1. What Crews Do: Context and Concepts of Threat and Error Management (TEM)
Robert L. Helmreich, Ph.D. FRAes
The University of Texas
Human Factors Research Project
LOSA WEEK
Kuala Lumpur
September 13, 2005

2. Goals Define threat and error management concepts
Demonstrate threat and error findings from Line Operations Safety Audits (LOSA)
Clarify relationship between CRM and TEM
Place threat and error management in the context of flight operations

3. Threat, Error, and Undesired Aircraft State
Definitions

4. Threat
Event or error that occurs outside the influence of the flight crew, but which requires crew attention and management if safety margins are to be maintained. Mismanaged Threat: A threat that is linked to or induces flight crew error. 

5. Types of Threats Observable Threats
Known
Hurricane
Unexpected
Engine failure on take off
Latent Threats – factors residing in the system, organization or individual that increase risk.
Latent threats are not directly observable at the ‘sharp end’ of operations. Usually uncovered by analysis of aggregate data such as confidential incident reports
Equipment design issues
Optical illusions
Air traffic system design
Training philosophy and practices
Organizational culture (positive or negative)

6. Error
Action or inaction that leads to a deviation from crew or organizational intentions or expectations

7. Communications

8. Crew-linked Undesired Aircraft State
An aircraft deviation or incorrect configuration associated with a clear reduction in safety margins

9. Undesired Aircraft States
Position wrong
Speed wrong
Heading wrong
Configuration wrong

10. Threat and Error Management is the Conceptual Framework for LOSA

11. Some Representative Data from 4,800 flights

12. Carving the data Data can be examined in several ways
% of all threats or errors of a particular type
% of all flights with a specific threat or error
Average number of threats or errors encountered

13. Variability of threat Range of threats/flight: 0 - 19
Average number of threats/flight: 3.7

14. Sources of Threat
2/3 of threats are environmental (wx, airport conditions, ATC, terrain)
43% of environmental threats occur during descent/approach/landing
1/3 are airline (ground, ramp, dispatch, cabin, operational pressure, mx)
75% of airline threats occur during pre-departure

15. The Top Three Threats
54% of all flights encountered one or more weather threats
54% faced one or more ATC threats
32% had aircraft malfunction/MEL threats with operational implications

16. 29% of flights had a threat that was mismanaged and led to some form of crew error

17. Mismanaged Threats Challenging clearance from ATC
Thunderstorms with turbulence/icing
Aircraft malfunction unexpected by crew
MEL item with operational implications
Operational time pressure
15% of all mismanaged threats
9% of all mismanaged threats
6% of all mismanaged threats
5% of all mismanaged threats

18. ATC Threats by Phase of Flight
50% of ATC threats during descent/approach/landing
22% pre-departure
15% during takeoff
9% during cruise
50% of mismanaged ATC threats occur during descent/approach/landing

19. Variability of Error Range of errors per flight: 0 - 24
Average number of errors per flight: 2.6

20. Errors & Undesired Aircraft States
75% of flights had 1 or more errors
35% of flights had a mismanaged error
3% of flights had additional error
32% of flights had an undesired aircraft state (UAS)
6% of flights had a mismanaged UAS

21. Type of Error Handling errors – 36% of all errors
Most common – unintentional speed deviation
Procedural errors – 52% of all errors
Most common – checklist from memory
Communications errors – 12% of all errors
Most common – missed ATC call

22. Most Common Errors
25% of all flights had manual handling/flight control errors
23% had automation errors
21% had checklist errors
20% had SOP cross-verification errors

23. When Crews Err: % of Errors by Phase of Flight
Pre-departure/taxi %
Take-off %
Cruise %
Descent/approach/landing 42%
Taxi in %

24. Other Applications of TEM

25. Using TEM Conceptual framework for flight crew training
Template for assessing threats during line checks
Basis for accident and incident analysis

26. TEM and CRM: Bob’s Error
In describing the evolution of CRM from its roots in executive management training to its current focus on cockpit behaviors, the sixth generation was described as ‘threat and error management’
Some airlines substituted TEM for CRM in training

27. Human Factors/CRM + TEM
CRM provides countermeasures against threat and error as well as supporting basic aspects of effective teamwork and leadership
TEM serves as a critical component of Human Factors/CRM training
CRM is not forever
Awareness and acceptance decay and need refresher reinforcement

28. Threat and Error Countermeasures: CRM 101
Planning
Share plan
Develop contingencies
Execution
Monitor and cross-check
Manage workload
Manage automation
Review
Inquire
Modify course of action

29. The Context of Threat and Error Management
TEM is an essential component of flight
It is influenced by system factors, the culture and characteristics of an organization, and its pilots

31. Conclusion
Threat and Error Management is a useful organizing concept for classification and understanding of crew performance in normal operations
TEM helps organizations to integrate data from different sources such as maintenance, dispatch, pilot reports, etc.

32. The University of Texas
Human Factors Research Project