Tem Ba 10-07

Flight Safety Foundation
CAC Workshop Oct. 17, 2007

Durwood
Durwood Heinrich,
Heinrich, Ph.D.
Ph.D.
A Threat & Error
Management Model
Latent External Crew TRM/CRM CRM
Threats & Outcomes Outcomes
Threats Errors Behaviors Behaviors
Errors
Organizational
System
Professional
Decision-making, SA,
Unexpected Threat recognition,
Events/Risks Error avoidance, Safe Flight
Safeguards,
Countermeasures
Expected
Events/Risks Violations,
Communication,
Procedural,
External Proficiency,
Error Decision Recovery to
Inconsequential Safe Flight
Error-management
Behaviors Undesired Undesired state
(avoid, trap, contain, aircraft management
mitigate, exacerbate, state behaviors
fail to respond)
Additional Additional
error error
Incident
Accident
* Adapted from Helmreich, 2003

Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Some Definitions
THREATS
 Threats are events that occur outside the
influence of the flight crew, but which require
crew attention and management if safety margins
are to be maintained
 Threats increase the complexity of the operation
and weaken barriers against error
 Observable Threats
– Known
• e. g., Thunderstorms, delays
– Unexpected
• e. g., Engine failure on take off
Threats = Red Flags!
Heinrich 2007
Fortunately,
Fortunately, not
not all
all events
events become
become accidents…
accidents…
Accident 1
Serious incident 10
Significant event 30
Routine occurrence
200
Statistical event
600
…
…but
but events/occurrences
events/occurrences can
can lead
lead to
to incidents
incidents and
and accidents
accidents
Flight Safety Foundation, 2006; Adapted with permission.
Latent Threats
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
 Latent threats are usually uncovered by
analysis of aggregate data such as confidential
incident reports, e.g.,
 Equipment design issues
 Optical illusions
 Air traffic system design
 Training philosophy and practices
 Organizational culture (positive or negative)
Heinrich 2007
Typical Latent Errors
 Poor planning or scheduling
 Inadequate design/poor equipment
 Improper allocation/lack of resources
 Flawed procedures
 Defective communications
 Training deficiencies
 Inadequate selection procedures
 Inspection and oversight flaws
 Neglect of known hazards
 Lack of motivation
Note that these are all management problems!
Flight Safety Foundation, 2006; Adapted with permission.

ERRORS
 Errors are actions or inactions by the flight crew
that lead to deviations from intention or expectation
 Traditional thinking focused on eliminating error in
the cockpit, i.e., Zero Error!
 Contemporary thinking acknowledges that error is a
part of life, i.e., humans make mistakes!
 Intentional non-compliance is not an error
 Types of errors:
 Flight handling errors (e.g., unintentional speed deviation)
 Procedural errors (e.g., performing checklist items from memory)
 Communications errors (e.g., missed ATC call)
Heinrich 2007
Pilots
Pilots are
are human…
human…
and
and humans
humans make
make errors!
errors!
(Note:
(Note: this
this does
does not
not mean
mean that
that errors
errors are
are OK!)
OK!)
Primary
Primary Causes
Causes of
of Aircraft
Aircraft Accidents
Accidents **
Percentage of Total Accidents with Known Causes
Primary Factor 10 20 30 40 50 60 70
Flight Crew
Airplane
Maintenance
Excludes:
Weather • Sabotage
• Military Action
Airport/ATC • Turbulence Injury
• Evacuation Injury
Other • Servicing Injury
The Crew usually makes the last mistake!

* Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.
Error Outcomes
* Helmreich, 1998
Strategies/Countermeasures
Strategies/Countermeasures are employed…

 to reduce the number of threats and
errors, and
 to increase the awareness of potential
threats and errors
Errors must be recognized and corrected
before negative consequences occur!
Focus on managing your future!
Heinrich 2007
Safeguards
Safeguards are the hardware & software that
serve as additional barriers to problems*:
 GPWS  SOPs
 TCAS  CHECKLISTS
 EVS  AUTOMATION
 MANUALS  ATC
*Note: Because these are also developed by humans, the potential
still exists for latent defects and errors.
Heinrich 2007
Awareness, Anticipation
 Awareness and anticipation are important

characteristics of effective CRM and TEM
 Awareness includes
 Search
 Perception
 Spatial orientation
 Knowledge of mission goals
 Anticipation includes
 Projection/forecasting
 Planning
 Threat awareness
Heinrich 2007
Desired OUTCOMES
or Undesired CONSEQUENCES ?
 Successful Threat and Error Management results in

outcomes that are desirable, i.e., safe flight
 Consequences of errors that are not corrected or
not contained can result in an undesired aircraft
state (UAS)
 An undesired aircraft state is an aircraft deviation or
incorrect configuration associated with a clear
reduction in safety margins
Heinrich 2007
TEM Principles
TEM Principles
The objective of Threat and Error
Management (TEM) …
 to obtain an understanding of how to

assess the various risk levels of threats
 to gain an insight on logical approaches
(strategies) to deal with them, and
 to reduce human error in dynamic daily
operations.
Heinrich 2007
TEM Principles
TEM is central to all safety processes and
provides defences against hazards in
operational situations; it involves…
 Identifying hazards to safety, i.e., threats,
errors, or undesired states (deviations)
 Assessing the risks of these hazards (the
consequence of accepting hazards)
 Avoiding or trapping threats and errors
 Containing the end result (mitigation)
Heinrich 2007
Important TEM Concepts
TEM Concepts
 The “mission” (i.e., safe, effective
mission/objective) may be a flight, an aircraft
repair, a trip plan, or even an ops manual or
company procedure…
 … i.e., TEM can be applied to all aviation
organizational entities.
 The crew is only one resource to the “operator” or
“systems manager” who must make accurate and
timely decisions for successful results.
 The operator is only as effective as the information
he or she receives from all resources (The TEAM).
Heinrich 2007
TEM Concepts
 Individuals are humans, and humans (all humans!)
make mistakes.
 The aviation mission or objective is dynamic.
 TEM is not a sequential system! Because all
organizational entities are made up of individuals,
threats (hopefully with innovative threat solutions!)
and human error (with error resolutions!) are
introduced throughout the timeline of the particular
“mission.”
 External threats also continuously occur and must
be dealt with utilizing all appropriate resources
available.
Heinrich 2007
Accurate Decision-Making
 The primary key to a successful mission outcome

is accurate decision-making by the individual or
individuals who are “steering the ship.”
Accurate Decision-Making = Successful Outcome!
 In the operational setting, the operator is only as
effective as the information (not data!) he or she
receives through proper teamwork and resource
management.
 The operator is the final authority regarding the
safety of the mission; e.g., a pilot can always
elect to abandon a dangerous approach.
Heinrich 2007
A Case Study
Case Study
G-III Fatal Accident, Aspen, March 2001
The Accident:
On March 29, 2001, about 1902 MST, a
Gulfstream III, N303GA, owned by
Airbourne Charter, Inc., and operated
by Avjet Corporation of Burbank,
California, crashed while on final
approach to runway 15 at Aspen-Pitkin
County Airport (ASE), Aspen, CO. The
charter flight had departed Los Angeles
International Airport (LAX) about 1711
with 2 pilots, 1 flight attendant, and 15
passengers. The airplane crashed into
sloping terrain about 2,400 feet short of
the runway threshold. All of the
passengers and crewmembers were
killed, and the airplane was destroyed.
The flight was being operated on an IFR
flight plan under CFR Part 135.
Case Study
G-III Fatal Accident, Aspen, March 2001
Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Errors
Organizational
System
Professional
Latent Threats:
(Factors residing in the system, organization or
individual
Decision-making, SA, that increase risk )
Unexpected
Events/Risks Organizational
Threat recognition,
Error avoidance, Safe Flight
 Company management
Safeguards,
Countermeasures
 Organization management
Expected  Resources

