IATA CRM Course

Threat and Error Management

Captain Zhou Yizhi
 Introductions

 Name
 Airline
 Position
 Flying experience
 Previous CRM experience

IATA CRM: TEM 2

 Course Schedule
0900 - Start
1030-1045 Break (approximate)
1200 - Lunch

1330 – Return
1515-1530 Break (approximate)
1700 - Finish

IATA CRM: TEM 3

 Course Outline
DAY 1
Introduction
Introduction to Threat and Error Management - TEM
Countermeasure (CRM) Skills
DAY 2
Review
Error Avoidance
Threat Management
Error Management
Undesired Aircraft State Management
DAY 3
Review
Threat and Error Management Model
Safety Management Systems
Test
IATA CRM: TEM 4
 Objectives of the course

 To understand the concept of threats.

 To understand that operational errors are normal,
expected and a consequence of mismanaged threats.
 To develop strategies to:
Recognize and manage threats
Identify and manage errors
Minimize the consequences of errors
 To recognise that the safety system can be improved by
the application of the TEM model to events.
 At the end of this course students will be able to apply
the TEM process to their area of operation.

IATA CRM: TEM 5

 Module 1
Overview History of CRM

IATA CRM: TEM 6

 Our Job is to fly
from point “A” to
point “B” safely
and efficiently.

IATA CRM: TEM 7

 To accomplish this we must deal with
threats and errors from the real
world…

IATA CRM: TEM 8

 … and the mistakes
we make as pilots ...

IATA CRM: TEM 9

 ...while maintaining productivity.

IATA CRM: TEM 10

 How are Pilots made safe?

Proficiency
Technical knowledge
Physical and mental well being
CRM

IATA CRM: TEM 11

Crew Resource
Management
 Evolution of CRM

NASA research inspired this

response to non-mechanical
accidents

Goal to reduce Human Error

IATA CRM: TEM 13

 First Generation CRM
 Derived from corporate management
development training
 Focus on individual management
style/interpersonal skills
 Insure captain accept input from F/O
 Addressed lack of assertiveness by F/O

“Cockpit Resource Management”

IATA CRM: TEM 14

 Second Generation CRM
 More team based
 Use of team building exercises
 Focus on concepts
 Situational Awareness
 Stress Management
 Modular
 Teach the error chain
 Train individual decision making, briefing strategies, team
building

“Crew Resource Management”

IATA CRM: TEM 15

 Third Generation CRM
Systems approach
 Focus on specific skills/behaviours
 Integration with technical performance
 Emphasis on evaluating human factors
 Special training for Instructor/Check pilots
 Broadened perspective
 Flight attendants, dispatchers, maintenance

“Advanced CRM”

IATA CRM: TEM 16

 Fourth Generation CRM
 Performance data guide training
 Integration of CRM into technical Training
 Proceduralization of CRM
Checklists include CRM issues
 Specialized curriculum topics
Automation, etc.
 Reinforcement of human factors in full mission
simulation (LOFT)

“Integrated CRM”
IATA CRM: TEM 17
 Problems with past CRM
 Adaptation of business models
 Confusing
 Industry has evolved and matured
 Diluted
 Separation of technical and CRM training
Forgot the primary objective of CRM…

IATA CRM: TEM 18

 …Reduce Human Error

IATA CRM: TEM 19

Error
 NTSB Study

Conclusions
- When flying the aircraft, captains appear to have
difficulty in monitoring their own performance

- Many new on the line crewmembers have

difficulty in voicing concerns about the captain’s
decision making, particularly if they have not flown
together before.

IATA CRM: TEM 21

IATA CRM: TEM 22
 Error environments

 Increasing workload
 Undo time pressure
 Fatigue
 Procedural non-compliance
 Poor crew coordination
 Interruptions/distractions

IATA CRM: TEM 23

 Error

Actions or inactions by the crew that lead to

deviations from organizational or flight crew
intentions or expectations.

Errors in the operational context tend to reduce

the margin of safety and increase the
probability of incidents or accidents.

IATA CRM: TEM 24

 Fifth Generation CRM

Cannot totally eliminate error

 Avoid errors being made
 Manage errors by trapping or mitigating
their consequences

“Error Management”

IATA CRM: TEM 25

Threat
 The Real World

What is a normal flight?

 What hazards do pilots have to deal with

on the line?

IATA CRM: TEM 27

 Threats

Are situations external to the flight deck,

that
must be managed by the cockpit crew during
normal, everyday flights.

