Multi Crew Licence & Threat and Error Management

[A37575]

Latest Australian Aviation magazine March 2007 has article on Alteon simulator training. Besides the well known PNF and PF or if you like PF and PM a new position of PO (pilot observing) is introduced to aviation lexicon. The article says:
"It is the Third Pilot's role that develops the discipline of Threat and Error Management that ICAO expects to be integrated at every stage of training for the MPL."
Can someone please explain in plain English what is this "Threat and Error" stuff the author describes? Sounds suspiciously like anti-terrorist measures stuff (hardened flight deck doors, ASIC cards, on board security guards with guns and steel capped boots etc) And why is all this stuff called a "discipline?" And what's so special about a trainee pilot who has the role of "Pilot Observing - PO, that this "Discipline" is needed to qualify him/her as PO?:8

[dodgybrothers]

next gen CRM, thats all

[hoss]

In a nutshell, Threat and Error Management(TEM) is an approach to flying that seeks to equip the pilot with the skills to recognise and counter everyday problems which, if ignored, will result in accidents or incidents.

Checkout page 51 of the latest Flight Safety Australia. TEM training is part of the Qantas group Line Auditing(LOSA/LOA). Over the last few years I've seen an increase in the terms TEM and LOSA, it's the way of the future.

:)

[Icarus53]

My understanding (and there will be many who can talk more intelligently on the subject) is that CRM describes the process, often adopted/trained/developed at company level, that allows the flight crew (and cabin crew) to deal with a particular situation as a team.

TEM on the other hand is a process by which the company as a whole reviews significant incidents, identifies potential future incidents, and then seeks to develop ways to prevent occurence/recurrence.

Although these terms get bandied around a lot, most of the time it's just doing what we would normally do using our common sense - only with a specified methodology and a gutload of authority behind it from the corporate side.

2 cents poorer - whose shout?

[No worries mate]

That's my understanding of TEM.

[A37575]

Thanks for replies. So basically it is more books to buy, more boxes to be ticked, more warm and fuzzy hand holding and a flashy certificate to pin in the log book?

[Gnadenburg]

If you have a guy with an MPL sitting next to you, he is the threat so don't make too many errors. My TEM experience flying with similar.

Regulators need to understand this and tighten up and increase requirements and recurrent training for the guy in the left hand seat. As he will be carrying the burden of a very inexperienced F/O.

[Jet_A_Knight]

raw experience is so valuable

From what i have read on some posts, apparently not to people without it! :{

[The Messiah]

The positive of TEM is that you use the word "threat". By identifying threats you reduce the chance for errors by coming up with strategies. Things like offset localisers if you get a late runway change are an example, such as JFK, or to say "once we have pulled reverse there will be no go-around".

[A37575]

A heavy landing caused by too late flare is a "threat." Noise abatement (Sydney for example)in curfew hours requiring only idle reverse thrust on landing is a "threat" in my book. Captain taxiing too fast around corners and causing FA to fall over is a "threat." ATC re-clearance for track shortening inside 20 miles causing a flurry of FMC activity and high speed gear lowering to compensate for high profile is a "threat."

Seems to me all the above facets of flying can be termed a "threat," when in fact it is all normal day to day activity with which a competent crew should have the skills to cope with. Doesn't the term "Threat and Error Management" smack of a two-bit Bollywood drama?

For years, the term CRM has spawned a lucrative cottage industry with mega bucks changing hands over CRM lectures, presentations and simulator hours, manuals and videos. And now we have spin doctors inventing TEM to start a whole new cottage industry sparking off again. Makes one wonder if we have lost plain English forever in the aviation world. Someone, somewhere, is making heaps of money out of TEM theory and practice..:ugh:

[The Messiah]

Some threats can be anticipated, like track shortening when you have been there 100 times before, and some can't.

If you think it is a load of bollocks then it was designed just for you.
Identifying threats and strategies cannot make multi-crew ops less safe that's for sure. It helps to remove the requirement to read the other guys mind.

A37575 you are quite right, the every day operation is full of threats so why not embrace TEM and help to improve it? It is not CRM with a new name it is something you would use to give a thorough descent briefing and if you do fly into places like Jakarta at night or Mumbai or JFK etc you would really benefit from its proper use.

I believe it could have been the difference for SIA at Taipei.

BTW taxying too fast causing the F/A to fall over or a heavy landing are not threats, they are errors. Proper TEM reduces the chances of identified threats leading to errors.

[Captain Stoobing]

By definition:
"A Threat is an outside influence, outside of the control of the crew causing them to modify their behaviour."

ie: Weather is outside of their control and as such they have to carry extra fuel, or divert
ie: Air traffic control not giving the crew the correct phraseology when giving an instruction, and inturn the crew have to ask for clarification on the instruction.
"An Error is caused by the crew and can either be intentional or non intentional."

ie: the crew forgot to move a certain switch at the correct time, but picked it up a few minutes later in the checklist.
ie: The crew decided to read the newspaper during cruise. ( Because it is so dangerous to do such a thing!!!!:= )

There are many sub headings under these but this gives you the general idea.
The process is worthwhile IMHO.
Capt Stoobing.

