Threat and error management перевод

From Wikipedia, the free encyclopedia

In aviation safety, threat and error management (TEM) is an overarching safety management approach that assumes that pilots will naturally make mistakes and encounter risky situations during flight operations. Rather than try to avoid these threats and errors, its primary focus is on teaching pilots to manage these issues so they do not impair safety. Its goal is to maintain safety margins by training pilots and flight crews to detect and respond to events that are likely to cause damage (threats) as well as mistakes that are most likely to be made (errors) during flight operations.^[1]

TEM allows crews to measure the complexities of a specific organization’s context — meaning that the threats and errors encountered by pilots will vary depending upon the type of flight operation — and record human performance in that context.^[2] TEM also considers technical (e.g. mechanical) and environmental issues, and incorporates strategies from Crew Resource Management to teach pilots to manage threats and errors.

The TEM framework was developed in 1994 by psychologists at University of Texas based on the investigation of accidents of high capacity Regular Public Transport (RPT) airlines.^[3] However, an evaluation method was needed to identify threats and errors during flight operations and to add information to existing TEM data.^[4][5] A Line Operations Safety Audit (LOSA) serves this purpose and involves the identification and collection of safety-related information — on crew performance, environmental conditions, and operational complexity — by a highly trained observer.^[5][6] LOSA data is used to assess the effectiveness of an organization’s training program and to find out how trained procedures are being implemented in day-to-day flights.

Importance of TEM[edit]

Threat and error management is an important element in the training of competent pilots that can effectively manage in-flight challenges.^[1][7] Many strategies have been developed (e.g. training, teamwork, reallocating workload) that were focused on improving on stress, fatigue, and error. Flight crew training stressed the importance of operational procedures and technical knowledge, with less emphasis placed on nontechnical skills, which became isolated from the real-world operational contexts.^[4] Safety training, including TEM, is important because a crew’s nontechnical (safety) knowledge helps more in managing errors effectively than crews’ familiarization with operations through experience.^[8] Candidates who are shortlisted during selection and training processes must demonstrate analytical and coordination capabilities.^[9] Possessing these nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.

Components of TEM[edit]

The following components are methods that help provide data for the TEM.

LOSA observation training[edit]

Training for LOSA experts includes two sessions: education in procedural protocols, and TEM concepts and classifications.^[10] A LOSA trainee is taught to find data first and then code them later for both sessions, during which a crew member must exhibit «LOSA Etiquette» — ability to notify the pilot as to why he or she was not able to detect an error or threat after a flight. The pilot’s responsibilities include his or her opinions on what safety issues could have had an adverse impact on their operations. A LOSA trainee must then record the specific responses of the pilot and thereafter code performance using behavioral markers. The order of the recording is as follows: a) record visible threats; b) identify error types, crew’s responses, and specific outcomes; and c) use CRM behavioral markers to rate crew.^[11]

Observers will finally record a pilot’s overall response on a 4-point Likert scale: 1) poor, 2) marginal, 3) good, and 4) outstanding. The data are then quantified and tabulated as exemplified by the following format:^[10]

Planning and execution of performance

Task	Task Description	Comments	Rating
Monitor cross-check	Active monitoring of crews	Situational awareness maintained	Outstanding
SOP briefing	Carried out necessary briefings	Thorough understanding of procedures
Contingency Management	Communicate strategies	Good management of threats and errors.

Identified Threats	Managed	Mismanaged	*Frequency (N)
Air Traffic Control	17	2	19
Airline Operational Pressure	9	0	9
Weather	6	6	12

Frequency is the total number of threats that occurred and is denoted by N.

Categories of the LOSA[edit]

LOSA identifies three main categories that must be recorded:

• Errors include procedural errors (mistakes or inadequacy of attention towards a task at hand), and violation of SOP (intentional or unintentional). Although crew members are encouraged not to be afraid of admitting their mistakes, they must be able to criticize themselves since the learning process helps them understand the potential danger presented other crew members.^[1]
• Undesired Aircraft States are aircraft configurations or circumstances that are caused either by human error or by external factors.^[10] The management of unintended states is vital since they can result in serious aircraft accidents. For example, navigation problems on the cockpit display may lead a pilot to make an incorrect decisions, potentially causing injuries or fatality to passengers and crew members alike.