Such events increase the operational

complexity of flight and pose a safety risk to
the flight at some level.

IATA CRM: TEM 28

 Types of Threat
 Weather Distractions  Ground Crew error
Missed Approaches  Maintenance error
 Flight Diversions   System Malfunctions
 Heavy Traffic  Time Pressures
 Similar call signs
 Automation Events
 Passenger Events
ATC error
 Cabin Crew error
  Unfamiliar Airport 

IATA CRM: TEM

  29
 Types of Threat
 Weather Distractions  Ground Crew error
Missed Approaches  Maintenance error
 Flight Diversions   System Malfunctions
 Heavy Traffic  Time Pressures
 Similar call signs
 Automation Events
 Passenger Events
ATC error
 Cabin Crew error
  Unfamiliar Airport 

IATA CRM: TEM 30

 
 What groups are responsible for the
safety of a flight?

IATA CRM: TEM 31

 Safety Defenses

Pilots

Safety Barriers

Company/
Organization

Aircraft Manufacturer

Government Regulations

Production

IATA CRM: TEM 32

 Safety Defenses - Errors

Pilots

Safety Barriers
Company/
Organization

Aircraft Manufacturer

Government Regulations

Production
Errors

IATA CRM: TEM 33

 Threat

Pilots

Safety Barriers
Company/
Organization

Aircraft Manufacturer

Government Regulations

Production
Threat
IATA CRM: TEM 34
 Threat Not Captured Incident / Accident

Pilots

Safety Barriers
Company/
Organization

Aircraft Manufacturer

Government Regulations

Production
Threats

IATA CRM: TEM 35

 Pilots are
the last line of defense!

IATA CRM: TEM 36

 What do Pilots have to do to fly safely
from A to B?
Avoid committing errors

Manage operational complexity

Safe
= Flight
Manage their own errors

Manage aircraft deviations

IATA CRM: TEM 37

 Crew Invulnerability
Perception
 Pilots perceive themselves as unbreakable under
pressure, that they can handle all problems
Reality
 Pilots are affected by various factors which
influence their ability to perform, their personal
limitations

IATA CRM: TEM 38

 Sixth Generation of CRM
 Focuses on CRM as set of countermeasures
against threat and error
 Error avoidance
 Threat and error management
 Undesired aircraft state management

“Threat and Error Management”

TEM

IATA CRM: TEM 39

 Countermeasures to Threat and Error

Avoid committing errors Error Avoidance

Manage operational complexity Threat Management

Manage their own errors Error Management

Undesired Aircraft State

Manage aircraft deviations Management
IATA CRM: TEM 40
 Our Goal

 Need to refocus CRM towards error

reduction and threat recognition

 Adaptation of existing skills towards

countermeasures in the real world

IATA CRM: TEM 41

Module 2 Countermeasures
Skill Groups to be used as
Countermeasures to
Threat and Error
 CRM Skill Groups

Four groupings of CRM skills are

threat and error countermeasures

1. Team building and climate

2. Planning
3. Execution
4. Review / modify

IATA CRM: TEM 43

 CRM Skill
① Team Climate Countermeasures
  In a large number of incidents, one
person knew something was wrong
and did not speak up!

 Least errors made by crews who

communicated the most!

IATA CRM: TEM 45

 Team Climate
How do you create an atmosphere for constructive
TEM?

 develop and maintain a good communication

environment
 effective leadership

Important in all aspects of safety ( CRM/TEM)

IATA CRM: TEM 46

 Communication Environment
Communication channels established and maintained

 Be assertive, yet respectful

 Ask for information and advice

 Create climate for critique – give and take

IATA CRM: TEM 47

 Some Communication Skills
Inquiry – asking questions
Active listening - acknowledge message
Clarity - clear communication
Appropriate assertiveness – proper level for
situation

IATA CRM: TEM 48

 What qualities make a good leader?

-In command
-Decisive
-Encourages participation
-?

IATA CRM: TEM 49

 Leadership Skills

Purpose -Explain reason for task

-Do what is right for the group

Direction -Define crewmembers responsibilities

-Good influence

Motivate -Build the team

-Give and receive feedback
-Maintain focus on objective

IATA CRM: TEM 50

 “ The Captain demonstrates responsibility
for the operation of the flight,
is the final authority and decision maker”

IATA CRM: TEM 51

 Conflict Management

How do you deal with conflict

in the flightdeck?

