intro to threat & error management welcome
TRANSCRIPT
Intro to Threat & Intro to Threat & Error ManagementError Management
Welcome
Accident Causal Factors Over Time
Human Causes
Machine Causes
Time
The Tip of the Iceberg
The Tip of the Iceberg
What is happening here?
What is CRM?
Effective use of all Effective use of all resources, to achieve the resources, to achieve the highest possible level of highest possible level of safety and efficiency. safety and efficiency.
(Transport Canada)(Transport Canada)
RESISTHARDWARE & SOFTWARE THAT
EXISTS BEFORE THE HUMAN ENTERS
RESOLVEWHAT THE HUMAN BRINGS TO THE SYSTEM
Continental Airlines
What’s a Threat?
Anything that Anything that increases increases
operational operational complexitycomplexity
Weather
MaintenanceMaintenance
Ground Crew
Cabin Crew
Passenger EventsPassenger EventsATC
Terrain
Similar Call Sign
Time Pressures
Heavy Traffic
Unfamiliar Airport
Automation EventAutomation Event
Missed Approach
Flight DiversionFlight Diversion
System MalfunctionSystem Malfunction
DistractionsDistractions
Example Threats
What’s the Threat?
ICAO
Northwest Airlines
UndesiredAircraft State
Trap:Managing Error
Avoid Error:Managing Threats
Threats
Layered System of Defenses
Undesired
Aircraft
State
TEM Toolkit
Case Study
What we did at NWA
What we did at NWA
Recurrent Training CBT
What we did at NWA
Instructor Briefing Guides
What we did at NWA
Briefing Room Posters
What we did at NWA
7-hole cards to all
5500 pilots
• Mailbox
• Briefing Rooms
• Jumpseat Handout
• Lounges
7-hole cards
Video Training & Scenario
What we did at NWA
Integrating Threat & Error Management
Flight StandardsLine checks to reinforce threat recognition, error avoidance and
management
Flight OperationsReview/revise SOPs and policies
SafetyError reporting system (ASAP) for dataSafety Programs (HF, FOQA)Ongoing QA Audits
TrainingThreat recognition & error avoidance and managementCaptain LeadershipFocus on technical and procedural excellence
More Info…
WATS
Thanks
Darren Smithwww.cfidarren.com
813-503-3322