CRM)

Threat Recognition & Error Management (TREM)

Tools from Ground Up: An Organisational Strategy

Building a Culture of Safety

TREM in Singapore Airlines

Threat Recognition and Error Management (TREM)

ContentsContents

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25 years of CRM with key issues that need to be

addressed:

CRM regulation

Integration of CRM into the Business of airlineoperations

CRM Evaluation and its relevance to shaping

skills to minimize human error

Have we indeed given the pilot the TOOLS for betterflightdeck error management?

Have we made the necessary link between CRM and the

business?

The Evolution of CRM

A Quick Heads UpA Quick Heads Up

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1st-3rd Generation CRM

4th-5th Generation CRM

6th Generation CRM

DISCIPLINE

CONCEPT

SCIENCE & TECHNOLOGY (TOOLIN

AF90 Potomac

UAL Everglades

UAL 232 Sioux City

FOQA/QAR

LOFT Development

TREM

KAL Guam

Behavioural Markers CRM

Incident Reporting/CHIRP/ASRS

LOSA

The Evolution of CRM

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CRM Instructors Behavioural Indicators

1st-5th Generation CRM Instructor(Aspirin to Ecstasy)

CRM Zealot--one sided, either

Management or Line;

The I or Experience Syndrome of

teaching: Been there, Done that;

Uses psychobabble to impress learning;

Inability to deal with classroom issues

and its relationship to fleet or flying

school concerns;

Views CRM as the magic potion; CRM

is localised as a teambuilding

technique

Increases pilot independence with other

flightcrew (cabin crew, mechanics etc)--

the Right Stuff or Clipper Captain

attitude

Very Charismatic and well-liked

6th Generation CRM Instructor(Antibiotic)

CRM Helper--sees that CRM is just one

of a host of error prevention strategies;

Focus of error management is building

an error tolerant crew or pilot

Veers away from behaviour and focuseson systems approaches to safety

Becomes a potent aid to flight

operations administration

Concerned with long-term solutions

which may not deliver initial positive

results

Upholds Captains Authority but only

after seeking information from crew

members

Uses a Just approach to things--

respected for views but sometimes

feared because of the truth.

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Engineer

Pilot

Cabin Crew

Station Manager

Organisation

ATCWorkplace

Environment Team

Eventsanomaly

incident

accident

Error Management

An Organisational Strategy

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Overt Threats: Organisational , Team, Individual, Environmental, External,

Aircraft

THREAT

RESPONSE

OUTCOME

Overt Threats: Organisational , Team, Individual, Environmental,

External, Aircraft

Latent Threats: National, Organisational, Professional cultures;

RegulatorySystem

CRM Skill

Countermeasures: Team Management,

Planning, Task Execution, Task

Review and Modification

Inciden

t

Inconsequential Safe

Flight

Undesired

Aircraft

State

New ErrorCrew Error(s)

ThreatMan

agement

ErrorManagement

TREM

A Preventive ToolA Preventive Tool

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*Red denotes SSE area of influence.

The Safety and Service Culture Context

InformedCulture

LearningCulture

Just

Culture

Safety &

Service

Culture

Actively Listening to Staff

Chronic Unease about Safety

Instilling Greater CustomerSatisfaction

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Informed

Culture

Learning

Culture

JustCulture

Safety

Culture

Listening to the Troops Chronic Unease about

Safety

Active Event

Reporting System Incident Knowledge

Base

CCRM Flight Ops

CCRM beyondFlight Ops

LLOSA

Proactive

Investigation Focused on Error

Avoidance, Trapping,

Mitigation

IInvestigation and

Discipline Process

I

CConfidential

Incident ReportingFFDAP/ Aviation

Quality Database

*Red denotes SSE area of influence.

The Safety and Service Culture Context

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Engineering &

Maintenance

Station

Managers

Cabin

Crew

Pilots

TCS-OASIS

TREM

TREM

SAFE Program

The Transcending Customer Service

& TREM Education Program

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Individual

Team

Workplace

Organisation

GreaterGreater

ProtectionProtection

GreaterGreater

VulnerabilityVulnerability

Sleeves Always in Motion MaturingCulture Values andBeliefsCompatibilitythroughoutLayers ofSleeves

Less Incidenceof Non-protected

Areas Predicting

Vulnerability is aWay of Life

DecreasingLoyalty tothe Companyand Business Unitsengaged inSelf-Protectionistaffairs ratherthanCollectiveWins Leaders aremore

concernedabout Self-preservation Safetyinformationresides witha critical few

A Culture of Safety Model: Overlapping Sleeves of Protection

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Flight OperationsFlight Operations

Cabin Crew

EngineeringCustomer Service

Officers

Ramp Operations IntegratedCRM

Practical Application

Joint Tech-Cabin CRM

embedded in SEP

Maintenance Resource

Management (MRM)

Context of CRM Integration (Areas of Influence)

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The Customers Line of Sight

Our Line of Sight

Takeoff

Initial

climb Landing

Final

approachLoad,

taxi,

unload

Climb Cruise Descent

Initial

approach

Flaps retracted

Outer markerNav fix

Ring

Reservat

ions

Check-In

CIQ/Baggag

e

Home

Service

Recovery

ERRORS?Service

Error Free

Product

Building in the Business: Excellent Service + Error Free Product)

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They are corrected

Behavior is readapted:- Margins are increased- Attention level is raised- Monitoring is improved

In a tolerantsystem, whenerrors are

detected ...

Short term performance is adaptedLong term performance is improved (learning)

Slide c/o Dedale Asia Pacific

Errors and Performance

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LOSA and the SIA Safety Agenda

Quality Assurance

Safety InformationSystemInvestigationManagement

LOSA

Safety, Efficiency, ReliabilitySafety, Efficiency, Reliability

System & Individual

Learning Process

IDP

Discipline

FDAP

Flight Ops Quality Management

Flight Safety PilotsFlight Safety Champions

CHFIRPS

Incident Reporting

Voyage Reports

Regular Audits

Executive Feedback

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Violation + Intent = Death and DestructionViolation + Intent = Death and Destruction

The New ICON of Intent

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Threats

& Errors

Threats / Errors detected

and managedSuccessful

flight

Threats /

Errors not

detected /

managed

Undesiredaircraft

stateACCIDENT/

INCIDENTUndesired aircraft

state not managed

Undesired aircraft

state managed

Inconsequential


Threat and Error Management

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16th Human Factors Symposium - Singapore 20021919 Slide c/o Dedale Asia Pacific

Violations Matter

Fl ight Safety Fou ndat ion Report

Helmreich: US LO SA data

40% of accidents in the global fatal accident

database had violations

Those who violate make twice as many other errors

as those who do not

Their errors are twice as likely to be consequential

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Forgetting to...

Time pressure

Distraction

Inattention

Manage time

Prioritise tasks

Use check list

Seeing / hearing

what was expected

Highly experienced/

Too much anticipation

What if my expectation

is incorrect?

Slip Routine errors

More attention

More monitoring

What may be different?

Wrong reasoning Inadequate knowledgeMake it simple

Stick to SOP

What happened? Why? What did you learn?


Learning From Errors

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Have we provided more tools than theory to addressoperational reality?

What are the opportunities to build TREM as an integral

component of airline business? Thinking Pilot + Thinking Crew = Error Tolerant Operation?

A Culture of Safety: Where is the balance betweeninvesting on the Hearts and Mind vv. Shaping the

Environment?

TREM is focused on the CEO of the Aircraft. What elsecan be done to focus on the CEO of the airline?

Threat Recognition and Error Management (TREM)

ConclusionConclusion

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