Threat and Error Management

[Gundog01]

I'm curious about how major airlines go about Threat and Error Management (TEM) training. Is this sort of thing outsourced or have most major carriers developed an in house training course.

Also interested in how threats and erros are incorporated into simulator re-currents etc with major carriers.

These questions are based around trying to introduce a more robust approach to TEM in my current organisation, and making maximum use of our simulator time.

Thanks

GD

[Enema Bandit's Dad]

Simple. Management view staff as the threats and errors! :mad:

[Skynews]

I did an in house course. Complete and utter waist of the short time I have left on is planet!

No discussion during sim exercises so far. It's one of these touchy feely subjects that may be important for newbies, one you have been around or 20 years in the industry, I don't see any value.

It covered some "terms" associated with TEM, nothing practical. As far as the company is concerned it ticked the boxes so all is well.

[framer]

It's one of these touchy feely subjects that may be important for newbies, one you have been around or 20 years in the industry, I don't see any value.


I don't agree with that statement. TEM is the nuts and bolts of being a pilot only now it has a name.
If it is explained well, younger or less experienced workers can gain a lot just by recognising that it exists. It's been formalised in my company right down to the fact that we start our briefings with the statement "Threats and considerations......" and we then say something along the lines of " Notams.....nothing to affect us, MEL's......nothing to affect us....weather, nup, beaut day...." and off we go.
My personal experience is that every now and then that process reminds us of either a notam or Mel that we would have forgotten or it makes us look closer at the atis and pick up on the fact that the wind is a bit taily or whatever, that usually reults in a discussion but more importantly it puts it into the front of the Flying pilots mind. Sometimes it even results in changing the plan, ie higher auto-brake setting or something.
Maybe once you've been around for twent years you've got that inbuilt and so it is of no personal value, but often you are working with people who are not so experienced and it is a benefit to the operation. I've done 18 years so far and have got quite a bit out of TEM. Mainly because it formalizes a process that I had developed over the years who knows, either way, it makes my flights safer.
Framer

[Skynews]

Framer,
I do agree with your comments with some variations.

TEM always had a name, it used to be Called common sense, and it is the nuts and bolts of being a pilot. The longer you are around, logically, the more you experience and hopefully you learn to recognize "threats" "errors" and you manage to avoid or handle them.
Having said that TEM should not be limited to aviation. Crossing a road, opening a can or turning on the TV all have elements of TEM in them, I may write to the education department suggesting they add it to their syllabus.
Good parents, good instructor/ training pilot would cover the TEM issues without using the term in the past and that's what's changed from my point of view, especially with the modern equipment. Pilots are taught how to manipulate the box, not manage the aircraft, and that includes TEM.

Your company sounds like they have formalized it considerably better than mine, no surprise there. Like I said, we spent a few hours learning some terms, not a practical point made.

I agree and id suggest that the younger guys may get more out of it than I did. 34 years since I started flying and I believe I have used the concept of TEM without formalizing a name for it.
It's a bit like ADHD, there has always been badly behaved children, recently some one dreamt up a name to explain it. Hasn't made it disappear though

[framer]

Hi skynews. Yeah I hear ya.
I'l tweak it a bit more though. I like to think I've always had good 'common sense' but now that it has been incorporated formally into the briefings it catches the days where I'm feeling a bit relaxed or maybe tired or whatever. Just for me personally, it has increased the likelyhood of me spotting something that needs a bit of thought. So I'm not fussed whether it's called 'common sense training' or TEM, it helps me out a bit.....and now that I think about it....probably more on the benign days than the 50kt 1200m viz nights because on those nights my senses are on full alert anyway. Have a good day mate , Framer

[Keg]

I was lucky enough to attend a Tony Kern seminar in Feb last year. One of the points he made is that the 'threat you discuss isn't going to be the one that kills you. It's the threat you don't see and discuss that is going to get you'.

[A37575]

I remember hearing of the TEM briefing introduced by a major airline. At line up the captain would be required to announce something like this. "The threat is the runway. It is damp and therefore braking efficiency may be reduced. I shall manage that threat by ensuring the automatic RTO feature is serviceable. Note the RTO disenage light is extinguished which means the threat is managed. Next threat is a CuNimb at 30 miles on the radar. I shall manage that threat by asking for radar vectors to circumnavigate the threat. Next threat is icing in the lower levels. You will manage that threat by turning on the engine anti-icing on my command."

