TEMTEM && LOSA:LOSA: The State of Affairs The State of Affairs

Captain Dan MaurinoCaptain Dan MaurinoFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAOThird IATA/ICAO LOSA/TEM ConferenceThird IATA/ICAO LOSA/TEM Conference

Kuala Lumpur, MalaysiaKuala Lumpur, Malaysia13 – 14 September 200513 – 14 September 2005

The Big Safety Data PictureThe Big Safety Data Picture Forensic systems – FailuresForensic systems – Failures

Accident investigationAccident investigationMajor incident Major incident

investigationinvestigation

Proactive systems – Routine Proactive systems – Routine operational events operational events Electronic safety data Electronic safety data

acquisition systems acquisition systems (FOQA)(FOQA)

Voluntary self-reporting Voluntary self-reporting systems (ASAP)systems (ASAP)

Direct observation safety Direct observation safety data acquisition systems data acquisition systems (LOSA & NOSS)(LOSA & NOSS)

Reactive systems – Reactive systems – AnomaliesAnomalies

Mandatory reporting Mandatory reporting systems (CAA’s) systems (CAA’s) Voluntary reporting Voluntary reporting

systems (ASRS/BASIS)systems (ASRS/BASIS)

LOSA [NOSS] & TEM: Clarifying a RelationshipLOSA [NOSS] & TEM: Clarifying a Relationship

The features in operational context – The features in operational context – ThreatsThreats What people do – What people do – ErrorsErrors The results of the features in operational context and The results of the features in operational context and

of what people do – of what people do – Undesired statesUndesired states

TEM = Framework – TEM = Framework – What What we look forwe look for

LOSA [NOSS]LOSA [NOSS] =Tool(s) – =Tool(s) – HowHow we collect what we look for we collect what we look for

The Ten Operating CharacteristicsThe Ten Operating Characteristics

Monitoring normal operations (LOSA & NOSS) Monitoring normal operations (LOSA & NOSS) Training – Flight & Cabin Crew/ATCO (ICAO, IATA, Training – Flight & Cabin Crew/ATCO (ICAO, IATA,

Airlines and ATS providers)Airlines and ATS providers) Safety management data analysisSafety management data analysis

Integrated Threat Analysis (ITA) – ICAO & IATAIntegrated Threat Analysis (ITA) – ICAO & IATA Cabin Operations Safety Toolkit (Turbulence & Cabin Operations Safety Toolkit (Turbulence &

inadvertent slide deployment) – IATAinadvertent slide deployment) – IATA Research and development (UT & Boeing)Research and development (UT & Boeing)

Rule-making – ICAO provisionsRule-making – ICAO provisions

TEM Framework – Expanding Role TEM Framework – Expanding Role

FCLT/P – State Letter AN 12/1.1-05/62FCLT/P – State Letter AN 12/1.1-05/62

Annex 1 – Personnel LicensingAnnex 1 – Personnel Licensing Knowledge requirementsKnowledge requirements

Human performance Human performance including principles of threat and including principles of threat and error managementerror management

Operational procedures – Operational procedures – Application of threat and Application of threat and error management to operational performanceerror management to operational performance

Skills requirementsSkills requirements Recognize and manage threats and errorsRecognize and manage threats and errors

FCLT/P – Multi-Crew Pilot License (MPL)FCLT/P – Multi-Crew Pilot License (MPL)

Note .— The application of threat and error management principles is a Note .— The application of threat and error management principles is a specific specific competency unit that is to be competency unit that is to be integratedintegrated with each of the other with each of the other competency units for training and testing purposes.competency units for training and testing purposes.

1)1) apply threat and error apply threat and error management (TEM) principles;management (TEM) principles;

2)2) perform aeroplane ground perform aeroplane ground operations;operations;

3)3) perform take-off;perform take-off;4)4) perform climb;perform climb;

5)5) perform cruiseperform cruise6)6) perform descent;perform descent;7)7) perform approach;perform approach;8)8) perform landing; andperform landing; and9)9) perform after landing and perform after landing and

aeroplane post-flight operations.aeroplane post-flight operations.

Competency units, competency elements and performance criteria Competency units, competency elements and performance criteria

FCLT/P – FCLT/P – MPLMPLCompetency Unit 2 – Perform aeroplane ground operations Competency Unit 2 – Perform aeroplane ground operations

Competency element:Competency element: Line up checks completed Line up checks completedATC call to give clearance interrupts checklist (ATC call to give clearance interrupts checklist ( threatthreat))Crew skips pitot heat checklist item (Crew skips pitot heat checklist item (errorerror))Aircraft is lined up for take off roll with pitot heat off Aircraft is lined up for take off roll with pitot heat off

((undesired aircraft stateundesired aircraft state) )

Performance criteria:Performance criteria: Example TEM countermeasures Example TEM countermeasures Keep finger in checklist item until check list is re-startedKeep finger in checklist item until check list is re-started Start checklist all over again after clearance read backStart checklist all over again after clearance read back Request ATC to hold clearance until checklist completedRequest ATC to hold clearance until checklist completed

FCLT/P – Annex 6, Operation of AircraftFCLT/P – Annex 6, Operation of AircraftChapter 9. Aeroplane Flight CrewChapter 9. Aeroplane Flight Crew

