Corporate Safety

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Corporate Safety

• Threat Error Management
• (TEM)

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INTRODUCTION

• The common goal of preventing incidents and
  accidents defines the point of intersection
  between safety, operations, and training.

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We Need to understand how a Human mind works!!!

• Once information is sensed, it passes along
  various neural pathways to the brain.
• Each Person obtains Information differently.
• The Human mind is like a map.

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Humans are Limited..

• Limited memory capacity
• Limited processing capacity
• multi-tasking capability
• Limits imposed by stressors
• tunnel vision
• Limits imposed by fatigue and other physiological
  factors
• Poor group dynamics
• Cultural influences

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BACKGROUND

• TEM Model as
• Licensing tool (ICAO)
• Training tool (Numerous airlines)
• Safety management tool (IATA)
• Research tool (Boeing)

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Definitions

• Threats
• Threats are factors or events whether expected or
  unexpected that will increase the operational
  complexity of an employee or organization and can
  lead to errors, threats are expected to be
  managed by the employee.

Tip Threats must be managed during normal,
everyday operations.
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Threats Are the Context
Distractions
Passenger events
ATC
Cabin Crew
Terrain
Weather
Similar call signs
Maintenance
Time pressures
Ground Crew
Flight diversions
Heavy traffic
System malfunctions
Unfamiliar airports
Automation events
Missed approaches
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Definitions

• Errors
• Are actions or inactions by the employee that
  prevent the management of threats or the
  accomplishment of tasks, and increase the
  probability of accidents or incidents.

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Definitions

• Contributing Factors
• Are conditions that can lead to errors and are
  not expected to be managed solely by the
  employee..

Fact Performance Demands Stable Technology
successful Management Human Error Management
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Threat and Error Management (TEM)
Threats
Threat Mgmt
Errors
Contributing Factors
Contributing Factors
Error Mgmt
Outcome
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There are five types of errors

• Intentional non-compliance errors
• Procedural errors
• Communication errors
• Proficiency errors
• Operational decision errors

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Response to Error

• Trap
• Exacerbate
• Fail to Respond

Human error has posed threats to safety since
humans began to deal with technology
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Error outcome

• Inconsequential
• The error has no effect on safety.
• Undesired state
• Risk or unsafe operational conditions increased.
  
• Additional error
• The error case a chain reaction of other errors.

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Error Model
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Error Management Results

• Error Responses Most errors are undetected
• 64 Undetected
• 31 Detected and effectively managed
• 5 Detected and mismanaged
• Error Outcomes Most errors are inconsequential
• Inconsequential 77
• Additional Errors 6 (Error Chains)
• Undesired Aircraft States 17

The results of research project absorbing 3
airlines conducted by HF Department University Of
Texas.
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Clarification (Relationship) between Threats,
Errors and Outcomes

• Errors originated by any person, organization,
  culture, and/or environment other than the
  concern person is a threat.
• Example
• A/C operation Aircraft B is taxing to the stand
  and told to hold short of the active runway. The
  hold-short lines are poorly painted and very
  faint. Aircraft B passes over the hold short
  lines. A runway incursion incident results.
• In this example
• The Threat is the poorly painted hold-short
  lines.
• The Error is committed by the flight crew of A/C
  B when they taxi onto the active runway.
• The Outcome is a runway incursion.

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Threat Error Relationships
Threats
Managed Unmanaged Consequential
Task Accomplished (uneventful)
Error
Contributing Factors
Undesired Process State
Loss Event
Managing threat and error requires data
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Managed vs. Mismanaged

• Managed an active response to a potential threat
  or error that may appear on a daily bases and
  could leads to an undesired error state or
  additional error state.
• Mismanaged inactive or lack of response to a
  threat or error that appears on a daily bases
  which led to undesired error state or additional
  error state.

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Decision Process Model Plan-Do-Check-Act
(PDCA)
Plan
Do
Act
Check

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PDCA Inputs and Outputs
Targets
Plan
Tasks
Changes
Do
Act
Understanding
Outcome
Check
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Latency in PDCA Processs
DELAY I
Plan
DELAY II
DELAY V
Do
Act
DELAY IV
DELAY III
Check
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Decision Error 1
Targets
Plan
Tasks
Changes
Do
Act
Outcome
Understanding
Check
Benefit Speed Risk Unknown Side Effects
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Decision Error 2
Targets
Plan
Tasks
Changes
Do
Act
Understanding
Outcome
Check
Benefit Stability Risk Inflexible Processes
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Decision Error 3
Targets
Plan
Tasks
Changes
Do
Act
Understanding
Outcome
Check
Benefit Quality Data Risk Unaligned Activities
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Simplified Error Model

Loss Event
Procedural
Procedural
Error 1
Error 2
Contributing
Contributing
Contributing
Contributing
Contributing
Factor 1
Factor 2
Factor 1
Factor 2
Factor 3
Recommendation
Recommendation
Recommendation
Recommendation
1
2
1
2
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Conflicting Goals Model

Production Loss
Conflicting
Conflicting
Goal 1
Goal 2
Contributing
Contributing
Contributing
Contributing
Contributing
Factor 1
Factor 2
Factor 1
Factor 2
Factor 3
Recommendation
Recommendation
Recommendation
Recommendation
1
2
1
2
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The Root Cause of Errors

• In the real world, most production losses are due
  to procedural errors.
• Errors are usually the result of the tension
  between risks to safety and risks to production.
  
