Threat and Error Management,Threat and Error Management,Line Operations Safety AuditLine Operations Safety Audit

y y Normal Operations Safety Survey:Normal Operations Safety Survey:

La perspectiva de la OACILa perspectiva de la OACI

Capt. Daniel MaurinoCapt. Daniel MaurinoFactores Humanos y Seguridad de Vuelo Factores Humanos y Seguridad de Vuelo –– OACIOACIConferencia ASPA/OACI sobre TEM/LOSA/NOSS Conferencia ASPA/OACI sobre TEM/LOSA/NOSS

Ciudad de MCiudad de Mééxico, 25 xico, 25 –– 26 de marzo del 200826 de marzo del 2008

SMS SMS –– A Tool BoxA Tool Box

Operational performance

Operational performance

OperationalOperationaldeploymentdeployment

System System designdesign

Baseline performanceBaseline performance

Operationaldrift

Learning from Failure & SuccessLearning from Failure & Success

Capturing the DriftCapturing the DriftReactive systems Reactive systems

Accident investigationAccident investigationIncident investigationIncident investigation

PredictivePredictive systemssystemsElectronic safety data Electronic safety data acquisition systems acquisition systems Direct observation safety Direct observation safety data acquisition systems data acquisition systems Proactive systemsProactive systems

Mandatory reporting Mandatory reporting systems systems VoluntaryVoluntary selfself--reportingreportingsystemssystemsConfidential reporting Confidential reporting systems systems

LOSA & NOSSLOSA & NOSS

Safety Data Systems and Levels of Intervention Safety Data Systems and Levels of Intervention

Baseline performanceBaseline performance

“Practicaldrift”

Operational performance

Operational performance organization

Predictive Proactive Reactive

Highly efficient Very efficient Efficient

Safety management levelsSafety management levels

Reactive

Desirable managementDesirable managementlevel level

Insufficient

ASRASRSurveysSurveysAuditsAudits

ASRASRMORMOR

AccidentAccidentand incidentand incident

reportsreports

HHii gghh MMiiddddllee LLooww

HazardsHazards

FDAFDADirectDirect

observationobservationsystemssystems

TEM, LOSA & NOSS TEM, LOSA & NOSS –– Similar is Similar is notnot the Samethe Same

HazardsHazards in operational contexts in operational contexts –– ThreatsThreatsPotential consequence (s)Potential consequence (s) of the hazards in of the hazards in operational contextsoperational contexts–– Operational ErrorsOperational ErrorsSafety risk (s)Safety risk (s) of the potential consequence (s) of the of the potential consequence (s) of the hazards in operational contexts hazards in operational contexts –– Undesired StatesUndesired States

TEM TEM = Framework = Framework –– What What we look forwe look for

LOSA & NOSSLOSA & NOSS = Tools = Tools –– HowHow we collect what we look forwe collect what we look for

Not Not flight crew/ATCO errorsflight crew/ATCO errorsNotNot [necessarily][necessarily] deficiencies in the systemdeficiencies in the systemErrors by third partiesErrors by third parties [external errors][external errors] are are classified as threats to the focus group classified as threats to the focus group

Must be managed by the flight crew/ATCO Must be managed by the flight crew/ATCO to maintain existing margins of safetyto maintain existing margins of safety

ThreatsThreatsEvents or errors that occur Events or errors that occur beyond the influencebeyond the influence of the flight of the flight crew/ATCO, crew/ATCO, increase operational complexityincrease operational complexity, and which must , and which must be be managedmanaged to maintain the margins of safetyto maintain the margins of safety

