How to minimise threats and errors professionally, you can read here:
1. Examples, the Beginning, and Interrelations
1.1. Threats and Errors in Our Daily Lives
We are driving in our car on a country road, the sun is about to set, and right in front of us a sounder of wild boars runs onto the road. We brake immediately and manage not to hit this sounder.
This was a threat from the outside, without anyone having made a mistake. We couldn´t help it and dealt with the situation deftly.
Still lost in our thoughts, we go on. Suddenly, our good friend in the passenger seat shouts: "Brake, for god´s sake, you have to give way, and someone is coming!" We brake hard, the lady who has the right of way does the same. At the last second, a collision is prevented.
Due to the threat before, which had still compromised our concentration, we almost made the mistake not to give way.
For the driver on the main road we were a threat as we speeded towards the crossroads. Both of us reacted, the mistake was corrected in time. Thus, it had no consequences other than the amazement.
Additionally remarkable here is our good friend´s speak up. He had noticed the danger and alerted us immediately. The speak up is an important element in the communication used in crew resource management . It helps us as a team to recognise errors in good time.
Threats come from the outside. We can predict some and prepare ourselves. Others are unpredictable. Threats require action and render a situation complex.
Errors, however, occur when someone has done something wrong, be it in the communication, during a procedure, or when driving a vehicle.
1.2. The Awareness of Threats and Errors is Established
The beginning dates back to 1994, when the University of Texas and Delta Airlines initialised a joint project.
During so-called Line Operation Safety Audits, LOSA, pilots are checked during routine flights. The focus is on what threats occur during a flight and how the crew responds to them. Additionally, it is on errors and undesired aircraft states.
Today, LOSA is fully established. It is not about avoiding threats and errors altogether, since this is not possible. It is about how to minimise them in advance and/or how to deal with them before threats and errors cause real harm.
1.3. Connections Concerning Threats and Errors
Errors Lead to Threats and Vice Versa
Threats distract us from our duties, we have to react to them first. Our situational awareness suffers. Sometimes, we even startle upon the threat, our concentration and our ability to think clearly are compromised. Hence, mistakes can easily happen.
On the other hand, a threat can be the result of an error. For instance, when preparing for a medical procedure, important material may be forgotten. Naturally, it is needed exactly when the situation becomes complicated, a hectic rush ensues, the flow is disturbed, subsequent faults become all the more likely.
Errors, Threats and Human Factors
The human factors such as lack of concentration, and lack of knowledge, lack of assertiveness, as well as insufficient communication, influence our successful management of threats and existing errors.
At the same time, errors occur due to the human factors, which we will examine under item 5.
How to Avoid and Deal with Threats and Errors Successfully Using CRM
As a Threat and Error Management, TEM, dealing with threats and errors is taught as an important topic in Crew Resource Management.
As we will elucidate under item 6., CRM components that are used otherwise as well, help us to avoid and successfully manage errors and threats.
2. Threats in Aviation
2.1. Threats Have Different Causes
In every phase of a flight, a wealth of threats can happen. Some are not confined to a single phase of a flight. Examples include:
On the Ground
- insufficient signage
- closed or contaminated taxiways or runways
During Take-off
- ATC instructions that are difficult to follow
- language difficulties
- mistakes on the part of ATC
In the Air
- all imaginable technical malfunctions and failures on the aeroplane
- delays and resulting time pressure
During Landing
- weather conditions such as strong winds, or thunderstorms
- a wet or icy runway
2.2. Two Threats Combined
The Crash of a Small Passenger Aircraft
On 8 January 2003, a Raytheon (Beechcraft) 1900D, Flight Air Midwest 5481, with 21 souls on board, plunged from the sky onto the premises of Charlotte-Douglas International Airport in North Carolina, USA, immediately after take-off.
Sadly, no one on board survived the disaster. Captain Katie Leslie managed at the last moment to avoid hitting a hangar with many people and aircraft inside, which saved many others´ lives.
The Aircrash Investigation
The excellent investigation by Lorenda Ward and her team from the National Transportation Safety Board, NTSB, revealed the cause of the crash. Two independent threats had combinend in a fatal manner, as we will discover in a moment. There were no pilot errors.
This aircrash investigation is retraced in the truly recommendable film „Mayday 05 – Dead Weight“ , it contains interviews, amongst others. The film is available on YT, as well.