IATA CRM: TEM 52

 CRM Skill
② Planning Countermeasures
 Planning

Preparation in dealing with threat and avoiding

error by using;

- Good Briefings
- Stating Plans
- Workload assignment
- Contingency management

IATA CRM: TEM 54

 Briefings

 What is a briefing?
 Why is it important to give good briefings?
 How do we accomplish this?

IATA CRM: TEM 55

 Briefing Points

 Must be short, less than 10 ideas to be fully understood

 Better to split the briefing into two parts if longer
 Individually prepared for each flight, automatic briefings
used as routine activate none of the memory and are
ineffective
 Must be understood by all crew members, better to
have a simple well understood plan than a brilliant
misunderstood one!

IATA CRM: TEM 56

 Plans Stated
Develop plan - Solicit input from other sources
- Responsibility of all crewmembers to
contribute to the decision making process

State plan - Make plan known to crew, company and

others as appropriate
- Communicating decisions clearly reduces
confusion and misunderstandings

Shared Mental Model - constructing and maintaining a

common image of the situation
- synchronization of ideas

IATA CRM: TEM 57

 Workload Assignment
Evaluate
-Determine work to be completed
-Calculate resources and time required

Prioritize
-Match abilities with available time
-Avoid distractions

Assign Work
-Assign actions based on crewmember
experience and workload
-Issue clear and concise instructions or guidance

IATA CRM: TEM 58

 Workload Assignment
One pilot is always monitoring during
low workload and both pilots are monitoring
as much as possible during high workload

Strategically plan workload to maximize

monitoring during those areas of vulnerability
i.e. stowing charts, approach briefing, PA’s

IATA CRM: TEM 59

 Contingency Management

Contingency Planning
- Anticipate potential outcomes
- Alternate plan is initiated when limits
are exceeded
Establish Limits
- Assess time available
- Assess capability to complete task
- Set limits

IATA CRM: TEM 60

 Missed Approach Policy

Back-up plan – to reduce stress in busy time

What is your policy?

IATA CRM: TEM 61

 Planning for Known Threats

How do you plan for known threats?

 Diagnose- identify, knowledge, memory,
problem solving skills
 Generate solutions – find alternatives, hard
to do under stress
 Assess risks – predict consequences and
success rate

IATA CRM: TEM 62

 CRM Skill
③ Execution Countermeasures
 Execution

Application of countermeasures to threat and

error

- Monitor / Crosscheck
- Workload Management
- Vigilance
- Automation Management

IATA CRM: TEM 64

 One way of assessing your current monitoring
ability is to ask:

“How often have I missed making the 1,000’

before altitude callout?”

IATA CRM: TEM 65

 Monitor/Crosscheck
Crosschecking of systems and actions such as;
- aircraft trajectory
- automation systems and mode status
- Aircraft systems and/or components

Inadequate flight crew monitoring has been cited

by a number of sources as a problem for
aviation safety

IATA CRM: TEM 66

 Monitoring for Error
Pilots must actively monitor the aircraft.

Consider changing title of “Pilot-Not-Flying” (PNF)

to “Pilot Monitoring” (PM)

Describes what the pilot should be doing,

(monitoring), versus what he/she is not doing,
(not flying)

IATA CRM: TEM 67

 Monitor / Crosscheck
This means mentally flying the aircraft, even
though the autopilot or other pilot is flying.

- monitor the flight instruments as when hand flying

- if the aircraft or Pilot Flying is not doing what it is

supposed to do, the take appropriate actions to
rectify

IATA CRM: TEM 68

 BARRIERS to Effective M/C

- Ego
- Complacency
- New in seat
- Fatigue

IATA CRM: TEM 69

 Fatigue
Less reliable memory – items missed
Reduced attention- tunnel vision, reduced
visual scan
Withdrawn mood - more accepting of own
errors
Rough motor skills – poor timing

IATA CRM: TEM 70

 Workload Management
Ability to manage required tasks.

- Know the capabilities and reliability of crew

- Detect work overload
- Initiate assistance when required

IATA CRM: TEM 71

 WM Countermeasures

 Speak up when overloaded

 Change level of automation
 Ask for more time - hold, delay vectors

IATA CRM: TEM 72

 BARRIERS to Effective W/M

- Stress
- Fatigue
- Distractions

IATA CRM: TEM 73

 Stress Curve

Performance

Peak Overload

Bored

Stress
IATA CRM: TEM 74
 In stressful situations, the captain will be
better able to manage the problem
when not flying the aircraft!

