Threat & Error Management
Threat and error management (TEM) is not new; we’ve been practicing it at some level for decades, and it occurs in just about every flight operation, every maintenance operation, and in everything we do hiyo3lg. We just don’t call it that, or think about it in those terms.
Back in the 1980’s I was training young co-pilot / mechanics to fly DC-3s. We adopted a policy (taken from my Dad’s experience at Pan Am as a professional flight engineer) of requiring our pilots to hold an A&P license. The DC-3s required constant maintenance, and my Dad was especially proud when a crew experienced an in-flight cylinder failure, made a precautionary engine shutdown, diverted to a remote airstrip and had the cylinder changed by next morning using their required tools and the aircraft fly-away kit.
Joe Salerno logged many thousands of hours as flight engineer on large radial-engine aircraft, including the Boeing 314, Martin M-130, DC-6, DC-7, Constellation, Stratocruiser and others. One of the many tips my Dad gave new co-pilots was to observe the fuel pressure gauge any time a boost pump was turned on or off. The obvious rise or drop in fuel pressure gave us immediate feedback as to whether the boost pump was working properly. Many co-pilots failed to do this at first, performing the in-flight checklist quickly and snapping both boost pump switches on or off simultaneously without observing fuel pressure or even looking at the fuel pressure gauge.
The THREAT, of course, was failure of a boost pump. During our climb check, if turning off a boost pump gave us no drop in fuel pressure (pressure remaining at 14 psi instead of dropping from 16 to 14), we were armed with important information; those pilots who failed to observe the anomaly (an ERROR), were left clueless.
Back then we thought it was a good policy; a ‘good idea’. Today we have a more in-depth understanding of what we were doing – using execution countermeasures to manage a potential threat (system / component failure) and then applying review / modify countermeasures to include evaluation of plans and time-critical risk management in order to make better inflight decisions ykvxvum.
Another benefit of applying these concepts is increased operational effectiveness. After landing, an observant pilot would know if a boost pump had become inoperative during approach or landing. Troubleshooting could commence and the problem corrected before the next departure, rather than discovering it during a pre-takeoff run-up.
The OmniSMS web application applies these concepts with configurable TEM taxonomies of threats, errors and barriers/controls why not find out more. The OmniSMS Manual and eLearning courses also describe and teach time-critical risk management, which applies to all departments, and is often overlooked during SMS training.
If you liked this short story, you may also enjoy my anecdote on the co-pilot candidate who was shocked to learn that we performed inbound mag checks on the DC-3.
Paul