Anti-Skid Inop – how to implement TEM ?
I am not certain that I can answer the question adequately; I am not with an airline and I do not have any specific information about those which might have implemented TEM.
I am researching TEM – well actually trying to create presentations and notes that explain the operational concept, process, and content, and in doing so identify what should be implemented. The teaching would be up to each operator; I suspect that many aspects of TEM, like CRM, will be ‘culturally adjusted’.
As I indicated previously, the ICAO approach to TEM may be confusing. The muddle continues with conferences that amalgamate
TEM and LOSA. Many of the operators who report on ‘so-called’ LOSA programmes actually relate to audits or line-checks that are normal practice elsewhere. LOSA provides an increasing database of error, which perhaps is to be expected – humans will make errors and if you go looking for them, you will find them. However, the error type, situation, detection, and management outcome data is interesting (particular application to each operator), but generic data and ideas behind the causes can be found in several text books, and data alone is not the answer.
The ICAO conference presentations on TEM tend to follow the ICAO / UT model – threats, errors, and undesired states; - avoid (detect), manage / mitigate, but without any ‘how to’. They only provide a description of the process. They give many examples of specific operational threats, but the list is endless – every situation has its own threat, thus TEM training / implementation in this area must provide a generic solution. And perhaps the largest threat is one’s self – the way in which we think.
Situations provide opportunity for error; humans ‘make’ the error, thus TEM must consider both situation awareness (human perception), and human behavior in the situation.
For some theory start with James Reason ‘Human Error’ and then look for more practical texts; not that Prof Reason doesn’t provide practical solutions:-
Combating omission errors through task analysis and good reminders.
Diagnosing "vulnerable system syndrome"
Beyond the organisational accident: the need for "error wisdom" on the frontline.
Human error: models and management.
How to? For the tangible threats, crew’s can stimulate the company SMS by using the safety reporting system – report the threats (latent factors). The SMS must communicate these threats and provide appropriate defenses (fix the system).
For the cognitive issues, I like the idea of a personal LOSA – audit yourself during flight. Ask if you have ‘seen’ the situation correctly; is the choice for a course of action the safest – why? Report any errors and the circumstances (detection and mitigation of active failures) – HF confidential reporting. This process should be reinforced with crew debriefing after every flight, if not, then encourage self debriefing – it adds to the level of experience.
Briefing is a powerful TEM tool in planning – avoid error due to a poor plan, or detect an error when a good plan is not working as expected.
Many aspects of briefing (self briefing) involve thinking. Some of de Bono’s books provide the basics, albeit somewhat tediously; the essentials are in:-
part 1, General Thinking Skills.
Briefing, and debriefing are usually structured on memory; a good memory tool is a sequence – a journey or specific events. However, many operational situations require more than a sequenced view (left brain thinking); it is necessary to get pilots to take a wider view, avoid absolutes or jumping to conclusions. Instead, allocate a value or credibility to components of a situation and check/recheck as these change (right brain thinking). At the appropriate time, these values have to be balanced to provide the best choices for action based on the understanding of the situation (decision making – preceded by situation assessment).
SOPs have a major role in TEM. Not too many, Specific, Measurable, Achievable, Relevant, and Timely (SMART). The users should ‘own’ the SOPs; safety reports are again part of this process, also audit operations to identify opportunity for violation.
Some elements of TEM: -
Planning and preparation (briefing).
Task and workload reduction (SOPs).
Self monitor, focus and maintain attention (discipline).
Scan plane, path, people; identify the unusual (situation awareness).
Monitor, and recheck, think, learn (debrief)
My aim is for practicality and integration into normal operations and training (CRM); minimum talk and chalk. The first and most critical element is to get everyone – everyone includes management, to accept that humans make (suffer) errors and that TEM is required.