IATA CRM: TEM 75

 Distractions

Interruptions can form holes in defenses

What can be done to prevent distractions?

 Sterile cockpit
 Locked cockpit door

IATA CRM: TEM 76

 Distractions

Identify the interruption

Ask what was I doing before...

being interrupted

Decide what action to take to get back on track

IATA CRM: TEM 77

 Work as a CREW

One pilot is always monitoring during low workload and both

pilots are monitoring as much as possible during high
workload

Perform non-essential duties/activities during

lowest workload periods such as cruise

Strategically plan workload to maximize monitoring during

those areas of vulnerability
i.e. stowing charts, approach briefing, PA’s

IATA CRM: TEM 78

 Vigilance
Is being alert to the situation, not only what is happening,
but what may happen
 Anticipate problems
 Gives you the ability to think about options without being
under the stress of an emergency
 Cannot be expected to be 100% vigilant during low
workloads ie long haul flights, take turns monitoring
 Particular attention must be devoted to altitude and
course changes

IATA CRM: TEM 79

 Vigilance - Situational Awareness

Is being alert and applying knowledge of what

is normal
 Anticipating what will happen
 Prepare for problems that may arise
 What skills are used to maintain SA?

IATA CRM: TEM 80

 SWA 1455

IATA CRM: TEM 81

 Automation Management

Balance of automation and workload

 During high workload, FMS inputs made by PM,
below 10,000 or within 1000 ft of transition altitude
 Confirm FMS input with the other pilot
 Activate the input
 Monitor mode announcements to ensure autoflight
system performs as desired
 Intervene if necessary

IATA CRM: TEM 82

 CRM Skill
④ Review / Modify Countermeasures
 Review/Modify Countermeasures
Use against unexpected threat or when aircraft is
in an undesired state.

Evaluation of plans – review and modify

plans when necessary
Inquiry – ask questions to clarify
Assertiveness – state critical information
with persistence

IATA CRM: TEM 84

 Evaluation of plans

Review and modify plans when necessary

- Review plan to asses if course of action

appropriate to the conditions
- Consider alternatives
- Consider time available
- Establish options

IATA CRM: TEM 85

 Inquiry
Ask questions to clarify – nothing taken for granted
- Actively seek information
- Question ambiguous or difficult situations until
there is understanding

Better to have questioned information before,

than to have to ask for help later!

IATA CRM: TEM 86

 Assertiveness

 Making sure your viewpoint is understood

 State critical information with persistence
 Make position known when safety is in
question
 Sense persons concern

IATA CRM: TEM 87

 Specific Phrases to Use

 Are you ready for…?

 What heading did he give us?
 I'm uncomfortable.
 We are off our heading/altitude.
 I thought he gave us….

IATA CRM: TEM 88

 Decision Making
for an Unexpected Threat
Perceive situation
- gather and process information
- vigilant – alert to situation
- knowledge- variation from the norm
What is the risk?
Is it time critical?
Select a course of action

IATA CRM: TEM 89

Error Avoidance
Module 3
 Preventing Error
 Maintaining your health
 High levels of training and proficiency
 Following SOP’s
 Proper use of Checklists
 Minimizing distractions
 Planning ahead
 Open two-way communication
 Maintaining situational awareness

IATA CRM: TEM 91

 Barriers to Help Prevent Error
Error Avoidance Planning

Team Climate

Checklists / SOP’s

Training / Proficiency

Health

IATA CRM: TEM 92

 Health

Your health affects everything you do.

Thorough awareness of one’s own limitations is a vital
prerequisite for adapting to our flying environment.
the following affects our ability to perform
 Noise
 Medication
 Diet
 Stress
 Fatigue - greatest workload is at the end of the flight,
when one is most fatigued - be aware

IATA CRM: TEM 93

 Technological Proficiency

 An expert pilot must constantly train. No

expertise without training and expertise is lost
if training is not maintained, need to practice

 Technical proficiency is important to TEM /

CRM

IATA CRM: TEM 94

 Standard Operating Procedures
 Establish a repeatable sequence or rhythm, so that all items can be
covered in a logical manner, easy to pick up where it was left off if
interrupted
 Standard use of phraseology – standard calls
 Increased margin of safety – confirming actions by other pilot
 Workload management is improved by specifying and prioritizing
the duties each person is responsible for
 Sets limits
 Teamwork is standardized - can work with any crew