Threats Threats –– Flight DeckFlight Deck

WeatherWeatherMaintenanceMaintenanceerrorserrors

GroundGround crewcrewerrorserrors

Cabin crewCabin crewerrorserrors

PassengerPassenger eventsevents ATCATC errorserrors

TerrainTerrain

SimilarSimilar callcall signssigns

Time pressuresTime pressures

Heavy trafficHeavy traffic

Unfamiliar airportsUnfamiliar airports

Automation eventsAutomation events MissedMissed approachesapproaches

Flight Flight diversionsdiversions

System System malfunctionsmalfunctions

DistractionsDistractions

Threats Threats –– ATCATC

Similar call signs

Reduced separationminima

Airspace restrictionsRunway crossings

System malfunctions

Missed approaches

Communication failure

Runway inspections

LAHSO

Noise restrictions

Weather

SIRO

Heavy trafficAirspacereclassification

Flight crew errors

Maintenanceerrors

ErrorsErrors

Equipment handling errorsEquipment handling errors –– incorrect interactions with the incorrect interactions with the equipmentequipmente.g. selecting an inappropriate radar source; making e.g. selecting an inappropriate radar source; making

incorrect inputs to an automated systemincorrect inputs to an automated systemProceduralProcedural errors errors –– deficiencies in execution deficiencies in execution e.g. wrong separation minima applied; leaving the e.g. wrong separation minima applied; leaving the

position before replacement is ready to take overposition before replacement is ready to take overCommunicationCommunication errorserrors –– deficiencies in the exchange of deficiencies in the exchange of operational informationoperational informatione.g. missed calls; misinterpretation of a requeste.g. missed calls; misinterpretation of a request

Actions or inactions by the Flight Crew/ATCO that lead to Actions or inactions by the Flight Crew/ATCO that lead to deviations deviations from organizational or Flight Crew/ATCO from organizational or Flight Crew/ATCO expectationsexpectations

Errors Errors –– Flight CrewFlight Crew

Handling errorsHandling errors –– deficiencies in stick and rudder skillsdeficiencies in stick and rudder skillse.g. inability to maintain proper speed/configuration e.g. inability to maintain proper speed/configuration

during ILS approachduring ILS approachProceduralProcedural errors errors –– deficiencies in execution deficiencies in execution e.g. correctly selecting an incorrect altitude in the altitude e.g. correctly selecting an incorrect altitude in the altitude

alerteralerterCommunicationCommunication errorserrors –– deficiencies in the exchange of deficiencies in the exchange of operational informationoperational informatione.g. misunderstanding an altitude clearancee.g. misunderstanding an altitude clearance

Undesired Aircraft StatesUndesired Aircraft States

Lateral deviationLateral deviationVertical deviationVertical deviationSpeed too high Speed too high Speed too lowSpeed too lowIncorrect aircraft Incorrect aircraft configurationconfigurationUnstable approachUnstable approach……

Flight crew inducedFlight crew induced aircraft states where risk is aircraft states where risk is increased and existing safety margins are reducedincreased and existing safety margins are reduced

OutcomesOutcomesReportable eventsReportable eventsIncidentsIncidentsAccidentsAccidents

Undesired StatesUndesired States

Aircraft climbing to a Aircraft climbing to a wrong altitudewrong altitudeAircraft turning in the Aircraft turning in the wrong directionwrong directionAircraft enters a Aircraft enters a wrong taxiway wrong taxiway Aircraft missing a Aircraft missing a crossing restriction crossing restriction ……

Operational conditions where an Operational conditions where an unintended traffic unintended traffic situationsituation results in a reduction of safety marginsresults in a reduction of safety margins

OutcomesOutcomesReportable eventsReportable eventsIncidentsIncidentsAccidentsAccidents

As of 23 November 2006As of 23 November 2006

Annex 1 Annex 1 –– Personnel LicensingPersonnel LicensingTEM training TEM training –– Licensing requirement for all pilot Licensing requirement for all pilot and ATCO licenses (Standard)and ATCO licenses (Standard)

Annex 6 Annex 6 –– Operation of AircraftOperation of AircraftTEM training TEM training –– requirement for flight crew training, requirement for flight crew training, initial and recurrent (Standard)initial and recurrent (Standard)

Annex 6, Annex 11 & Annex 14 Annex 6, Annex 11 & Annex 14 Safety management requirementsSafety management requirements

The ICAO SMS course (The ICAO SMS course (www.icao.int/anb/safetymanagementwww.icao.int/anb/safetymanagement))ICAO Safety Management Manual ICAO Safety Management Manual (Doc 9859)(Doc 9859)TEM, LOSA & NOSSTEM, LOSA & NOSS