1. 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

2. 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)

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. 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…

9. 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

10. 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

11. Threats – ITA

12. Environmental Threats – ITA

13. Airline Threats – ITA

14. Flight Crew Errors – ITA

15. 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

16. 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

17. 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.”

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