Flight Safety Foundation CAC Workshop Oct 17 2007

Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph. D.

A Threat & Error Management Model

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Some Definitions

THREATS Threats are events that occur outside the influence of the flight crew, but which require crew attention and management if safety margins are to be maintained Ø Threats increase the complexity of the operation and weaken barriers against error Ø Ø Observable Threats – Known • e. g. , Thunderstorms, delays – Unexpected • e. g. , Engine failure on take off Threats = Red Flags! Heinrich 2007

Fortunately, not all events become accidents… Accident 1 Serious incident 10 Significant event 30 Routine occurrence Statistical event 200 600 …but events/occurrences can lead to incidents and accidents Flight Safety Foundation, 2006; Adapted with permission.

Latent Threats – factors residing in the system, organization or individual that increase risk. Ø Latent threats are not directly observable at the ‘sharp end’ of operations Ø Latent threats are usually uncovered by analysis of aggregate data such as confidential incident reports, e. g. , Ø Equipment design issues Ø Optical illusions Ø Air traffic system design Ø Training philosophy and practices Ø Organizational culture (positive or negative) Heinrich 2007

Typical Latent Errors ü ü ü ü ü Poor planning or scheduling Inadequate design/poor equipment Improper allocation/lack of resources Flawed procedures Defective communications Training deficiencies Inadequate selection procedures Inspection and oversight flaws Neglect of known hazards Lack of motivation Note that these are all management problems! Flight Safety Foundation, 2006; Adapted with permission.

ERRORS Ø Ø Ø Errors are actions or inactions by the flight crew that lead to deviations from intention or expectation Traditional thinking focused on eliminating error in the cockpit, i. e. , Zero Error! Contemporary thinking acknowledges that error is a part of life, i. e. , humans make mistakes! Intentional non-compliance is not an error Types of errors: Flight handling errors (e. g. , unintentional speed deviation) Ø Procedural errors (e. g. , performing checklist items from memory) Ø Communications errors (e. g. , missed ATC call) Ø Heinrich 2007

Pilots are human… and humans make errors! (Note: this does not mean that errors are OK!) Primary Causes of Aircraft Accidents * Percentage of Total Accidents with Known Causes Primary Factor 10 20 30 40 50 60 70 Flight Crew Airplane Maintenance Weather Airport/ATC Other Excludes: • Sabotage • Military Action • Turbulence Injury • Evacuation Injury • Servicing Injury The Crew usually makes the last mistake! * Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.

Error Outcomes Crew Response Exacerbate Miss Errors Increased Probability of Incident or Accident Mitigate Trap Errors Increased Probability of Safe Flight * Helmreich, 1998

Strategies/Countermeasures are employed… ü to reduce the number of threats and errors, and ü to increase the awareness of potential threats and errors Errors must be recognized and corrected before negative consequences occur! Focus on managing your future! Heinrich 2007

Safeguards are the hardware & software that serve as additional barriers to problems*: Ø Ø GPWS TCAS EVS MANUALS Ø Ø SOPs CHECKLISTS AUTOMATION ATC *Note: Because these are also developed by humans, the potential still exists for latent defects and errors. Heinrich 2007

Awareness, Anticipation Awareness and anticipation are important characteristics of effective CRM and TEM Ø Awareness includes Ø § § Ø Search Perception Spatial orientation Knowledge of mission goals Anticipation includes § § § Projection/forecasting Planning Threat awareness Heinrich 2007

Desired OUTCOMES or Undesired CONSEQUENCES ? Successful Threat and Error Management results in outcomes that are desirable, i. e. , safe flight Ø Consequences of errors that are not corrected or not contained can result in an undesired aircraft state (UAS) Ø An undesired aircraft state is an aircraft deviation or incorrect configuration associated with a clear reduction in safety margins Ø Heinrich 2007

TEM Principles

TEM Principles The objective of Threat and Error Management (TEM) … ü ü ü to obtain an understanding of how to assess the various risk levels of threats to gain an insight on logical approaches (strategies) to deal with them, and to reduce human error in dynamic daily operations. Heinrich 2007