And so on ad nauseum...:sad:

[displaced gangster]

Strongly agree with Framer,

TEM in isolation is not the "missing link" in achieving absolute safety in aviation (or any other industry). However when TEM is packaged with best practice CRM/HF skills, the risk factor inherent in aviation is greatly reduced.

For experienced pilots with exceptional situationally awareness (the reality is, that this group of pilots is not the majority) the benefits of TEM/HF training will not be as great, compared to the rest of us.

For the infidels, I am consistently amazed with the limitations of our single channel processor (our brain) in particular during high work load periods.

My thoughts are that we will see massive improvements in the quality of TEM/CRM/HF facilitators and course content in the near future.

[Capn Bloggs]

we will see massive improvements in the quality of TEM/CRM/HF facilitators and course content in the near future.
I hope so, because at the moment it is a WOFTAM, at least the one I did.

[Chimbu chuckles]

No...we will see a massive increase in the quantity...not quality...just like CRM over the last decade.

It is a load of dung which stinketh...abide ye not.

[Jack Ranga]

common sense

From what I have seen over 30 years in a number of safety critical industries, no such thing exists. It is very un-common in fact.

[Gundog01]

Thanks for the thoughts so far, please keep them coming.

Framer, interesting that your briefs commence with the TEM concept. Has your company taken TEM into the sim and looked and practical application of TEM during flight? My current employer has very good pre-flight briefing requirements although we don't address the threats and considerations so specifically more as a part of the overall mission.

I am particularly interested in how TEM is taught during SIM sessions so if anyone has practical examples please forward them on.

Cheers

[Mr.Buzzy]

TEM???......
Aeroplanes are the threat. Learn to manage them through experience and stop wasting time on more TLA jargon during the brief.

Too much jibber jabber is uncool fool.

Bbbbbzbzbzbzzzzzzz

[framer]

heh heh...jibber jabber :D

[Wally Mk2]

'Skynews' couldn't have said it better myself.

TEM 'Total Empty Mess'..........what a crock of sh1t! What the hell did we do pre all this touchy feely crap? We flew the damn plane & took responsibility for it with a well structured path of experience to the top end.
Of course there's threats & errors there was before someone invented this waste of time & they will still be there after!!! Shheeez :ugh:

The world is a nutty place now run by so called uni degree educated people:yuk:
God save us from the nutters out there!

Wmk2

[HF3000]

The reason they put TEM into the briefings is that over the years they filled the briefings with so much useless jibber jabber that on the rare occasion when there was something important to talk about in the briefing, they didn't talk about it because they were too busy talking useless jibber jabber and the other bloke had stopped listening 5 minutes ago anyway.

They're not there yet, but it's a step in the right direction. The principle should be to stop and have a little think about whether there is something new, unusual or unfamiliar that might have some effect on the operation, and might be worth having a chat about. This might include a NOTAM, an MEL, weather, terrain, unfamiliar airport, anything. If so, what are we going to do to make sure we don't fk it up? It's that simple. What it should not include is briefing useless crap like the flamin' MSA at an airport you fly to every day in radar assisted CAVOK conditions.

[Chimbu chuckles]

That I completely agree with. But the same 'They', too often, have demanded canned spiels which actually stop people thinking. Canned briefings that seek to cover every possible eventuality also guarantee your offsider will not be listening because he has heard it a million times - so he will miss the odd important bit of information. The number of times I have ended a briefing with the words "Any questions?" only to be asked something I actually emphasised in the brief:ugh:

TEM 'training' will follow the same path. It will just add to the length of the spiel. 95% of the departures I fly have no latent threats but I will be expected to spout the party line every time - examples have already been given on this thread. How can you 'Manage' 'Errors' that haven't been made yet? You have NO IDEA what errors will be made, if any, ahead of time.

The very few departure/arrivals I do fly with a 'latent threat' are very well known and understood by both pilots - a special procedure departing HKG for example - beyond reviewing that special procedure what value is there in saying "The threat to this departure is high terrain"? That is every bit as redundant as saying "The runway is long enough and wide enough..." When I hear that I want to ask "Anywhere we go that isn't?"

