Intro to Threat &
Error Management
Welcome
Accident Causal Factors Over Time
Human Causes
Machine Causes
Time
The Tip of the Iceberg
The Tip of the Iceberg
What is
happening
here?
What is CRM?
Effective use of all
resources, to achieve the
highest possible level of
safety and efficiency.
(Transport Canada)
Continental Airlines
RESIST
HARDWARE & SOFTWARE THAT
EXISTS BEFORE THE HUMAN ENTERS
RESOLVE
WHAT THE HUMAN BRINGS TO THE SYSTEM
What’s a Threat?
Anything that
increases
operational
complexity
Example Threats
Distractions
Passenger Events
Cabin Crew
ATC
Terrain
Weather
Similar Call Sign
Maintenance
Time Pressures
Ground Crew
Flight Diversion
Heavy Traffic
System Malfunction
Unfamiliar Airport
Automation Event
Missed Approach
What’s the Threat?
ICAO
Northwest Airlines
Undesired
Aircraft State
Trap:
Managing Error
Avoid Error:
Managing Threats
Layered System of Defenses
Threats
TEM Toolkit
Case Study
What we did at NWA
What we did at NWA
Recurrent Training CBT
What we did at NWA
Instructor Briefing Guides
What we did at NWA
Briefing Room Posters
What we did at NWA
7-hole cards to all
5500 pilots
• Mailbox
• Briefing Rooms
• Jumpseat Handout
• Lounges
7-hole cards
What we did at NWA
Video Training & Scenario
Integrating Threat & Error Management
Flight Standards
Line checks to reinforce threat recognition, error avoidance and
management
Flight Operations
Review/revise SOPs and policies
Safety
Error reporting system (ASAP) for data
Safety Programs (HF, FOQA)
Ongoing QA Audits
Training
Threat recognition & error avoidance and management
Captain Leadership
Focus on technical and procedural excellence
More Info…
WATS
Thanks
Darren Smith
www.cfidarren.com
813-503-3322