Part 5
Continuing the Threat and Error Management discussion......
Okay, the question has been asked,
"Why bother with the TEM model? What good is it?"
The TEM model is widely used in aviation, and it is a fundamental part of the language of aviation safety. It often is the language that is directed toward flight crews by their airlines in order to build a case for better safety practices. I am suggesting that it is also a useful tool not only for an individual pilot's safety assessment, but also as a way to engage in a dialogue back up the management chain. I am admittedly putting an unorthodox spin on TEM by raising the issue of "barriers as threats." However, sometimes when our airlines think they are creating barriers, they may actually be creating threats. By looking closely at some of the assumptions underlying many barriers, it is possible to identify these new potential threats. Once these threats are identified, steps can then be taken to mitigating those threats, perhaps by building additional barriers. Yes, there is a potential matryoshka doll type quality to this recursive analysis, but I don't it needs to be taken through too many layers.
In Part 4 of this series, I listed some questions to asked regarding the traditional barriers available to the flight crew. Perhaps you have some of your own. Those questions may lead to the identification of a threat in the guise of a barrier.
Examples of responses that raise some flags:
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- Our company SOP's emphasis on automation as a "safety" tool is causing my hand-flying skills to degrade.
- Our company's established reporting system for for operational concerns is so onerous that most pilots don't bother using it.
- Our training program's focus on standardization relies too much on rote actions, predetermined training events, and a "tick box" mentality that does not allow for the introduction of novel events that require higher order thinking. There are no attempts to induce a "startle" effect or create ambiguity.
- Our company's hierarchical structure and emphasis on the Captain's authority makes First Officers reluctant to speak up and correct the Captain when necessary.
- The First Officers I fly with know their systems, are whizzes at programming the box and have no problem with the automation, but they seem to have little "feel" for flying or having the "big picture."
- When I point out that one of our checklists has a potential trap, the response is something like, "Smarter people than you made that checklist. Just stick to it."
- We hire people from around the world, and frankly communicating with some of them outside the expected checklist responses is challenging.
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In each of these cases, one of the traditional barriers of the TEM model was hiding a potential threat. Now what?
The TEM model shows the way. Once threats are identified, the flight crew (or individual pilot) should use whatever tools available to mitigate those threats or even develop a new barrier. How the pilot mitigates the threat will depend heavily to his company's openness to dialogue as well as that pilot's personal initiative to mitigate threats as they arrive in daily operations.
On a group or organizational level this may include lobbying the airline managers and/or regulators for appropriate changes to training standards, automation policy, and operational reporting system.
Use the TEM model as a tool this dialogue. Push for enhanced training for First Officers that emphasizes their role as a proactive barrier on the flight deck, and recommend creating a forum where operational safety concerns can be freely discussed without fear of retribution. Where managements are resistant, engage with outside safety organizations or other entities that have influence. Remind managers that not all costs can be entered into a spreadsheet before the fact, but they can certainly be tallied later. Some of those costs are paid in bent metal and broken bodies.
Carry a picture of the crater left by ET302 as a constant reminder of the consequences of ignoring these issues.
On an individual level, spend some time looking at your company's safety culture and identify existing threats. If the airline will not take appropriate steps to mitigate the threat (e.g. pressure to meet schedule or contain costs overrides your specific issue), use whatever tools you have to contain the threat even if it means walking off the airplane. Brief every flight as if it were your last. If you are a Captain, make your expectations clear to your First Officers and insist that they speak up as necessary. If you are a First Officer and you have a "difficult" Captain, remember its your butt up in the cockpit, too. Use diplomacy, social skills, and/or direct language as appropriate. If your airline won't provide the training you think you need, train yourself.
Memorize the "mantra" and share it with the pilots you fly with. "Chair" flying is always available and desktop simulators are cheaper than ever. Click off the automation every chance you get. Review your procedures, memory items, and limitations regularly. Look for potential traps in those procedures and have a plan for them. If you have a concern in the cockpit, speak up! It may be nothing, it may be something. Don't assume the other person is aware of everything that you are aware of. Don't assume that you are aware of everything you need to be aware of. Get plenty of rest, and take care of your health.
Yes, it is a lot to ask, however, never forget that the pilots are usually the first ones to the scene of the accident. Our standards and expectations ought to be higher.
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"Our problem is not that we aim too high and miss, but that we aim too low and hit." - Aristotle
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