[haughtney1]

Have to concur with Grandpa Aerotart on this one, soooo often you hear a wrote briefing, and all you try to do is avoid going to zzzzzz, and try to look mostly interested.
IMHO, the concept is far more threat management..i.e. whats got the potential to kill us today?
Anymore indepth for the other stuff just gets lost in the white noise.
Of course however, given that I probably fly with the same guy once every 3 years or so, it is important to establish that you are on the same page....mostly we are:E

[trashie]

It concerns me when so many are ready to ridicule programs that are designed to reduce errors in aviation, particularly when over 90% of accidents and incidents are a result of human errors or violations.

Admittedly some programs are better than others but to just say it is common sense reflects the ignorance of some in our industry. What is common sense? It is totally subjective, biased and individual and reflects our individual values and beliefs, therefore it is totally variable and vague.

My understanding of threat and error management is being able to identify when conditions exist that make us more susceptible to making and error or commiting a violation (fatigue to just name one). It is also about being accountable for your actions and basing behaviour on sound principles of professionalism.

Sometimes I think the immature comments on this forum in relation to safety reflect individual biases and denial and do not reflect the professionalism we would like to portray to the community.

[Skynews]

Threat and error management is best taught in an aircraft by an experienced and capable instructor/training pilot. The current scenario of TEM designed by "degrees and PHDs" is a non sense and complete and utter waist of time.

Name 5 types of threats?
Define the term threat.
Name 5 types of errors?
Define the term error,

Well done you have pas see and are now much safer having attended this course.
BOLLOCKSWhat is common sense? It is totally subjective, biased and individual and reflects our individual values and beliefs, therefore it is totally variable and vague.

The way an individual reacts to a threat or error is not black and white either, OR is it?

[mcgrath50]

Personally I think TEM is a great way to structure something that has been done by experienced guys for years. Yes you lot who have been flying for as long as I have been alive probably do it better, more efficiently and in a more interesting way but you only got that way after many years.

As a relative new kid on the block it's given me a framework to think through that my experience lacks. It's like when you learnt to write, you had those lines to help get your letters the right size, you don't need them now, but they sure helped when you were new to it!

It also helps for the cowboys who think they don't need to do these things (either TEM or the common sense you guys are talking about). Basically everything CASA and the airlines are doing in Human Factors has come about because someone dropped the ball and it led to an accident. If we were all perfect, we wouldn't need it.

[Skynews]

As a relative new kid on the block it's given me a framework to think through that my experience lacks. It's like when you learnt to write, you had those lines to help get your letters the right size, you don't need them now, but they sure helped when you were new to it!
I think you are correct.
It used to be the norm that training pilots and CFI wherethe most experienced and capable pilots available. In the modern organization that has changed to using the "company friendly" pilots, giving them a hand up the greasy pole. With this change I have noticed a distinct change in exchange of experience. This lack of experience is being supported by theoretical courses, again taught by the inexperienced.

How many people can effectively use a weather radar these days?
Not many. They may know the theory behind it, but the interpretation is completely lacking. How do we fix it, send out a useless video and run a TEM course. problem solved.

[framer]

Well said McGrath.

The current scenario of TEM designed by "degrees and PHDs" is a non sense and complete and utter waist of time.


It may be a waist of time for you but does that mean it's a waist of time to others as well? Is it possible that while you don't easily apply the theoretical concepts to your everyday situations that others can and do?

Statements like TEM 'Total Empty Mess'..........what a crock of sh1t! and It is a load of dung which stinketh...abide ye not. and The current scenario of TEM designed by "degrees and PHDs" is a non sense and complete and utter waist of time.

remind me of something I read on the company intranet, it states "While attitudes towards CRM are not perfect predictors of behaviour, it is a truism that those whose attitudes show rejection of CRM are unlikely to follow its precepts behaviourally. These attitudes identified assessing the impact of CRM were the ones identified as playing a role in air accidents and incidents (Helmreich &Foushee, 1993).