Safety change process[edit]

Safety change process (SCP), which is part of LOSA, is a formal mechanism that airlines can use to identify active and latent threats to flight operations.^[12] It is a guideline that communicates in detail what is an imminent threat to current operations or who is causing the threat. In the past, SCP data were based on investigation of accidents or incidents, experiences, and intuitions but nowadays SCP focuses more on the precursors to accidents.^[12] There are several steps involved in conducting SCP:^[12]

Safety Change Process (SCP) model
1. Collect safety issues (LOSA expert) 2. Conduct detailed analysis of Risks/data 3. Identify improvement strategies 8. Revise any changes Safety Change Process 4. Risk Analysis 7. Observe the impact of changes 6. Apply changes to operations 5. Funding of changes

An unnamed airline conducted base-line observations from 1996 to 1998 using the defined SCP and LOSA data to improve its organization’s safety culture and the results were positive. The crew error-trapping rate was significantly increased to 55%, meaning that crews were able to detect about 55% of the errors they caused.^[12] A 40% reduction in errors related to checklist performance and a 62% reduction in unstabilized approaches (tailstrikes, controlled flight into terrain, runway excursions, etc.) were observed.^[12] A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.

See also[edit]

• Accident Classification
• Aviation safety
• Crew Resource Management
• Pilot Error
• Error Management
• The curse of expertise

References[edit]

From Wikipedia, the free encyclopedia

In aviation safety, threat and error management (TEM) is an overarching safety management approach that assumes that pilots will naturally make mistakes and encounter risky situations during flight operations. Rather than try to avoid these threats and errors, its primary focus is on teaching pilots to manage these issues so they do not impair safety. Its goal is to maintain safety margins by training pilots and flight crews to detect and respond to events that are likely to cause damage (threats) as well as mistakes that are most likely to be made (errors) during flight operations.^[1]

TEM allows crews to measure the complexities of a specific organization’s context — meaning that the threats and errors encountered by pilots will vary depending upon the type of flight operation — and record human performance in that context.^[2] TEM also considers technical (e.g. mechanical) and environmental issues, and incorporates strategies from Crew Resource Management to teach pilots to manage threats and errors.

The TEM framework was developed in 1994 by psychologists at University of Texas based on the investigation of accidents of high capacity Regular Public Transport (RPT) airlines.^[3] However, an evaluation method was needed to identify threats and errors during flight operations and to add information to existing TEM data.^[4][5] A Line Operations Safety Audit (LOSA) serves this purpose and involves the identification and collection of safety-related information — on crew performance, environmental conditions, and operational complexity — by a highly trained observer.^[5][6] LOSA data is used to assess the effectiveness of an organization’s training program and to find out how trained procedures are being implemented in day-to-day flights.

Importance of TEM[edit]

Threat and error management is an important element in the training of competent pilots that can effectively manage in-flight challenges.^[1][7] Many strategies have been developed (e.g. training, teamwork, reallocating workload) that were focused on improving on stress, fatigue, and error. Flight crew training stressed the importance of operational procedures and technical knowledge, with less emphasis placed on nontechnical skills, which became isolated from the real-world operational contexts.^[4] Safety training, including TEM, is important because a crew’s nontechnical (safety) knowledge helps more in managing errors effectively than crews’ familiarization with operations through experience.^[8] Candidates who are shortlisted during selection and training processes must demonstrate analytical and coordination capabilities.^[9] Possessing these nontechnical skills allows pilots and crew members to carry out their duties efficiently and effectively.

Components of TEM[edit]

The following components are methods that help provide data for the TEM.

LOSA observation training[edit]

Training for LOSA experts includes two sessions: education in procedural protocols, and TEM concepts and classifications.^[10] A LOSA trainee is taught to find data first and then code them later for both sessions, during which a crew member must exhibit «LOSA Etiquette» — ability to notify the pilot as to why he or she was not able to detect an error or threat after a flight. The pilot’s responsibilities include his or her opinions on what safety issues could have had an adverse impact on their operations. A LOSA trainee must then record the specific responses of the pilot and thereafter code performance using behavioral markers. The order of the recording is as follows: a) record visible threats; b) identify error types, crew’s responses, and specific outcomes; and c) use CRM behavioral markers to rate crew.^[11]

Observers will finally record a pilot’s overall response on a 4-point Likert scale: 1) poor, 2) marginal, 3) good, and 4) outstanding. The data are then quantified and tabulated as exemplified by the following format:^[10]

Planning and execution of performance

Task	Task Description	Comments	Rating
Monitor cross-check	Active monitoring of crews	Situational awareness maintained	Outstanding
SOP briefing	Carried out necessary briefings	Thorough understanding of procedures
Contingency Management	Communicate strategies	Good management of threats and errors.