IATA CRM: TEM 95

 Accident Cause Factors
Source: Boeing (1982-1991)

Percentage of Accidents
Primary Factor 10 20 30 40 50 60
Flying pilot non-adherence to procedure
Other operational procedural considerations
Non-flying pilot non-adherence to procedure
Embedded piloting skills
Design improvement
Captain or instructor exercise of authority
Maintenance or inspection action
Approach path stability
ATC system performance
First officer’s cross check performance
as non-flying pilot
Go-around decision
Runway hazards eliminated
IATA CRM: TEM 96
 Accident Cause Factors
Source: Boeing (1982-1991)

Percentage of Accidents
Primary Factor 10 20 30 40 50 60
Flying pilot non-adherence to procedure
Other operational procedural considerations
Non-flying pilot non-adherence to procedure
Embedded piloting skills
Design improvement
Captain or instructor exercise of authority
Maintenance or inspection action
Approach path stability
ATC system performance
First officer’s cross check performance
as non-flying pilot
Go-around decision
Runway hazards eliminated
IATA CRM: TEM 97
 How SOP’s relate to error

 data show that crews who intentionally erred

by not following SOP’s were 1.8 times more
likely to commit another error with
consequential results

 Intentional crew non-compliance was a factor

in 39.5% of accidents

IATA CRM: TEM 98

 Checklists

Proper checklist usage is...

...a basic strategy for error avoidance.

...essential for safe flight operation of complex

equipment.

...a countermeasure to mistakes .

IATA CRM: TEM 99

 Checklists

 Helps prioritize items

 Frees up brainpower for other tasks
 Reminds us of items when under pressure
 Good reminder when we are fatigued
 Standardization

IATA CRM: TEM 100

 What is Checklist abuse?

- Memorizing
- Self-initiating
- Ignoring, not completing
- Not getting any responses
- Accepting incorrect response
- Crew failed to verify settings visually

How do you handle the pilot who abuses checklists?

IATA CRM: TEM 101

 Checklist Errors

Fatigue and stress – increase chance of

overlooking or missing item when fatigued we
prioritize tasks in order of perceived importance

Interruptions – lose place

Do not put checklist down in its normal spot

during interruption

IATA CRM: TEM 102

 Error Avoidance
Using CRM skills as countermeasures
 Things you can do to help avoid error

 Create a positive team climate

 Develop planning strategies

IATA CRM: TEM 104

 Team Climate
How do you create an atmosphere for constructive
TEM?

 by developing and maintaining a good

communication environment
 effective leadership

Important in all aspects of safety ( CRM/TEM)

IATA CRM: TEM 105

 Error Avoidance - Planning

What/why is planning?
How accomplished
 Briefings
 Plans stated
 Workload assignment – distractions
 Contingency management?

IATA CRM: TEM 106

 Module 4
Threat Management
 What was a threat on a
recent flight?

IATA CRM: TEM 108

 What is threat?
Are situations external to the flight deck, that must
be managed by the cockpit crew during normal,
everyday flights.

 Why is it a problem?
Such events increase the operational complexity of
flight and pose a safety risk to the flight at some level –
increase error potential

 How do we respond to threat?

Countermeasures

IATA CRM: TEM 109

Threats which originate outside the cockpit.

 expected or unexpected things like mechanical failures,

adverse weather conditions, and ill passengers.

 errors made by the people we deal with during our flight,

ground crew, air traffic control, maintenance

 oversight in decisions made by those responsible for our

working environment (latent).

IATA CRM: TEM 110

Threats which originate outside the cockpit.

 expected or unexpected things like mechanical failures,

adverse weather conditions, and ill passengers.

 errors made by the people we deal with during our flight,

ground crew, air traffic control, maintenance

 oversight in decisions made by those responsible for our

working environment (latent).