Communication,
System
Procedural,
 SOPs
 Policies Safe Flight
Inconsequential
 Procedures
 Techniques
Error-management
 Professional
(avoid, trap, contain,
mitigate, exacerbate,
aircraft
state
management
behaviors
failtoOperators
respond)
 Crew
 Team error error
Incident
Accident

Organizational
Latent Threats System
Professional
What are some of the Latent Threats in the

Aspen Accident?
 ?
 ?
 ?
 ?
Organizational
Professional
Some of the Latent Threats in the Aspen Accident

 The March 27, 2001, NOTAM regarding the nighttime
restriction on the VOR/DME-C approach was vaguely worded
and ineffectively distributed:
 The NOTAM stated, “circling NA at night,” but the intended meaning
was to prohibit the entire approach procedure at night.
 Pilots might have inferred that an approach without a circle-to-land
maneuver to runway 15 was still authorized.
 If the FAA had worded the first NOTAM more clearly, it might have
made more of an impression on the first officer when he received the
preflight briefing from the Automated Flight Service Station and might
have affected the conduct of the flight.
 The local controller could not notify the flight crew of the NOTAM
because Denver Center had not sent a copy to the ASE tower.
Heinrich 2007
Organizational
Professional
Some of the Latent Threats in the Aspen Accident
 Company Standard Operating Procedures

Manual incomplete:
 No sterile cockpit procedure
 No procedure/restrictions regarding the use of
cockpit observers (jump seat)
 No guidance regarding weather minimums for
mountain operation
Heinrich 2007
What would have happened if the
Organization…
 …Utilized Corporate Flight Operations Quality

Assurance (C-FOQA) to uncover latent threats
and dangerous procedures/techniques? Safe Flight
 Had an effective Safety Management System

and Incident Reporting System? Safe Flight
 Conducted Line Operational Safety Audits

(LOSA)? Safe Flight
 Conducted confidential surveys? Safe Flight
 Regularly performed training evaluations? Safe Flight
 Redesigned policies, procedures, tasks, and

equipment? Safe Flight
Heinrich 2007
Errors
Unexpected External Threats
Organizational
System Threats/Events/Risks Events that occur
Professional  Latent threats outside the influence
 System failures of the flight crew, but
Decision-making, SA, which require crew
Unexpected  WX/ Environmental
Threat recognition, changes attention and
Events/Risks  Other dynamics
Error avoidance, Safe Flight management if safety
Safeguards, margins are to be
Countermeasures maintained.
Expected
Events/Risks
Expected External
Violations,
Threats/Events/Risks
Communication,
 Destination
Procedural, issues
External  Proficiency,
Terrain
 Environmental problems Safe Flight
Inconsequential
 Logistics
Error-management
External Error
 ATC errors
fail to respond)
 Other aircraft
Other aircraft
 Communication issues Additional Additional
 Time pressures error error
Incident
Accident

Unexpected
External Events/Risks
Threats & Errors

Expected
Events/Risks
External
Error
What are some of the External Threats &

Errors in the Aspen Accident?
 ?
 ?
 ?
 ?
Unexpected
External Events/Risks
Threats & Errors

Expected
Events/Risks
External
Error
Some of the External Threats and Errors

 The Flight Crew was under pressure to land at ASE
 Because of the flight’s delayed departure from LAX and the
landing curfew at ASE, the crew could attempt only one approach
before having to divert to the alternate.
 The charter customer had a strong desire to land at ASE, and his
communications before and during the flight most likely
heightened the pressure on the flight crew.
 The presence of a passenger on the jumpseat, especially if it
were the charter customer, most likely further heightened the
pressure on the flight crew to land.
 Darkness, reduced visibility, and light snow showers significantly
degraded the flight crew’s ability to see and safely avoid terrain.
Heinrich 2007
In the Dynamic environment…
What would have happened if…
 …The organization had advised the
passengers of the need to arrive on time
because of the night curfew at Aspen? Safe Flight
 The flight attendant had recognized the

potential problems associated with allowing
passengers to occupy the jumpseat,
especially in adverse conditions?
 The crew had advised the jumpseat Safe Flight
passenger of an organization sterile cockpit

rule?
Safe Flight
Heinrich 2007
Errors
Organizational
System Crew Errors *
Professional  Non-compliance (violation)
Crew Errors
Unexpected
 Communication
Threat recognition,
Actions or
Events/Risks Error avoidance,
 Procedural
Safeguards,
Safe Flight
inactions by Countermeasures
the flight crew
Expected  Proficiency
Events/Risks
that lead to Violations,
Communication,
 Poor or uninformed decision
deviations Procedural,
from intention
External
Error
Proficiency,
Decision
* All humans
Recovery to
or expectation make mistakes!
Error-management
fail to respond)
error error
Incident
Accident

