Threat and Error Management Model.ppt

1、Threat and Error Management Model,Robert Helmreich Capt. Bruce Tesmer University of Texas Continental AirlinesATA CRM Conference Comair, Cincinnati September 21,1999,Applying TEMM to a pilot error incident: Landing at the wrong airport,The Flight Scenario,Houston to Corpus Christi second leg of the

2、first day of a trip that began in Newark Captain was PF from Newark, FO to CRP Captain was highly experienced check airman conducting IOE CRP ATIS “good, 6,000 broken 10 miles, wind 010, 10kts. Expect loc app to Rwy 31.” Descent started early expecting VORTAC vectors to Rwy 31 localizer. On autopilo

3、t until intercepting final approach course After CRP Vortac, App Cont. gives vectors to, and clearance for intercepting localizer and “Cleared Approach.Rwy 31 Localizer”,The Scenario continued,Turning final, the Capt sees the airport and reports to tower “Runway in sight.” Crew has slowed and config

4、ured early to allow time to reach landing configuration and be stable by 500 AGL. They are surprised runway so close. A normal landing was completed but runway shorter than expected. Landing completed with 500 remaining There was no terminal, only hangers. Crew taxis off Rwy and realizes they are no

5、t at CRP The call Tower which knows they have landed at Cabaniss,Known Threats First day as crew IOE being given 1st leg in 737-300 round dial, 2nd in 737-500 EFIS 1st EFIS leg for FO FO only exposure to EFIS in Level 5 device FOs 1st trip to CRP Capt had not been to CRP in 3 years & had never lande

6、d to North at CRP,Unexpected ThreatsATIS doesnt mention 2000 scattered cloud layer. Doesnt warn about location of Cabaniss Field A/C on autopilot, has problem intercepting localizer Scattered 2,000 cloud layer blocks fwd vision but allows ground contact for 5 miles,External Error ATC had localizer s

7、et to Rwy 13 for previous A/C doing training,Crew Error,Latent Systemic ThreatsRegulatory: Cabniss Field located 6nm on Corpus localizer Regulatory: no ATIS warning about Cabaniss on weekend Regulatory: chart depiction hard to read Regulatory: Cabaniss field layout looks like CRP Regulatory: MSAW wa

8、rning for Cabniss disabled Regulatory: runway alignment (31) same as Corpus Navy: allows racing events except special days (Mothers Day) System: information on other near approaches to Cabaniss existed, but not available Organizational: no mention of Cabaniss on10-7 page in manual Professional: oper

9、ational and professional pressure to make landing,Proficiency Crew lacked knowledge about Cabaniss location,Fail to Respond,Undesired State,Additional Error,Error Types,Error Responses,Error Outcomes,Procedural Crew briefed and were flying ILS approach, did not check DME to confirm FAF,Fail to Respo

10、nd,Undesired State,Additional Error,Error Types,Error Responses,Error Outcomes,Decision Error Crew high & fast when lined up for Cabaniss but stable at 500 chose riskier decision,Fail to Respond,Undesired State Approach tp wrong airport,Error Types,Error Responses,Undesired Aircraft State Outcomes,F

11、ail to Respond,Error Outcomes,Threat and Error Totals,External Threats Expected Unknown,External Error,Threat Recognition and Error Avoidance Behaviors -,System - Organizational - ProfessionalLatent Systemic Threats,Mitigate Exacerbate Fail to Respond,Incident,Additional Error,Recovery,Inconsequenti

12、al,Undesired Aircraft State,Intentional Noncompliance -ProceduralCommunication Proficiency Operational Decision,Fail to Respond,Additional Error,External Threats Expected -6 Unknown -3,External Error 1,Threat Recognition and Error Avoidance Behaviors - 2,System - Organizational - Professional10 Late

13、nt Systemic Threats,Mitigate Exacerbate 1 Fail to Respond,1 Incident,Additional Error,Recovery,Inconsequential,Undesired Aircraft State,Intentional Noncompliance 1 -ProceduralCommunication 1 Proficiency 1- Operational Decision,3- Fail to Respond,Additional Error,Conclusion,A short flight with a high

14、ly competent captain became very complex because of numerous latent systemic threatsThese were compounded by external threat and error and crew errorsAny of a number of actions could have broken the incident sequence,About Latent Threats,Latent threats are highly variable. They can exist for a long

15、time be based on tradition Weve always done it this way. be associated with new technology fail to appear as threats or seem to be based on good decisions be difficult to resolve because corrective actions cross too many jurisdictions and no entity takes responsibility for corrective action are ofte

16、n known by some but not communicated to others frequently involve local knowledge Latent threats dont show up in training,The Future,The identification of Latent Systemic Threats is essential to safety Application of the model points to training needs and to latent threats that need to be modified S

17、afety, CRM, Training and Flight Ops need to coordinate to address threat and error management,CRM Countermeasures,CRM Countermeasures Possible,External Threat and error Mental models Mental model check,Cockpit Communication error,Situation was high threat but not fully recognized,Conclusions,Crew fa

18、ced a variety of external threats and error Crew recognized and managed several threats Latent Systemic Threats played a critical role They can be addressed in CRM if identified CRM countermeasures were available for error management Mental models of ATC and Crew were understandable but led to misinterpretation of actions A Mental Model Check could have served as the critical countermeasure,