IATA CRM: TEM 111

 Threats
Adverse weather Operational time pressures
Terrain Non-normal operations
Airport conditions ATC command events/errors
Aircraft malfunctions Cabin events/errors
Automation events Maintenance events/errors
Communication events Dispatch events/errors
Ground crew events/errors

IATA CRM: TEM 112

 Threats by Phase of Flight
Phase of Flight Threats by Phase

Pre-Departure / Taxi 30%

Takeoff / Climb 22%

Cruise 10%

Descent / Approach / 36%

Land
Taxi / Park 2%

IATA CRM: TEM 113

 Latent Threats
Factors that affect our ability to operate safely
without our prior knowledge of their
consequences.
People unwillingly create conditions for crews to
commit error by negligence in;
- design
- manufacture
- regulations
- procedures

IATA CRM: TEM 114

 Latent Threats

 ATC practices
 Scheduling practices that result in fatigue
 Organizational, national, professional culture
 Aircraft characteristics
 Qualification standards
 Regulatory practices

IATA CRM: TEM 115

 Locked Cockpit Door

 Ambiguous regulations – government

 Untested aircraft systems – manufacturer
 Flawed procedures – SOP’s
-

 Inadequate training – company

IATA CRM: TEM 116

 Runway incursions

 Both pilots have taxi charts available

 Both pilots monitor taxi clearance
 Captain will verbalize any hold short
instructions, FO to request confirmation from
Captain if not received

IATA CRM: TEM 117

 Singapore Airlines SQ006

IATA CRM: TEM 118

 Threat Management

IATA CRM: TEM 119

 Barriers to Manage Threat
Threat Management Review / Modify
(Unexpected Threat)

Planning
(Expected Threat)

Team Climate

Training / Proficiency

External Alerting Systems

Aircraft Warning Systems

IATA CRM: TEM 120

 What are countermeasures for
Expected Threat?
Unexpected Threat?

IATA CRM: TEM 121

 Team Climate

 Why is communication and leadership

important to threat management?
 Review skills relevant to threat management
with examples

IATA CRM: TEM 122

 Planning

 Used for expected threat

 Brief, state plans, assign work and
contingency strategies

IATA CRM: TEM 123

 LOSA Data

 In complex or high threat conditions,

performance is better when First Officer is
pilot fling
 Captain can manage situation
 Use automation to decrease workload

IATA CRM: TEM 124

 Review/Modify

Unexpected threat
 Evaluation of plans – reviewed and modified
plans when necessary
 Inquiry – asked questions to clarify
 Assertiveness – stated critical information
with persistence

IATA CRM: TEM 125

 Module 5
Error Management
 Why do we make errors?
 Lack of experience
 Rushed
 Distractions
 Stress
 Crews make mistakes several times during each
flight, most of which are unimportant
 However it can be beneficial to recognize and learn
from errors, since it will help manage your resources
better during the next flight

IATA CRM: TEM 127

 Distractions

 How do you manage distractions?

 Prioritize
 Tell intruder to be quiet
 Sterile cockpit
 Look in books

IATA CRM: TEM 128

 Professional culture

 Pilots have a strong professional culture with

positive and negative aspects
 Positive
 Strong motivation to do well
 Pride in profession
 Negative
 Training that stresses the need for perfection
 Sense of personal invulnerability

IATA CRM: TEM 129

 Personal Invulnerability
The majority of pilots agree that
 Their decision-making is as good in
emergencies as in normal situations
 Their performance is not affected by personal
problems
 They do not make errors under high stress
 True professional can leave behind personal
problems
ALL FALSE

IATA CRM: TEM 130

 Areas of Vulnerability
Cruise / Descent
transition
Within 1,000 ft of level off
Descent, approach
and landing
Transition Alt.

10,000 ft

Taxi-out Taxi-in

IATA CRM: TEM 131

 Flight Safety Foundation
 Many of the accidents raise questions about pilot
training
 Most accidents occur during the approach & landing
phase
 The approach is only 11% of the flight time
 The landing is only 4% of the flight time
 55% of all commercial aviation deaths are caused by
controlled flight into terrain

IATA CRM: TEM 132

 Errors by Phase of Flight
Phase of Flight Errors by Mismanaged
Phase Errors

Pre-Departure / Taxi 24% 18%

Takeoff / Climb 22% 16%

Cruise 6% 17%

Descent / Approach / Land 44% 35%

Taxi / Park 4% 24%

IATA CRM: TEM 133

 Highlighting CRM in the Blue Box

Brief TOD
18000ft

10000ft
Slow and Stabilized
Configure Approach
FAF/OM Bottom
Line

Flare / Touchdown

IATA CRM: TEM 134

 Blue Box

 Most crew errors (LOSA)

 Most consequential crew errors (LOSA)
 Most accidents worldwide (ALAR)
 CFIT
 Errors dealing with automated systems
represent the largest source of error

