1 Intro to Threat & Error ManagementWelcome

2 One of the advantages of being captain is being able to ask for advice without necessarily having to take it. Peace or utter destruction, its up to you. If you’d keep your nose off my bridge, I’d be thankful.

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4 You can see from the graph, that the accident rate has gone down significantly. Most of the early accidents were largely attributable to unreliable aircraft equipment.

5 Accident Causal Factors Over TimeHuman Causes Source: ICAO 1984 Human Error has remained a major contributing factor in aviation accidents Machine Causes Time

6 The Tip of the Iceberg Once you see it, its too late.

7 The Tip of the Iceberg What is happening here?

8 What is CRM? Effective use of all resources, to achieve the highest possible level of safety and efficiency. (Transport Canada)

9 Heinrich Safety Triangle1 Accident Serious Accident Minor Accident with Damage and Injury Incidents and Near Misses Observed Work Errors Lagging Indicators ~ 29 Incidents Leading Indicators ~ 300 Hazardous Conditions ~ 3,000 Unreported “Unsafe“ Acts Mr. Heinrich was an Industrial Safety Engineer, who in 1931 developed a model describes how major injuries/industrial accidents occur.  For a given population of workers, his model proposes that for every 300 unsafe acts (defined as FAR violations, Hazardous Attitudes, Safety Reports) there are 29 minor injuries and one major injury.  Heinrich's theory accounts for the first three levels of the model.  For more than 75 years, industrial safety managers have tried to reduce such accidents and injuries by attacking the problem from different ends of a three level pyramid. If investigative efforts are focused only on those rare occurrences where there is serious injury, or significant damage, its a wasted opportunity. The latent factors contributing to such accidents may be present in hundreds of other incidents, and could be identified – before serious injury or damage ensues. We all understand close calls.  We've all had them.  Some more than others.  And that's the point.  Some folks simply have more close calls, take more shortcuts & unnecessary risks.  Sometimes they are lucky.  Sometimes luck runs out.  If you keep playing darts, eventually you'll get a bulls eye.  Out of 3,000 unreported “unsafe” acts, one is going to be the winner that awards the pilot a check in the fatal column.  Those are defined as taking shortcuts, unnecessary risks, and close calls. Even more insidious is the "Pilot Qualifications" layer.  Imagine an employer reviewing all your flights, all the decisions you made on those flights, and all the little things that surprised you on all those flights.  Would the employer select you to be a pilot for them?   This layer includes (but not limited to): Pilot qualifications Decision making skills Legally qualified & current? Proficient & skilled? Hazardous Attitudes? Flying habits Current Life Stress Events Psychological make-up Substance use? Medically qualified?  Healthy? Mature thinking style? Conservative? Risk adverse? Personal Lifestyle Choices (Credit-Criminal-Educational) (Source: cfidarren.com) Just remember the cost to learn the lesson grows as you get to the top of the triangle. Intervening at the lowest level saves more lives, pain and suffering. ~ 30,000 Pilot Qualification – Selection Issues

10 Strategies Continental Airlines RESIST RESOLVE ERRORS CONSEQUENCETHREATS Strategies ERRORS RESIST HARDWARE & SOFTWARE THAT EXISTS BEFORE THE HUMAN ENTERS RESOLVE WHAT THE HUMAN BRINGS TO THE SYSTEM Resist Resolve CONSEQUENCE

11 Anything that increases operational complexityWhat’s a Threat? Anything that increases operational complexity Definition of a threat: A threat is anything that makes a flight more complicated. Threats are not always a danger to a flight, but can cause distractions if not managed properly. Distractions increase the chance that a crew will commit an error. Facts of life about threats: Inevitable - part of the territory External conditions or events that must be managed during normal, everyday flights, in order to maintain safety margins. Events which increase operational complexity, posing a safety risk to the flight at some level

12 Example Threats Passenger Events Distractions ATC Cabin Crew TerrainWeather Similar Call Sign Maintenance Time Pressures Ground Crew Flight Diversion You’ve all seen this chart… Let’s dig into error more indepth. I want to show you a video on medical errors because it similar to what we do. It has similar: Complexity Training intensity Time constraints Scrutiny Teamwork dependency [Show CBS HealthWatch clip, Medical Error] Heavy Traffic System Malfunction Unfamiliar Airport Missed Approach Automation Event

13 Real Threats Child Support Spouse(s) Work Rules Chief Pilot PayManagement Flight Attendants Sleep Parent Airline Ground Crew Schedule You’ve all seen this chart… Let’s dig into error more indepth. I want to show you a video on medical errors because it similar to what we do. It has similar: Complexity Training intensity Time constraints Scrutiny Teamwork dependency [Show CBS HealthWatch clip, Medical Error] 14 Hour Day Friends Inexperienced Crewmembers Merger? My career isn’t going the way I thought it would

14 What’s the Threat? KWOK 14

15 ICAO

16 Northwest Airlines Undesired Aircraft State Trap: Managing ErrorHere’s a simplified model of Threat & Error Management. You spend your time managing threats, and if you don’t manage the threat, it becomes an error, and a mismanaged error becomes an undesired aircraft state (incident/accident). Just remember the cost to learn the lesson grows as you get to the top of the triangle. Intervening at the lowest level saves more lives, pain and suffering. Let’s define a few of these things properly… Avoid Error: Managing Threats

17 Layered System of DefensesUndesired Aircraft State Elements of layered system (e.g., Preflight) Read and sign paperwork (weather, clearance) Conduct exterior inspection Conduct cockpit inspection Brief cabin crew Preflight checklist Threats

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19 TEM Toolkit

20 Error Types Intentional Noncompliance – violationsex) Performing a checklist from memory Procedural – Followed procedures but wrong execution ex) Wrong altitude setting dialed into the MCP Communication – Missing information or misinterpretation ex) Miscommunication with ATC Proficiency – Error due to a lack of knowledge or skill ex) Lack of knowledge with automation Decision – Discretionary decision that unnecessarily increased risk ex) Unnecessary navigation through adverse weather Source Flight Safety Foundation

21 When Do Errors Occur? 49.4% 10.7% 16.3% Source: Helmreich, 1998 23.6%

22 Case Study What we did at NWA

23 What we did at NWA Recurrent Training CBT

24 What we did at NWA Instructor Briefing Guides

25 What we did at NWA Briefing Room Posters

26 What we did at NWA 7-hole cards to all 5500 pilots Mailbox Briefing Rooms Jumpseat Handout Lounges 7-hole cards

27 Video Training & ScenarioWhat we did at NWA Video Training & Scenario

28 Integrating Threat & Error ManagementFlight Standards Line checks to reinforce threat recognition, error avoidance and management Flight Operations Review/revise SOPs and policies Safety Error reporting system (ASAP) for data Safety Programs (HF, FOQA) Ongoing QA Audits Training Threat recognition & error avoidance and management Captain Leadership Focus on technical and procedural excellence

29 Because Flying IS our Business:Threats must be identified and reduced or eliminated. Crew Errors must be avoided and managed. -- Therefore -- Threat & Error Management must be integrated into Flt Ops culture.

30 More Info… WATS

31 Darren Smith www.cfidarren.com 813-503-3322Thanks Darren Smith