Violations,
Crew Errors Communication,

Procedural,
Proficiency,
Decision
What are some of the Crew Errors in the

Aspen Accident?
 ?
 ?
 ?
 ?
 ?
 ?
 ?
Violations,

Procedural,
Proficiency,
Decision
Some of the Crew Errors

 Procedural errors & deviations during Final Approach Segment:
 Crossed step-down fixes below minimum specified altitudes
 Descended below the MDA, even though aircraft maneuvers and
comments on CVR indicated neither pilot had established or maintained
visual contact with the runway or its environment.
 Contrary to manufacturer’s procedures, the captain deployed spoilers
after gear and final flap extension and set power to 55% N2 rather than
64% N2
 When the aircraft was 1.4 miles from the runway (21 sec before impact),
captain asked, “where’s it at?” but did not abandon the approach, even
though he had not identified, or had lost sight of, the runway.
 Radar data and CVR comments indicated that, until the aircraft began
turning left about 10 sec. before impact, the crew probably did not have
the runway or its environment in sight.
Heinrich 2007
Violations,

Procedural,
Proficiency,
Decision
Some of the Crew Errors (continued)

 Poor Crew Coordination/CRM:
 Captain failed to discuss the instrument approach procedure, the
missed approach procedure, and other required elements during his
approach briefing because he anticipated using a visual approach.
 The first officer never challenged the captain even though he
crossed step-down fixes below minimum specified altitudes.
 The captain and the first officer failed to make required instrument
approach callouts, and the first officer did not call out required
course, fix, & altimeter information.
 The crew failed to discuss a missed approach after receiving a third
report of a missed approach to the airport and a report of
deteriorating visibility in the direction of the approach course.
Heinrich 2007
 …The first office would have challenged the
captain about missing stepdown altitudes? Safe Flight
 The crew would have briefed and planned on

an instrument approach, especially after
hearing that three other aircraft had executed
the missed approach procedure? Safe Flight
 The crew would have abandoned their

obsession with finding visual landmarks? Safe Flight
 The crew would have altered their thinking

from “landing unless…” to “go around
unless…” ? Safe Flight
Heinrich 2007
Errors
TRM/CRM Behaviors
Organizational
 Decision-making – must have “information” from all Team resources (integration)
System
Situation Awareness and “Projection” in a very dynamic environment
Professional
 Threat recognition
 Error avoidance Decision-making, SA,
 Safeguards – hardware and software
Events/Risks that serve as
Error avoidance, additional barriers to problems
Safe Flight
 Countermeasures – increase awareness
Safeguards,and reduce number of threats/errors
Countermeasures
Error ManagementViolations,
Behaviors
Expected
Events/Risks
 Avoid Communication,
 Trap Procedural,
 Contain Error Decision Recovery to
 Mitigate Safe Flight
Inconsequential
 Exacerbate
 Fail to respond Error-management
(trap, contain, aircraft management
Undesired State Management Behaviors
 Errors/deviations require immediate action before negative
fail to respond) consequences occur!
 Additional error can lead to an incident or accidentAdditional Additional
 Note: Pilots can always elect to abandon a dangerous approach
error or phase oferror
flight!
Incident
Accident