TEM Principles TEM is central to all safety processes and provides defences against hazards in operational situations; it involves… ü Identifying hazards to safety, i. e. , threats, errors, or undesired states (deviations) ü Assessing the risks of these hazards (the consequence of accepting hazards) ü Avoiding or trapping threats and errors ü Containing the end result (mitigation) Heinrich 2007

Important TEM Concepts

TEM Concepts Ø Ø The “mission” (i. e. , safe, effective mission/objective) may be a flight, an aircraft repair, a trip plan, or even an ops manual or company procedure… … i. e. , TEM can be applied to all aviation organizational entities. The crew is only one resource to the “operator” or “systems manager” who must make accurate and timely decisions for successful results. The operator is only as effective as the information he or she receives from all resources (The TEAM). Heinrich 2007

TEM Concepts Ø Ø Individuals are humans, and humans (all humans!) make mistakes. The aviation mission or objective is dynamic. TEM is not a sequential system! Because all organizational entities are made up of individuals, threats (hopefully with innovative threat solutions!) and human error (with error resolutions!) are introduced throughout the timeline of the particular “mission. ” External threats also continuously occur and must be dealt with utilizing all appropriate resources available. Heinrich 2007

Accurate Decision-Making The primary key to a successful mission outcome is accurate decision-making by the individual or individuals who are “steering the ship. ” Accurate Decision-Making = Successful Outcome! Ø In the operational setting, the operator is only as effective as the information (not data!) he or she receives through proper teamwork and resource management. Ø The operator is the final authority regarding the safety of the mission; e. g. , a pilot can always elect to abandon a dangerous approach. Ø Heinrich 2007

A Case Study

Case Study G-III Fatal Accident, Aspen, March 2001 The Accident: On March 29, 2001, about 1902 MST, a Gulfstream III, N 303 GA, owned by Airbourne Charter, Inc. , and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, CO. The charter flight had departed Los Angeles International Airport (LAX) about 1711 with 2 pilots, 1 flight attendant, and 15 passengers. The airplane crashed into sloping terrain about 2, 400 feet short of the runway threshold. All of the passengers and crewmembers were killed, and the airplane was destroyed. The flight was being operated on an IFR flight plan under CFR Part 135.

Case Study G-III Fatal Accident, Aspen, March 2001

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Latent Threats External Threats & Errors Organizational System Professional Unexpected Events/Risks External Error Threat & Error Management Crew Errors TRM/CRM Behaviors CRM Outcomes Behaviors Outcomes Latent Threats: (Factors residing in the system, organization or individual Decision-making, SA, that increase risk ) Threat recognition, Error avoidance, Safe Flight Safeguards, Ø Company management Countermeasures Ø Organization management Ø Resources Violations, Communication, Procedural, Proficiency, Decision Ø SOPs Recovery to Ø Policies Safe Flight Inconsequential Ø Procedures Ø Techniques Error-management Undesired state Behaviors aircraft management (avoid, trap, contain, state behaviors mitigate, exacerbate, failØto. Operators respond) Ø Crew Additional Ø Team error Organizational § System § Professional Incident Accident * Adapted from Helmreich, 2003

Latent Threats Organizational System Professional What are some of the Latent Threats in the Aspen Accident? ü? ü?

Latent Threats Organizational System Professional Some of the Latent Threats in the Aspen Accident Ø The March 27, 2001, NOTAM regarding the nighttime restriction on the VOR/DME-C approach was vaguely worded and ineffectively distributed: The NOTAM stated, “circling NA at night, ” but the intended meaning was to prohibit the entire approach procedure at night. ü Pilots might have inferred that an approach without a circle-to-land maneuver to runway 15 was still authorized. ü If the FAA had worded the first NOTAM more clearly, it might have made more of an impression on the first officer when he received the preflight briefing from the Automated Flight Service Station and might have affected the conduct of the flight. ü The local controller could notify the flight crew of the NOTAM because Denver Center had not sent a copy to the ASE tower. ü Heinrich 2007

Latent Threats Organizational System Professional Some of the Latent Threats in the Aspen Accident Ø Company Standard Operating Procedures Manual incomplete: ü No sterile cockpit procedure ü No procedure/restrictions regarding the use of cockpit observers (jump seat) ü No guidance regarding weather minimums for mountain operation Heinrich 2007

Time Out!

