IATA国际航空运输协会Threat-and-Error-Management

ThreatandErrorManagement:theLCCandIATAExperienceJoeyAncaIATAOverviewRegionalandInternationalAviation-theGoodNewsandBadNewsTheFutureinAviationRedefiningSAFETYExperiencewithLowCostCarriersThreatandErrorManagement(TEM)ToolsCRMintheCountermeasureContextTEMasaFramworkTakeAwayandtheCultureofSafetyWorldAviation:BadNews&GoodNewsBisignani,G(2005)StateoftheAirTransportIndustry.IATA.GlobalTurmoildrivenby:•FuelCosts•LegacyvsLowCostCarriers•ImbalancedTaxationbyGovernmentsAirTransportisaUSD400BillionIndustryIATAcombinedFuelBillfor2005isUSD83Billion,equaltotheGNPofNewZealandWinnersandLosers:NorthAmericaUSD9BAfricaUSD150MLatinAmericaEuropeUSD1.4BAsiaUSD2.6BMiddleEastUSD100MSafety:1.8Billionflewin2004;428Fatalities(similarto1945figureswhere9millionpeopletraveledbyairAsia-Pacific:BadNews,GoodNewsHarbison,Peter(2005).IndianSubcontinent&MiddleEastAviation&TourismSummitRegionalIssuesdrivenby:•FuelCosts•AirlineRestructuring•InadequateRegulatorySystemsHighGrowthMarketsattractingrapidforeigninvestments(China,India,MiddleEast)AsiaPacificAirlinesreportedUS$5Bprofits(2004)Indiatorequire10000trainedstaffeachyearovernext5yearsDemandforpilotstoexceedfactorofthreeinnext5years;Salarybillforpilotsupby30-40%Indiaplacedordersof190aircraftinlastParisAirShow;numberexpectedtoescalateto490-500aircraftby2010CorpusofExperienceinthisReportFutureTransformation:theJetsons•AffordabilityofMicroJetstoalargersegmentofEntrepreneurs•IncreasedCapabilityofdistalandagileAirTrafficControl•IncreasedvulnerabilityofSituationalAwareness•DevolutionofSafetyManagementSystemstomicrousers•NeedforGlobalEquipageharmonizationtocounteractpresentdifferentiation•TheFutureisScaryBaker,D(2005)NGATSFAARedefiningSafetyRedefiningSafetyforanOrganisationtoReflectRealitySafety(MiddleEnglish,saufte)1.Thestateofbeingsafefromundergoingorcausinghurt,injuryorloss2.AbilliardshotmadewithnoattempttoscoreorsoastoleavetheballsinanunfavorablepositionfortheopponentViolationErrorThreatsLatentConditionsTheproblemis…astateofsafetydoesnotexist100%oftheTimeViolationErrorRiskLatentConditionsSAFETYSAFETYSAFETYSAFETYSafetyisaMeasureofOrganisationalResistancetoRISK.Safety(MiddleEnglish,saufte)DynamicprotectionsfrommishapsInterventionsforsystemintegrityandcomplianceCreative“buffering”forlatentconditions…insteadofaharm-freeSTATE,ThreatandErrorManagementToolsRestating(CRM)astheCountermeasurestothreats,errorsandundesiredequipagestatesReinforcingThreatandErrorManagement(TEM)asaframeworkTheRiddleofthe5DaughtersMary’sParentshad5DaughtersTheirnameswere:MaraMareMariMaro…Whatisthenameofthefifthdaughter?TheSummitsofCRM1stGeneration-CockpitResourceManagementBusinessManagementorientationInterpersonalRelationships/LeadershipStylesPsychobabblelanguagedistantfromPilotsThe“Unassertive”Co-pilot2ndGeneration-CrewResourceManagementErrorChain&AccidentCausalityTeambuildingGamesSituationalAwarenessandStressManagementConceptsClusterKnowledge(DecisionMaking,Briefing,etc)3rdGeneration-AdvancedCRMCRMIntegrationwithtechnicaltraining/performanceInstructorCRMTrainingIncludedDispatchers,FlightAttendants,Engineers4thGeneration-IntegratedCRMCRMembeddedinprocedures/checklistsSpecializedtopicseg.AutomationPerformancebasedCRM5thGeneration-ErrorManagementUbiquityofHumanErrorManageErrorsbyAvoidance/Trapping/Mitigation6thGeneration?ApplyingtheRiddletoGenerationsofCRMThenextgenerationisnotaboutanewformofCRMItisaboutusingTEMasaFrameworkandCRMasatrainingcountermeasuretool—Marudoesnotexist,butMarydoesItisaboutgoingbacktothefoundationofflyingoperations—themanagementofoperationalthreatsanderrorsThreatandErrorManagement(TEM)TEMtrainingisbothaframeworkofCRMaswellasadetourbacktoCRMBeginnings—atrainingtooltomanageHumanErrorTheTEMModel—outlinespropagationandbreachofHumanError(Threat-Error-UndesiredEquipageState-Incident)AppropriatelypositionsCRMasasetofCountermeasuresinmanagingThreatsandErrorsTheIATATEMProgramPositionsTEMasacontextofCRMCRMSkillTrainingasthesetofcountermeasurestomanagethreatsanderrorsIncludesaTrain-the-TrainercomponenttocritiquethedeliveryofCRMProgramssuitedtolocalconditionsLatentThreatsNational,Organizational,ProfessionalCultureStandardsandPoliciesRegulationsOvertThreatsEnvironmentFactorsOrganizationalFactorsIndividual,Team,CrewFactorsEquipageFactorsThreat©Bombala,MCapt(2004)IATAThreats:ElementsandConditionsthatareoutsidetheCrew’sControlErrorTypesCommunicationIntentionalNon-Compliance(Violation)ProceduralLapseProficiencyFaultyDecisions&JudgmentCrewErrorThreat©Bombala,MCapt(2004)IATACrewError:MismanagementofThreatsMosterrorsareinconsequentialEquipageisnotwhereitissupposedtobebecauseofthreatsormismanagedthreatsCrewErrorThreatUndesiredEquipageState©Bombala,MCapt(2004)IATAUndesiredStateCrewErrorThreatUndesiredEquipageStateIncident-AccidentResultofmismanagedthreatand/orerror“thetipoftheiceberg”©Bombala,MCapt(2004)IATAIncidentorAccidentManagingThreatsandErrors:theTEMSolutionEnsurecompetencytrainingonCRMCountermeasuresCountermeasuresErrorAvoidanceThreatManagementErrorManagementUndesiredEquipageStateMan