Maintenance Errors on the Elevator
Due to errors during maintenance, the elevator was not fully deployable. Thus, during too steep a climb, the nose of the plane could not be lowered. The steep climb was causes by too heavy a weight aft.
Wrong Standards Were Used when Calculating the Overall Weight
The heavy weight due to too heavy baggage on board was not an error in the pilots´ calculations. It resulted from decades old, far too low assumptions for the average weight of passengers and baggage.
According to the standards, the pilots had not used the actual weight of all pieces of luggage and passengers in their calculations.
The painstaking Investigation of air disasters helps to make aviation continuously safer. Also here, TEM is applied.
3. Errors in Aviation
3.1. Definition of Errors in Aviation
Errors in aviation are actions or inactions of the crew which
- lead to a deviation from the intentions or expectations of the crew or the organisation
- reduce safety margins
- can lead to adverse events
3.2. Sources and Examples for Errors in Aviation
Errors in aviation concern aircraft handling, procedures, and communication. Examples include:
Errors with Respect to Aircraft Handling
- wrong speed or altitude
- wrong thrust, wrong position of the flaps
- wrong runway or taxiway
Procedural Errors
- missing important items during briefing
- disregarding standard operating procedures or government regulations
- flawed documentation
Errors in the Communication
- with ATC
- the crew in the cockpit amongst themselves
- with the cabin crew
3.3. Reporting Errors for Continuous Improvement
In the same way as threats, crews report errors to the reporting system of the airlines.
These reports, their processing, and the drawn conclusions are an important part of TEM.
4. Undesired Aircraft State, UAS
On our road trip we speeded much too fast towards the crossroads. Our car was in an undesired state so to speak, which we had caused by our mistake. There was no technical failure of the brakes.
Thus, the undesired state results from an error and not from a threat. It reduces the safety margins.
The same applies to aircraft. As opposed to threats, for instance, the engine fire on Qantas flight 32,the undesired state is due to errors the crew has made.
Examples of undesired aircraft states include:
- taxiing the airliner onto the wrong runway
- wrong altitudes in any phase of a flight
- wrong heading
- insufficient line-up with the runway on the approach
It doesn´t take much imagination to work out the consequences of an UAS. Collisions can happen on the ground, in the air, but also with the surrounding terrain if a plane deviates from the runway on approach.
5. Errors, Threats, and Us - How to Master Human Factors
We all know how it feels to be too tired, or to have far too little time, where we lack the necessary knowlegde despite all our efforts, and where we have miscommunicated. These human factors are sometimes presented as the dirty dozen together with a few more:
- Fatigue
- Stress
- pressure, real or self induced
- Distraction
- Complacency
- lack of resources
- lack of communication
- lack of teamwork
- lack of assertiveness (speak up)
- Lack of Knowledge
- lack of attentiveness
- norms (attitude and habits)
If we look at this dirty dozen during CRM training and apply appropriate solutions, we minimise its potential influence and, thus, our risk of errors.
6. Threat and Error Management is Part of CRM
6.1. The Philosophy of Threat and Error Management, TEM
The philosophy of TEM emphasises three essential concepts: anticipation, recognition, and recovery.
Anticipation
Generally speaking, we anticipate that threats and errors cannot be avoided, but will certainly appear. However, it is not clear, where and when. Therefore, we maintain the vigilance which is important in all safety-critical professions.
This vigilance helps us to recognise threats and errors.
Recognition
As soon as we recognise errors and threats, we can act and induce countermeasures. This leads to:
Recovery
As we attend to the error or threat, we recover the safety margins in the first place. Depending on our line of business, we make sure that errors or threats do not influence a patient´s safety, or the safety of a flight, or other procedures.
It is imperative to recover first and analyse the causes later.
6.2. How the Particular CRM Components Help Us
Using different examples, we will elucidate the important and valuable role that CRM components play in the recognition and the handling of threats and errors.
Situational Awareness
If we maintain our situational awareness concerning space and time, available information, as well as personal and material resources at any time, we are able to detect threats early and to use our resources to react properly.
Examples:
- spatial: dense air traffic around the airport, threats caused by other airliners, collision avoidance necessary
- time: a patient´s compromised circulation after an accident, rapid measures and transport are necessary
- information: There are heavy thunderstorms at the destination as a threat, should one aim for another airport?
