Threat and Error Management Trainingfor Air Traffic Control Officers

Greg Down

ICAO Global TEM & NOSS Symposium EUROCONTROL IANS

LuxembourgNovember 9, 2005

Presentation Overview

• Background• Overview of TEM Training• Benefits• Review

NAV CANADATEM Background

• In 2001, visited Continental Airlines and University of Texas to research the application of TEM in ATS

• Participated in Continental’s TEM Training and experienced first hand the impact and value of this training

Continental AirlinesTEM Training

• A consistent and operationally focused perspective on Threats and Errors in the operational environment

• TEM was (and still is) consistently applied throughout the organisation: – Training (Initial and Recurrent)– Simulator ‘Checks’– Auditing (FOQA & LOSA)– Dispatch, Ramp

NAV CANADA TEM Training

• Delivered in 2001 to all operational staff (ATCOs and FSSs) and Line Management

• Included FAA Video “Collision Course”• Opportunity to discuss experiences through

the TEM “lens”• Well received by staff and management

TEM Training Overview

What is the TEM Framework?

What is a Threat?

What is an Error?

What is an Undesired State?

Strategies for Managing Threats and Errors

What is the TEM Framework?

A safety management framework:

• to enhance aviation safety and efficiency

•through an operationally relevant and highly intuitive framework

• to better understand and manage system and human performance in operational contexts

TEM FrameworkThreats

Errors

Undesired States

OutcomeOutcome

Threat Management

Error Management

Undesired StateManagement

Errors

What is a Threat?

Events or conditions which occur:• beyond the influence of the air traffic

controller;• increase a situation’s complexity; and• must be managed to maintain

the margins of safety.

“It’s a Beautiful Day in the Neighbourhood…”

The Ideal Shift

• Overstaffed

• All aircraft on radar

• All systems operational

• Beautiful VFR Weather

• Happy, supportive supervisor

• Pilots are attentive and responsive

• Co-workers are pleasant and supportive

“It’s a Beautiful Day in the Neighbourhood…”

A More Typical Shift

• Short staffed • Non-radar aircraft• Maintenance on critical systems• IFR / Marginal VFR Weather• Not-so-supportive supervisor• Pilots - slow to respond to instructions• Co-workers - demanding and create workload

Threats Threats (Aerodrome Environment)(Aerodrome Environment)

Weather

Maintenance

Airspacerestrictions

Visitors

Runway crossings Comm. failure/stuck mike

Shift change

Similar call signs

Non-standard procedures

Heavy traffic

Unfamiliar crews

Automation events Missed approaches

Runway inspections

System malfunctions

Distractions

Threats Threats (Radar Environment)(Radar Environment)

Weather

Maintenance

Airspacerestrictions

Visitors

Military activities Comm. failure/‘Stuck’ mike

Shift change

Similar call signs

Non-standard local procedures

Heavy traffic

Co-ordinationother sectors

Automation events Differing equipment

Diversions

System malfunctions

Distractions

Threat Error

Threat

What is a Threat?

What is Threat Management?

The process of detecting and responding to threats with countermeasures to maintain safety margins.

Tools to Teach About Threats

• Discussion of Common Threats• Promote use of the phrase

“RED FLAGS”• “DIPs” – Distractions

InterruptionsPreoccupations

What does Error mean in TEM?

Actions or inactions by air traffic controllers that lead to deviations from organizational or air traffic controller intentions or expectations.

Examples of Error

•Incomplete Briefing•Full Readback Not Obtained•Wrong Call Sign Used•Non-Standard Phraseology•Incorrect information passed

What is Error Management?

The process of detecting and responding to errors with countermeasures that mitigate the probability and / or severity of further errors or undesired states.

What about Error Preventionor Error Avoidance?

We cannot PREVENT all errors

Nor can we AVOID all errors

We can MANAGE errors

Managing Errors

• Follow procedures• Use proper phraseology• Continuously monitor traffic• Clarify / challenge inconsistencies

What is an Undesired State?

Operational conditions where anunintended traffic situation resultsin a reduction in margins of safety.

– ‘Transitional’ safety phase between normal operations and an outcome

– Indicator that earlier Threats and / or Errors were not adequately managed

Undesired State Examples

• Aircraft climbing / descending to altitude beyond its clearance

• Aircraft deviating from assigned heading / track / route

• Incomplete coordination

• Inaccurate flight info on the radar screen

• Not using appropriate indicators when crossing vehicles across an active runway

Undesired States are NOT ‘Outcomes’?

• an Outcome is an ‘end state’• Incident• Operational Error• Operating Irregularity• Accident

• Once an Outcome has occurred, normal operations cannot be recovered

• Undesired States can be effectively managed and normal operations regained

Goals of TEM

Discover, assess and manage threats

Enhance the detection and management of error

Improve resistance to errors

Diagnose factors that may create threats and errors

TEM FrameworkThreats

Errors

Undesired States

OutcomeOutcome

Threat Management

Error Management

Undesired StateManagement

Errors

Strategies to Improve Safety Margins

•Identify ‘Threats’ in Operation and reduce or eliminate before they lead to error or consequence

•Promote use of ‘common language’ to focus attention on safety issues(RED FLAGS)

•Make errors ‘visible’ so that they can be easily identified and managed

Strategies to Improve Safety Margins

•Make it ‘safe’ to report errors (‘just / error tolerant’ culture)

•Treat errors as a feedback mechanism for learning and continuous improvement

•Errors are EXPECTED and WILL occur. HOW they are MANAGED is what is important

Challenges to TEM Training

• Tendency to focus to be on Errors rather than Threats

• Can devolve into a debate over Risk vs. Hazard vs. Threat contextual meanings if not managed

• Can appear overly simplistic to those who are accustomed to more elaborate frameworks

Benefits Of TEM Training

• TEM is intuitive– Gives structure to what controllers already do on a daily basis

• Simple, robust operational ‘Lens’ to view the operational environment– Identifies external factors that impact the operation– ‘See’ factors that effect safety in a new way

• ‘Common language’ – Can facilitate rapid identification and communication of factors

that could impact operations (Red Flags)

Benefits Of TEM Training

• Consistent with Safety Management Systems– Can be deployed independently or to reinforce existing SMSs

• Promotes movement toward ‘Just Culture’ – improved reporting of safety concerns through focus

on external factors rather than individuals

• Creates foundation for improved safety data collection – programs such as NOSS

• Illuminates that ATCOs are effective Threat Managers

Presentation Review

• Background• Overview of TEM Training• Benefits• Review

TEM Promotes an Effective Safety Culture

33

An organization’s safety culture can be defined by the extent to which it is:

• Informed

• Wary

• Just

• Flexible

• Learning

Threat and Error Management Trainingfor Air Traffic Control Officers

Greg Down

ICAO Global TEM & NOSS Symposium EUROCONTROL IANS

LuxembourgNovember 9, 2005