Threat and error management question
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Threat and error management question
Got my ATPL Human factors exam tomorrow. Saw the following example question on another forum but couldn't find an answer anywhere.
A pilot uses an out of date chart and inadvertently flies the aircraft towards CTA, which is the error:
a) Using the out of date chart
b) Flying the aircraft towards CTA
Couldn't figure this out, would you consider the aircraft flying towards CTA as an undesired aircraft state rather than an error?
Be grateful for any help,
J
A pilot uses an out of date chart and inadvertently flies the aircraft towards CTA, which is the error:
a) Using the out of date chart
b) Flying the aircraft towards CTA
Couldn't figure this out, would you consider the aircraft flying towards CTA as an undesired aircraft state rather than an error?
Be grateful for any help,
J
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Well....
A = Threat, ie, could cause a problem
B = Error, due to A
Moral, don't use out of date anything, apart from all else it will get your butt kicked if you get a ramp check.
Thank god I have been medically taken out of this godforsaken industry and am now free to earn real money elsewhere. What happened to CDF?? 
A = Threat, ie, could cause a problem
B = Error, due to A
Moral, don't use out of date anything, apart from all else it will get your butt kicked if you get a ramp check.
Thank god I have been medically taken out of this godforsaken industry and am now free to earn real money elsewhere. What happened to CDF??
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Tricky question, ill break down my thought process for you:
The definition of Errors as per Human Being Pilot = "Actions or inactions by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations". Human being pilot also goes on to say an error can be a link in a chain of errors.
Sometimes it helps thinking to try and pick the answer that cant be wrong (if that makes sense), so based on that id argue that the out of date maps was the first error in the chain of errors which led to the a/c flying towards cta (also possibly a handling error BUT is DEFINATELY a UAS). So since the a/c flying towards CTA is definately a UAS then the only other answer would be taking the outdated maps (which is a procedural error).
The definition of Errors as per Human Being Pilot = "Actions or inactions by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations". Human being pilot also goes on to say an error can be a link in a chain of errors.
Sometimes it helps thinking to try and pick the answer that cant be wrong (if that makes sense), so based on that id argue that the out of date maps was the first error in the chain of errors which led to the a/c flying towards cta (also possibly a handling error BUT is DEFINATELY a UAS). So since the a/c flying towards CTA is definately a UAS then the only other answer would be taking the outdated maps (which is a procedural error).
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RED BARON you make it seem more complex than it is.
Pilot uses out of date map; Threat
Pilot inadvertently flies towards CTA; Error
Pilot flies into and busts CTA; UAS
That's my opinion.
T&G
Pilot uses out of date map; Threat
Pilot inadvertently flies towards CTA; Error
Pilot flies into and busts CTA; UAS
That's my opinion.
T&G
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Touch and go - I had been thinking along the same lines. This is what annoys me about the whole concept. Out of date charts by themselves could be considered a latent threat, but a human being using the out of date charts could be considered a procedural error. 
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I'd go with a) as using the old chart IMHO fits better with all three elements of the error definition according to the handout on TEM I found
Flying towards the CTA arguably reduces safety margins and increases the probability of an adverse event, too, but in this example it would probably be in accordance with the crew's intentions and expectations (which are however wrong because based on the outdated chart).
BTW, given that kind of questions, I can understand why the potential contribution of CRM/TEM etc. to safety is not too enthusiastically valued among many pilots. What a waste.
Error: Flight crew actions or inactions that:
• lead to a deviation from crew or organisational intentions or expectations;
• reduce safety margins; and
• increase the probability of adverse operational events on the ground and during flight.
• lead to a deviation from crew or organisational intentions or expectations;
• reduce safety margins; and
• increase the probability of adverse operational events on the ground and during flight.
Flying towards the CTA arguably reduces safety margins and increases the probability of an adverse event, too, but in this example it would probably be in accordance with the crew's intentions and expectations (which are however wrong because based on the outdated chart).