Identified Threats	Managed	Mismanaged	*Frequency (N)
Air Traffic Control	17	2	19
Airline Operational Pressure	9	0	9
Weather	6	6	12

Frequency is the total number of threats that occurred and is denoted by N.

Categories of the LOSA[edit]

LOSA identifies three main categories that must be recorded:

• Errors include procedural errors (mistakes or inadequacy of attention towards a task at hand), and violation of SOP (intentional or unintentional). Although crew members are encouraged not to be afraid of admitting their mistakes, they must be able to criticize themselves since the learning process helps them understand the potential danger presented other crew members.^[1]
• Undesired Aircraft States are aircraft configurations or circumstances that are caused either by human error or by external factors.^[10] The management of unintended states is vital since they can result in serious aircraft accidents. For example, navigation problems on the cockpit display may lead a pilot to make an incorrect decisions, potentially causing injuries or fatality to passengers and crew members alike.

Safety change process[edit]

Safety change process (SCP), which is part of LOSA, is a formal mechanism that airlines can use to identify active and latent threats to flight operations.^[12] It is a guideline that communicates in detail what is an imminent threat to current operations or who is causing the threat. In the past, SCP data were based on investigation of accidents or incidents, experiences, and intuitions but nowadays SCP focuses more on the precursors to accidents.^[12] There are several steps involved in conducting SCP:^[12]

Safety Change Process (SCP) model
1. Collect safety issues (LOSA expert) 2. Conduct detailed analysis of Risks/data 3. Identify improvement strategies 8. Revise any changes Safety Change Process 4. Risk Analysis 7. Observe the impact of changes 6. Apply changes to operations 5. Funding of changes

An unnamed airline conducted base-line observations from 1996 to 1998 using the defined SCP and LOSA data to improve its organization’s safety culture and the results were positive. The crew error-trapping rate was significantly increased to 55%, meaning that crews were able to detect about 55% of the errors they caused.^[12] A 40% reduction in errors related to checklist performance and a 62% reduction in unstabilized approaches (tailstrikes, controlled flight into terrain, runway excursions, etc.) were observed.^[12] A proper review and management of SCP and LOSA data can prevent further disasters in flight operations.

See also[edit]

• Accident Classification
• Aviation safety
• Crew Resource Management
• Pilot Error
• Error Management
• The curse of expertise

References[edit]

На основании Вашего запроса эти примеры могут содержать грубую лексику.

На основании Вашего запроса эти примеры могут содержать разговорную лексику.

Другие результаты

Threat&error management (управление ошибками в экипаже).

TEM (Threat and Error Management).

Threat&error management (управление ошибками в экипаже).

Swiss Alpha Management были назначены финансовым консультантом проекта.

Swiss Alpha Management were appointed as the financial advisor and lead funding group for the project.

На Западе существуют четыре понятия, характеризующие подходы к управлению недвижимостью: Facility Management, Property Management, Building Management и Asset Management.

In the West, there are four concepts that characterize the approach to property management: Facility Management, Property Management, Building Management and Asset Management.

Администрирование происходит через оснастку Microsoft Management Console.

Instead, all the administrative tasks are performed through the Microsoft Management Console.

Long-Term Capital Management угодило в российский финансовый кризис.

Long-Term Capital Management ran into, among other things, the Russian financial crisis.

Pure Star Management — не исключение.

And «Pure Star Management» is not an exception.

Дополнительная область знания — Управление заинтересованными лицами (разделили область знаний Communication Management на две: Communication Management и Stakeholders Management).

A further area of knowledge is stakeholder management (divided the Communication Management knowledge domain into two: Communication Management and Stakeholders Management).

Microsoft Dynamics Management Reporter — приложение для финансовой отчётности и анализа.

Management Reporter for Microsoft Dynamics ERP is a financial reporting and analysis solution.

Исследование будет опубликовано в одном из следующих выпусков Management Science.

The study will be published in a forthcoming issue of Management Science.

Подобный слой можно реализовать путем применения API Management.

This task can also be performed using the Management API.

Object Management Group — это интернациональный, открытый, некоммерческий консорциум стандартов компьютерной индустрии.