TRM/CRM Decision-making, SA,
Threat recognition,
Error-management
Behaviors (+/-)
Error avoidance , (avoid, trap, contain,
Behaviors
Undesired state
Safeguards, mitigate, exacerbate, management
Countermeasures fail to respond) Behaviors (+/-)
What are some of the TRM/CRM Behaviors in the Aspen Accident?
?
Threat recognition,
Error avoidance,
Safeguards,
Countermeasures ?
Error-management
Behaviors (+/-)
(avoid, trap, contain,
?
fail to respond)
Undesired state
management
Behaviors (+/-)
?
TRM/CRM Decision-making, SA,
Threat recognition,
Error-management
Behaviors (+/-)
Error avoidance , (avoid, trap, contain,
Behaviors
Undesired state
Safeguards, mitigate, exacerbate, management
Countermeasures fail to respond) Behaviors (+/-)
Some TRM/CRM Behaviors
Decision-making, SA,  Captain and another Avjet captain discussed nighttime landing
Threat recognition, restriction at ASE.
Error avoidance,
Safeguards,  Captain asked controller whether the pilot of N527JA was practicing or
Countermeasures had actually missed.
Error-management
 When airplane is at 10,400 feet, captain states, “Okay...I'm breaking
Behaviors (+/-) out," and asks local controller, about 5 seconds later, whether runway
(avoid, trap, contain, lights are all way up. The controller indicates, “Affirmative they're on
fail to respond)
high." First officer says, “Okay you can go...ten thousand two hundred
[the MDA].”
Undesired state  Descended below MDA, even though aircraft maneuvers and comments
management on CVR indicated neither pilot had established or maintained visual
Behaviors (+/-)
contact with the runway or its environment.
Heinrich 2007
 …The crew had expected to execute a missed Missed
Approach!
approach after hearing that the Challenger
ahead (N527JA) had executed the missed Safe Flight
approach?
 The crew had realized that when they were
Missed
“breaking out” that they were not in a position Approach!
to land when they were unable to see the

runway lights? Safe Flight
 The crew had executed a missed approach

when they reached the MDA missed- approach Missed
Approach!
point and were unable to see the runway or its
environment?
Safe Flight
Heinrich 2007
Latent External
Threats & Safe Crew
Flight TRM/CRM Outcomes CRM Outcomes
 Effective
ErrorsDM, SA, threat recognition, error
avoidance
Organizational
 Appropriate application of T&E strategies
System
result in desirable outcomes
Professional
Inconsequential Outcome
 Management
Events/Risks of threats & errors (i.e.,
Error avoidance, Safe Flight
avoiding, trapping, containing) results in little
Safeguards,
or no adverse consequences Countermeasures
Expected
Events/Risks
Undesired Aircraft State
Violations,
Communication,
 Aircraft deviation or incorrect configuration
Procedural,
associated with a clearProficiency,
External reduction in safety
marginsError Decision Recovery to
Recovery to Safe Flight

Error-management
 Effective undesired state management
behaviors (avoid, trap, contain, aircraft management
fail to respond)
Additional Error
 Additional error(s) requires further error Additional Additional
management behaviors error error
 Exacerbation or failure to respond can result
in an incident or accident Incident
Accident

Safe Flight Undesired
aircraft
Outcomes Inconsequential state

Incident
Additional Recovery to Accident
error Safe Flight
What are some of the Crew CRM Behaviors and subsequent Outcomes in the
Aspen Accident?
Safe Flight
 ?
Inconsequential
 ?
Recovery to  ?
Safe Flight
 ?
Additional
error
Undesired
 ?
aircraft
state
 ?
Accident
Safe Flight Undesired
aircraft
Outcomes Inconsequential state

Incident
Additional Recovery to Accident
error Safe Flight
Crew CRM Behaviors and subsequent Outcomes
Safe Flight  Flight crew properly certificated & qualified; aircraft properly certified, equipped,
& maintained; the first officer obtained a weather briefing
Inconsequential  Crew crossed the FAF 100’ low, descended 300’ below the next stepdown, and
crossed the 9.5 DME fix 900’ low
Recovery to
Safe Flight
 At about 1901:53, the captain added max power (less than a second before
impact)
Additional
error
 Determination to continue with the original plan of action despite the presence
of cues suggesting the need for a modified course of action
Undesired
aircraft
state
 High descent rate (GPWS sink rate alerts) & excessive bank angle near ground
 Descent below MDA without visual contact with the runway or environment
Accident
Heinrich 2007
 The crew had received general TEM training? Safe Flight
 TEM training had been integrated into formal simulator

training? Safe Flight
 The organization had a non-punitive approach to error? Safe Flight
 The crew had applied CRM training?

