Threat and Error Management
What is TEM?
“Defensive flying”
ICAO and FAA
In 2000, LOSA baseline results showed that error management had been incorporated into everyday operations.
Improved checklist usage and a 70% reduction in non-stabilised approaches.
ICAO made LOSA the central focus of flight safety and human factors programmes.
TEM and LOSA recognised Worldwide.
TEM Philosophy
Three basic concepts:- Anticipation- Recognition- Recovery
Recover first, analyse the cause later.
Threats
May be internal or external. They are not caused by the crew. They increase the operational complexity of a flight. Require crew attention and management if safety
margins are to be maintained.
What is a latent Threat?
A threat that is not directly obvious to flight crew. A threat that is not directly obvious to flight crew.
Equipment design.Equipment design.
Threat Management - GPS
Threats & errors- Poor standardisation of
GPS receivers
- Poor integration with AP
- Mis-interpretation of HSI
Management
Obtain training & practice (VMC) with make & model
Use HDG mode when changing any detail
In non-integ. cockpit, double-check mode
Errors
Error is a crew action or inaction that leads to a deviation from crew or organisational intentions or expectations.
Put simply: threats come “at” the crew, while errors come “from” the crew.
An Error that is detected and effectively managed has no adverse impact on the flight.
An error that is not detected cannot be managed.
Flight Crew Errors
Can be divided into three types: Aircraft Handling Procedural Communication Errors.
Consequence of Error
The very same error can have completely different consequences, depending on the factors involved.
Error : setting the flaps correctly for landing is forgotten.
- Aircraft type and performance
- Actual landing weight
- Runway length and obstructions ahead
Undesired Aircraft State (UAS)
A UAS is defined as a position, speed, attitude or configuration of an aircraft that:- Results from flight crew error, actions or inaction- Clearly reduces safety margins
UAS can be managed effectively or mismanaged, leading to an additional error, UAS, an incident or accident.
A Decision MUST be made
Identify the Threats?
TEM Application
T Terrain W Weather O Operational P Plan
TWO-P
Terrain old Terrain new Weather good Weather bad Operational in Operational out
TWO-P
Assessing threats does not make them go away.
A threat briefing must contain effective strategies.
There must be a plan.
Levels of Situational Awareness
Level One: Perceive Level Two: Comprehension Level Three: Projection
Understand
Notice
Think
Ahead
NUTA
The NUTA/TEM Links
Situation Awareness
Threat Management
Notice
Understand
Think Ahead
Mitigate
Trap
Avoid
Countermeasures
Anticipation builds vigilance. Recognition leads to recovery. Recover first, analyse causes later. Planning. Execution. Review or modify.
What is an Unexpected Threat?
Just because you deal with a situation everyday does not mean that it is not a
threat.
Discussion Time