IATA CRM: TEM 135

 Types of Error
Intentional Noncompliance – violations
Ex) Checklist from memory
Procedural – followed procedures with incorrect execution
Ex) Wrong altitude setting dialed
Communication – Missing information or misinterpretation
Ex) Miscommunication with ATC
Proficiency – Lack of knowledge or skill
Ex) Lack of knowledge with automation
Decision – Crew decision unbounded by procedures that
unnecessarily increased risk
Ex) Unnecessary navigation through adverse wx

IATA CRM: TEM 136

 Barriers to Manage Error

Error Management Execution

Team Climate

External Alerting Systems

Aircraft Warning Systems

IATA CRM: TEM 137

 Managing Errors

 Once an error is committed, it is difficult to

catch (trap) your own error
 Other people are more likely to catch your
error
 Therefore redundancy is one strong defense
against error

IATA CRM: TEM 138

 Managing Error Topics

 Pilot invulnerability?
 Culture?
 Team Climate is important also
 Distractions?
Execution
 Monitor crosscheck
 Workload management
 Vigilance
 Automation management

IATA CRM: TEM 139

 Guidelines and Techniques for
EFFECTIVE CHALLENGING

- Timely
- With respect
- Constructive intent
- Specific
- Use questions

IATA CRM: TEM 140

 Summary
 What error management is
 Why we need it
 How are we going to accomplish this
 Team Building
leadership
Communication environment
 Execution
Monitor / crosscheck
Workload management
Vigilance
Automation management

IATA CRM: TEM 141

 NWA 1482

IATA CRM: TEM 142

 Module 5A
Undesired Aircraft
State Management
 Undesired Aircraft State Management

UAS - Aircraft deviations at edge of the

safety envelope
Incorrect aircraft configurations Path/glide slope deviations
Vertical deviations Unstable approach
Lateral deviations Long landing
Speed too high Firm landing
Speed too low Wrong taxiway/runway
Abrupt aircraft handling Runway incursion

IATA CRM: TEM 144

 Barriers to Manage Aircraft Deviations

Undesired Aircraft State

Management Review / Modify

Team Climate

Aircraft Systems
(Stick pusher etc.)

External Alerting
(ATC)

IATA CRM: TEM 145

 Countermeasures
 Team Climate

 Review/Modify

IATA CRM: TEM 146

 Module 6 TEM
Threat and Error Management
 “The Tip of the Iceberg...”

IATA CRM: TEM 148

 ...is a small part of what lies beneath”

IATA CRM: TEM 149

 Threat

Threat

Latent Threats – National Culture,

Organizational Culture &

Policies
Professional Culture
Regulation

Overt Threats – Environmental Factors

Organizational Factors
Individual Factors
Team / Crew Factors
Aircraft Factors
External Error
IATA CRM: TEM 150
 Crew Error

Threat

Crew Error

Crew mismanages threat

Error Types - Communication

Intentional Non-Compliance
Procedural
Proficiency
Decision Error

IATA CRM: TEM 151

 Undesired Aircraft State
Threat

Crew Error

Undesired Aircraft
State Aircraft is not where
it is supposed to be
due to mismanaged
threat and/or error

IATA CRM: TEM 152

 Incident (Accident)

Threat

Crew Error

Undesired Aircraft
State

Result of mismanaged threat

and error
Incident

“the tip of the iceberg”

IATA CRM: TEM 153
 Threat

Crew Error

Undesired Aircraft
State
Threat and Error
Model

Incident

IATA CRM: TEM 154

 Application

 Apply the TEM model to SQ006

IATA CRM: TEM 155

 Application

 Apply the TEM model to SQ006

IATA CRM: TEM 156

 How to Manage Threat and Error

Error Avoidance

Threat Management

Countermeasures

Error Management

Undesired Aircraft State

Management

IATA CRM: TEM 157

 Countermeasure Skills

 Team Climate
 Planning
 Task Execution
 Review and Modify

IATA CRM: TEM 158

How do we apply these
skills?
 Error Avoidance

Proactive strategies to avoid committing errors

 Planning
 Following Sop’s and checklists
 Team climate behaviours such as active leadership and
establishing a team environment
 SMS?
 Complete avoidance is impossible – errors are inevitable
 Must look for sources of error to strengthen system
defenses

IATA CRM: TEM 160

 Error Avoidance
Human limitations lead to error
 Limited memory capacity
 Limited processing capacity
 Multi-tasking capability
 Limits imposed by stressors
 Tunnel vision
 Limits imposed by fatigue or other physiological factors
 Poor group dynamics
 Cultural influences
 Organizational
 Professional
 National