What would have happened if the Organization… ü ü ü …Utilized Corporate Flight Operations Quality Assurance (C-FOQA) to uncover latent threats and dangerous procedures/techniques? Had an effective Safety Management System and Incident Reporting System? Conducted Line Operational Safety Audits (LOSA)? Conducted confidential surveys? Regularly performed training evaluations? Redesigned policies, procedures, tasks, and equipment? Safe Flight Safe Flight Heinrich 2007

Latent Threats External Threats & Errors Organizational System Professional Unexpected Events/Risks External Error Threat & Error Management Crew Errors TRM/CRM Behaviors Outcomes Unexpected External Threats/Events/Risks Ø Ø Latent threats System failures SA, Decision-making, WX/ Environmental Threat recognition, changes Error avoidance, Safe Flight Other dynamics Safeguards, Countermeasures Expected External CRM Outcomes Behaviors Threats Events that occur outside the influence of the flight crew, but which require crew attention and management if safety margins are to be maintained. Violations, Threats/Events/Risks Communication, Procedural, Ø Destination issues Ø Proficiency, Terrain Decision Ø Ø Recovery to Safe Flight Environmental problems Inconsequential Logistics Error-management Behaviors External Error (avoid, trap, contain, mitigate, exacerbate, Ø ATC errors fail to respond) Ø Other aircraft Undesired aircraft state Ø Ø Additional error Communication issues Time pressures Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

External Threats & Errors Unexpected Events/Risks External Error What are some of the External Threats & Errors in the Aspen Accident? ü? ü?

External Threats & Errors Unexpected Events/Risks External Error Some of the External Threats and Errors Ø The Flight Crew was under pressure to land at ASE ü Because of the flight’s delayed departure from LAX and the landing curfew at ASE, the crew could attempt only one approach before having to divert to the alternate. ü The charter customer had a strong desire to land at ASE, and his communications before and during the flight most likely heightened the pressure on the flight crew. ü The presence of a passenger on the jumpseat, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land. Ø Darkness, reduced visibility, and light snow showers significantly degraded the flight crew’s ability to see and safely avoid terrain. Heinrich 2007

Time Out!

In the Dynamic environment… What would have happened if… …The organization had advised the passengers of the need to arrive on time because of the night curfew at Aspen? ü The flight attendant had recognized the potential problems associated with allowing passengers to occupy the jumpseat, especially in adverse conditions? ü The crew had advised the jumpseat passenger of an organization sterile cockpit rule? ü Safe Flight Heinrich 2007

Latent Threats External Threats & Errors Organizational System Professional Crew Errors Unexpected Events/Risks Actions or inactions by Expected the flight crew Events/Risks that lead to deviations External from intention Error or expectation Threat & Error Management Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Crew Errors * Ø Non-compliance (violation) Decision-making, SA, Ø Communication Threat recognition, Error avoidance, Safe Flight Ø Procedural Safeguards, Countermeasures Ø Proficiency Violations, Ø Poor or uninformed decision Communication, Procedural, Proficiency, Decision * All humans make mistakes! Inconsequential Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Recovery to Safe Flight Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Crew Errors Violations, Communication, Procedural, Proficiency, Decision What are some of the Crew Errors in the Aspen Accident? ü? ü?

Crew Errors Violations, Communication, Procedural, Proficiency, Decision Some of the Crew Errors Ø Procedural errors & deviations during Final Approach Segment: ü Crossed step-down fixes below minimum specified altitudes ü Descended below the MDA, even though aircraft maneuvers and comments on CVR indicated neither pilot had established or maintained visual contact with the runway or its environment. ü Contrary to manufacturer’s procedures, the captain deployed spoilers after gear and final flap extension and set power to 55% N 2 rather than 64% N 2 ü When the aircraft was 1. 4 miles from the runway (21 sec before impact), captain asked, “where’s it at? ” but did not abandon the approach, even though he had not identified, or had lost sight of, the runway. ü Radar data and CVR comments indicated that, until the aircraft began turning left about 10 sec. before impact, the crew probably did not have the runway or its environment in sight. Heinrich 2007

Crew Errors Violations, Communication, Procedural, Proficiency, Decision Some of the Crew Errors (continued) Ø Poor Crew Coordination/CRM: ü Captain failed to discuss the instrument approach procedure, the missed approach procedure, and other required elements during his approach briefing because he anticipated using a visual approach. ü The first officer never challenged the captain even though he crossed step-down fixes below minimum specified altitudes. ü The captain and the first officer failed to make required instrument approach callouts, and the first officer did not call out required course, fix, & altimeter information. ü The crew failed to discuss a missed approach after receiving a third report of a missed approach to the airport and a report of deteriorating visibility in the direction of the approach course. Heinrich 2007

Time Out!

