Pleasant greetings to all. I feel immensely privileged to be able to address you all and it is a position that I will never take lightly. The process of Threat and Error Management is one of my favorite subjects in Aviation Safety. It is applicable to absolutely every kind of flying and it is indeed filled with jargon and terminology, that while necessary, it may overwhelm the reader and take away from its goal: ensure Safe Operations. So, I will do my very best to stay on point! My main resources are United Airlines’s Flight Operations Manual, the FAA’s safety briefing on SRM (Single-Pilot Resource Management) and my personal experience. At the end of the article, I will solicit your input about the Threats that YOU encounter while flying for AFW and in the future we will collectively discuss ways to mitigate them. Apologies in advance, as the format of this email report might not be ideal, as it is transferred from a word document.
Threat and Error Management (TEM) refers to the process of managing operational threats and human errors. Threat management reduces the potential for pilot error, while error management mitigates the negative consequences of errors. These combined techniques are known as Threat and Error Management, or TEM. TEM promotes vigilance versus complacency by implementing an active, continuous process of identifying and preparing for threats and identifying and repairing errors at the earliest opportunity. Failing to effectively manage either threats or errors will negatively influence a pilot’s ability to maintain a safe operation.
You may ask, how do all these fancy words and concepts apply to my single-pilot GA flying? Bear with me and I’ll show you.
So, what are we trying to accomplish when we fly? We want to maintain Safe Operations. Yet we inevitably encounter Threats. We must prepare for those Threats, in order to return to Safe Operations. If we don’t, we will likely make Errors. We must repair those Errors in order to return to Safe Operations. If we do not, we will likely end up in an Undesired Aircraft State (UAS). We must recover from the UAS in order to return to Safe Operations. If we do not, we may end up in an Incident/Accident. We use our SRM/TEM skills to prepare for threats, repair our errors and/or recover from UAS, in order to always return to Safe Operations. We need to be deliberate and purposeful with this process.
Before we get into the details of Threats, Errors and UAS, what do we consider a UAS? Are we thinking we are upside down with imminent ground contact, or parts are flying off of our aircraft? No, it certainly doesn’t have to be that dramatic! Allow me to elaborate. Let’s say we are about to depart from our local airport. The weather is not VFR, but it’s not “nasty” either. We have filed IFR, because we have some broken cloud cover. The temperature is slightly below 10 degrees C. There is a Threat: the weather. We depart, but we make an Error: we forget to turn on our pitot heat. We now enter the clouds and our pitot heat is still off, with a relatively low temperature. We are now in a UAS! An Undesired Aircraft State. We have a Threat (the weather) that we may or may have not prepared for, which lead us to an Error (we did not turn on the pitot heat) that we did not repair, which ultimately lead us to a UAS. We now must recover (turn on the pitot heat and other anti-ice equipment we may have) in order to return to Safe Operations. If we do not recover, we may have an Incident/Accident due to potential erroneous airspeed indications and/or structural icing.
We have multiple tools that allow us to deal with Threats. At my airline, we are required to brief all Threats prior to departure and prior to arrival. It’s called the Threat Forward briefing concept and I carry it over to my GA flying.
We break the Threats into three categories:
Personal Threats: personal stressors, currency/proficiency, distractions, fatigue, etc.
Environmental Threats: weather, terrain, operational pressure, passengers, airport operations, complicated clearance, etc.
Technical Threats: aircraft systems, performance, maintenance issues, etc.
The FAA has issued a safety briefing regarding SRM that I will hyperlink here.
They refer to the five Ps and other methods to highlight Threats and how to mitigate them. You choose what method works best for you, as long as you seriously consider adding this process to your daily pre-departure and pre-arrival briefings.
In another safety report we will discuss how to effectively and simply debrief ourselves after each flight, in order to best apply Threat and Error Management into our future flights.
Now let’s take a deeper dive into TEM.
Operational threats and human errors are inevitable within the aviation environment. Many years ago, I had the privilege of participating in our airline’s first Line Operational Safety Audit (LOSA). I was a “fly on the wall” in our flight decks, observing crews and my purpose was to observe Threats and Errors and document them while imposing no threat to the crew and maintaining complete anonymity. Each flight took me about 4 hours of thoroughly documenting the Threats and Errors, after the fact. It was an eye opening experience as to how complex flying can be. The data shows that on average, pilots encounter three operational threats per flight. Threats are operational events or concerns that:
1. Occur outside the influence of the pilot
2. Increase operational complexity
3. Require pilot attention to maintain safety margins
Threats can be either anticipated or unanticipated. For example, anticipated threats could include terrain, adverse weather, maintenance items, or airport conditions. Examples of unanticipated threats are system malfunctions, medical emergencies, or an unpredicted wind-shear encounter.
