Threat and Error Management
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Threat and Error Management
Having recently attended a TEM course I am at a loss to see what all the fuss is about. It seems to be just a re-packaging of Flight Planning and monitoring/cross-checking/briefing. Old wine in new bottles or have I missed the point?
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Leopold
Nope you haven't missed the point. I thought exactly the same, but i guess thats how PhD's make their name/money. Its like every year at christmas, you get socks! Different colour, different packaging, but they're still socks.
Nope you haven't missed the point. I thought exactly the same, but i guess thats how PhD's make their name/money. Its like every year at christmas, you get socks! Different colour, different packaging, but they're still socks.
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When I was working as a pilot, like both of you, I thought that TEM was just another generation of CRM. However, I’m currently undertaking postgraduate study in human factors and I can understand the difference. Put simply, TEM was a framework for identifying deficiencies and strengths within the operational area of an organization, with CRM as a set of countermeasures. Now, TEM is being applied to the flight deck and used as a tool for increasing situational awareness, or what we think of as that illusive and indefinable quantity of ‘airmanship’. It has proven to be a very useful tool, and there is a lot of empirical evidence to back up its claims. So give it a chance and you might be surprised 
A problem to be avoided is that TEM, or at least TEM training, could turn out like CRM training, where each person, operator, culture, etc, makes his or her own interpretation of its content and application.
Where a restrictive regulatory definition of CRM is used, TEM might be viewed as another bolt-on such as ‘Aeronautical Decision Making’ to support or make good the shortfall in the cognitive aspects of CRM. Alternatively, the error management aspects of TEM could be introduced independently as the 5th generation CRM.
The situation is not aided by the ICAO view – TEM as an overarching concept of safety. Whilst at the highest levels this is correct, an operator has to separate the organizational aspects of an SMS (audit, data, culture, reporting) and the much needed sharp-end operational defences represented to-date by CRM, airmanship, leadership, etc.
A problem with the ICAO view (now being taken up by FAA, AC 120-90) is that the University of Texas led concept, intertwines the high level view of TEM and the specifics of LOSA, (an audit) with other items of a SMS (too much of a hard sell), but it only provides the operator/individual with a theoretical model of TEM (a process). There is no ‘what and how’ content for a training programme. There is some insight in the ICAO HF Training Manual Doc 9683, chap 2, ‘CRM’ (revised 2003); where the 5th generation CRM and the TEM model are used together, and the guidance for training suggests integrating TEM into CRM training – “CRM is the training tool to achieve the objective of TEM”. Yet elsewhere ICAO states that TEM is not CRM; confused? Perhaps in recognition of the muddled situation the UT has written a further paper titled An introduction to TEM.
A much more practical approach stems from an Australian study of Error Management Training.
I prefer a simpler view still. The threat aspects of TEM can be likened to a personal SMS; by use of self audits during preflight, in-flight, and always of your thoughts. This can be related to situation awareness and monitoring; Scan - Plane, Path, People (PPP).
Error management (defenses) should be aligned with the principle instigators of error – poor attention for slips and lapses, or mistakes in intended action. For problem solving mistakes involving intended actions, the errors come from a poor plan, or inappropriate choice of action.
Attention defenses are strengthened with behavior training, i.e. aspects of CRM.
Problem solving involves situation awareness, decision making, knowledge (experience), and judgment, which are key components of airmanship.
Violations, intended action other than willful intent, also require behavioral training and SMS input to check or provide appropriate procedures.
Simpler still … TEM could be seen as teaching pilots to think!
Will964 Evidence? TEM proven to be a very useful tool? I have yet to see anything meaningful, will you please elaborate.
Where a restrictive regulatory definition of CRM is used, TEM might be viewed as another bolt-on such as ‘Aeronautical Decision Making’ to support or make good the shortfall in the cognitive aspects of CRM. Alternatively, the error management aspects of TEM could be introduced independently as the 5th generation CRM.
The situation is not aided by the ICAO view – TEM as an overarching concept of safety. Whilst at the highest levels this is correct, an operator has to separate the organizational aspects of an SMS (audit, data, culture, reporting) and the much needed sharp-end operational defences represented to-date by CRM, airmanship, leadership, etc.