BTW, given that kind of questions, I can understand why the potential contribution of CRM/TEM etc. to safety is not too enthusiastically valued among many pilots. What a waste.
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Threat Definition = "Events or errors made by others, that occur beyond the influence of the flight crew, increase operational complexity, and which must be managed to maintain margins of safety"
Error Definition = "Actions or inactions by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations"
UAS Definition = "UAS are flight crew induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration, associated with a reduction in margins of safety"
The pilot taking out of date maps is a procedural error, the actions of the pilot taking out of date maps lead to the deviation from flight crew intention of not flying towards CTA. Also, all errors are threats.
Flying the aircraft towards CTA is a flight crew induced position associated with a reduction in margins of safety (UAS).
Furthermore, Flying the aircraft towards CTA would not be "an action by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations"... BECAUSE it is already a deviation from flight crew intentions, it was the wrong maps that LEAD to the deviations of flight crew intentions + expectations... Therefore T&G answer B) is NOT an error but a UAS...
Error Definition = "Actions or inactions by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations"
UAS Definition = "UAS are flight crew induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration, associated with a reduction in margins of safety"
The pilot taking out of date maps is a procedural error, the actions of the pilot taking out of date maps lead to the deviation from flight crew intention of not flying towards CTA. Also, all errors are threats.
Flying the aircraft towards CTA is a flight crew induced position associated with a reduction in margins of safety (UAS).
Furthermore, Flying the aircraft towards CTA would not be "an action by the flight crew that LEAD to deviations from organisational or flight crew intentions or expectations"... BECAUSE it is already a deviation from flight crew intentions, it was the wrong maps that LEAD to the deviations of flight crew intentions + expectations... Therefore T&G answer B) is NOT an error but a UAS...
Last edited by xxRED BARONxx; 6th Sep 2012 at 13:39.
A threat is an event outside of the pilots control. Placing the out of date chart on the aircraft is the threat, and it is managed by checking the date of the chart (cross checking in the case of two crew ops.)
Using the chart is an error, the error in managing the threat, and
... the result of entering controlled airspace without a clearance is an Undesired Aircraft State (UAS).
The question specifically asks about using the chart.
Using the chart is an error, the error in managing the threat, and
... the result of entering controlled airspace without a clearance is an Undesired Aircraft State (UAS).
The question specifically asks about using the chart.
The chart may be out of date, but do we know the information shown on the chart in relation to the particular CTA is out of date?
More info required.
More info required.
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Holy smokes!!!! Sorry to add nothing to yet another thread but what a load of absolute bollocks!!!!! Who cares what kind of cock up it is called. Wrong map, wrong position, whatever. It's like tossing over which blade failed in your jet engine. The outcome is the same on a stormy black night and the names etc should be a concern to someone else.
Someone needs reminding that flying aeroplanes is still a practical job. How about teaching practical application of PNR / CP, an area criticised in the ATSB report into the Norfolk ditching.
Overcomplicating this stuff leads to people learning to pass exams and leaving little brainspace for realworld application!
Time the universities got back to doing what they do best. Telling bosses when their pilots are fatigued!!!!!
Bbbbzbzbzbbzbzbzbzzbzbzzbznznzbznzn
Someone needs reminding that flying aeroplanes is still a practical job. How about teaching practical application of PNR / CP, an area criticised in the ATSB report into the Norfolk ditching.
Overcomplicating this stuff leads to people learning to pass exams and leaving little brainspace for realworld application!
Time the universities got back to doing what they do best. Telling bosses when their pilots are fatigued!!!!!