 Active sharing of concerns & ideas
 Limitations of human performance
 Threat and error recognition
Safe Flight
 Error avoidance
 Error management strategies
 The crew had learned and practiced techniques to apply in
specific situations?
Safe Flight
Heinrich 2007
Gulfstream III - Aspen, Colorado
March 2001
* Eighteen Fatalities
NTSB Findings
 Procedural Errors
 Poor Crew Coordination
 Time Pressures
 Passenger Expectations
Latent External Crew TRM/CRM CRM Outcomes
Threats & Errors
Errors Additional
“Oh, really!”
error
PAX to FA:
YES Captain :
“Can I ride
Reminds PAX
on the Safe Flight
about 3 MAs
jumpseat?”
and Safety #1!
No sterile Additional
FA to PAX: error
“Would anyone No! cockpit
like to ride on Captain:
the jumpseat?” “Please,
flight issues Safe Flight
only!”
Additional
First officer
error
hesitant to
challenge
captain First officer:
“You’re too low! Safe Flight
Let’s miss!”
Captain Additional
error
determined
to land Captain:
“3 MAs! Let’s Safe Flight
plan for MA!”
Safe Flight
Heinrich 2007
Threats & Errors
Errors Additional
“Oh, really!”
error
PAX to FA:
YES Captain :
“Can I ride
Reminds PAX
on the Safe Flight
about 3 MAs
jumpseat?”
and Safety #1!
FA to PAX: error
only!”
Additional
First officer
error
hesitant to
challenge
Let’s miss!”
Captain Additional
error
determined
to land Captain:
plan for MA!”
Safe Flight
Incident
Accident
Heinrich 2007
Threats & Errors
Errors Additional
“Oh, really!”
error
PAX to FA:
YES Captain :
“Can I ride
Reminds PAX
on the Safe Flight
about 3 MAs
jumpseat?”
and Safety #1!
FA to PAX: error
only!”
Additional
First officer
error
hesitant to
challenge
Let’s miss!”
Captain Additional
error
determined
to land Captain:
plan for MA!”
Safe Flight
Heinrich 2007
Threats & Errors
Errors Additional
“Oh, really!”
error
PAX to FA:
YES Captain :
“Can I ride
Reminds PAX
on the Safe Flight
about 3 MAs
jumpseat?”
and Safety #1!
FA to PAX: error
only!”
Additional
First officer
error
hesitant to
challenge
Let’s miss!”
Captain Additional
error
determined
to land Captain:
plan for MA!”
Safe Flight
Heinrich 2007
Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Questions?
Durwood
Durwood Heinrich,
Heinrich, Ph.D.
Ph.D.
Backup Slides
TEM Take-Aways
• TEM does not replace CRM; rather, CRM is the

foundation of an effective TEM program
• Keys to using TEM and the automated flightdeck:
– Identify automation threats
– Develop automation strategies
– Verbalize, verify, and monitor!
– Treat interruptions as “red flags”
• “What gets measured gets managed”
– Utilize check airmen, observers (LOSA), FOQA
– Record best practices
– Track progress
– Revise procedures and processes
Heinrich 2007
TEM Take-Aways (continued)
• Encourage good communication

