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Good
Decisions on
the Fly
Putting TEM on Your Safety Team
--by Paul Preidecker, FAA Safety Briefing Guest Writer
If I told you that you had only had five minutes to buy a new
car, would you make the right decision? I definitely would not. I
would need to take my time, do some research, maybe create a
database of information, analyze, and compare. Only then would
I feel ready to make that kind of decision. Put another way, most
of us do not make good decisions under time pressure.

As pilots, though, we make dozens of decisions … literally on

the fly, without the luxury of time. Most often, we manage
decisions concerning our flight with relative ease. Our
experiences have helped build an internal database of answers.
We have a host of flight planning resources available, and
technology such as ADS-B to help make the right decisions en
route.
Effective risk management is essential to safe operations, so the
well-known mantra of aviate, navigate, and communicate has
evolved to add mitigate. But in order to mitigate risk, we have to
know, or at last anticipate, what those risks are. The risk
management section of the Airman Certification Standards
(ACS) can help, but let me offer an additional idea. GA pilots
can also mitigate risk by using a model borrowed from the
airlines: Threat and Error Management (TEM).
The goal of TEM is simply to identify and recognize threats,
reduce errors, and prevent undesired aircraft states. TEM
acknowledges that there is no such thing as a perfect flight, that
we operate in a complex environment, and that we will make
mistakes.
TEM further recognizes that accidents rarely occur due to a
single event or error; rather, they result from a chain or series of
events or errors. Breaking the chain can stop an accident, and
the best approach is to break the chain at the earliest point. That
means you must become aware of threats and errors that
constitute the beginning of the accident chain. So, the TEM
approach is designed to help pilots recognize and prevent those
mistakes from escalating into operational errors.

Pilots can easily get caught up in the “Vortex

of Error” where threats lead to errors, which
can lead you down the hole to an undesired
aircraft state.
TEM Terms
In the parlance of TEM, a threat is an event or situation that
occurs outside the pilot’s ability to influence, increases the
operational complexity of a flight, and requires
attention/management to maintain safety margins. For example,
dealing with adverse meteorological conditions, airports
surrounded by high mountains, congested airspace, aircraft
malfunctions, and errors committed by other people outside of
the cockpit, such as air traffic controllers, flight attendants, or
maintenance workers. Threats can be classified into three
categories: operational threats (e.g., equipment malfunctions or
taxiway closures); environmental threats (e.g., weather and
ATC); and mismanaged threats (e.g., stepping on the wrong
rudder in an engine out situation.) The threat in this example
starts as an engine out. Stepping on the correct rudder helps
mitigate the threat of the engine out. Stepping on the wrong
rudder (mismanaged) is an error that now induces another threat,
loss of control. It’s important to know that threats are not just
observable events or situations; they can also arise from the
decisions we make about those situations. The all-too-familiar
visual meteorological conditions (VMC) into instrument
meteorological conditions (IMC) scenario is just one example.
An error is a pilot action or inaction that leads to a deviation
from intentions or expectations, reduces safety margins, and
increases the probability of adverse operational events on the
ground or during flight. Errors also come in three categories:
aircraft handling errors (e.g., speed, configuration, or
automation); procedural errors (e.g., intentional or unintentional
deviation from regulations or aircraft operating limitations); and
communication errors (e.g., misunderstanding between you and
ATC). Note that errors do not always arise from threats.
Selecting flaps above published flap operating speed is an error
that may not be associated with any threat.
Although what I have described above is not an all-inclusive
description of the typical TEM model, here’s a simple way to
distinguish between threats and errors:
Threats come at you; errors come from you.

How Do CRM/SRM
Play with TEM?
CRM and SRM are both valuable players on the safety team. As
you will read in other articles, CRM — now generally known as
crew resource management (CRM) — is about leveraging all
available resources to help you manage a flight. Adapted from
CRM, single pilot resource management (SRM) is a tool that
individual pilots can use for this purpose. When I fly for the
airlines, I have the benefit of fellow crew members, ATC,
dispatchers, gate agents, and others. When I fly GA, I view ATC
and flight service as part of my crew. GA pilots also have flight
planning tools, maybe a pilot partner, and technology such as
GPS and ADS-B.
Here’s the distinction:
CRM/SRM is about managing resources, and
TEM is about managing threats.

