Threat and Error
Management
What is TEM?
 “Defensive flying”
ICAO and FAA
 In 2000, LOSA baseline results showed that error
management had been incorporated into everyday
operations.
 Improved checklist usage and a 70% reduction in
non-stabilised approaches.
 ICAO made LOSA the central focus of flight safety
and human factors programmes.
 TEM and LOSA recognised Worldwide.
TEM Philosophy
 Three basic concepts:
- Anticipation
- Recognition
- Recovery
 Recover first, analyse the cause later.
Threats
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May be internal or external.
They are not caused by the crew.
They increase the operational complexity of a flight.
Require crew attention and management if safety
margins are to be maintained.
What is a latent Threat?
A threat that is not directly obvious to flight crew.
Equipment design.
Threat Management - GPS
 Threats & errors
- Poor standardisation of
GPS receivers
- Poor integration with AP
- Mis-interpretation of HSI
Management
Obtain training &
practice (VMC) with
make & model
Use HDG mode when
changing any detail
In non-integ. cockpit,
double-check mode
Errors
 Error is a crew action or inaction that leads to a deviation from
crew or organisational intentions or expectations.
 Put simply: threats come “at” the crew, while errors come “from”
the crew.
 An Error that is detected and effectively managed has no
adverse impact on the flight.
 An error that is not detected cannot be managed.
Flight Crew Errors
Can be divided into three types:
 Aircraft Handling
 Procedural
 Communication Errors.
Consequence of Error

The very same error can have
completely different
consequences, depending on the
factors involved.

Error : setting the flaps correctly
for landing is forgotten.
- Aircraft type and performance
- Actual landing weight
- Runway length and
obstructions ahead
Undesired Aircraft State (UAS)
 A UAS is defined as a position, speed, attitude or
configuration of an aircraft that:
- Results from flight crew error, actions or inaction
- Clearly reduces safety margins
 UAS can be managed effectively or mismanaged,
leading to an additional error, UAS, an incident or
accident.
 A Decision MUST be made
Identify the Threats?
TEM Application
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T
W
O
P
Terrain
Weather
Operational
Plan
TWO-P
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Terrain old
Terrain new
Weather good
Weather bad
Operational in
Operational out
TWO-P
 Assessing threats does not
make them go away.
 A threat briefing must
contain effective strategies.
 There must be a plan.
Levels of Situational Awareness
 Level One:
 Level Two:
 Level Three:
Perceive
Comprehension
Projection
Notice
Understand
Think
Ahead
NUTA
The NUTA/TEM Links
Notice
Mitigate
Understand
Trap
Think Ahead
Avoid
Situation
Awareness
Threat
Management
Countermeasures
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Anticipation builds vigilance.
Recognition leads to recovery.
Recover first, analyse causes later.
Planning.
Execution.
Review or modify.
What is an Unexpected Threat?
Just because you
deal with a situation
everyday does not
mean that it is not a
threat.
Discussion Time