9.3 Flight crew member training programmes9.3 Flight crew member training programmes9.3.19.3.1 An operator shall establish and maintain a ground An operator shall establish and maintain a ground

and flight training programme, approved by the and flight training programme, approved by the State of the operator…The training programme State of the operator…The training programme shall also include…training in knowledge and shall also include…training in knowledge and skills related to human performance skills related to human performance and threat and threat and error management…and error management…The training programme The training programme shall be given on a recurrent basis…shall be given on a recurrent basis…

Aligned Safety Management ProvisionsAligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and IIIAnnex 6 – Operation of Aircraft, Parts I and III Annex 11 – Air Traffic ServicesAnnex 11 – Air Traffic Services Annex 14 – AerodromesAnnex 14 – Aerodromes

A basic safety management “template” A basic safety management “template” Two basic conceptsTwo basic concepts

Safety programme – StatesSafety programme – States Safety management system – OperatorsSafety management system – Operators

The ICAO Safety Management Manual (Doc xxxx)The ICAO Safety Management Manual (Doc xxxx) LOSALOSA NOSSNOSS

Normal Ops Normal Ops ArchieArchie

IncidentsIncidentsSTEADES STEADES

AccidentsAccidentsADREP ADREP

TEM – Aggregate Safety AnalysisTEM – Aggregate Safety Analysis

Integrated Threat Analysis (ITA) – A Joint ICAO/IATA ProjectIntegrated Threat Analysis (ITA) – A Joint ICAO/IATA ProjectCase study: TEM analysis – Runway excursions Case study: TEM analysis – Runway excursions

34 ADREP narratives34 ADREP narratives36 STEADES narratives36 STEADES narratives

Long landingsLong landings Floated landingsFloated landings Off centre-line landingsOff centre-line landings

The “bridge” between ADREP/STEADES & The “bridge” between ADREP/STEADES & ArchieArchie: UAS: UAS

164 LOSA narratives164 LOSA narratives

Threats – ITAThreats – ITA

25

67

20

85

58

17

13

15

0 20 40 60 80 100

Normal Operations

Incidents

Accidents

Environmental Threats – ITAEnvironmental Threats – ITA

60

5

5

21

69

5

35

5

42

30

5

18

0 20 40 60 80

WX

Airport

Terrain

Unfamiliarrunway

ATC

Normal operations

Incidents

Accidents

Airline Threats – ITAAirline Threats – ITA

25

80

20

26

75

74

0 20 40 60 80 100

A/Cmalfunction

Ferry flight

OPS pressure(airline)

Normal Operations

Incidents

Accidents

Flight Crew Errors – ITAFlight Crew Errors – ITA

6

72

11

61

32

7

94

17

0 20 40 60 80 100

Normal Operations

Incidents

Accidents

Safety Management: Data, not OpinionSafety Management: Data, not Opinion

Threat scenarios – Threat scenarios – Accidents & incidentsAccidents & incidents Weather (heavy rain, Weather (heavy rain,

TS, wind gusts, TS, wind gusts, tailwind)tailwind)

A/C malfunctions, RTOA/C malfunctions, RTO Night operationsNight operations Proficiency issuesProficiency issues

Threat Scenarios – Threat Scenarios – ITAITA ATCATC Weather (heavy rain,TS, Weather (heavy rain,TS,

wind gusts, tailwind)wind gusts, tailwind) OperationalOperational pressurepressure A/C malfunctions, RTOA/C malfunctions, RTO Night operationsNight operations Proficiency Proficiency and and

proceduralprocedural issues issues

Clearing the Air – LOSAClearing the Air – LOSA Is notIs not the same as IATA’s IOSA the same as IATA’s IOSA Is not Is not the same as Airbus’ LOASthe same as Airbus’ LOAS Is notIs not the same as the JAA’s NOTECHS the same as the JAA’s NOTECHS Is not Is not an evaluation of CRM an evaluation of CRM Is not Is not the sixth generation CRMthe sixth generation CRM Is notIs not a research tool a research tool Is notIs not culturally incompatible culturally incompatible

LOSA [NOSS] LOSA [NOSS] isis a safety management data collection a safety management data collection tool[s] that generates safety management data otherwise tool[s] that generates safety management data otherwise not available not available

Clearing the Air (II) – TEM & CRM Clearing the Air (II) – TEM & CRM

“…“…TEM is an TEM is an overarching safety concept with multiple overarching safety concept with multiple applications in aviationapplications in aviation; while CRM is exclusively a ; while CRM is exclusively a training training interventionintervention. The basic concepts underlying TEM (threats, errors . The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example and undesired aircraft states) can be integrated – for example as an additional module – within existing CRM programmes. as an additional module – within existing CRM programmes. This is because TEM countermeasures build in part – although This is because TEM countermeasures build in part – although not exclusively – upon CRM skills. The combination of TEM not exclusively – upon CRM skills. The combination of TEM concepts with CRM skills thus introduces the opportunity to concepts with CRM skills thus introduces the opportunity to present the utilization of CRM skills by flight crews anchored in present the utilization of CRM skills by flight crews anchored in the operational environment, from an operational perspective. the operational environment, from an operational perspective. It It is emphasized that TEM is emphasized that TEM trainingtraining does not replace CRM training, does not replace CRM training, but rather complements and enhances it.”but rather complements and enhances it.”

TEM & LOSA – Safety Management Tools TEM & LOSA – Safety Management Tools

FDAFDAVoluntary Voluntary ReportingReporting

Direct Direct observationsobservations