Now before anyone gets upset because they think I am saying that they as an individual are likely to have an accident or incident, I am not, I am sure that you have ammassed a wealth of experience and skill and apply it to its best effect. I do wonder though if there is any truth in it in general. Personally I think there is because although the person who rejects the concepts is most likely very capable, they IMHO make their off-siders job more difficult by not recognising their experience levels and understanding that everyone works differently and some people do in fact get a lot out of CRM.

[Chimbu chuckles]

Do you teach this stuff trashie?:E

My understanding of threat and error management is being able to identify when conditions exist that make us more susceptible to making and error or commiting a violation (fatigue to just name one). It is also about being accountable for your actions and basing behaviour on sound principles of professionalism.

Fatigue? Mate we don't fly fatigued..who flies fatigued? Is not allowed.:= :rolleyes:

mcgrath50 all good points...but would you be better served being taught how to 'manage threats' by the experienced training captains in the airline you just joined or by a tosser with a degree and no experience?

Further to that TEM will make virtually no difference to the international accident rate because 'good' airlines already teach new pilots what they need to be thinking about, and when, and bad airlines won't bother. For 'good' and 'bad' think 1st world and 3rd world.

TEM, like CRM and Cert 4 english proficiency, won't gain any traction in those areas of the world that have most of the accidents...Africa, parts of Asia, the Middle East and South America. There are cultural factors that no amount of western theories will fix.

Make no mistake, I think the concept of TEM is fine. I merely have a problem with the application. No doubt it started life as part of the Human factors curriculum but that is where the term should have stayed. Its an answer in search of a problem.

When you give someone a formula to work to several things tend to happen,

* People try to cram in every conceivable threat or error most of which are not real threats...a TS at 20nm on departure for instance...or terrain that would only be a factor in a Twin Comanche,

* It rapidly becomes too formalised and people stop listening,

* Other stuff that maybe more important gets missed.

I go to Manila and Jakarta a lot...how long before "The threats tonight are crap ATC, ****ty runway full of soft spots and slippery, storms, bad airport signage and lots of other aircraft crewed by people who didn't/haven't/couldn't pass english proficiency" becomes redundant, meaningless noise? Every pilot in the company knows that is the case already - a new pilot joining tomorrow will be taught that on line training and experience it constantly.

Why verbalise it in a formulaic way?

[Skynews]

Framer
It may be a waist of time for you but does that mean it's a waist of time to others as well? Is it possible that while you don't easily apply the theoretical concepts to your everyday situations that others can and do?

You are not applying what I said to this discussion.

First, tell me how I apply the definition of a "threat" to an everyday situation? The "course" was a non sense.

I also said the guys who were new to the company believed they got some thingout of the course. I can't imagine hat, but hey, I accept we all learn in a different way. I also have o say, the guys that came out of the course believing they learnt something are the ones that could do with a good practical lesson on TEM in the aircraft by an experienced trainer, but they can define a threat so all is good.

[trashie]

CC

I may have something to do with facilitating this stuff (not teaching) but it comes from 40 years in the industry and not from a PhD. Human factors, error management or what ever you like to call it should not be a tick the box exercise and the most appropriate facilitators are those that have made the mistakes or seen the errors and can quote from experience. HF is also not something you cover off every two years but should be continually reinforced and preferably by the Captain and crew. What is discussed these days in the cockpit on a long haul flight? Where would you divert to now if ------?. I doubt very much if this happens often.

The 380 incident in Singapore said a lot about CRM, experience and knowledge of the senior pilots on board. With 50 or more warnings the right decisions were made by drawing on the experience available to handle a unique situation. These types of scenarios are what should be used to create a greater understanding of HF and error management.

[mcgrath50]

* People try to cram in every conceivable threat or error most of which are not real threats...a TS at 20nm on departure for instance...or terrain that would only be a factor in a Twin Comanche,

* It rapidly becomes too formalised and people stop listening,

* Other stuff that maybe more important gets missed.

I totally agree and even see this becoming a problem in flight schools and GA. The last place I flew wanted perfectly scripted takeoff safety briefs and I know that I comprehended it less than when the take off safety brief followed a framework (and covered the same points) but was more of a discussion and had each pilots own style.

I think TEM might be something that's benefits come with time. CRM seems stupid now but if you look at the change in 'gradient' (sorry to use a HF buzz word) between the LHS and RHS over the last 50 years I would imagine you would see a positive change.