Bbbbzbzbzbbzbzbzbzzbzbzzbznznzbznzn
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Thanks for all of the input guys. Just finished the exam, passed but didn't do anywhere near as well as expected, and certainly not for lack of preparation. Is it just me or do the team at CASA go out of there way to make their questions ridiculously subjective and vague. Here are some I remember from today that I believe I got wrong based on my KDR. Would be interested to hear your thoughts. J
1/ Which of the following methods would be beneficial to improving your night vision:
a) Wearing sunglasses during the day
b) Avoiding excessive sun and snow glare during the day
c) Allowing the night vision 30 - 40 minutes for full dark adaptation
d) Eating a lot of carrots
e) Looking at objects with the peripheral rather than direct vision
f) Taking vitamin E supplements from the doctor
I chose a,b,c, and e which was apparently wrong. My only guess could be that looking "slightly off centre" is not the same as using the peripheral vision (quite subjective if you ask me).
2/ A co-pilot notices that the number 1 engine oil temperature is abnormally high on climb out. He informs the captain of the situation who gives him a thumbs up and tells him not to worry. The first officer doesn't think anymore about the problem. What dangerous attitude is evident in the first officers perception of the situation?
a) Resignation
b) Invulnerability
c) Deference
d) Impulsiveness
I originally selected a) but changed my answer to b) based on the last sentence which suggested that the problem was no longer on the co-pilots mind and he wasn't worried about it.
3/ During flight you notice that the captain appears unwell, in terms of threat and error management you have effectively.
a) Recognised a threat
b) Anticipated a threat
c) Responded to a threat
d) Recongnised an error
I selected a) which was apparently incorrect
Oh well on to the next one
1/ Which of the following methods would be beneficial to improving your night vision:
a) Wearing sunglasses during the day
b) Avoiding excessive sun and snow glare during the day
c) Allowing the night vision 30 - 40 minutes for full dark adaptation
d) Eating a lot of carrots
e) Looking at objects with the peripheral rather than direct vision
f) Taking vitamin E supplements from the doctor
I chose a,b,c, and e which was apparently wrong. My only guess could be that looking "slightly off centre" is not the same as using the peripheral vision (quite subjective if you ask me).
2/ A co-pilot notices that the number 1 engine oil temperature is abnormally high on climb out. He informs the captain of the situation who gives him a thumbs up and tells him not to worry. The first officer doesn't think anymore about the problem. What dangerous attitude is evident in the first officers perception of the situation?
a) Resignation
b) Invulnerability
c) Deference
d) Impulsiveness
I originally selected a) but changed my answer to b) based on the last sentence which suggested that the problem was no longer on the co-pilots mind and he wasn't worried about it.
3/ During flight you notice that the captain appears unwell, in terms of threat and error management you have effectively.
a) Recognised a threat
b) Anticipated a threat
c) Responded to a threat
d) Recongnised an error
I selected a) which was apparently incorrect
Oh well on to the next one
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Years ago, companies issued Route Data Cards to the pilots. A lot of pilots liked them because they were easy to use. It was determined that RDCs often contained errors: wrong frequencies, DME steps, CTA boundaries, etc, etc..
So it was recognised by the industry in the early '90s (in Australia it was the '90s... the rest of the world were already ahead of us and got rid of RDCs years before), that RDCs were actually a really bad idea! RDCs were seen for what they are- a source of Threats and Errors. As a result, RDCs were abandoned, or managed out of use.
Except for at Skywest, who were using them well into the 21st centuary and might still be using them. Remember the F100 that flew 2000' into CTA without a clearance because the lower limit of Class A was wrong on the RDC?
So it was recognised by the industry in the early '90s (in Australia it was the '90s... the rest of the world were already ahead of us and got rid of RDCs years before), that RDCs were actually a really bad idea! RDCs were seen for what they are- a source of Threats and Errors. As a result, RDCs were abandoned, or managed out of use.
Except for at Skywest, who were using them well into the 21st centuary and might still be using them. Remember the F100 that flew 2000' into CTA without a clearance because the lower limit of Class A was wrong on the RDC?