– Make sure everyone is “on the same page” (good CRM!)
– Discourage the “Hint and Hope” syndrome (dropping a
subtle hint, hoping the other person will get the
message)
– Communicate anything that can reduce your ability to
detect errors or anything that can increase your chance
of making errors
– Statistically, better communication = fewer errors
• Follow SOPs:
– Crews who fail to follow SOPs are twice as likely to
commit subsequent errors
• “Buy time” for your crew – pause to properly
assess the situation, develop strategies, and
make informed decisions
Heinrich 2007
Organizations that have a proactive safety culture…
Understand that…
 …aviation professionals are human and therefore
prone to error
 acceptance of vulnerability is the first step in
taking responsibility and avoiding risk-taking
behaviors
 detecting, reducing, and containing human errors
are the most effective ways of improving safety
 it is important to have incident reporting
programs that are confidential and non-punitive
Heinrich 2007
Understand that…
 … adherence to SOPs can greatly reduce the
opportunities for accidents and incidents
 internal and external audits are critical to
safety “health”
 risks can most times be mitigated by risk-
compensation
 when risk compensation cannot be
accomplished, alternatives must be found
that provide adequate margins of safety
Heinrich 2007
Understand that…
 …safety is an attitude on and off the job
 safety can be proactively managed, i.e., all
accidents and incidents can be prevented
 all operating exposures can be safeguarded;
barriers must be erected and maximized
 safety comes from proper decision-making,
usually a product of good CRM, MRM, or TRM
 safety should be continually recognized and
re-enforced
Heinrich 2007
Understand that…
 …both management and employees are
responsible for avoiding accidents and
incidents
 employees must be trained and given the
tools/resources to work safely – i.e., there
should be no incentives to take short cuts or
break the rules
 prevention of personal injuries is a product of
caring, but it is also good business
 working safely and responsibly should be a
condition of employment
Heinrich 2007
Latent External Crew CRM CRM
Errors
Organizational
System
Professional
Safeguards,
Countermeasures
Expected
Communication,
Procedural,
Error-management
fail to respond)
error error
Incident
Accident

Questions?
Durwood
Durwood Heinrich,
Heinrich, Ph.D.
Ph.D.

Tem Ba 10-07

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Flight Safety Foundation

CAC Workshop Oct. 17, 2007

* Adapted from Helmreich, 2003

* Adapted from Helmreich, 2003

* Adapted from Helmreich, 2003

* Adapted from Helmreich, 2003

* Adapted from Helmreich, 2003

Threats = Red Flags!

Flight Safety Foundation, 2006; Adapted with permission.

The Crew usually makes the last mistake!

Strategies/Countermeasures are employed…

 Awareness and anticipation are important

 Successful Threat and Error Management results in

 to obtain an understanding of how to

 The primary key to a successful mission outcome

* Adapted from Helmreich, 2003

* Adapted from Helmreich, 2003

What are some of the Latent Threats in the

Some of the Latent Threats in the Aspen Accident

Some of the Latent Threats in the Aspen Accident

 Company Standard Operating Procedures

 …Utilized Corporate Flight Operations Quality

 Had an effective Safety Management System

 Conducted Line Operational Safety Audits

 Conducted confidential surveys? Safe Flight

 Regularly performed training evaluations? Safe Flight

 Redesigned policies, procedures, tasks, and

* Adapted from Helmreich, 2003

Threats & Errors

What are some of the External Threats &

Threats & Errors

Some of the External Threats and Errors

 The flight attendant had recognized the

passenger of an organization sterile cockpit

* Adapted from Helmreich, 2003

Crew Errors Communication,

What are some of the Crew Errors in the

Crew Errors Communication,

Some of the Crew Errors

Crew Errors Communication,

Some of the Crew Errors (continued)

 The crew would have briefed and planned on

 The crew would have abandoned their

 The crew would have altered their thinking

* Adapted from Helmreich, 2003

What are some of the TRM/CRM Behaviors in the Aspen Accident?

Some TRM/CRM Behaviors

to land when they were unable to see the

 The crew had executed a missed approach

Recovery to Safe Flight

* Adapted from Helmreich, 2003

Outcomes Inconsequential state

Outcomes Inconsequential state

Crew CRM Behaviors and subsequent Outcomes

 TEM training had been integrated into formal simulator

 The organization had a non-punitive approach to error? Safe Flight

 The crew had applied CRM training?

* Adapted from Helmreich, 2003

• TEM does not replace CRM; rather, CRM is the

• Encourage good communication

* Adapted from Helmreich, 2003

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