• This tension leads to conflicting goals.

Identifying the source of an error is an
important step towards taking effective
protective measures.
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Data for a Safety Culture

• How do airlines monitor safety?
• ALL Kinds of reports (CSR, ASR,)
• Accident investigation
• Incident reports
• Data slanted to events resulting from system and
  flight crew failures
• Line checks
• Data show crew proficiency and procedural
  knowledge
• Flight Data Recorders FOQA
• Data show what happened in terms of flight
  parameters
• Observing normal flights Line Operations Safety
  Audit (LOSA)
• Gives data on why things happen and how they are
  managed
• Provides a more realistic baseline of safety

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Cultural Approaches to Error

• Moral/Legal
• Technical
• Systemic

Error is everywhere
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Moral Approach to Error

• Magnitude of loss
• Speed of closure
• Sophisticated but Emotional
• Emotional separated from Financial
• Root causes versus Multiple causes
• Drives Propaganda
• Maximum Information Loss

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Technical Approach to Error

• Loss contained by Management
• Equipment Environment focused
• Technical separated from Emotional
• Silver Bullets
• Questionable effects
• Can be costly
• No more harm...

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Systemic Approach to Error

• Errors are Symptoms
• Acknowledges Interactions in the larger System
  (technical, financial, emotional)
• Focuses on Contributing Factors
• Produces Maximum Information
• Requires Personal Mastery

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Systemic Interactions(SHEL) Model
4
Liveware
L
Humans
H
Software
S
H
Hardware
2
1
E
Environment
3
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Safety Responsibilities Are SharedSafe Airplane
Safe Operation Safe Infrastructure Safe Air
Travel
Air Safety
Governments
Manufacturers

• Safe airplane design
• Safety-enhancing technologydevelopment
• Flight and maintenance operations,
  recommendations,documents, training, andsupport
• Maintenance planning
• Safety-related analysis
• Safety initiatives

Operators

• Operations policy andprocedures
• Airplane/pilot publications
• Approved maintenanceprogram
• Maintenance, policy, andprocedures
• Maintenance publications
• Safety program
• Training

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Manufacturers Problem

• Engineering World vs. the Real World
• Greatest need structured feedback from real
  world
• Greatest obstacle liability

• structured Engineering Language

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Operators Problem

• Managing Human Error
• Greatest need structured feedback from
  employees
• Greatest obstacle liability

• structured Management Language

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Government Challenges

• Maintaining and Operating
• conflicting goals
• Balancing Innovation and Economics
• service effort
• Managing Politics and Technical Issues
• complex interactions

Must look for roots of error to strengthen system
defenses
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System Safety Safety Management System

• The effective management of safety requires a
  realistic balance between safety, productivity
  and cost.
• The process for achieving this balance called
  System Safety.

Quality Management System Safety
Safety Management System
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SMS Tools

• Reactive tools
• PEAT (Procedural Event Analysis Tool)
• MEDA (Maintenance Error Decision Aid)
• CPIT (Cabin Procedural Investigation Tool)
• REDA (Ramp Error Decision Aid)
• Proactive tools
• Audits (IOSA, LOSA, etc.)
• Employee Reporting System (ERS)
• Employee Efficiency Survey (EES)

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SMS Implementation Support
Senior Management Overview
Management Workshop
Investigators Workshop
Implementation Planning
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SMS Training Objective

• Help Managers Become More Effective Risk Takers.

Complete error avoidance is impossible. errors
are inevitable
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Management is simultaneously an art and science.

• The meaning of leadership
• A leader in a given situation is a person whose
  ideas and actions influence the thought and the
  behavior of others.

• Responsible for implementing goals

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Tasks of a leader

• Motivating
• Reinforcement
• Example
• Maintaining the group
• Managerial role

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Luck or Consistency?

• Successful Risk Takers
• Predict Positive Outcomes
• Detect Hazards Proactively
• React to Hazards Effectively
• KEY

FEEDBACK
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Management Actions
Phase 1 Refuse to accept blame as data.
(Management-led culture) Collect contributing
factors data. (SMS tools) Phase 2 Integrate
contributing factors and financial/operational
data. Refine performance measures.

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More Prevention strategies
TEM can be applied to your day to day activities
even your home.

• Airlines need to go beyond the traditional
  approach of identifying "what went wrong" and
  fixing it, to a more proactive approach of also
  determining "what went right" and encouraging
  that countermeasure. Threat and Error management
  model provides one of the primary lines of
  defense against external threats and staff error.
  Airlines need to understand the importance of
  determining the status of their own operations
  rather than assuming that their organizations
  conform to some industry standards.