Object Management Group (OMG) is an international, open membership, not-for-profit computer industry standards consortium.

Научное мышление и физические законы MANAGEMENT повлияли на окружающую среду, человек начинает манипулировать природу.

THE SCIENTIFIC THOUGHT AND MANAGEMENT OF PHYSICAL LAWS has impacted on the environment, man begins to manipulate nature.

Кроме того, мы внимательно следим за новейшими европейскими тенденциями в области facility management.

In addition, we are closely following the latest European trends in the field of facility management.

Wealth Management является ведущей деятельностью в финансовой индустрии в Швейцарии и в мире.

Wealth Management is a leading activity in the financial industry in Switzerland and in the world.

Как известно, Total Quality Management имеет восемь основных принципов.

As it is known, Total Quality Management has eight basic principles.

Мы только начали развивать Lean Management в AsstrA.

We have just started to develop Lean Management at AsstrA.

Cloud Management постарался порадовать конечного пользователя.

Cloud Management has tried to please the end user.

Поэтому переговоры с Wellington Management Company были не слишком сложными.

Therefore, the negotiations with Wellington Management Company were not very difficult.

Подготовьтесь к уникальному опыту в Alfred Ford School Of Management.

Prepare for a unique experience at the Alfred Ford School of Management.

Ничего не найдено для этого значения.

Результатов: 10621. Точных совпадений: 0. Затраченное время: 416 мс

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threat [θret] n gen. негативный фактор (Alexander Demidov); повышенная опасность (Alexander Demidov); бедствие (Notburga) avia. угроза применения взрывчатого устройства в полёте; опасная цель; летательный аппарат противника; средство нападения biol. угроза busin. грозное предзнаменование; риск (Alexander Matytsin); фактор риска (Alexander Matytsin) comp., MS угроза (A possible entry point to an asset that could be used by an adversary to adversely affect that asset) disast. опасное событие (Georgy Moiseenko) econ. источник беспокойства (пример: And this gave rise to a new label for the Japanese – they had developed a miracle economy that became a threat to any field they entered. A.Rezvov); источник тревоги (пример: And this gave rise to a new label for the Japanese – they had developed a miracle economy that became a threat to any field they entered. A.Rezvov); источник проблем (пример: The threat was not from the grassroots progressives. Rather, the threat came from online commerce. A.Rezvov) energ.ind. угроза (напр., безопасности АЭС, хищения ядерных материалов) fig. подводный камень (Vadim Rouminsky) Gruzovik, obs. пристрастие IT попытка преодоления системы защиты данных mil. вероятные действия противника (Киселев); возможные действия противника (Киселев); нападение (Киселев); противник (Киселев); средство нападения противника (Киселев); цель (представляющая угрозу Киселев); наиболее опасная цель; средства нападения; цель, представляющая угрозу (из кн.: Киселёв Б.В. Англо-русский словарь военно-технической и сопутствующей лексики и сокращений с комментариями Alex_Odeychuk) nano атакующая ракета; источник угрозы; средство воздушного нападения; средство поражения; угрожающая цель patents. опасность product. угроза возникновения (Yeldar Azanbayev) progr. угроза безопасности (ssn) sec.sys. потенциально возможное неблагоприятное воздействие  

threats n Gruzovik, inf. гроза inf., obs. гроза progr. угрозы безопасности (ssn)  

threat [θret] v nano угрожать  

threat [θret] adj. nano атакующий ЛА  

threat [θret] abbr. mil. СНП (средство нападения противника | из кн.: Киселёв Б.В. Англо-русский словарь военно-технической и сопутствующей лексики и сокращений с комментариями Alex_Odeychuk)  English thesaurus  

threat [θret] n IT Anything e.g., object, substance, human that is capable of acting against an asset in a manner that can result in harm (A potential cause of an unwanted incident (ISO/IEC 13335)) mil., logist. Realization or realization of a risk of nuisance, neutralization or destruction by a hostile entity having a will and a capacity of aggression. 2. Risk of aggression against the interests of the nation, and underpinned by a will and capacities. (FRA)  

threats SWOT n IT A combination of an organizational audit listing the enterprise’s strengths and weaknesses and an environmental scan or analysis of external opportunities and threats  

