Threat and Error Management: the LCC and IATA Experience

Joey AncaIATA

Overview Regional and International Aviation- the Good News and Bad

News The Future in Aviation Redefining SAFETY Experience with Low Cost Carriers Threat and Error Management (TEM) Tools

CRM in the Countermeasure Context TEM as a Framwork

Take Away and the Culture of Safety

World Aviation: Bad News & Good News

Bisignani, G (2005) State of the Air Transport Industry. IATA.

Global Turmoil driven by:•Fuel Costs•Legacy vs Low Cost Carriers•Imbalanced Taxation by Governments

Air Transport is a USD 400 Billion Industry

IATA combined Fuel Bill for 2005 is USD83 Billion, equal to the GNP of New Zealand

Winners and Losers:North America USD 9BAfrica USD 150MLatin America Europe USD 1.4BAsia USD 2.6BMiddle East USD 100M

Safety: 1.8 Billion flew in 2004; 428 Fatalities (similar to1945 figures where 9 million people traveled by air

Asia-Pacific: Bad News, Good News

Harbison, Peter (2005). Indian Subcontinent & Middle East Aviation & Tourism Summit

Regional Issues driven by:•Fuel Costs•Airline Restructuring•Inadequate Regulatory Systems

High Growth Markets attracting rapid foreigninvestments (China, India, Middle East)

Asia Pacific Airlines reported US$ 5B profits (2004)

India to require 10 000 trained staff each yearover next 5 years

Demand for pilots to exceed factor of threein next 5 years; Salary bill for pilots up by 30-40%

India placed orders of 190 aircraft in lastParis Air Show; number expected to escalateto 490-500 aircraft by 2010

Corpus of Experience in this Report

Future Transformation: the Jetsons

• Affordability of Micro Jets to a larger segment of Entrepreneurs

• Increased Capability of distal and agile Air Traffic Control

• Increased vulnerability of Situational Awareness

• Devolution of Safety Management Systems to micro users

• Need for Global Equipage harmonization to counteract present differentiation

• The Future is Scary

Baker, D (2005) NGATS FAA

Redefining Safety

Redefining Safety for an Organisation to Reflect Reality

Safety (Middle English, saufte)

1. The state of being safe from undergoing or causing hurt, injury or loss

2. A billiard shot made with no attempt to score or so as to leave the balls in an unfavorable position for the opponent

Threats

LatentConditions

The problem is…a state of safety does not exist 100% of the Time

Risk

LatentConditions

SAFETYSAFETY

SAFE

TYSA

FETY

Safety is a Measure of Organisational Resistance to RISK.

Safety (Middle English, saufte)

Dynamic protections from mishaps

Interventions for system integrity and compliance

Creative “buffering” for latent conditions

…instead of a harm-free STATE,

Threat and Error Management Tools

Restating (CRM) as the Countermeasures to threats, errors and undesired equipage states

Reinforcing Threat and Error Management (TEM) as a framework

The Riddle of the 5 Daughters Mary’s Parents had 5 Daughters

Their names were: Mara Mare Mari Maro…

What is the name of the fifth daughter?

The Summits of CRM

1st Generation- Cockpit Resource ManagementBusiness Management orientationInterpersonal Relationships/ Leadership StylesPsychobabble language distant from PilotsThe “Unassertive” Co-pilot

2nd Generation- Crew Resource ManagementError Chain & Accident CausalityTeambuilding GamesSituational Awareness and Stress Management ConceptsCluster Knowledge (Decision Making, Briefing, etc)

3rd Generation-Advanced CRMCRM Integration with technical training/performanceInstructor CRM TrainingIncluded Dispatchers, Flight Attendants, Engineers

4th Generation-Integrated CRMCRM embedded in procedures/checklistsSpecialized topics eg. AutomationPerformance based CRM

5th Generation- Error ManagementUbiquity of Human ErrorManage Errors by Avoidance/Trapping/Mitigation

6th Generation?

Applying the Riddle to Generations of CRM The next generation is not about a new form of CRM It is about using TEM as a Framework and CRM as a training

countermeasure tool—Maru does not exist, but Mary does

It is about going back to the foundation of flying operations—the management of operational threats and errors

Threat and Error Management (TEM) TEM training is both a framework of CRM as well as a detour

back to CRM Beginnings—a training tool to manage Human Error

The TEM Model—outlines propagation and breach of Human Error (Threat-Error-Undesired Equipage State-Incident)

Appropriately positions CRM as a set of Countermeasures in managing Threats and Errors

The IATA TEM Program Positions TEM as a context of CRM CRM Skill Training as the set of countermeasures to manage

threats and errors Includes a Train-the-Trainer component to critique the

delivery of CRM Programs suited to local conditions

Latent Threats National, Organizational, Professional CultureStandards and Policies Regulations

Overt ThreatsEnvironment FactorsOrganizational FactorsIndividual, Team, Crew FactorsEquipage Factors

ThreatThreat

© Bombala, M Capt (2004) IATA

Threats: Elements and Conditions that are outside the Crew’s Control

Error Types Communication Intentional Non-Compliance (Violation)Procedural LapseProficiencyFaulty Decisions & Judgment

Crew ErrorCrew Error

ThreatThreat

© Bombala, M Capt (2004) IATA

Crew Error: Mismanagement of Threats

Most errors are inconsequentialMost errors are inconsequential

Equipage is not where it is supposed to be because of threats or mismanaged threats

Crew ErrorCrew Error

ThreatThreat

Undesired EquipageUndesired EquipageStateState

© Bombala, M Capt (2004) IATA

Undesired State

Crew ErrorCrew Error

ThreatThreat

Undesired EquipageUndesired Equipage StateState

Incident-Incident-AccidentAccident

Result of mismanaged threat and/or error “the tip of the iceberg”

© Bombala, M Capt (2004) IATA

Incident or Accident

Managing Threats and Errors: the TEM Solution

Ensure competency training on

CRM Countermeasures

Countermeasures

Error Avoidance

Threat Management

Error Management

Undesired Equipage State Management

ThreatThreat

Crew ErrorCrew Error

Undesired EquipageUndesired Equipage StateState

IncidentIncident

Error AvoidanceError Avoidance

Team ClimatePlanning

© Bombala, M Capt (2004) IATA

CRM Countermeasure 1

ThreatThreat

Crew ErrorCrew Error

Undesired Undesired EquipageEquipage

StateState

IncidentIncident

Error AvoidanceError Avoidance

Threat ManagementTeam ClimatePlanningReview /Modify

© Bombala, M Capt (2004) IATA

CRM Countermeasure 2

ThreatThreat

Crew ErrorCrew Error

UndesiredUndesired EquipageEquipage

StateState

IncidentIncident

Error AvoidanceError Avoidance

Threat Management

Error ManagementTeam ClimateExecution

© Bombala, M Capt (2004) IATA

CRM Countermeasure 3

ThreatThreat

Crew ErrorCrew Error

IncidentIncident

Error AvoidanceError Avoidance

Threat Management

Error Management

Undesired Undesired Equipage StateEquipage State

Undesired EquipageState Management

Team ClimateReview / Modify

© Bombala, M Capt (2004) IATA

CRM Countermeasure 4

ThreatThreat

Crew ErrorCrew Error

Undesired EquipageUndesired Equipage StateState

IncidentIncident

Error AvoidanceError Avoidance

Threat Management

Error Management

Undesired EquipageState Management

Threat and ErrorThreat and ErrorManagement FrameworkManagement Framework

CRM CountermeasureCRM CountermeasureCompetenciesCompetencies

Team ClimatePlanningExecutionReview /Modify

TEM and A Culture of Safety

A Culture of Safety Change Model

© Anca, JM (2000)

Take Away Questions we should ask:

The CEO Regulator Crew Union Human Resources Head

The Questions to Your CEO: Overlapping Sleeves of Protection

Individual

Team

Workplace

OrganisationIncreasingProtection

IncreasingVulnerability

Sleeves in Perpetual Motion

•Maturing Culture: are your Values and Beliefs Compatible?

•Vulnerability: Can you Predict your Next Accident?

•Staff Loyalty: Collective SUCCESS or Individual Wins?

•Are Your Leaders more concerned about THEIR Self-preservation?

•Safety Information: is it Meaningful to a critical few or is it OWNED by ALL?

© Anca, JM (2000)

A Prologue

Discretion is the better half of Valor. Thank You.