An Introduction to

1. An Introduction to Threat and Error Management 1

2. What we will look at 3

3. What is Threat and Error Management It’s not Rocket Science 17

4. Assumptions of Human Factors Training • Humans have limitations in their performance • Error is inevitable 5

5. “To err is human” 6

6. Threats in the Operational Environment What is a “Threat” An indication of something coming; a menace or likely cause of harm TEM Definition: An event or error that occurs outside the influence of the controller, but which requires his or her attention and management if safety margins are to be maintained 8

7. Error Threat Threat Threats 9

8. Threats (Aerodrome Environment) Comsfailure/ sticking mic Distractions Runway crossings Visitors Shift handovers Weather Similar call signs Pilots and Other Controllers Maintenance Non-standard local procedures Restricted Airspace Runway inspections Heavy traffic System malfunctions Unfamiliar pilots Automation events Missed approaches

9. Methods to Identify Threats Just because you deal with a situation every day doesn’t mean that its not a Threat 13

10. Methods to Identify Threats Just because you deal with a situation every day doesn’t mean that its not a Threat 13

11. NOSS / TEM Methodology Threats Errors Undesired States

12. Methods to Assess a Threats Impact • Threat= Incorrect readback (pilot) • Threat Management=Nil • Error= Hearback Error (ATC) • Error Management= Nil • U/S= Aircraft climbing/ descending to altitude other than expected • U/S Management= Nil • Outcome= Loss of separation / Air Safety Incident 15

13. DIP’s Barriers to Monitoring Threats • Distractions • Interruptions • Preoccupations DIP’s should always trigger a red flag 16

14. Method to Monitor Threats Strategies to Reduce DIPs - • Recognize conversation is a powerful distracter • Recognize heads-down work greatly reduces your ability to monitor • Minimize conflicts between tasks • Avoid focusing on a single task for too long • Assign responsibility • Treat DIPs as RED FLAGS

15. Understand the difference between Error Managementversus Error Avoidance 7

16. What is an Error An action or inaction that leads to deviation from one’s intention or procedural requirements.

17. What is an Error An action or inaction that leads to deviation from one’s intention or procedural requirements.

18. Types of Errors

19. ER ORS R Errors and Violations Errors and Violations VIOLATIONS • You make an error when your action deviates from your intention, or when your intention is inappropriate • An error is not intentional • The effect of errors can be accounted for within the system • You commit a violation when you intentionally deviate from a regulation or from a procedure • A violation is originally intentional but can become routine

20. 67%of errors went undetected or were ignored 41% Airborne -Readback errors -Failure to respond -Parachuting near BDY 35% ANSP -Distractions,conversation -Incorrect co-ordination 23% Environmental -WX deviations -Low / poor visibility Overall R/T comms produced the most threats and occurred on 70% of Obs Threat Prevalence 100% of observations had at least one threat Total 363 threats observed Threat Management 82% of 362 threats were effectively managed 18% were mismanaged Total 65 threats mismanaged Threats - Undesired State Linkage 7% of threats were linked to undesired states 63% of 40 undesired states were linked to threats Threat to Error Linkage 44% of 165 errors were linked to mismanaged threat 56% of errors were not Total 63 observations Error Prevalence 81% of observations had at least one error 19% were error free Total 165 errors were observed Error Management 76% of 165 errors had inconsequential outcomes 22% led to an undesired state 2% led to additional error Total 40 errors mismanaged Detected Error Outcomes 74% of errors that were detected were inconsequential 22% were linked to undesired states 4% were linked to additional error Undesired State Prevalence and Management 45% of observations had US Total 40 USs 100% of 40 US were inconsequential Error Response 13% of 165 errors were detected by the observed controller 20% were detected by another party 67% went undetected or were ignored Undetected Error Outcomes 76% of errors that were detected were inconsequential 22% were linked to undesired states 2% were linked to additional error

21. 2008 NOSS Findings

22. The TEM Partnership

23. Summing it all up