THREAT [θret] abbr. abbr., scottish Threat Related Attrition

system of axes

3-component LDV system

3-D LDV system

4-D system

4-D flight-management system

4-D guidance system

AC electrical system

actuation system

aerial delivery system

aerostat system

AEW system

afterburning control system

AI-based expert system

aileron-to-rudder system

air bleed offtake system

air cushion system

air cycle system

air data system

air defence system

air induction system

air refueling system

air traffic control system

air-combat advisory system

air-conditioning system

air-path axis system

air-turbine starting system

airborne early warning system

aircooling system

aircraft reference axis system

aircraft weight-and-balance measuring system

aircraft-autopilot system

aircraft-based system

aircraft-bifilar-pendulum system

aircraft-carried earth axis system

aircraft-carried normal earth axis system

aircrew escape system

airfield lighting control system

airframe/rotor system

airspeed system

alcohol-wash system

alignment control system

all-electronic system

all-weather mission system

altitude loss warning system

angle-of-attack command system

anti-collision system

anti-g system

antitorque system

anti-icing system

antiskid system

area-navigation system

ARI system

artificial feel system

artificial intelligence-based expert system

artificially augmented flight control system

ATC system

attitude and heading reference system

audio system

audiovisual system

auto-diagnosis system

auto-hover system

autolanding system

automatic cambering system

automatic trim system

autostabilization system

autotrim system

axis system

B system

balance-fixed coordinate system

base-excited system

basic axis system

beam-foundation system

bifilar pendulum suspension system

bladder system

blowing system

blowing boundary layer control system

blown flap system

body axis system

body axis coordinate system

body-fitted coordinate system

body-fixed reference system

boom system

boosted flight control system

braking system

breathing system

buddy-buddy refuelling system

cabin pressurization system

cable-mount system

CAD system

canopy’s jettison system

cardiovascular system

cargo loading system

cargo-handling system

carrier catapult system

cartesian axis system

Cat III system

central nervous system

CGI system

circulating oil system

closed cooling system

closed-loop system

cockpit system

cockpit management system

collision avoidance system

combined cooling system

command-by-voice system

command/vehicle system

commercial air transportation system

compensatory system

computer-aided design system

computer-assisted system

computer-generated image system

computer-generated visual system

concentrated-mass system

conflict-alert system

conservative system

constant bandwidth system

constant gain system

consultative expert system

control system

control augmented system

control loader system

cooling system

coordinate system

counterstealth system

coupled system

coupled fire and flight-control system

covert mission system

crew systems

cueing system

curvilinear coordinate system

damped system

data system

data acquisition system

data handling system

data transfer system

data-gathering system

DC electrical system

decision support system

defensive avionics system

deicing system

demisting system

departure prevention system

deterministic system

dual-dual redundant system

4-D navigation system

6-DOF motion system

diagnosable system

dial-a-flap system

direct impingement starting system

displacement control system

display system

display-augmented system

divergent system

DLC system

dogfight system

door-to-door system

Doppler ground velocity system

double-balance system

drive system

drive train/rotor system

dry air refueling system

dual-field-of-view system

dual-wing system

dynamic system

early-warning system

Earth-centered coordinate system

earth-fixed axis system

earth/sky/horizon projector system

ejection system

ejection display system

ejection seat escape system

ejection sequence system

ejector exhaust system

ejector lift system

election safety system

electric starting system

electro-expulsive deicing system

electro-impulse deicing system

electro-vibratory deicing system

electronic flight instrumentation system

Elint system

emergency power system

emitter locator system

EMP-protected system

engine monitoring system

engine-propeller system

engine-related system

enhanced lift system

envelope-limiting system

environmental control system

escape system

excessive pitch attitude warning system

exhaust system

FADEC system

fault-tolerant system

FBW system

feathering system

feedback system

feel system

fin axis system

fire detection system

fire suppression system

fire-extinguishing system

fire-protection system

five-point restraint system

fixed-structure control system

flap system

flap/slat system

flash-protection system

flexible manufacturing system

flight control system

flight control actuation system

flight director system

flight inspection system

flight management system

flight path system

flight path axis system

flight test system

flight-test instrumentation system

flotation system

fluid anti-icing system

flutter control system

flutter margin augmentation system

flutter suppression system

fluttering system

fly-by-light system

fly-by-light control system

fly-by-wire system

fly-by-wire/power-by-wire control system

foolproof system

force-excited system

force-feel system

forward vision augmentation system