[framer]

The "course" was a non sense
I think that may be a key point in this discussion. Some airlines run great courses facilitated by active line pilots with examples and scenarios coming straight from their own operation while others present outdated boring information with a 'death by powerpoint' approach that doesn't give the crews anything concrete to take onto the line with them and often comes across as condescending.

[Chimbu chuckles]

What is discussed these days in the cockpit on a long haul flight? Where would you divert to now if ------?. I doubt very much if this happens often.

We don't sit there saying in a formulaic way "If we suffer an engine failure/depressurisation/other at this point I will turn right and descend to.....and track....for an ILS approach at...." but we do, or at least I and the guys I fly with do, program something useful into FMC route 2 and the FIX pages. I saw someone do this in a different way the other day...it was an awesome idea which I will now copy...we never stop learning.

If you seek to formalise that process then it will soon become counter productive. Its like Govt picking economic winners and losers - think pink batts. They get it wrong 100% of the time because the real world (people) is too complicated to micro manage.

What happens is a management pilot (who invariably rarely if ever flies the route) decides that you must do A. Then someone else says "Ok, well then we should make them do B as well". Before you know it you have a brain dead crew flying along without a care in the world because the whole sector has been micromanaged for them.

Its fine to teach HF and TEM as part of the theory courses a pilot will study for their CPL or ATPL. Its probably good to have that formal knowledge - but then you go out to the real world and experience it in a different and more practical way.

CRM is similar. Great to learn the limitations of human communication and how to ask questions in the right way...non threatening communications, open and closed questions etc...but annual re currency? It VERY quickly becomes a box ticking exercise of very limited value and just frustrates people.

[John Eacott]

The Guild of Air Pilots and Air Navigators (Australian Region) have produced a TEM package (http://www.gapan.org.au/main/index.php?option=com_content&task=view&id=13&Itemid=29) which is still available, even though the courses ran some years ago. Designed to 'train the trainer', if anyone needs such a course they can contact [email protected]

[trashie]

Grandpa,

My grand daughter also calls me that and I melt immediately,

Back on the subject!

I am not avocating formalised "what if" type enroute training, but when I go back to my training in antiquity, our informal discussions on various airmanship topics and various scenarios provided me with a sound basis in regard to judgement, decision making and situational awareness. Technical discussions also provided me with the knowledge to make informed decisions in regard to engine and other systems problems and decisions associated with inflight emergencies. No one can envisage all emergency scenarios that may present themselves but the more knowledge that can be gained from both an operational and technical perspective will prepare aircrew to be more effective when confronted with an emenrgency situation, eg the Qantas 380.

I agree that any formalised training will become tedious and ineffective, and I have seen this when behavioural type education programs have been introduced and gradually lost their effect due to the regimentation and repetive nature of such programs (particularly in the maintenance environment).

[Gundog01]

Definately two distinct camps when it comes to these "touchy feely" topics.

I am a big believer in using all available tools to assist in reducing accidents/incidents and I believe TEM is just another of those tools we can use. It's not for everyone but neither is airline flying / military / GA etc, everyone has different needs based on their training and experience level.

For example, at my current work we regularly have 2 pilot crews with 600hrs total combined, flying twin turbo props into the flight levels and in and out of complex airpsace/CTAFs /mountainous terrain etc so i'm looking for every advantage I can give these guys to not kill themselves and other crew/passengers. If TEM gets through to just 1 person...job done.

[Two_dogs]

Gundog, is this military flying??

I cant think of any other opportunity for 2 crew 600 hrs total combined to be doing this type of flying.

[Centaurus]

My understanding of threat and error management is being able to identify when conditions exist that make us more susceptible to making and error or commiting a violation (fatigue to just name one). It is also about being accountable for your actions and basing behaviour on sound principles of professionalism

TEM also means the CVR is recording every word you say about the emotional word "SAFETY." It is all about arse covering in the event even the smallest and most inconsquential event hits the media. Lawyers for the other side will mull over every uttered word to find an angle to pin you to the floor. By announcing the words "Threat and Error Management" into the CVR and then going into minute detail of the "threat" and how you will "manage" it, gives the CVR listener the impression that you are a true professional. Your job is then secure for the time being. :D

[Gundog01]

Two Dogs :ok: