ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005 Threat and Error Management Training for Air Traffic Control Officers Greg Down

Presentation Overview Background Overview of TEM Training Benefits Review

NAV CANADA TEM Background In 2001, visited Continental Airlines and University of Texas to research the application of TEM in ATS Participated in Continental’s TEM Training and experienced first hand the impact and value of this training

Continental Airlines TEM Training A consistent and operationally focused perspective on Threats and Errors in the operational environment TEM was (and still is) consistently applied throughout the organisation: Training (Initial and Recurrent) Simulator ‘Checks’ Auditing (FOQA & LOSA) Dispatch, Ramp Use of data-driven information made great impact on pilots (B777 captain & newspaper)

NAV CANADA TEM Training Delivered in 2001 to all operational staff (ATCOs and FSSs) and Line Management Included FAA Video “Collision Course” Opportunity to discuss experiences through the TEM “lens” Well received by staff and management

TEM Training Overview What is the TEM Framework? What is a Threat? What is an Error? What is an Undesired State? Strategies for Managing Threats and Errors

What is the TEM Framework? A safety management framework: to enhance aviation safety and efficiency through an operationally relevant and highly intuitive framework to better understand and manage system and human performance in operational contexts

TEM Framework Threats Threat Management Errors Errors Undesired States Error Management Undesired States Show and discuss model Can use your own pre-drawn if you want. Can show OAK departure video clip Note: Reword tower clearance to “Change departure to the Oakland 5” (So clip will work!) Can talk about it as a Umbrella or shield. Use an example or story to show how this works (How we saw people use it) Undesired State Management Outcome

What is a Threat? Events or conditions which occur: beyond the influence of the air traffic controller; increase a situation’s complexity; and must be managed to maintain the margins of safety.

“It’s a Beautiful Day in the Neighbourhood…” The Ideal Shift Overstaffed All aircraft on radar All systems operational Beautiful VFR Weather Happy, supportive supervisor Pilots are attentive and responsive Co-workers are pleasant and supportive

“It’s a Beautiful Day in the Neighbourhood…” A More Typical Shift Short staffed Non-radar aircraft Maintenance on critical systems IFR / Marginal VFR Weather Not-so-supportive supervisor Pilots - slow to respond to instructions Co-workers - demanding and create workload

Threats (Aerodrome Environment) Distractions Runway crossings Comm. failure/ stuck mike Visitors Shift change Weather Similar call signs Maintenance Non-standard procedures Airspace restrictions Runway inspections Heavy traffic System malfunctions Unfamiliar crews Automation events Missed approaches

Threats (Radar Environment) Distractions Military activities Comm. failure/ ‘Stuck’ mike Visitors Shift change Weather Maintenance Similar call signs Non-standard local procedures Airspace restrictions Heavy traffic Diversions Co-ordination other sectors System malfunctions Automation events Differing equipment

What is a Threat? Threat Error Threat

What is Threat Management? The process of detecting and responding to threats with countermeasures to maintain safety margins.

Tools to Teach About Threats Discussion of Common Threats Promote use of the phrase “RED FLAGS” “DIPs” – Distractions Interruptions Preoccupations

What does Error mean in TEM? Actions or inactions by air traffic controllers that lead to deviations from organizational or air traffic controller intentions or expectations.

Examples of Error Incomplete Briefing Full Readback Not Obtained Wrong Call Sign Used Non-Standard Phraseology Incorrect information passed

What is Error Management? The process of detecting and responding to errors with countermeasures that mitigate the probability and / or severity of further errors or undesired states.

What about Error Prevention or Error Avoidance? We cannot PREVENT all errors Nor can we AVOID all errors We can MANAGE errors

Managing Errors Follow procedures Use proper phraseology Continuously monitor traffic Clarify / challenge inconsistencies

What is an Undesired State? Operational conditions where an unintended traffic situation results in a reduction in margins of safety. ‘Transitional’ safety phase between normal operations and an outcome Indicator that earlier Threats and / or Errors were not adequately managed

Undesired State Examples Aircraft climbing / descending to altitude beyond its clearance Aircraft deviating from assigned heading / track / route Incomplete coordination Inaccurate flight info on the radar screen Not using appropriate indicators when crossing vehicles across an active runway

Undesired States are NOT ‘Outcomes’? an Outcome is an ‘end state’ Incident Operational Error Operating Irregularity Accident Once an Outcome has occurred, normal operations cannot be recovered Undesired States can be effectively managed and normal operations regained

Goals of TEM Discover, assess and manage threats Enhance the detection and management of error Improve resistance to errors Diagnose factors that may create threats and errors

TEM Framework Threats Threat Management Errors Errors Undesired States Error Management Undesired States Show and discuss model Can use your own pre-drawn if you want. Can show OAK departure video clip Note: Reword tower clearance to “Change departure to the Oakland 5” (So clip will work!) Can talk about it as a Umbrella or shield. Use an example or story to show how this works (How we saw people use it) Undesired State Management Outcome

Strategies to Improve Safety Margins Identify ‘Threats’ in Operation and reduce or eliminate before they lead to error or consequence Promote use of ‘common language’ to focus attention on safety issues (RED FLAGS) Make errors ‘visible’ so that they can be easily identified and managed

Strategies to Improve Safety Margins Make it ‘safe’ to report errors (‘just / error tolerant’ culture) Treat errors as a feedback mechanism for learning and continuous improvement Errors are EXPECTED and WILL occur. HOW they are MANAGED is what is important

Challenges to TEM Training Tendency to focus to be on Errors rather than Threats Can devolve into a debate over Risk vs. Hazard vs. Threat contextual meanings if not managed Can appear overly simplistic to those who are accustomed to more elaborate frameworks

Benefits Of TEM Training TEM is intuitive Gives structure to what controllers already do on a daily basis Simple, robust operational ‘Lens’ to view the operational environment Identifies external factors that impact the operation ‘See’ factors that effect safety in a new way ‘Common language’ Can facilitate rapid identification and communication of factors that could impact operations (Red Flags)

Benefits Of TEM Training Consistent with Safety Management Systems Can be deployed independently or to reinforce existing SMSs Promotes movement toward ‘Just Culture’ improved reporting of safety concerns through focus on external factors rather than individuals Creates foundation for improved safety data collection programs such as NOSS Illuminates that ATCOs are effective Threat Managers

Presentation Review Background Overview of TEM Training Benefits

TEM Promotes an Effective Safety Culture An organization’s safety culture can be defined by the extent to which it is: Informed Wary Just Flexible Learning 33

ICAO Global TEM & NOSS Symposium EUROCONTROL IANS Luxembourg November 9, 2005 Threat and Error Management Training for Air Traffic Control Officers Greg Down