fuel conservative guidance system

fuel management system

fuel transfer system

full-vectoring system

full-authority digital engine control system

full-motion system

full-state system

full-time system

fully articulated rotor system

fuselage axis system

g-command system

g-cueing system

g-limiting system

gas generator control system

gas turbine starting system

global positioning system

governing system

ground collision avoidance system

ground proximity warning system

ground-axes system

ground-fixed coordinate system

ground-referenced navigation system

gust alleviation system

gust control system

gyroscopic system

gyroscopically coupled system

halon fire-extinguishing system

halon gas fire-fighting system

hands-off system

head-aimed system

headup guidance system

helmet pointing system

helmet-mounted visual system

hierarchical system

high-damping system

high-authority system

high-lift system

high-order system

high-pay-off system

high-resolution system

higher harmonic control system

hose-reel system

hot-gas anti-icing system

hub plane axis system

hub plane reference axis system

hub-fixed coordinate system

hydraulic system

hydraulic starting system

hydropneumatic system

hydrostatic motion system

hysteretic system

ice-protection system

icing cloud spray system

icing-protection system

identification friend or foe system

image generator system

in-flight entertainment system

incidence limiting system

inert gas generating system

inertial coordinate system

inertial navigation system

inertial reference system

infinite-dimensional system

information management system

inlet boundary layer control system

inlet control system

input system

instruction system

instrument landing system

instrumentation system

intelligence system

intelligent system

interconnection system

intermediate axis system

intrusion alarm system

intrusion detection system

inverted fuel system

landing guidance system

large-travel motion system

laser-based visual system

lateral attitude control system

lateral control system

lateral feel system

lateral seat restraint system

lateral-directional stability and command augmentation system

lead compensated system

left-handed coordinate system

leg restraint system

life support system

liferaft deployment system

lift-distribution control system

lighter-than-air system

lightly damped system

lightning protection system

lightning sensor system

lightning warning system

limited-envelope flight control system

linear vibrating system

liquid oxygen system

load control system

load indication system

local-horizon system

loom system

low-damping system

low-order system

LQG controlled system

lubrication system

lumped parameter system

Mach number system

main transmission system

maintenance diagnostic system

maintenance record system

man-in-the-loop system

man-machine system

maneuver demand system

maneuvering attack system

mass-spring-dashpot system

mass-spring-damper system

mast-mounted sight system

mechanical-hydraulic flight control system

microwave landing system

MIMO system

mine-sweeping system

missile system

missile-fixed system

mission-planning system

mobile aircraft arresting system

modal cancellation system

modal suppression system

mode-decoupling system

model reference system

model-based visual system

model-following system

modelboard system

molecular sieve oxygen generation system

monopulse system

motion system

motion generation system

multi-input single-output system

multi-input, multi-output system

multimode system

multibody system

multidegree-of-freedom system

multiloop system

multiple-input single output system

multiple-input, multiple-output system

multiple-loop system

multiple-redundant system

multiply supported system

multishock system

multivariable system

navigation management system

navigation/attack system

navigation/bomb system

NDT system

neuromuscular system

night/dusk visual system

portable aircraft arresting system

nitrogen inerting system

no-tail-rotor system

nonminimum phase system

nonoscillatory system

nonconservative system

normal earth-fixed axis system

Notar system

nozzle control system

nuclear-hardened system

observer-based system

obstacle warning system

oil system

on-board inert gas generation system

on-board maintenance system

on-board oxygen generating system

on-off system

one degree of freedom system

one-shot lubrication system

open cooling system

open seat escape system

open-loop system

operability system

optic-based control system

optimally controlled system

orthogonal axis system

oxygen generation system

parachute system

partial vectoring system

partial vibrating system

performance-seeking system

perturbed system

pilot reveille system

pilot vision system

pilot-aircraft system

pilot-aircraft-task system

pilot-in-the-loop system

pilot-manipulator system

pilot-plus-airplane system

pilot-vehicle-task system

pilot-warning system

pilot/vehicle system

pitch change system

pitch compensation system

pitch stability and command augmentation system

pitch rate system

pitch rate command system

pitch rate flight control system

pneumatic deicing system

pneumatic ice-protection system

pneumodynamic system

position hold system

power system

power-assisted system

power-boosted system

powered high-lift system

powered-lift system

precognitive system

pressurization system

preview system

probabilistically diagnosable system

probe refuelling system

pronated escape system

propeller-fixed coordinate system

propulsive lift system

proximity warning system

pursuit system

