TEM & LOSA: The State of Affairs Captain Dan Maurino Flight Safety and Human Factors – ICAO Third IATA/ICAO LOSA/TEM Conference Kuala Lumpur, Malaysia 13 – 14 September 2005 1 1 1

The Big Safety Data Picture Forensic systems – Failures Accident investigation Major incident investigation Proactive systems – Routine operational events Electronic safety data acquisition systems (FOQA) Voluntary self-reporting systems (ASAP) Direct observation safety data acquisition systems (LOSA & NOSS) Reactive systems – Anomalies Mandatory reporting systems (CAA’s) Voluntary reporting systems (ASRS/BASIS)

LOSA [NOSS] & TEM: Clarifying a Relationship TEM = Framework – What we look for The features in operational context – Threats What people do – Errors The results of the features in operational context and of what people do – Undesired states LOSA [NOSS] =Tool(s) – How we collect what we look for The Ten Operating Characteristics

TEM Framework – Expanding Role Monitoring normal operations (LOSA & NOSS) Training – Flight & Cabin Crew/ATCO (ICAO, IATA, Airlines and ATS providers) Safety management data analysis Integrated Threat Analysis (ITA) – ICAO & IATA Cabin Operations Safety Toolkit (Turbulence & inadvertent slide deployment) – IATA Research and development (UT & Boeing) Rule-making – ICAO provisions This is our introduction to the RED FLAG concept. It is important to build recognition here. Many more Red Flags will be shown in the discussion of AA1420. Also important to note here that, as the slide states, “a threat does not equal an error”. It only allows for the potential to commit an error. However, a threat should be perceived as a Red Flag to the crew, and even talked about amongst themselves as such. Take one of the threats previously listed by the group and use as an example of how the threat could have become an error or not an error.

FCLT/P – State Letter AN 12/1.1-05/62 Annex 1 – Personnel Licensing Knowledge requirements Human performance including principles of threat and error management Operational procedures – Application of threat and error management to operational performance Skills requirements Recognize and manage threats and errors

FCLT/P – Multi-Crew Pilot License (MPL) Competency units, competency elements and performance criteria 1) apply threat and error management (TEM) principles; 2) perform aeroplane ground operations; 3) perform take-off; 4) perform climb; 5) perform cruise 6) perform descent; 7) perform approach; 8) perform landing; and 9) perform after landing and aeroplane post-flight operations. Note .— The application of threat and error management principles is a specific competency unit that is to be integrated with each of the other competency units for training and testing purposes.

FCLT/P – MPL Competency Unit 2 – Perform aeroplane ground operations Competency element: Line up checks completed ATC call to give clearance interrupts checklist (threat) Crew skips pitot heat checklist item (error) Aircraft is lined up for take off roll with pitot heat off (undesired aircraft state) Performance criteria: Example TEM countermeasures Keep finger in checklist item until check list is re-started Start checklist all over again after clearance read back Request ATC to hold clearance until checklist completed

FCLT/P – Annex 6, Operation of Aircraft Chapter 9. Aeroplane Flight Crew 9.3 Flight crew member training programmes 9.3.1 An operator shall establish and maintain a ground and flight training programme, approved by the State of the operator…The training programme shall also include…training in knowledge and skills related to human performance and threat and error management…The training programme shall be given on a recurrent basis…

Aligned Safety Management Provisions Annex 6 – Operation of Aircraft, Parts I and III Annex 11 – Air Traffic Services Annex 14 – Aerodromes A basic safety management “template” Two basic concepts Safety programme – States Safety management system – Operators The ICAO Safety Management Manual (Doc xxxx) LOSA NOSS

TEM – Aggregate Safety Analysis Accidents ADREP Incidents STEADES Normal Ops Archie Integrated Threat Analysis (ITA) – A Joint ICAO/IATA Project Case study: TEM analysis – Runway excursions 34 ADREP narratives 36 STEADES narratives The “bridge” between ADREP/STEADES & Archie: UAS Long landings Floated landings Off centre-line landings 164 LOSA narratives

Threats – ITA

Environmental Threats – ITA

Airline Threats – ITA

Flight Crew Errors – ITA

Safety Management: Data, not Opinion Threat Scenarios – ITA ATC Weather (heavy rain,TS, wind gusts, tailwind) Operational pressure A/C malfunctions, RTO Night operations Proficiency and procedural issues Threat scenarios – Accidents & incidents Weather (heavy rain, TS, wind gusts, tailwind) A/C malfunctions, RTO Night operations Proficiency issues

Clearing the Air – LOSA Is not the same as IATA’s IOSA Is not the same as Airbus’ LOAS Is not the same as the JAA’s NOTECHS Is not an evaluation of CRM Is not the sixth generation CRM Is not a research tool Is not culturally incompatible LOSA [NOSS] is a safety management data collection tool[s] that generates safety management data otherwise not available

Clearing the Air (II) – TEM & CRM “…TEM is an overarching safety concept with multiple applications in aviation; while CRM is exclusively a training intervention. The basic concepts underlying TEM (threats, errors and undesired aircraft states) can be integrated – for example as an additional module – within existing CRM programmes. This is because TEM countermeasures build in part – although not exclusively – upon CRM skills. The combination of TEM concepts with CRM skills thus introduces the opportunity to present the utilization of CRM skills by flight crews anchored in the operational environment, from an operational perspective. It is emphasized that TEM training does not replace CRM training, but rather complements and enhances it.”

TEM & LOSA – Safety Management Tools Voluntary Reporting FDA Direct observations