IATA CRM: TEM 161

 Error Avoidance

Threat

Crew Error
Team Climate
Planning

Undesired Aircraft
State

Incident

IATA CRM: TEM 162

 Threat Management

Manage operational complexity, which translates

into threat management.
 Team climate behaviours such as active
leadership and establishing a team environment
 planning
 Review and modify countermeasures which
include evaluation of plans, inquiry and
assertiveness

IATA CRM: TEM 163

 Error Avoidance

Threat

Threat Management

Crew Error
Team Climate, Planning
Review /Modify

Undesired Aircraft
State

Incident

IATA CRM: TEM 164

 Error Management

 Manage crew errors.

 Error is an inevitable result of human limitations such
as fatigue and other physiological factors, limited
memory and processing capacity, external stressors,
poor group dynamics and cultural influences
 Task execution behaviours such as monitoring and
workload management are central to error
management

IATA CRM: TEM 165

 Error Avoidance

Threat

Threat Management

Crew Error

Error Management

Team Climate
Undesired Aircraft
Execution
State

Incident

IATA CRM: TEM 166

 Undesired Aircraft State Management

 Manage aircraft deviations, wrong

configurations, speed etc.
 Review and modify countermeasures which
include evaluation of plans, inquiry and
assertiveness

IATA CRM: TEM 167

 Error Avoidance

Threat

Threat Management

Crew Error

Error Management

Undesired Aircraft
State
Undesired Aircraft
State
Management
Team Climate
Incident Review / Modify

IATA CRM: TEM 168

 Error Avoidance

Threat

Threat Management

Crew Error

Error Management

Undesired Aircraft
State
Undesired Aircraft
Threat and Error State
Management
Management Model
Incident

IATA CRM: TEM 169

 Error Avoidance

Threat

Threat Management

Crew Error

Error Management

Undesired Aircraft
State
Undesired Aircraft
Threat and Error State
Management
Management Model
Incident

IATA CRM: TEM 170

 AA 1420

IATA CRM: TEM 171

Safety Management
Systems
Module 7
 Our Job is to fly
from point “A” to
point “B” safely
and efficiently.

IATA CRM: TEM 173

 Productivity

 Errors cost money

 Find out where mistakes are being made
and adjust resources
 Better use of training

IATA CRM: TEM 174

 Expose Yourself!!!

How can management better understand what

is happening on the line?
 By fostering a culture where crews can
confess honest mistakes without fearing
reprisal
 Using your own incidents for training

IATA CRM: TEM 175

 Management’s Role
 establish trust, which includes

a commitment to reduce
error-inducing conditions.

 adopt a non-punitive
policy toward error

 provide training

 collect ongoing data?

IATA CRM: TEM 176
 Feedback

 Need a process to identify and feedback

threat and error information, not only from the
crew but from the other safety barriers

IATA CRM: TEM 177

 Error Avoidance

Threat

Threat Management

Crew Error

Error Management

Undesired Aircraft
State
Undesired Aircraft
Threat and Error State
Management
Management Model
Incident

IATA CRM: TEM 178

 How does TEM fit into a
Safety Management System?

 TEM supports SMS by bringing in hard data

 Linkage between Safety and CRM /TEM
 Safety change process
 TEM can be used for a focus group at an airline

IATA CRM: TEM 179

 TEM at the Organizational
level

 Recognize dangers of threat and error

 Provide training in threat and error
management
 Understand limitations of crew
 Collect data - LOSA and Latent threats
 Mistakes will be made, reward crew for
pointing it out and correcting it

IATA CRM: TEM 180

 Data Collection
Company, industry and regulating authorities get
information of the “real” problems that line
pilots face
Cannot prevent the creation of latent threats but
make their adverse consequence visible to
those who manage and operate the system

IATA CRM: TEM 181

 More Realistic Training

 Focus on Threat and Error Recognition

 Provide countermeasure skills to crews
 Feedback-help management understand
line operation

IATA CRM: TEM 182

 Tools to Improve Safety
 SOP’s and Checklists
- strategies put forth by the company

 Training - Technical proficiency

- Countermeasure (CRM) skills

 TEM model as an analytical tool of incidents

IATA CRM: TEM 183

 Line Orientated Safety Audit LOSA

 Safety data acquisition tool

 Non-jeopardy, jumpseat observations of flight
crews during regularly scheduled flights
 Provides feedback of threat and error on the
line

IATA CRM: TEM 184