[22N114E]

Or more simply put:

Threat management is managing the future.
Error management is managing the past.

[maui]

Messiah


I believe it could have been the difference for SIA at Taipei.



I am intrigued as to just how, you consider TEM could have affected the outcome in TPE (I am presuming we are talking of the wrong runway accident)

Had the any of the crew identified the threat do you not think they would have talked about it.

If they did not talk about it, it is resonable to assume that they did not recognise it as a threat. So where does TEM help. If you want to train people on how to develop their general awareness and logically apply what if's, then that is a different story.

As someone else said, this is all stuff that comes down to common sense and is practised on a dialy basis by most competent crews. Just as CRM is largely a formalisation of methods used by most to run their environment efficiently. The people who need it are the very same ones who will not listen to it.

Another bunch of Theorists trying to extract a few more bucks by creating another parasitic industry.

Maui

[The Messiah]

TEM based briefings are focused towards identifying threats rather than the old XYZ departure crap of the past, so a TEM briefing out of TPE on that night might have gone something like, "the weather is a significant threat tonight so we need to positively identify we are lined up on the correct runway before we roll", or words to that effect.

If you read a few LOSA reports you will see how useful a tool it is.

Not so big a deal in Australia where ATC speak with the same accent, there is nosig terrain, the weather is good and traffic is light. That is what you would call a low threat environment.

[4Greens]

Good CRM cover all Threat type briefing.

[maui]

Messiah

Are you inferring that you don't positively identify your runway when weather is not bad?

Is it not an automatic procedure that goes without saying?

If a crew is trained in and has developed an attitude of awareness (airmanship), and run what if's they should already be doing that ****. Why do we have to generate a whole new industry to codify it.

Maui

[Captain Sand Dune]

Sounds similar to the bolleaux the ADF has been saddled with - AVRM.
Requires a ****e load of needless paperwork in the name of ass-covering.
Attempts (badly) to quantify "captaincy" and "supervision" to the n'th degree.
But of course if the USAF do it, it must be good............:mad:

[UnderneathTheRadar]

Maui,

You've unwittingly hit the nail on the head - "Is it not an automatic procedure that goes without saying?" didn't work for SIA that night.

Speculating of course but if someone had said it out loud then the accident would have been unlikely to have happened. The crew all either didn't think of it or did subconciously consider it but assumed that either someone else was looking after it or it was such an insignificant threat that it wasn't worth voicing.

UTR

[A37575]

or it was such an insignificant threat that it wasn't worth voicing.


Or more likely the other pilots on the flight deck were so s..t scared of questioning the captains actions (cultural mores in action) that they were not game to voice their reservations - prefering to think "it can't happen to me."

[The Messiah]

Some people fly only 2 or 3 times a month and only 1 of them as PF, and often into places they haven't been for a year or so.

Maybe you guys should read a few LOSA reports and get your head out of the sand and your egos out of the cockpit.

BTW Maui

The departure runway is 99% of the time plainly obvious but the one time it wasn't it cost 80 odd people their lives.

A37575

TEM based briefings allow junior crew members to contribute to the briefings rather than just listen to them. I am fully aware of the fear culture at SIA and TEM addresses this better than any other method around. I detect a real
"it can't happen to me" attitude from a few on this topic that's for sure.

[Tee Emm]

TEM based briefings allow junior crew members to contribute to the briefings rather than just listen to them

In the perfect world, yes. But in the words of the immortal Sir Humphrey in "Yes Minister" it would be a courageous decision indeed by a junior crew member to voice a disagreement with some senior captains during a briefing. Sometimes it pays to listen and shut up. Promotion in the airline industry depends very much on not making waves - same as the public service.:ok:

[The Messiah]

Rubbish......promotion in the airline industry is by regular attendance. Everybody gets their shot.

Haven't flown with a Captain yet who didn't say thank you after having something pointed out that he had overlooked, after all it is his career on the line. Raising an important point during the briefing is hardly disagreeing. This is exactly the mindset we need to get away from. If you feel it is important then damn well speak up. We are there to do a job not protect our job.:ugh:

[maui]

Messiah

Lets start with your last one first.

In your world it may be that everyone gets a shot. I can assure you that that is not universal. In some cultures/companies, promotion is very much influenced by the waves or lack thereof that you have generated in the past. But we digress.

I am aware that the departure runway is usually self evident, however if you adopt a procedure to apply EVERY time, like your mothers name you will not forget it. A bit likethe insanity of only pulling reverse when necessary. We had a bit of a lesson with that one didn't we.

Can you please answer the question of my original post. "how could a TEM briefing" alter the outcome of the TPE accident.
To manage a threat you must first recognise that a threat exists. Obviously these guys didn't recognise the threat, and therefore did not address it. A briefing will only address it when it has been recognised.
Hence my comment that training to recognise threats is more appropriate than training to talk about it. It used to be called airmanship and was usually developed in two ways, either going out and scareing the b'jesus out of yourself, and/or by quizzing and listening to the boring old fart in the left seat, instead of trying to oust him.
Unfortunately with the newer ways of how guy's end up in the cockpit, a lot have not had the opportunity to scare themselves enough, and because of the higher academic qualifications a lot feel that they have little to learn from those who have been there.
End result is that the traditional qualities of airmanship have been eroded to the point that in some cases it is non existent. This in turn has been reflected in some alarming FOQA revelations.