A problem with the ICAO view (now being taken up by FAA, AC 120-90) is that the University of Texas led concept, intertwines the high level view of TEM and the specifics of LOSA, (an audit) with other items of a SMS (too much of a hard sell), but it only provides the operator/individual with a theoretical model of TEM (a process). There is no ‘what and how’ content for a training programme. There is some insight in the ICAO HF Training Manual Doc 9683, chap 2, ‘CRM’ (revised 2003); where the 5th generation CRM and the TEM model are used together, and the guidance for training suggests integrating TEM into CRM training – “CRM is the training tool to achieve the objective of TEM”. Yet elsewhere ICAO states that TEM is not CRM; confused? Perhaps in recognition of the muddled situation the UT has written a further paper titled An introduction to TEM.
A much more practical approach stems from an Australian study of Error Management Training.
I prefer a simpler view still. The threat aspects of TEM can be likened to a personal SMS; by use of self audits during preflight, in-flight, and always of your thoughts. This can be related to situation awareness and monitoring; Scan - Plane, Path, People (PPP).
Error management (defenses) should be aligned with the principle instigators of error – poor attention for slips and lapses, or mistakes in intended action. For problem solving mistakes involving intended actions, the errors come from a poor plan, or inappropriate choice of action.
Attention defenses are strengthened with behavior training, i.e. aspects of CRM.
Problem solving involves situation awareness, decision making, knowledge (experience), and judgment, which are key components of airmanship.
Violations, intended action other than willful intent, also require behavioral training and SMS input to check or provide appropriate procedures.
Simpler still … TEM could be seen as teaching pilots to think!
Will964 Evidence? TEM proven to be a very useful tool? I have yet to see anything meaningful, will you please elaborate.
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TEM and the real world
I found this on a previous thread (thank you Messiah), seems to more practical. As you say one of the main problems is untangling the academics theorising in order to be able to extract real - world practical advice ie "OK understand the reasoning but what do we do?".
" 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."
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."
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ALF5071H,
Thank you for your informative post! Could you give me an example of how your airline or how other worldwide airlines have implemented TEM recognition.
i.e. What are your briefing procedures, checklists and SOP's regarding TEM.
Much appreciated!!!
Thank you for your informative post! Could you give me an example of how your airline or how other worldwide airlines have implemented TEM recognition.
i.e. What are your briefing procedures, checklists and SOP's regarding TEM.
Much appreciated!!!
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.
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.
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alf507h - I must admit that the empirical evidence I was alluding to relates to TEM within the context of LOSA.
You seem to have a very good understanding of the issues currently facing the practical implementation of TEM. But surely when you suggest that pilots “allocate a value or credibility to components of a situation” and then go on to suggest that “At the appropriate time, these values have to be balanced to provide the best choices for action based on the understanding of the situation”, what you are in essence describing is a prescriptive analytical approach to decision making/situational assessment, and a model that I thought we had all moved away from some time ago?
I would definitely agree with you regarding the implementation of a TEM based incident reporting system, as has been done by several US airlines. Whereby individuals report on incidents, describing the threats that were present, the errors that may have been made, how the event was handled, and how the event may have been avoided or managed better. This form of reporting also provides valuable additional data on the ongoing efficacy of any TEM strategy/CRM training, but very much relies on the concept of a ‘just culture’.
Anyway, it’s certainly an interesting area and there is no doubt the TEM has merits. It’s just a shame it’s such an illusive concept to meaningfully implement!
You seem to have a very good understanding of the issues currently facing the practical implementation of TEM. But surely when you suggest that pilots “allocate a value or credibility to components of a situation” and then go on to suggest that “At the appropriate time, these values have to be balanced to provide the best choices for action based on the understanding of the situation”, what you are in essence describing is a prescriptive analytical approach to decision making/situational assessment, and a model that I thought we had all moved away from some time ago?
I would definitely agree with you regarding the implementation of a TEM based incident reporting system, as has been done by several US airlines. Whereby individuals report on incidents, describing the threats that were present, the errors that may have been made, how the event was handled, and how the event may have been avoided or managed better. This form of reporting also provides valuable additional data on the ongoing efficacy of any TEM strategy/CRM training, but very much relies on the concept of a ‘just culture’.
Anyway, it’s certainly an interesting area and there is no doubt the TEM has merits. It’s just a shame it’s such an illusive concept to meaningfully implement!