In the Dynamic environment… What would have happened if… …The first office would have challenged the captain about missing stepdown altitudes? ü The crew would have briefed and planned on an instrument approach, especially after hearing that three other aircraft had executed the missed approach procedure? ü The crew would have abandoned their obsession with finding visual landmarks? ü The crew would have altered their thinking from “landing unless…” to “go around unless…” ? ü Safe Flight Heinrich 2007

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational Ø Decision-making – must have “information” from all Team resources (integration) System Ø Situation Awareness and “Projection” in a very dynamic environment Professional Ø Threat recognition Decision-making, SA, Ø Error avoidance Unexpected Threat recognition, Ø Safeguards – hardware and software that serve as. Safe additional barriers to problems Events/Risks Error avoidance, Flight Ø Countermeasures – increase awareness Safeguards, and reduce number of threats/errors Countermeasures Error Management. Violations, Behaviors Expected Events/Risks Ø Ø Ø Avoid Trap External Contain Error Mitigate Exacerbate Fail to respond Communication, Procedural, Proficiency, Decision Inconsequential Error-management Undesired Behaviors aircraft (trap, contain, state mitigate, exacerbate, fail to respond) immediate action before negative Threat Undesired State Management Behaviors & Error Ø Errors/deviations require Ø Management Additional error can lead to an incident or accident Additional Ø Recovery to Safe Flight Note: Pilots can always elect to abandon a Undesired state management behaviors consequences occur! dangerouserror approach or phase Additional oferror flight! Incident Accident * Adapted from Helmreich, 2003

TRM/CRM Behaviors Decision-making, SA, Threat recognition, Error avoidance , Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) What are some of the TRM/CRM Behaviors in the Aspen Accident? Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures ü? Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) ü? Undesired state management Behaviors (+/-) ü?

TRM/CRM Behaviors Decision-making, SA, Threat recognition, Error avoidance , Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) Some TRM/CRM Behaviors Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Error-management Behaviors (+/-) (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired state management Behaviors (+/-) Captain and another Avjet captain discussed nighttime landing restriction at ASE. ü Captain asked controller whether the pilot of N 527 JA was practicing or had actually missed. ü ü When airplane is at 10, 400 feet, captain states, “Okay. . . I'm breaking out, " and asks local controller, about 5 seconds later, whether runway lights are all way up. The controller indicates, “Affirmative they're on high. " First officer says, “Okay you can go. . . ten thousand two hundred [the MDA]. ” ü Descended below MDA, even though aircraft maneuvers and comments on CVR indicated neither pilot had established or maintained visual contact with the runway or its environment. Heinrich 2007

Time Out!

In the Dynamic environment… What would have happened if… …The crew had expected to execute a missed approach after hearing that the Challenger ahead (N 527 JA) had executed the missed approach? ü The crew had realized that when they were “breaking out” that they were not in a position to land when they were unable to see the runway lights? ü The crew had executed a missed approach when they reached the MDA missedapproach point and were unable to see the runway or its environment? ü Missed Approach! Safe Flight Heinrich 2007