push-rod control system

quantized system

random system

rating system

reconfigurable system

rectangular coordinate system

reduced-gain system

reference axis system

refuelling system

remote augmentor lift system

remote combustion system

response-feedback system

restart system

restraint system

restructurable control system

retraction system

ride-control system

ride-quality system

ride-quality augmentation system

ride-smoothing system

right-handed axis system

right-handed coordinate system

rigid body system

robotic refueling system

rod-mass system

roll augmentation system

roll rate command system

rotating system

rotor system

rotor isolation system

rotor-body system

rotor-wing lift system

route planner system

rudder trim system

rudder-augmentation system

sampled-data system

scheduling system

schlieren system

sea-based system

seat restraint system

seatback video system

self-adjoint system

self-contained starting system

self-diagnosable system

self-excited system

self-repairing system

self-sealing fuel system

self-tuning system

shadow-mask system

shadowgraph system

ship-fixed coordinate system

shock system

short-closed oil system

sighting system

simulation system

simulator-based learning system

single degree of freedom system

single-input multiple-output system

singularly perturbed system

situational awareness system

six-axis motion system

six-degree-of-freedom motion system

six-puck brake system

ski-and-wheel system

skid-to-turn system

snapping system

soft mounting system

soft ride system

sound system

speed-stability system

spherical coordinate system

spin recovery system

spin-prevention system

spring-mass-dashpot system

stability and control augmentation system

stability augmentation system

stability axis coordinate system

stability enhancement system

stall detection system

stall inhibitor system

stall protection system

stall warning system

starting system

stealth system

stochastic system

storage and retrieval system

store alignment system

stores management system

strap-down inertial system

structural system

structural-mode compensation system

structural-mode control system

structural-mode suppression system

STT system

suppression system

suspension system

tactile sensory system

tail clearance control system

tail warning system

task-tailored system

terrain-aided navigation system

terrain-referencing system

test system

thermal control system

thermal protection system

threat-warning system

three-axis augmentation system

three-body tethered system

three-control system

three-gyro system

through-the-canopy escape system

thrust modulation system

thrust-vectoring system

tilt-fold-rotor system

time-invariant system

time-varying system

tip-path-plane coordinate system

torque command/limiting system

tractor rocket system

trailing cone static pressure system

training system

trajectory guidance system

translation rate command system

translational acceleration control system

trim system

trim tank system

triple-load-path system

tutoring system

twin-dome system

two degree of freedom system

two-body system

two-input system

two-input two-output system

two-pod system

two-shock system

two-step shock absorber system

unpowered flap system

unpowered high-lift system

utility services management system

vapor cycle cooling system

variable feel system

variable stability system

variable structure system

vestibular sensory system

vibrating system

vibration isolation system

vibration-control system

vibration-damping system

video-disc-based visual system

visor projection system

visual system

visual display system

visual flying rules system

visual sensory system

visual simulation system

visually coupled system

voice-activated system

vortex system

vortex attenuating system

VTOL control system

wake-imaging system

warning system

water injection cooling system

water-mist system

water-mist spray system

weather system

wheel steering system

wide angle visual system

wind coordinate system

wind shear system

wind-axes system

wind-axes coordinate system

wind-fixed coordinate system

wing axis system

wing flap system

wing sweep system

wing-load-alleviation system

wing-mounted system

wing/propulsion system

wiring system

yaw vane system

Note: This article is based on the preliminary edition of Threat and Error Management (TEM) in Air Traffic Control (ICAO).

Introduction to TEM

Threat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. TEM is not a revolutionary concept, but one that has evolved gradually, as a consequence of the constant drive to improve the margins of safety in aviation operations through the practical integration of Human Factors knowledge.

TEM was developed as a product of collective aviation industry experience. Such experience fostered the recognition that past studies and, most importantly, operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context (i.e., organisational, regulatory and environmental factors) within which people discharged their operational duties.

TEM Background

The origin of TEM can be traced to the Line Operations Safety Audit (LOSA) concept. A partnership between the University of Texas Human Factors Research Project (UT) and Delta Airlines in 1994 developed a line audit methodology utilising jump-seat observations on scheduled flights. Both parties agreed that in order for the audit to be productive and show realistic and un-obscured results, confidentiality of the findings with no regulatory or organisational jeopardy to the flight crews should be guaranteed.

