1. The University of Texas at Austin Threat and Error Management Model Robert Helmreich Capt. Bruce Tesmer University of Texas Continental Airlines ATA CRM Conference Comair, Cincinnati September 21,1999

2. The University of Texas at Austin Applying TEMM to a ‘pilot error’ incident: Landing at the wrong airport

3. Aerospace Crew Research Project

5. The Flight Scenario nHouston to Corpus Christi second leg of the first day of a trip that began in Newark nCaptain was PF from Newark, FO to CRP nCaptain was highly experienced check airman conducting IOE nCRP ATIS “..good, 6,000 broken 10 miles, wind 010, 10kts. Expect loc app to Rwy 31.” nDescent started early expecting VORTAC vectors to Rwy 31 localizer. ….. On autopilot until intercepting final approach course nAfter CRP Vortac, App Cont. gives vectors to, and clearance for intercepting localizer and “Cleared Approach. Rwy 31 Localizer”

6. Aerospace Crew Research Project The Scenario – continued nTurning final, the Capt sees the airport and reports to tower “Runway in sight.” nCrew has slowed and configured early to allow time to reach landing configuration and be stable by 500’ AGL. They are surprised runway so close. nA normal landing was completed but runway shorter than expected. Landing completed with 500’ remaining nThere was no terminal, only hangers. Crew taxis off Rwy and realizes they are not at CRP nThe call Tower which knows they have landed at Cabaniss

7. External Threats Known Threats First day as crew IOE being given 1 st leg in 737-300 round dial, 2 nd in 737-500 EFIS 1 st EFIS leg for FO FO only exposure to EFIS in Level 5 device FO’s 1 st trip to CRP Capt had not been to CRP in 3 years & had never landed to North at CRP Unexpected Threats ATIS doesn’t mention 2000’ scattered cloud layer. Doesn’t warn about location of Cabaniss Field A/C on autopilot, has problem intercepting localizer Scattered 2,000’ cloud layer blocks fwd vision but allows ground contact for 5 miles External Error ATC had localizer set to Rwy 13 for previous A/C doing training

8. Aerospace Crew Research Project Crew Error Latent Systemic Threats Regulatory: Cabniss Field located 6nm on Corpus localizer Regulatory: no ATIS warning about Cabaniss on weekend Regulatory: chart depiction hard to read Regulatory: Cabaniss field layout looks like CRP Regulatory: MSAW warning for Cabniss disabled Regulatory: runway alignment (31) same as Corpus Navy: allows racing events except special days (Mothers’ Day) System: information on other near approaches to Cabaniss existed, but not available Organizational: no mention of Cabaniss on10-7 page in manual Professional: operational and professional pressure to make landing

9. Proficiency Crew lacked knowledge about Cabaniss location Fail to Respond Undesired State Additional Error Error Types Error Responses Error Outcomes

10. Procedural Crew briefed and were flying ILS approach, did not check DME to confirm FAF Fail to Respond Undesired State Additional Error Error Types Error Responses Error Outcomes

11. Decision Error Crew high & fast when lined up for Cabaniss but stable at 500’ chose riskier decision Fail to Respond Undesired State Approach tp wrong airport Error Types Error Responses Incident Undesired Aircraft State Outcomes Fail to Respond Error Outcomes

12. The University of Texas at Austin Threat and Error Totals

13. External Threats Expected Unknown External Error Threat Recognition and Error Avoidance Behaviors - System -- Organizational -- Professional Latent Systemic Threats Mitigate Exacerbate Fail to Respond Incident Additional ErrorRecovery Inconsequential Undesired Aircraft State Intentional Noncompliance -Procedural Communication Proficiency Operational Decision Fail to Respond Additional Error OutcomesExternalThreatsAction Error Actions Actions FinalOutcome

14. Aerospace Crew Research Project External Threats Expected - 6 Unknown - 3 External Error 1 Threat Recognition and Error Avoidance Behaviors - 2 System -- Organizational -- Professional 10 Latent Systemic Threats Mitigate Exacerbate 1 Fail to Respond 1 Incident Additional ErrorRecovery Inconsequential Undesired Aircraft State Intentional Noncompliance 1 -Procedural Communication 1 Proficiency 1- Operational Decision 3- Fail to Respond Additional Error OutcomesExternalThreatsAction Error Actions Actions FinalOutcome

15. Aerospace Crew Research Project Conclusion nA short flight with a highly competent captain became very complex because of numerous latent systemic threats nThese were compounded by external threat and error and crew errors nAny of a number of actions could have broken the incident sequence

16. Aerospace Crew Research Project About Latent Threats nLatent threats are highly variable. They can –exist for a long time –be based on tradition ‘We’ve always done it this way.’ –be associated with new technology –fail to appear as threats or seem to be based on good decisions –be difficult to resolve because corrective actions cross too many jurisdictions and no entity takes responsibility for corrective action –are often known by some but not communicated to others –frequently involve ‘local knowledge’ nLatent threats don’t show up in training

17. Aerospace Crew Research Project The Future nThe identification of Latent Systemic Threats is essential to safety nApplication of the model points to training needs and to latent threats that need to be modified nSafety, CRM, Training and Flight Ops need to coordinate to address threat and error management

18. The University of Texas at Austin CRM Countermeasures

19. Aerospace Crew Research Project CRM Countermeasures Possible nExternal Threat and error nMental models nMental model check nCockpit Communication error Situation was high threat but not fully recognized

20. Aerospace Crew Research Project Conclusions nCrew faced a variety of external threats and error nCrew recognized and managed several threats nLatent Systemic Threats played a critical role –They can be addressed in CRM if identified nCRM countermeasures were available for error management nMental models of ATC and Crew were understandable but led to misinterpretation of actions –A ‘Mental Model Check’ could have served as the critical countermeasure