An Introduction to

Threat and Error Management

What we will look at

What is Threat and Error Management

Its not
Rocket
Science

17

Assumptions of Human Factors Training

Humans have limitations
in their performance

Error is inevitable
5

To err is human

Threats in the Operational Environment

What is a Threat

An indication of something coming; a menace or likely cause of harm

TEM Definition: An event or error that occurs outside the influence of the
controller, but which requires his or her attention and management if safety
margins are to be maintained

Threats

Threat

Error

Threat
9

Threats (Aerodrome Environment)

Distractions

Runway crossings

Visitors
Weather
Maintenance
Restricted
Airspace
Heavy traffic

Comsfailure/
sticking mic
Shift
handovers

d rs
n
a
e
l
l
s
t
o
r
o
l
t
i
n
P Co
r
e
h
t
O

Unfamiliar pilots
Automation events

Missed approaches

Similar call signs

Non-standard local
procedures
Runway
inspections
System
malfunctions

Methods to Identify Threats

Just because you
deal with a
situation every
day doesnt mean
that its not a
Threat

13

Methods to Identify Threats

Just because you
deal with a
situation every
day doesnt mean
that its not a
Threat

13

TEM Methodology

Threats
Errors
Undesired
States

Methods to Assess a Threats Impact

Threat= Incorrect readback

(pilot)

Threat Management=Nil

Error= Hearback Error (ATC)

Error Management= Nil

U/S= Aircraft climbing/

descending to altitude other
than expected

U/S Management= Nil

Outcome= Loss of
separation / Air Safety
Incident
15

Barriers to Monitoring Threats

Distractions
Interruptions

DIPs

Preoccupations
DIPs should always trigger a red flag
16

Method to Monitor Threats

Strategies to Reduce DIPs

Recognize conversation is a powerful distracter

Recognize heads-down work greatly reduces your

ability to monitor
Minimize conflicts between tasks
Avoid focusing on a single task for too long
Assign responsibility
Treat DIPs as RED FLAGS

Understand the difference between

Error Management
versus

Error Avoidance

What is an Error
An action or inaction that leads
to deviation from ones intention
or procedural requirements.

What is an Error
An action or inaction that leads
to deviation from ones intention
or procedural requirements.

Types of Errors

Errors and
and Violations
Violations
Errors

ER ORS

VIOLATIONS

You make an error when your

action deviates from your
intention, or when your intention
is inappropriate

An error is not intentional

The effect of errors can be

accounted for within the system

You commit a violation when you

intentionally deviate from a regulation
or from a procedure

A violation is originally intentional but

can become routine

Threat
Threat Prevalence
Prevalence
100%
100%ofofobservations
observationshad
hadatat
least
leastone
onethreat
threat
Total
Total363
363threats
threatsobserved
observed

Threat
ThreatManagement
Management

Threats
Threats--Undesired
Undesired State
State Linkage
Linkage

82%
82%ofof362
362threats
threatswere
wereeffectively
effectivelymanaged
managed
18%
18%were
weremismanaged
mismanaged
Total
Total65
65threats
threatsmismanaged
mismanaged

7%
7%ofofthreats
threatswere
werelinked
linkedtotoundesired
undesiredstates
states
63%
63%ofof40
40undesired
undesiredstates
stateswere
werelinked
linkedtotothreats
threats

41% Airborne
Threat
Threatto
to Error
ErrorLinkage
Linkage
Total
Total63
63observations
observations

44%
44%ofof165
165errors
errorswere
werelinked
linkedtoto
mismanaged
mismanagedthreat
threat
56%
56%ofoferrors
errorswere
werenot
not

-Readback errors
-Failure
to respond
67%of errors went
undetected
or were
-Parachuting
near
BDY
ignored
35% ANSP

-Distractions,conversation
-Incorrect co-ordination

23% Environmental -WX deviations

-Low / poor visibility
Error
Error Prevalence
Prevalence
81%
81%ofofobservations
observationshad
hadatatleast
least
one
oneerror
error
19%
19%were
wereerror
errorfree
free
Total
Total165
165errors
errorswere
wereobserved
observed

Error
ErrorManagement
Management
76%
76%ofof165
165errors
errorshad
hadinconsequential
inconsequential
outcomes
outcomes
22%
22%led
ledtotoan
anundesired
undesiredstate
state
2%
2%led
ledtotoadditional
additionalerror
error
Total
Total40
40errors
errorsmismanaged
mismanaged

Overall R/T comms produced the most

threats and occurred on 70% of Obs
Detected
Detected Error
ErrorOutcomes
Outcomes
74%
74%ofoferrors
errorsthat
thatwere
weredetected
detectedwere
were
inconsequential
inconsequential
22%
22%were
werelinked
linkedtotoundesired
undesiredstates
states
4%
4%were
werelinked
linkedtotoadditional
additionalerror
error

Error
Error Response
Response
13%
13%ofof165
165errors
errorswere
weredetected
detected
by
the
observed
controller
by the observed controller
20%
20%were
weredetected
detectedby
byanother
another
party
party
67%
67%went
wentundetected
undetectedor
orwere
were
ignored
ignored

Undetected
Undetected Error
ErrorOutcomes
Outcomes
76%
76%ofoferrors
errorsthat
thatwere
weredetected
detectedwere
were
inconsequential
inconsequential
22%
22%were
werelinked
linkedtotoundesired
undesiredstates
states
2%
2%were
werelinked
linkedtotoadditional
additionalerror
error

Undesired
UndesiredState
State
Prevalence
Prevalence
and
andManagement
Management
45%
45%ofofobservations
observationshad
hadUS
US
Total
Total40
40USs
USs
100%
100%ofof40
40US
USwere
were
inconsequential
inconsequential

2008 NOSS Findings

Threat Indexes

Sectors
AA

WN

CH

OH

BAY/RAN

NAK/KAI/STH

17%

14%

14%

13%

18%

24%

22%

13%

14%

12%

17%

22%

3.3

2.5

2.7

2.4

2.5

2.4

1.7

1.6

1.6

1.1

1.3

1.2

0.9

0.4

0.6

0.7

0.5

0.6

0.7

0.5

0.5

0.6

0.7

0.6

16%

15%

23%

29%

22%

16%

Percentage of all (140)

NOSS Observations
Percentage of Airborne
threats accounted for by
each Sector Group
Number of Airborne threats
per observation
R/T Communication threats
per observation
Pilot/Aircraft Performance
threats per observation
Traffic
threats
per
observation
Percentage of Airborne
threats
that
were
consequential
Number of consequential
Airborne
threats
per
observation
Most frequent Airborne
threat

0.54

0.36

0.63

0.72

0.54

0.38

Incomplete
readback

Incomplete
readback

Incomplete
readback

Pilot failure to
respond to call

Pilot failure to
respond to call

Next most frequent Airborne

threat

Pilot failure to
respond to call

Incorrect
readback

Pilot failure to
respond to call

Incomplete
readback
Training flight
or flight crew
failure to
report

Parachute
activity

Parachute
activity

Number of standard pilot

requests per observation

3.4

4.3

3.7

6.7

6.1

2.7

The TEM Partnership

Summing it all up