What then is a company (or the industry as a whole) to do to protect themselves within reasonable economic restraints.

"Lets invent a new course on Threat and Error Management, run everone through a course, give them a certificate, and if they do manage to bend metal, we the management (line ops and standards) can demonstrate that we have been pro active and are therefore blameless. That'll keep the regulators the insurance companies and the punters deluded."

Cynical? You bet. This is a program to deflect responsibility for a breakdown in training and standards.

I commend you for your advice about reading LOSA reports. It sounds very much like some of the advice I recieved when I did my first Auditing course about 13 years ago. It is advice I feel is still valid and still find it educational even though I have authored several hundeds of similar reports.

Anything that can be done to improve the awareness and situational analysis must be benificial to the industry as a whole and is to be applauded. However the last 25,0000 hours have convinced me, among other things, that most airmanship is learned in the cockpit, not in the classroom.

Maui

[The Messiah]

Maui
Congratulations on your 25000 hours.

I believe in TEM. It is not CRM rehashed, it is a genuine proactive attempt to increase safety and operational awareness in a multi-crew environment. By your own admission airmanship is not what it was even 20 years ago, and with more cadets and low experience pilots on the flight deck there is less experience to draw from when assessing a safe departure or arrival in a heavy jet. Simply using the word threat now has changed the emphasis away from the old "ok this a xyz departure from rwy 21 etc etc blah blah" to really looking at the big picture from a threat point of view, whether it be sig terrain or sig weather or a/c MEL's or indeed RWY works, the focus is now those elements not what we have programmed in the box.

I'm sure in Taipei they all read the NOTAMS about the RWY like we had been for 30 years, but did not verbalise it as a threat and agree on a suitable strategy to avoid stuffing it up, it really is as basic as that. The threat was not the RWY works but the weather in fact. I agree sound airmanship would have dealt with it easily enough but 99% of the accidents in the last 10 years have shown very poor airmanship so what do we do? Do we just demand better airmanship? Obviously that is not possible so TEM is the next best thing. It is certainly not going to make aviation LESS safe.

Unless you have a better idea.

P.S see my previous post as to how TEM could have helped to avoid TPE.

[maui]

Messiah
You are correct, it will not make things less safe. However it will not fix the problem, for the same reason as your assertion regards TPE is flawed.

They did not percieve a threat, so they did not see the need to brief it.

On the other hand if they had a bit of common garden airmanship that say's "when you roll on to a runway you review your environment and your departure" if done properly EVERY time, they would probably have realised something was amiss.

Get back to basics and apply "common dog f#$%"

Maui

[The Messiah]

It was a runway being used as a taxiway so appeared to them just like a runway. Poor weather made positive identification quite difficult. They didn't perceive it as a threat because their mindset wasn't about threats, they had never even heard the term "threat", but we'll have to agree to disagree on TPE.

If we can get people thinking of threats right from the start then funnily enough they will identify threats automatically. It aint rocket science. Briefings traditionally have been box ticking exercises which were designed by lawyers, whereas TEM is operationally oriented designed by pilots, and anyone with common dog f#*k as well has a slightly bigger picture which is even better.

Unfortunately its the old school who are most averse to change. The same people who couldn't take to glass cockpits or properly manage automatics which have both increased safety when used and understood correctly.

My old company had 15 mandatory items which needed to be covered in an arrival briefing which sadly encouraged people to look forward to getting it over with rather than using it for what it was for.

Yes you are correct TEM will not fix the problem, nothing will "fix" the problem, aeroplanes will continue to crash as aviation is inherently dangerous but, TEM will improve safety so long as crews are commited.

Let's just agree to disagree. Potatos and potartos.

[Captain Sand Dune]

I'm with MAUI on this one. Seems all this CRM/TEM/whatever goobledegook is no more than what used to called "airmanship". IMHO what would be more useful is promoting an environment where all crew members can feel free to speak up at any time. Then again a good captain would promote this environment as part of good airmanship.
Appears to be a case of re-inventing the wheel to me.

[aviationascent]

What is the school of thought regarding the Multi-crew Pilots Licence and employment prospects for someone in the position to do it. I have only recently discovered its existance and am in the position of being ready to become a pilot with funding ready to go after years of hard-earned savings!

I could imagine that the prospect of having a very inexperienced pilot in the RHS could be quite unnerving to say the least, and that i would be annoyed at best to see some young upstart that cannot even fly a 172 solo getting into the RHS in the airlines before me?

What I am really getting at is... should I consider it as a feesible option for getting into the airlines??

Cheers
R

[Ricky Bobby]

aviationascent, unless there is a job waiting for you, at completion you'll have a MPL and still can't fly a C172!