Setting the Trap

Most threats, and the errors that may arise from them, increase
the complexity of a flight. Typically, they require time or action
to manage. Therefore, workload increases. Increasing workload
is in fact a threat. The sooner we manage threats and break the
chain, the more effective we will be at maintaining safety. Left
unmanaged, threats can compound creating a multiplying effect
of errors.

Even minor incidents can lead to taxiway,

runway, and even airport closures for an
extended period of time.
In the language of TEM, we talk about trapping errors. A
trapped error is the first step in breaking the chain of events that
may lead to trouble. Here’s an example: ATC clears you to a
new altitude while you are listening to ATIS. You are not certain
you heard the assigned altitude. Rather than changing to the
altitude you thought you heard, you request clarification.
An un-trapped error is just that: You make an error and you fail
to recognize it. Un-trapped errors may or may not have
associated safety consequences. For example, suppose you are
flying an instrument approach and you do not set or brief the
missed approach altitude. If you land without incident, there is
no safety consequence. But if you miss the approach and fail to
climb to the appropriate altitude, there’s an obvious safety
problem.
So here’s another definition: The result of not effectively
managing threats and trapping errors is the undesired aircraft
state. An undesired aircraft state is an aircraft position, speed,
altitude, or configuration that results from pilot error, actions, or
inactions. It clearly reduces safety margins. It can result from
something as simple as flying an incorrect heading or crossing a
hold short line without a clearance.

We Are the Problem,

and We Are the
Solution
Human beings are most often the problem in that we fail to
recognize our errors or the errors of others. Fortunately, we are
also the solution. Through training and practicing TEM, we can
adopt strategies and countermeasures to effectively mitigate
risks.
The TEM approach starts with anticipation. Anticipation is
recognizing that something is likely to go wrong, even if we do
not know exactly what or when. Anticipation thus leads to
vigilance, which means following the discipline of always being
on guard, even on the most routine flight. The next step is
recognizing a problem, and after recognition comes recovery,
correcting the situation before it leads to an error or unintended
aircraft state.

Applying the Swiss Cheese model to TEM.

Recognition and recovery are both countermeasures. There are
many other countermeasures we can use to prevent threats from
turning into errors. For example:
Technology (e.g., flight planning tools, GPS, and ADS-B) can
help provide increased situational awareness and information
both prior to, and after departure. However, keep in mind that
technology can be a threat if it is a distraction. Don’t forget to
look outside and know your equipment well.
 Modern avionics have not eliminated the potential for malfunctions.
Briefings are essential in a crew environment, as they create a
shared mental model. In GA, though, you can brief yourself.
Some pilots like to brief an approach out loud. Proper pre-flight
planning requires getting a weather briefing from a qualified
briefer or from flight planning programs.
Checklists and procedures that you consistently follow are also
safeguards. Creating and following standard operating
procedures on every flight will help you become a more reliable
pilot, especially if you are tired, distracted, or dealing with
unexpected weather or a mechanical issue.
As PIC, you are the last line of defense. As final authority, it is
your responsibility to mitigate risk and manage safety. You trust
your mechanic, but it is up to you to thoroughly preflight your
aircraft and make sure paperwork is in order. You trust the fuel
handler, but always check to make sure you received fuel. You
trust ATC, but it’s up to you to embrace the meaning of PIC.
The PAVE model can be a starting point to help you apply TEM
strategy.

Paul J. Preidecker ([email protected]) is a pilot and

check airman for a regional airline. He is active in GA and
seeks to improve training by developing best practices and
standard operating procedures for GA pilots.
This article was originally published in the November/December 2019 issue
of FAA Safety Briefing magazine.
 FAA Safety Briefing Webpage
CREATED BY
FAA Safety Team
Appreciated

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