Last edited by Will964; 26th Apr 2007 at 04:52.
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Practical Tips for TEM
Thanks to alf507h and will964 for those very illuminating posts. If you are willing to share I would be very interested in any training material that you produce. I currently teach the TEM theory then follow up with a practical exercise consisting of a real Heli tasking form, other background information and a weather forecast. The group then has to identify the threats and errors and suggest practical strategies to minimise the threats and CRM skills to cope with the errors. This is followed by a case study in which the group has to look at an incident using the TEM framework. The biggest practical application is that it has made us look more closely at our "routine" briefs and really think ahead in a more structured way.
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TEM
If SOP's are part of the TEM and the suggestion is to look at things and analyse -have i done everything-lets recheck etc, then surely it goes against the grain of having standard departure(emergency) briefs(sop's being part of TEM)
I have listened to briefs rattled off by both experienced and in-experienced pilots-iaw sop's.Is there any real understanding of what they have just said, or it just relaying ver batum the brief they have learnt because it is in the sops?The inference is that the sop's are right and if you stick by those then it will all be ok-WRONG.
Sop's in my mind are there as a guideline to keep everything standard-to reduce the posibilty of errors-dont get me wrong-i stongly believe in them, but i think too much emphasis is put on them, as to them being right.TEM is inferring that we question and re-question-to that end,this automotive rattling off and blindly following sop's has got to be wrong?!!!The cavait of deviating from sop's in the interest of safety would suggest that we just blindly accept that whoever wrote the sop's has got it right!
What i'm trying to say-probably not very well-is that TEM is about questioning/checking and then going over it all again(incorporating sop's,discipline,crm,planning etc)to reduce the errors creeping in and being able to recognise them, but it seems to be contradicted by falling into the trap of routine-beit briefs ,planning, sop's.
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chinny
I have listened to briefs rattled off by both experienced and in-experienced pilots-iaw sop's.Is there any real understanding of what they have just said, or it just relaying ver batum the brief they have learnt because it is in the sops?The inference is that the sop's are right and if you stick by those then it will all be ok-WRONG.
Sop's in my mind are there as a guideline to keep everything standard-to reduce the posibilty of errors-dont get me wrong-i stongly believe in them, but i think too much emphasis is put on them, as to them being right.TEM is inferring that we question and re-question-to that end,this automotive rattling off and blindly following sop's has got to be wrong?!!!The cavait of deviating from sop's in the interest of safety would suggest that we just blindly accept that whoever wrote the sop's has got it right!
What i'm trying to say-probably not very well-is that TEM is about questioning/checking and then going over it all again(incorporating sop's,discipline,crm,planning etc)to reduce the errors creeping in and being able to recognise them, but it seems to be contradicted by falling into the trap of routine-beit briefs ,planning, sop's.
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chinny
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Simpler still would be not having to "think". . .
alf5071h: "Simpler still … TEM could be seen as teaching pilots to think!"
The correct system design philosophy should include VOICE generated commands, that in this case would complement the cabin altitude warning horn. "...beep...beep...beep...don oxygen masks...beep...beep...beep...don oxygen masks..." It's so simple it's almost stupid, but it would have saved the day for these pilots, cabin crew and passengers. A voice generated warning precludes the necessity of having to think; reaction would be instant and instinctive.
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Identifying Red flags
Cool thread guys.
I believe TEM has taken CRM to a higher ( call it 5th generation ) level.
Combined with Error Management training it is more practical.
Identifying the " Red flags " threats combined with error management is a very powerful training tool.
A threat could be a beautiful flight attendant who comes in to the cockpit below 10,000.
Her (or him ) distracting you may cause you to make an error.
A pre action awareness can get it out there on the " radar "
Trapping threats and errors can stop the error train, I call it.
I believe TEM has taken CRM to a higher ( call it 5th generation ) level.
Combined with Error Management training it is more practical.
Identifying the " Red flags " threats combined with error management is a very powerful training tool.
A threat could be a beautiful flight attendant who comes in to the cockpit below 10,000.
Her (or him ) distracting you may cause you to make an error.
A pre action awareness can get it out there on the " radar "
Trapping threats and errors can stop the error train, I call it.
chinny, I agree with your points about the hazards of ‘standard’ briefings and the incorrect implementation of SOPs. We must avoid complacency associated with standard or routine operational behaviors. I also agree with the principles of checking / questioning – if you determine the appropriate question for a situation (question yourself), then where the ‘answer’ is obvious, situation awareness, decision making, etc follow naturally.