External Latent Crew TRM/CRM Safe Flight Threats & Threats Errors Behaviors Ø Effective Errors. DM, SA, threat recognition, error avoidance Organizational Ø Appropriate application of T&E strategies System result in desirable outcomes Professional Decision-making, SA, Inconsequential Outcome Unexpected Threat recognition, Ø Management (i. e. , Events/Risks of threats & errors Error avoidance, avoiding, trapping, containing) results in little Safeguards, or no adverse consequences Countermeasures Expected Events/Risks Violations, State Undesired Aircraft Communication, Ø Aircraft deviation or incorrect configuration Procedural, associated with a clear. Proficiency, reduction in safety External margins Error Decision Outcomes CRM Outcomes Behaviors Safe Flight Recovery to Safe Flight Inconsequential Recovery to Safe Flight Error-management Ø Effective undesired state management Behaviors behaviors (avoid, trap, contain, Threat mitigate, exacerbate, & Error fail to respond) Additional Error Management Ø Additional error(s) requires further error management behaviors Ø Exacerbation or failure to respond can result in an incident or accident Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Safe Flight Outcomes Inconsequential Undesired aircraft state Additional error Recovery to Safe Flight Incident Accident What are some of the Crew CRM Behaviors and subsequent Outcomes in the Aspen Accident? Safe Flight ü ? Inconsequential ü ? Recovery to Safe Flight ü ? Additional error Undesired aircraft state Accident

Safe Flight Outcomes Inconsequential Undesired aircraft state Additional error Recovery to Safe Flight Incident Accident Crew CRM Behaviors and subsequent Outcomes Safe Flight ü Flight crew properly certificated & qualified; aircraft properly certified, equipped, & maintained; the first officer obtained a weather briefing Inconsequential ü Crew crossed the FAF 100’ low, descended 300’ below the next stepdown, and crossed the 9. 5 DME fix 900’ low Recovery to Safe Flight ü At about 1901: 53, the captain added max power (less than a second before impact) Additional error ü Determination to continue with the original plan of action despite the presence of cues suggesting the need for a modified course of action Undesired aircraft state ü High descent rate (GPWS sink rate alerts) & excessive bank angle near ground ü Descent below MDA without visual contact with the runway or environment Accident Heinrich 2007

Time Out!

In the Dynamic environment… What would have happened if… ü ü ü The crew had received general TEM training? TEM training had been integrated into formal simulator training? The organization had a non-punitive approach to error? The crew had applied CRM training? ü Active sharing of concerns & ideas ü Limitations of human performance ü Threat and error recognition ü Error avoidance ü Error management strategies The crew had learned and practiced techniques to apply in specific situations? Safe Flight Safe Flight Heinrich 2007

Gulfstream III - Aspen, Colorado March 2001 * Eighteen Fatalities NTSB Findings ü Procedural Errors ü Poor Crew Coordination ü Time Pressures ü Passenger Expectations

The Error Chain Effect in a Dynamic Environment Latent Threats External Threats & Errors Crew Errors PAX to FA: “Can I ride on the jumpseat? ” FA to PAX: “Would anyone like to ride on the jumpseat? ” Threat & Error Management TRM/CRM Behaviors Errors CRM Behaviors Additional error “Oh, really!” YES No! Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Captain: “Please, flight issues only!” Safe Flight First officer: “You’re too low! Let’s miss!” Safe Flight No sterile cockpit First officer hesitant to challenge captain Captain determined to land Outcomes Additional error Captain: “ 3 MAs! Let’s plan for MA!” Safe Flight Heinrich 2007

The Error Chain Effect in a Dynamic Environment Latent Threats External Threats & Errors Crew Errors PAX to FA: “Can I ride on the jumpseat? ” FA to PAX: “Would anyone like to ride on the jumpseat? ” Threat & Error Management TRM/CRM Behaviors Errors CRM Behaviors Additional error “Oh, really!” YES No! Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Captain: “Please, flight issues only!” Safe Flight First officer: “You’re too low! Let’s miss!” Safe Flight No sterile cockpit First officer hesitant to challenge captain Captain determined to land Outcomes Additional error Captain: “ 3 MAs! Let’s plan for MA!” Safe Flight Incident Accident Heinrich 2007

The Error Chain Effect in a Dynamic Environment Latent Threats External Threats & Errors Crew Errors PAX to FA: “Can I ride on the jumpseat? ” FA to PAX: “Would anyone like to ride on the jumpseat? ” Threat & Error Management TRM/CRM Behaviors Errors CRM Behaviors Additional error “Oh, really!” YES No! Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Captain: “Please, flight issues only!” Safe Flight First officer: “You’re too low! Let’s miss!” Safe Flight No sterile cockpit First officer hesitant to challenge captain Captain determined to land Outcomes Additional error Captain: “ 3 MAs! Let’s plan for MA!” Safe Flight Heinrich 2007