Communication
Matter-of-fact, clearly formulated messages, which are confirmed, help us to point out the relevant items unmistakably and to make sure that the message is understood.
In a 10-for-10, meaning ten seconds for the next ten minutes, we discuss as a team, using a scheme, what problems exist, what steps there are necessary in the next minutes, and how we are going to distribute the workload. When there are no more questions, we start working as agreed.
Managing Stress
As stress impairs our ability to think clearly and to act, we need to keep our stress in check. As in an interrelationship, the CRM components help us with that. Of great help are also deliberate relaxation, and the positive attitude, as well as the confidence in our well-trained skills, which we bring to our teamwork.
Workload Management
If we know the personal resources in our team well, we are able to distribute the workload wisely when facing a threat. In the emergency medical service, the increasing swelling of a patient´s airway is a threat.
We have to recognise this early and decide, whether an intubation in general anaesthesia, as well as ventilation, are needed. If so, we discuss briefly, who is going to prepare what and who is going to perform what tasks during the procedure.
Gaining and Processing Information
Gaining information early and actively is advantageous in order to recognise threats quickly.
Decision-Making
We perceive the situation, gather information, also regarding threats and errors. Using our resources, such as team members and auxiliaries, we decide how we are going to proceed.
7. Threats and Errors Successfully Minimised
If we are aware of the presence of threats and errors, their different types and underlying human factors, we are able to counter them using our resources.
7.1. We Master Anticipatable Threats
During simulator training sessions, probable threats are anticipated and the appropriate responses are rehearsed. Such threats may be engine failures during a flight, or rescuing people from a vehicle that is about to burst into flames.
If the situation occurs, we startle less easily, we don´t freeze in shock. We handle the procedure more confidently with an optimised result. Hence, the risk of ensuing errors is reduced, as well.
7.2. More Capacities to Deal with Unexpected Threats
If we apply CRM consistently, we are aware of the possibility that unexpected threats may occur at any time. If we are vigilant a priori, if we work as a team in a well structured manner and finish our tasks swiftly, we have more capacities for the unexpected.
7.3. We Make Anticipatable Errors Less Often
If we rehearse and discuss potential causes of errors consequently, we recognise the errors we are able to avoid in the first place. Examples include the confusion of different medications. As we look at the ampullae together whilst we prepare the syringes, we can keep the risk of a mix-up at bay.
7.4. Minimising the Consequences of Errors
Starting with appropriate communication (speak up, closed communication loops), moving on to the use of mnemonics (have we really prepared everything), and ending with the continuous reevaluation of our steps and measures as a team, we try to spot possible errors immediately, before they have any consequences.
Before the departure of an ambulance to a hospital, we check whether the entire monitoring, including heart rate, blood pressure and oxygen saturation, is established. We also check whether we have prepared every medication we might need en route, but also whether we have informed the right hospital in advance. If we find any omissions now, we can still correct them.
7.5. We Grow as We Investigate Threats and Errors
Whenever we have encountered threats or made an error, we discuss them constructively. What did we do well, where is still room for improvement? What can we learn for our next calls?
8. Master Threats and Errors in Your Line of Business
Now you have read concentratedly for a long time, which is a huge achievement! Of course, you cannot remember everything at once and apply it.
However, don´t you fancy a challenge and wish to put your new knowlegde into action step by step? Just go ahead together with your team and celebrate your successes!
Anticipate, Recognise, Recover
What threats and errors do you anticipate in your profession? How can you recognise them? What will you do to recover?
The Vexatious Human Factors
What human factors play a role in your line of business? What steps can you take in your work environment?
Using CRM Components
Where can you use CRM in order to minimise errors and threats?
Your Questions and Suggestions
Of course, you can ask your questions and send me your suggestions. Please use the form below.
9. In My Next Blog Article You Can Read About:
Unfortunately, it is not as beautiful as a string of pearls: the error chain. It originated in aviation, too. How many links has it got? How many of these are necessary to cause an air accident? How can we prevent fatal errors using this knowledge?
On my blog page , I have linked earlier blog articles for you.
Author: Eva-Maria Schottdorf
Date: July 17th 2021