The initial observation forms of the audit were designed by the University of Texas researchers to evaluate Crew Resource Management (CRM) behaviour on the flight deck. The process was then extended to include error and its management as well as the type of error observed. This enabled trained observers to categorise the origin of, detection of and response to (if any) and outcome of each recorded error.

The first full scale TEM-based LOSA was conducted at Continental Airlines in 1996. Together with the original CRM indicators (leadership, communication, and monitoring/cross-checking) the extended concept of TEM was used to identify most frequent threats. This method provided a picture of the most common errors and threats, both those that were well managed and the more problematic and mismanaged.

The recognition of the influence of the operational context in human performance led to the conclusion that the study and consideration of human performance in aviation operations should not be an end in itself. TEM as developed therefore aims to enable broad examination of the dynamic and challenging complexities of the operational context in human performance.

TEM Framework

The TEM framework is a conceptual model that assists in understanding, from an operational perspective, the inter-relationship between safety and human performance in dynamic and challenging operational contexts.

The TEM framework focuses simultaneously on the operational context and the people discharging operational duties in such a context. The framework is descriptive and diagnostic of both human and system performance. It is descriptive because it captures human and system performance in the normal operational context, resulting in realistic descriptions. It is diagnostic because it allows quantifying the complexities of the operational context in relation to the description of human performance in that context, and vice-versa.

The TEM framework can be used in several ways. As a safety analysis tool, the framework can focus on a single event, as is the case with accident/incident analysis; or it can be used to understand systemic patterns within a large set of events, as is the case with operational audits. The TEM framework can be used to inform about licensing requirements, helping clarify human performance needs, strengths and vulnerabilities, thus allowing the definition of competencies from a broader safety management perspective. Subsequently the TEM framework can be a useful tool in On the-Job Training (OJT). The TEM framework can be used as guidance to inform about training requirements, helping an organisation improve the effectiveness of its training interventions, and consequently of its organisational safeguards. The TEM framework can be used to provide training to quality assurance specialists who are responsible for evaluating facility operations as part of certification.

Originally developed for flight deck operations, the TEM framework can nonetheless be used at different levels and sectors within an organisation, and across different organisations within the aviation industry. It is therefore important, when applying TEM, to keep the user’s perspective in the forefront. Depending on «who» is using TEM (i.e. front-line personnel, middle management, senior management, flight operations, maintenance, air traffic control), slight adjustments to related definitions may be required.

The Components of the TEM Framework

There are three basic components in the TEM framework. From the perspective of their users, they have slightly different definitions: threats, errors and undesired (aircraft) states. The framework proposes that threats and errors are part of everyday aviation operations that must be managed by the aviation professionals, since both threats and errors carry the potential to generate undesired states. The undesired states carry the potential for unsafe outcomes thus undesired state management is an essential component of the TEM framework, as important as threat and error management. Undesired state management largely represents the last opportunity to avoid an unsafe outcome and thus maintain safety margins in aviation operations.

• Threats — generally defined as events or errors that occur beyond the influence of the line personnel, increase operational complexity, and which must be managed to maintain the margins of safety.
• Errors — generally defined as actions or inactions by the line personnel that lead to deviations from organisational or operational intentions or expectations. Unmanaged and/or mis-managed errors frequently lead to undesired states. Errors in the operational context thus tend to reduce the margins of safety and increase the probability of an undesirable event.
• Undesired states — generally defined as operational conditions where an unintended situation results in a reduction in margins of safety. Undesired states that result from ineffective threat and/or error management may lead to compromised situations and reduce margins of safety aviation operations. Often considered the last stage before an incident or accident.

Note: “Line personnel” in the context above means air traffic controllers or flight crew.

Related Articles

• For more details about specific TEM characteristics see TEM in ATC and Threat and Error Management (TEM) in Flight Operations.

Further Reading

ICAO

• Threat and Error Management (TEM) in Air Traffic Control, Preliminary Edition 2005;
• Threat and Error Management (TEM), Captain Dan Maurino, Coordinator, Flight safety and Human Factors Programme — ICAO, Canadian Aviation Safety Seminar (CASS), Vancouver, Canada, 18-20 April 2005;

Others

• Defensive Flying for Pilots: An Introduction to Threat and Error Management, Ashleigh Merritt, Ph.D. & James Klinect, Ph.D., The University of Texas Human Factors Research Project, The LOSA Collaborative December 12, 2006.