TEM

1
TEM LOSA The State of Affairs

• Captain Dan Maurino
• Flight Safety and Human Factors ICAO
• Third IATA/ICAO LOSA/TEM Conference
• Kuala Lumpur, Malaysia
• 13 14 September 2005

2
The Big Safety Data Picture

• Forensic systems Failures
• Accident investigation
• Major incident investigation

• Proactive systems Routine operational events
• Electronic safety data acquisition systems (FOQA)
• Voluntary self-reporting systems (ASAP)
• Direct observation safety data acquisition
  systems (LOSA NOSS)

• Reactive systems Anomalies
• Mandatory reporting systems (CAAs)
• Voluntary reporting systems (ASRS/BASIS)

3
LOSA NOSS TEM Clarifying a Relationship

• TEM Framework What we look for

• The features in operational context Threats
• What people do Errors
• The results of the features in operational
  context and of what people do Undesired states

• LOSA NOSS Tool(s) How we collect what we
  look for

• The Ten Operating Characteristics

4
TEM Framework Expanding Role

• Monitoring normal operations (LOSA NOSS)
• Training Flight Cabin Crew/ATCO (ICAO, IATA,
  Airlines and ATS providers)
• Safety management data analysis
• Integrated Threat Analysis (ITA) ICAO IATA
• Cabin Operations Safety Toolkit (Turbulence
  inadvertent slide deployment) IATA
• Research and development (UT Boeing)
• Rule-making ICAO provisions

5
FCLT/P State Letter AN 12/1.1-05/62

• Annex 1 Personnel Licensing
• Knowledge requirements
• Human performance including principles of threat
  and error management
• Operational procedures Application of threat
  and error management to operational performance
• Skills requirements
• Recognize and manage threats and errors

6
FCLT/P Multi-Crew Pilot License (MPL)
Competency units, competency elements and
performance criteria
5) perform cruise 6) perform descent 7) perform
approach 8) perform landing and 9) perform
after landing and aeroplane post-flight
operations.
1) apply threat and error management (TEM)
principles 2) perform aeroplane ground
operations 3) perform take-off 4) perform climb
Note . The application of threat and error
management principles is a specific competency
unit that is to be integrated with each of the
other competency units for training and testing
purposes.
7
FCLT/P MPL
Competency Unit 2 Perform aeroplane ground
operations

• Competency element Line up checks completed
• ATC call to give clearance interrupts checklist
  (threat)
• Crew skips pitot heat checklist item (error)
• Aircraft is lined up for take off roll with pitot
  heat off (undesired aircraft state)

• Performance criteria Example TEM countermeasures
• Keep finger in checklist item until check list is
  re-started
• Start checklist all over again after clearance
  read back
• Request ATC to hold clearance until checklist
  completed

8
FCLT/P Annex 6, Operation of Aircraft

• Chapter 9. Aeroplane Flight Crew
• 9.3 Flight crew member training programmes
• 9.3.1 An operator shall establish and maintain a
  ground and flight training programme, approved by
  the State of the operatorThe training programme
  shall also includetraining in knowledge and
  skills related to human performance and threat
  and error managementThe training programme shall
  be given on a recurrent basis

9
Aligned Safety Management Provisions

• Annex 6 Operation of Aircraft, Parts I and III
• Annex 11 Air Traffic Services
• Annex 14 Aerodromes
• A basic safety management template
• Two basic concepts
• Safety programme States
• Safety management system Operators
• The ICAO Safety Management Manual (Doc xxxx)
• LOSA
• NOSS

10
TEM Aggregate Safety Analysis
Normal Ops Archie
Incidents STEADES
Accidents ADREP

• Integrated Threat Analysis (ITA) A Joint
  ICAO/IATA Project
• Case study TEM analysis Runway excursions
• 34 ADREP narratives
• 36 STEADES narratives

• The bridge between ADREP/STEADES Archie UAS

• Long landings
• Floated landings
• Off centre-line landings

• 164 LOSA narratives

11
Threats ITA
12
Environmental Threats ITA
13
Airline Threats ITA
14
Flight Crew Errors ITA
15
Safety Management Data, not Opinion

• Threat Scenarios
• ITA
• ATC
• Weather (heavy rain,TS, wind gusts, tailwind)
• Operational pressure
• A/C malfunctions, RTO
• Night operations
• Proficiency and procedural issues

• Threat scenarios Accidents incidents
• Weather (heavy rain, TS, wind gusts, tailwind)
• A/C malfunctions, RTO
• Night operations
• Proficiency issues

16
Clearing the Air LOSA

• Is not the same as IATAs IOSA
• Is not the same as Airbus LOAS
• Is not the same as the JAAs NOTECHS
• Is not an evaluation of CRM
• Is not the sixth generation CRM
• Is not a research tool
• Is not culturally incompatible

• LOSA NOSS is a safety management data
  collection tools that generates safety
  management data otherwise not available

17
Clearing the Air (II) TEM CRM

• TEM is an overarching safety concept with
  multiple applications in aviation while CRM is
  exclusively a training intervention. The basic
  concepts underlying TEM (threats, errors and
  undesired aircraft states) can be integrated
  for example as an additional module within
  existing CRM programmes. This is because TEM
  countermeasures build in part although not
  exclusively upon CRM skills. The combination of
  TEM concepts with CRM skills thus introduces the
  opportunity to present the utilization of CRM
  skills by flight crews anchored in the
  operational environment, from an operational
  perspective. It is emphasized that TEM training
  does not replace CRM training, but rather
  complements and enhances it.

18
TEM LOSA Safety Management Tools