The Error Chain Effect in a Dynamic Environment Latent Threats External Threats & Errors Crew Errors PAX to FA: “Can I ride on the jumpseat? ” FA to PAX: “Would anyone like to ride on the jumpseat? ” Threat & Error Management TRM/CRM Behaviors Errors CRM Behaviors Additional error “Oh, really!” YES No! Captain : Reminds PAX about 3 MAs and Safety #1! Safe Flight Captain: “Please, flight issues only!” Safe Flight First officer: “You’re too low! Let’s miss!” Safe Flight No sterile cockpit First officer hesitant to challenge captain Captain determined to land Outcomes Additional error Captain: “ 3 MAs! Let’s plan for MA!” Safe Flight Heinrich 2007

Latent Threats External Threats & Errors Crew Errors TRM/CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Questions? Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph. D.

Backup Slides

TEM Take-Aways • TEM does not replace CRM; rather, CRM is the foundation of an effective TEM program • Keys to using TEM and the automated flightdeck: – Identify automation threats – Develop automation strategies – Verbalize, verify, and monitor! – Treat interruptions as “red flags” • “What gets measured gets managed” – Utilize check airmen, observers (LOSA), FOQA – Record best practices – Track progress – Revise procedures and processes Heinrich 2007

TEM Take-Aways (continued) • Encourage good communication – Make sure everyone is “on the same page” (good CRM!) – Discourage the “Hint and Hope” syndrome (dropping a subtle hint, hoping the other person will get the message) – Communicate anything that can reduce your ability to detect errors or anything that can increase your chance of making errors – Statistically, better communication = fewer errors • Follow SOPs: – Crews who fail to follow SOPs are twice as likely to commit subsequent errors • “Buy time” for your crew – pause to properly assess the situation, develop strategies, and make informed decisions Heinrich 2007

Organizations that have a proactive safety culture… Understand that… Ø …aviation professionals are human and therefore prone to error Ø acceptance of vulnerability is the first step in taking responsibility and avoiding risk-taking behaviors Ø detecting, reducing, and containing human errors are the most effective ways of improving safety Ø it is important to have incident reporting programs that are confidential and nonpunitive Heinrich 2007

Organizations that have a proactive safety culture… Understand that… Ø … adherence to SOPs can greatly reduce the opportunities for accidents and incidents Ø internal and external audits are critical to safety “health” Ø risks can most times be mitigated by riskcompensation Ø when risk compensation cannot be accomplished, alternatives must be found that provide adequate margins of safety Heinrich 2007

Organizations that have a proactive safety culture… Understand that… Ø …safety is an attitude on and off the job Ø safety can be proactively managed, i. e. , all accidents and incidents can be prevented Ø all operating exposures can be safeguarded; barriers must be erected and maximized Ø safety comes from proper decision-making, usually a product of good CRM, MRM, or TRM Ø safety should be continually recognized and re-enforced Heinrich 2007

Organizations that have a proactive safety culture… Understand that… Ø …both management and employees are responsible for avoiding accidents and incidents Ø employees must be trained and given the tools/resources to work safely – i. e. , there should be no incentives to take short cuts or break the rules Ø prevention of personal injuries is a product of caring, but it is also good business Ø working safely and responsibly should be a condition of employment Heinrich 2007

Latent Threats External Threats & Errors Crew Errors CRM Behaviors Outcomes CRM Outcomes Behaviors Organizational System Professional Unexpected Events/Risks External Error Decision-making, SA, Threat recognition, Error avoidance, Safeguards, Countermeasures Safe Flight Violations, Communication, Procedural, Proficiency, Decision Recovery to Safe Flight Inconsequential Threat & Error Management Error-management Behaviors (avoid, trap, contain, mitigate, exacerbate, fail to respond) Undesired aircraft state Undesired state management behaviors Additional error Incident Accident * Adapted from Helmreich, 2003

Questions? Flight Safety Foundation CAC Workshop Oct. 17, 2007 Durwood Heinrich, Ph. D.