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Holy smokes!!!! Sorry to add nothing to yet another thread but what a load of absolute bollocks!!!!! Who cares what kind of cock up it is called. Wrong map, wrong position, whatever. It's like tossing over which blade failed in your jet engine. The outcome is the same on a stormy black night and the names etc should be a concern to someone else.
They think TEM is a necessity for young pilots and thus believe that up staging more threat and error management information would be beneficial to CRM!
QJB, firstly congrates on passing the exam
1) C & E, Surely wearing sunglasses and avoiding excessive sunlight/glare protects your eyes but it wouldn't really improve your night vision.
2) Leaning towards A than D would've been my second option.
3) I would've chosen D, based on the fact that it was an Error for the pilot in command (captain) to continue flying knowing he was sick..
T&G
That was a good spray, Anthill, but largely rubbish. Computer flight plans (complete with Navaid freqs) negated the need for tracks and distances on RDCs, and the rest of the world moved on from jets flying in and out of CTA.
If you reckon having a handful of maps flapping around the cockpit as the crew tried to work out if they were approaching CTA at a great rate of knots is a good idea then you need a bit of TEM training yourself.
I believe UAS has changed to UOS!
If you reckon having a handful of maps flapping around the cockpit as the crew tried to work out if they were approaching CTA at a great rate of knots is a good idea then you need a bit of TEM training yourself.
I believe UAS has changed to UOS!
Last edited by Capn Bloggs; 7th Sep 2012 at 23:54. Reason: Spelin.
Oooh! A quiz!
1. C & E, as above
2. C. The FO was concerned, but that concern was completely abrogated by the cheery by the captain. The FO is deferring to the Captain's experience.
It's not "resignation", as that would infer that he still knew it was a problem, but was resigned to the outcome.
It's not "Invulnerability", as that would mean that he still knew it was a problem, but wouldn't affect him.
It's not "Impulsiveness", as he has made a considered effort to bring it to the Captain's attention.
3. D Errors result from crew decisions. The crew are always considered as a unit - i.e. an error from the captain is not a threat to the FO. It is classified as one or the other - in this case if the captain is sick, and still operating then it is a crew error.
1. C & E, as above
2. C. The FO was concerned, but that concern was completely abrogated by the cheery
by the captain. The FO is deferring to the Captain's experience.It's not "resignation", as that would infer that he still knew it was a problem, but was resigned to the outcome.
It's not "Invulnerability", as that would mean that he still knew it was a problem, but wouldn't affect him.
It's not "Impulsiveness", as he has made a considered effort to bring it to the Captain's attention.
3. D Errors result from crew decisions. The crew are always considered as a unit - i.e. an error from the captain is not a threat to the FO. It is classified as one or the other - in this case if the captain is sick, and still operating then it is a crew error.
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Correct answers are:
1) B & C Wearing sunnies, eating carrots and vitamin supplements don't improve night vision. Looking with you peripheral vision is technique using existing night vision.
2) C Deference.The FO has defered responsibility to the captain.
3) B. You have anticipated that the captain may make errors due to being unwell or becoming incapacitated.
If you reckon having a handful of maps flapping around the cockpit as the
crew tried to work out if they were approaching CTA at a great rate of knots is
a good idea
Where did I say that ??
1) B & C Wearing sunnies, eating carrots and vitamin supplements don't improve night vision. Looking with you peripheral vision is technique using existing night vision.
2) C Deference.The FO has defered responsibility to the captain.
3) B. You have anticipated that the captain may make errors due to being unwell or becoming incapacitated.
If you reckon having a handful of maps flapping around the cockpit as the
crew tried to work out if they were approaching CTA at a great rate of knots is
a good idea
Last edited by Anthill; 8th Sep 2012 at 00:12.
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Thanks for the replies guys. Actually I'm confident that both wearing sunglasses and avoiding glare during the day improve your night vision. Something about the Rhodopsin in the rods of the eye. In any case it is drilled into you in the Bob Tait notes that both of those do improve night vision. In any case let's hope the next has some more friendly questions! Met exam next
