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Cabin Crew

Threat and Error Management


Carolyn Vaughan - Principal Human Factors
27th November 2014

Asiana Flight 214 San Francisco, July 2013

FC told to Initiated
after hearing 2Ls
commands
Initiated evac after
seeing fire at 2R
Main Exit point

Briefly lost
consciousness
Door wouldnt open,
CC redirected pax to
3R

Door torn from


frame, slide inflated
inside cabin

1L

2L

3L

4L

Slide inflated
inside trapping
2x CC

2R

Fire outside
Slide inflated
inside, created
bottleneck of
pax to 2L

3R

CC injured, door
opened by pax

1R

4R

Severe damage.
Slide would not have
worked due
maintenance error

Real accidents are not as


black and white as EPs!

Procedures v Threat and Error Management

How do procedures and Threat and Error Management work together?


Have we got the right emphasis?
Will our crew be willing to think outside the box if needed?

Risk assessed procedures


v
Risk evaluation on the day

Threat and Error Management Toolbox


The Non Technical strategies and tools that you learn in Human Factors
are your tools to help you:
Avoid

/ Prevent

Detect
Manage

Threats and Errors in the operation.

TEM Strategies are also embedded into procedures and practices.

Structure of Topics

Stress

Situational
Awareness
Fatigue

Design

Decision Making

Threat & Error Management


Avoid
/ Prevent
Communication
Identify
Manage / Recover
Leadership and

Teamwork

Technology

Managerial Skills

Culture

Distractions
and
Interruptions

Threat & Error Management Model

TEM Stages

AVOID

PREVENT

Threats

Errors

IDENTIFY
Threats and Errors

MANAGE and RECOVER


from Threats and Errors

AVOID
Normal Procedures Training
Briefings and communication between crew

Silent Review
Maintaining a shared or connected mental model
Reporting
Anticipating potential threats

PREVENT

IDENTIFY
Allocating attention and managing distractions
Cue recognition What information is important?
Recognising an action or situation as a threat or error

MANAGE and RECOVER


Know the objective and put a strategy in place to meet it
New objective New strategy
Use all available resources

Effective decision making methods that consider risk


Awareness of factors affecting or limiting performance
Evaluation loop

Underlying beliefs for Threat and Error Management to work


Identifying and managing threats is a core part of
the Cabin Crew role.
-

They may be expected (anticipated) or unexpected


(unanticipated)

Errors should not be punished, but rather


expected and managed.
-

Managing errors is part of the Cabin Crew role

Cabin Crew are an integral part of the System.


-

What I do matters! Its up to me!

Behaviour for effective TEM


Preparation, Anticipation, Communication
If it is not possible to follow an exact procedure, follow the intent of the procedure
Chronic unease not complacent
Actively managing and maintaining situational awareness

Attitudes towards Threat and Error Management

They managed to catch it before anyone was hurt but why


didnt they avoid the situation altogether?

OR
Sometimes errors happen, fortunately the crew caught it
and managed it effectively.

Thankyou!
Carolyn Vaughan
carolynvaughan@qantas.com.au