Effective threat management reduces the potential for pilot error. The first step in effective threat management is to identify threats, both anticipated and unanticipated. The earlier a threat is identified, the more quickly and effectively it can be managed, minimizing the impact on safe operations.
Effective threat management strategies include proper preparation by:
1. Adhering to standard operating procedures and regulations.
2. Applying applicable SRM/TEM skills.
3. Persistently briefing applicable threat(s) to safe operations.
Stated simply: Identify And Prepare.
Errors may occur when a threat is not identified, or identified but not effectively managed.
An error is an unintentional deviation from desired performance. Errors are things we do incorrectly, or things we neglect to do. These are referred to as acts of commission or omission, respectively. While error is inevitable in human activity, the numbers and severity of these can be mitigated through training, vigilance, communication and monitoring strategies, and SRM/TEM skills. In short, while error may be inevitable, many controls are available to reduce them. Still, pilot error is an ever-present threat each individual pilot poses to safe operations.
Effective error management utilizes tools and techniques to proactively mitigate and/or eliminate the negative consequences of errors. Proper threat management prevents many errors from taking place. However, errors also occur in the absence of threats. Therefore, good error management begins with error identification.The earlier an error is identified, the sooner it can be repaired and alleviate potential for an Undesired Aircraft State (UAS). The complete return to safe operations does not end there. A thorough debrief of our performance will enable a true understanding of the root causes of error and mismanaged threats; providing opportunity to improve. As mentioned earlier, we will discuss that in a future report.
The strategies for error management are the implementation of applicable SRM/TEM skills. These may include:
1. Monitor/Cross-Check by maintaining awareness of the aircraft status and the pilot’s actions
2. Workload management by ensuring tasks are properly prioritized and managed
3. Automation management by ensuring proper automation levels, settings and configurations are selected.
Stated simply: Identify And Repair.
An Undesired Aircraft State (UAS) may occur if an error is not identified, or not properly repaired.
Intentional Non-Compliance (INC) Impact on TEM Performance
Intentional non-compliance is a decision to operate outside established standard operating procedures and/or governing regulations. Acts of INC are related to subsequent pilot errors and mismanaged threats relative to safe operations. According to Line Operations Safety Audit (LOSA) industry data, intentionally non-compliant flight crews and pilots are far more likely to commit errors. LOSA refers to errors caused by INC as “intentional non-compliance errors.” When INC becomes habitual in the absence of consequences, Normalization of Deviation is established as an alternative to compliance. This creates opportunity for exponential errors, and a growing systemic threat to safe operations. The best defense against intentional non-compliance is holding one’s self and each other accountable to the established standard operating policies and procedures. Food for thought: how many of us conduct checklists, or navigation programming while taxiing? Or skip the run-up on the last flight home with no passengers? Are we engaging in INC and therefore normalizing it? Take a hard look at your practices and make the decision to err on the side of safety.
UNDESIRED AIRCRAFT STATE (UAS)
Undesired Aircraft State is a position, attitude, condition, or configuration of an aircraft that reduces safety margins. It is a safety-compromising state that results from ineffective error management. Identifying an UAS is the first step to returning the flight to safe operations. The earlier an UAS is identified the earlier recovery can occur. Pilots must take immediate action that may include a combination of SRM/TEM and technical skills. These may include:
1. Monitor/Cross-check to actively verify aircraft position and configuration
2. Automation management to ensure proper automation levels, settings and configuration are selected
3. Technical skills (stick and rudder) to fly the aircraft
Stated simply: Identify And Recover.
An aircraft operating in an undesired state and not promptly recovered may lead to an incident or accident.
A safe operation is maintained by combining technical skills with managing threats and errors through the effective implementation of SRM and TEM skills. These observable and assessable human behaviors include both SRM and TEM skills that when combined enhance flight safety by giving pilots tools to manage operational threats and human errors. Effective application of SRM/TEM skills creates a path away from an incident/accident and will turn a divergent trend back toward safe operations.
I realize that this was an abundance of information. I promise that the next report will not be anywhere near as lengthy! However, it will hopefully give us all something to seriously consider. I have yet to fly the “perfect flight”, without errors. However, my goal is to strive for it, always. And I know that you feel the same way.
Let’s therefore take this opportunity to observe the types of Threats that we encounter during our flights and specifically with AFW. For me personally, a Threat that I did not envision prior to starting AFW flights was passenger “interference”. Despite what I thought were solid passenger briefings, I would still have passengers innocently trying to “chat me up” during the take off roll!
What Threats do you encounter in your flights?
I will be absent most of the month of April. However, Bruce and I would appreciate it if you could email us (email address provided below and please copy us both in your replies) a brief paragraph with the most common Threats that you encounter. While we might not respond to all the emails, after a certain timeframe, we will collect and categorize those Threats and publish them anonymously, for all of us to see. I suspect that we will find lots of common elements.
Thank you for your time.