THREAT AND ERROR MANAGEMENT

Lt Ali Bouzaienne 31st AU

The dynamic nature of aviation demands a vigilant approach to safety, particularly in the realm of
military operations. For the Tunisian Air Forces, where precision and adaptability are paramount,
navigating the skies requires a comprehensive strategy to address potential threats and errors.

This article aims to explore and contextualize the principles of Threat and Error Management (TEM),
shedding light on its significance within the dynamic realm of aviation operations.

Understanding Threat and Error Management

Threat and error management (TEM) is a safety-focused approach to managing risks in aviation. TEM
has become increasingly popular in recent years due to its effectiveness at reducing the risk of accidents
or incidents. It helps to lower the chance of errors and accidents by identifying potential hazards before
they occur, responding to them quickly when they do occur, and minimizing any damage caused by
existing threats or errors. The objectives of TEM are to enhance safety within an operation by reducing
human errors, resolving emerging issues as soon as possible, maintaining a safe environment through
proactive risk identification and mitigation measures, and promoting situational awareness among those
involved in the operations so they can make well-informed decisions in case of unexpected events.

Threat and Error Management model

The Threat and Error Management (TEM) model is a conceptual framework that helps to understand
the connection between safety and human performance in dynamic operational contexts. It focuses on
both the operational context and the people who perform operational tasks. The model is both descriptive
and diagnostic, providing realistic descriptions by capturing human and system performance in typical
operating situations. It makes it possible to quantify the complexities in the operational context
concerning human performance.

The TEM model serves several purposes. It can be used as a safety analysis tool by focusing on single
events such as accident/incident analysis or by understanding systemic patterns in operational audits. It
can also function as a licensing tool for clarifying human performance needs, strengths and
vulnerabilities, and for defining competencies from a wider safety management perspective.
Additionally, the TEM model serves as a training tool to enhance the effectiveness of organizational
training interventions and safeguards.

The components of the TEM model

In the TEM model, as perceived by flight crews, there
are three basic components: threats, errors, and
undesired aircraft states. The model suggests that
threats and errors are inherent in daily aviation
operations and must be managed by flight crews,
because they can lead to undesired aircraft states.
Flight crews are also responsible for managing
undesired aircraft states, as they carry the potential for
unsafe outcomes and dangerous consequences.
Managing undesired state is as important as managing
threat and error in the TEM model, representing the
last opportunity to avoid unsafe outcomes and
maintain safety margins in different flight operations.
 THREAT AND ERROR MANAGEMENT
Lt Ali Bouzaienne 31st AU

 Threats :

Threat
“Events or errors that occur beyond the influence of the flight crew, increase
Definition operational complexity, and which must be managed to maintain the margins of
safety”
 Certain threats can be anticipated, since they are
Anticipated expected or known to the flight crew

 Certain threats can occur unexpectedly, suddenly and

without warning. In this case, flight crews must apply
Categories
Unanticipated skills and knowledge acquired through training and
operational experience

 Certain threats may not be directly obvious to, or

Latent observable by, flight crews immersed in flight
operations, and may need to be uncovered by safety
analysis

Environmental threats
arise from the conditions
in which flight operations
take place . While certain
environmental threats can
be anticipated and
planned for, others
emerge spontaneously.
Flight crews must
manage all these types of
threats in real-time. On
the other hand,
organizational threats can
be controlled, meaning
they can be eliminated or
at least reduced, directly
by aviation organizations.
These threats are
typically latent. They
require proactive
measures from aviation
organizations, offering
opportunities for
mitigation before
reaching flight crews
who, nonetheless, serve
as the last line of defense.

Note: Whether threats are expected, unexpected, or latent, the effectiveness of a flight crew’s
ability to manage threats is measured by whether threats are detected with the necessary
anticipation to allow the crew to respond to them by deploying appropriate countermeasures.
 THREAT AND ERROR MANAGEMENT
Lt Ali Bouzaienne 31st AU

 Errors:

Error
Definition “actions or inactions by the flight crew that lead to deviations from organizational
or flight crew intentions or expectations”
 Failures in the execution of the intended action.
Slips and lapses  Slips are actions that do not go as planned, while
lapses are memory failures
Types
 Failures in the plan of action.
 Even if execution of the plan were correct, it would
Mistakes not have been possible to achieve the intended
outcome.

Aircraft  To classify the error as Aircraft handling Error, the

handling pilot or flight crew must be interacting with the
Categories aircraft.
(List not inclusive) Procedural  To classify the error as Procedural Error, the pilot or
flight crew must be interacting with a procedure.
Communications  To classify the error as Communications Error, the
pilot or flight crew must be interacting with each other
or other people.

Regardless of the type of error, an error’s effects on safety depends on the ability of the flight crew to
detect and to respond to it before leading to an undesired aircraft state with potentially dangerous
outcome.This is why one of the goals of TEM is to comprehend error management rather than solely
focusing on error causality. From a safety perspective, timely and promptly addressed errors do not
lead to UAS, do not reduce the safety margins of flight operations and therefore become operationally
inconsequential.

 Undesired Aircraft States (UAS):

UAS
Definition “flight crew-induced aircraft position or speed deviations, misapplication of flight
controls, or incorrect systems configuration, associated with a reduction in
margins of safety”
 Aircraft control (attitude).
aircraft  Vertical, lateral or speed deviations.
handling  Unnecessary weather penetration.
 Operation outside aircraft limitations.
Categories  Unstable approach
(List not inclusive)  Continued landing after unstable approach.
ground  Proceeding towards wrong taxiway/runway.
navigation  Wrong taxiway, ramp, gate or hold spot

incorrect  Incorrect systems configuration.

aircraft  Incorrect flight controls configuration
configurations  Incorrect engine configuration.
 Incorrect weight and balance configuration
 THREAT AND ERROR MANAGEMENT
Lt Ali Bouzaienne 31st AU

Countermeasures

To maintain safety margins in flight operations, flight crews must implement countermeasures against
threats, errors, and Unmanned Aircraft Systems (UASs). These countermeasures, such as planning,
checklists, briefings, training, standard operating procedures (SOPs), and crew resource management
(CRM), can be categorized into three groups: planning, execution, and review.

Planning countermeasures involve comprehensive preparation, transparent communication of plans and

decisions, delineation of roles and responsibilities, and effective contingency management.

Execution countermeasures concentrate on real-time error detection and response, highlighting active
monitoring, cross-checking, proper automation management, and proficient recovery techniques.

Review countermeasures are crucial for adapting to changing conditions, encompassing the evaluation
and modification of plans, open analysis of crew decisions, encouragement of questions, promotion of
open communication, and ensuring the expression of critical information without hesitation.