Flexibility, a way of avoiding complacency, starts with a good briefing (the plan); this requires experience and skill – abilities that have to be acquired. There should never be a ‘standard brief’; TEM requires that the unusual (difference) is correctly identified and then related to the safety of the operation. Every flight – taxi, take off, climb, etc will be different; route, weight, speeds, weather; all or any one of these are components of the situation, and thus can provide a threat or opportunity for error. The skill in briefing is to identify the differences and relate them to the planned operation and the expected situations, i.e. create a plan against which each stage of flight can be checked at a later time. The check provides the opportunity to detect, avoid, or respond to emerging threats and errors.
Generally, SOPs are restricted to a narrow range of situations, often just one case. Thus, the identification (understanding) of the situation is a vital TEM activity (does the SOP apply here?). SOPs should not be followed blindly; they provide guidance for action based on current understandings, the generation of options, and careful judgment. Many of the perceived problems with the use of SOPs originate with their content or format; their production may not have been well thought through – well tested in foreseeable situations; thus there is a need for the working level to be involved – to provide feedback about SOPs.
GlueBall, I agree that in the situation encountered by the Helios crew, the design of the warning system was poor, but it is similar to that in many aircraft types. Yes, the system could (should) be improved, but when balanced against many occasions when it has been correctly identified, then the specific of issues applying to Helios should also be considered. Some are discussed in Past the edge of Chaos. Not every cabin high-altitude alert requires the use of oxygen, but they all require assessment - thinking.
I disagree with your view about thinking being a dangerous waste of time.
How we should think, the processes (the types of thinking) that make up the concept of ‘thinking’, depend on the situation. Retaining control of our thinking is a vital activity (an extension of staying in control of the situation). This is the basis of mainstream theories of behavior – skill, rule, or knowledge based activity.
In critical time-limited situations, skill based behavior relies on subconscious thought. We act apparently without thinking, quickly and usually accurately. However, this is based on training and education – previous thoughts and embedded memories. This is the basis of a skill that gives humans unique abilities in well-known, well practiced situations. However, in unfamiliar situations care must be taken to avoid responding incorrectly (error) – we should switch to conscious thought (behavior - direct your attention to ...) and check that the situation is understood. Apparently, the Helios crew did not do this.
Whilst most ‘stick and throttle’ activities are ‘subconscious’ skills, there are only be a few non normal / emergency situations that require skill based thinking and action – RTO (if acting on a call), EGPWS, Windshear, and ACAS maneuvers. Most other warnings occur in situations that enable time for more considered thought (usually with reference to checklists or SOPs). Thus, it is the correct identification of the situation that drives our thinking – focus of attention, analysis, recall from memory, judgment, etc, and provides some degree of error checking – self monitoring, cross monitoring. With incorrect thinking – poor control or behavior can result in hazardous situations, but the use of the appropriate mode of thinking for the situation is never a waste of time and is the most valuable TEM resource that we have.
Flexibility, a way of avoiding complacency, starts with a good briefing (the plan); this requires experience and skill – abilities that have to be acquired. There should never be a ‘standard brief’; TEM requires that the unusual (difference) is correctly identified and then related to the safety of the operation. Every flight – taxi, take off, climb, etc will be different; route, weight, speeds, weather; all or any one of these are components of the situation, and thus can provide a threat or opportunity for error. The skill in briefing is to identify the differences and relate them to the planned operation and the expected situations, i.e. create a plan against which each stage of flight can be checked at a later time. The check provides the opportunity to detect, avoid, or respond to emerging threats and errors.
Generally, SOPs are restricted to a narrow range of situations, often just one case. Thus, the identification (understanding) of the situation is a vital TEM activity (does the SOP apply here?). SOPs should not be followed blindly; they provide guidance for action based on current understandings, the generation of options, and careful judgment. Many of the perceived problems with the use of SOPs originate with their content or format; their production may not have been well thought through – well tested in foreseeable situations; thus there is a need for the working level to be involved – to provide feedback about SOPs.
GlueBall, I agree that in the situation encountered by the Helios crew, the design of the warning system was poor, but it is similar to that in many aircraft types. Yes, the system could (should) be improved, but when balanced against many occasions when it has been correctly identified, then the specific of issues applying to Helios should also be considered. Some are discussed in Past the edge of Chaos. Not every cabin high-altitude alert requires the use of oxygen, but they all require assessment - thinking.
I disagree with your view about thinking being a dangerous waste of time.
How we should think, the processes (the types of thinking) that make up the concept of ‘thinking’, depend on the situation. Retaining control of our thinking is a vital activity (an extension of staying in control of the situation). This is the basis of mainstream theories of behavior – skill, rule, or knowledge based activity.
In critical time-limited situations, skill based behavior relies on subconscious thought. We act apparently without thinking, quickly and usually accurately. However, this is based on training and education – previous thoughts and embedded memories. This is the basis of a skill that gives humans unique abilities in well-known, well practiced situations. However, in unfamiliar situations care must be taken to avoid responding incorrectly (error) – we should switch to conscious thought (behavior - direct your attention to ...) and check that the situation is understood. Apparently, the Helios crew did not do this.
Whilst most ‘stick and throttle’ activities are ‘subconscious’ skills, there are only be a few non normal / emergency situations that require skill based thinking and action – RTO (if acting on a call), EGPWS, Windshear, and ACAS maneuvers. Most other warnings occur in situations that enable time for more considered thought (usually with reference to checklists or SOPs). Thus, it is the correct identification of the situation that drives our thinking – focus of attention, analysis, recall from memory, judgment, etc, and provides some degree of error checking – self monitoring, cross monitoring. With incorrect thinking – poor control or behavior can result in hazardous situations, but the use of the appropriate mode of thinking for the situation is never a waste of time and is the most valuable TEM resource that we have.
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Thinking?
I agree that a major failing in the Helios accident was a poorly designed warning system. There are quite a few similar 737 incidents on the books (Aer Lingus and Ryanair) with the same root cause, in one of those it was the cabin crew who saved the day. However, I can't agree that teaching pilots not to think is the way ahead!
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CRM/TEM is focused on operating philosophies which assume that pilots have significant experience and training, and a good command of the English language. But in the real world that is no longer valid. Nowadays copilots with 500 hours are sitting in the right seat of sophisticated wide body jets. For some, the B747, in fact, has become their primary trainer.
Add to that the effects of globalization: Chinese captain mixed with Philippine copilot and Tunesian captain and Malaysian copilot, all together as augmented crew, flying together long haul across many third world countries where many air traffic controllers possess no more than a 200 word English aviation vocabulary. Any conversation or phrase "outside the box" can pose a communications challenge. Because rudimentary English as the second language in many instances will compel them to mentally translate the English conversation into their mother tongue and to think and to make sense of it in their native language and culture.
Many years ago when Kentucky Fried Chicken set up shop in China, their slogan "It's Finger Licking Good" couldn't exactly be translated into Mandarin with the same meaning. The closest translation was: "It's so good that you lick your fingers." The biggest problem in aviation is communications; speaking, understanding and comprehending the English language in non English speaking cultures.
Airplane operating design logic must become even more simpler and more automated with multiple layers of fail safe system redundancies. System problems must be displayed visually and simultaneously announced aurally with voice generated alerts, . . . all this to shorten the pilots' decision making process and thinking time!
Add to that the effects of globalization: Chinese captain mixed with Philippine copilot and Tunesian captain and Malaysian copilot, all together as augmented crew, flying together long haul across many third world countries where many air traffic controllers possess no more than a 200 word English aviation vocabulary. Any conversation or phrase "outside the box" can pose a communications challenge. Because rudimentary English as the second language in many instances will compel them to mentally translate the English conversation into their mother tongue and to think and to make sense of it in their native language and culture.
Many years ago when Kentucky Fried Chicken set up shop in China, their slogan "It's Finger Licking Good" couldn't exactly be translated into Mandarin with the same meaning. The closest translation was: "It's so good that you lick your fingers." The biggest problem in aviation is communications; speaking, understanding and comprehending the English language in non English speaking cultures.
Airplane operating design logic must become even more simpler and more automated with multiple layers of fail safe system redundancies. System problems must be displayed visually and simultaneously announced aurally with voice generated alerts, . . . all this to shorten the pilots' decision making process and thinking time!
