Author: Patrick Mendenhall
Threat and Error Management is the cornerstone of Crew Resource Management – so much so that it is the only training element the new Transport Canada Contemporary CRM guide (Transport Canada AC 700-042) will require to be presented annually, as opposed to the other training elements which are required every other year after initial training is complete. This is the first of a series of posts on Threat and Error Management.
The ideal outcome of effective Threat and Error Management is to never reach the “Error Management” portion of the concept, if at all possible. Although every threat cannot be identified and mitigated in advance, if we maintain a vigilant watch for the most likely and the most impactful threats, we can significantly reduce the chances of reaching an undesired aircraft state.
Let us start with “Expected Threats”: These are threats that can be anticipated in advance, such as possible wind shear, bird activity, high density altitude or, obstacles that require special engine out procedures and so on. Expected threats and their mitigations should be discussed before the event that prompts them; and by “discussed,” we do not suggest a monologue. One of the foundational assumptions of CREW Resource Management is that every person that is a part of the flight operations team has life experiences that the others do not. The briefer should encourage a dialogue and elicit the other crew members’ participation as appropriate.
And don’t forget, it’s not just about the pilot stuff. What about briefing the flight attendant(s)? S/he may have concerns that need to be considered – for example, a passenger with a known health condition: this could be a threat that requires the crew to be more vigilant about medical emergency procedures, including a constant watch on potential divert fields, should the need arise. What about dangerous goods? A discussion with the loader about the location, packaging, and coding of the DGs would be a valuable threat consideration.
For each specific flight, always consider the most likely threat (e.g. numerous birds reported in the vicinity of the departure end of the runway) and the most impactful threat (e.g. engine failure at V1 at heavy weight). Talk about it, and be specific. If there is a way to eliminate the threat, do it. Articulate your “bottom line” (e.g. “Because we are at max gross takeoff weight with gusty conditions, if there are any reports of wind speed deviations of +/- 5 knots or more, we’ll wait until the system passes to takeoff…”) and have a plan in place in the event that the threat does come to fruition.
So think about Threat Management every time you fly and at every stage of flight. Thinking is an antidote to complacency, and the Threat and Error Management process causes us to think. Indeed, it forces us to think! We must all use our collective noggins and consider the, “what ifs” constantly. If your attitude is, “the company doesn’t pay me to think,” you have just made the choice to become a Bus Driver versus a Professional Aviator. The choice really is ours…our fellow pilots and employers deserve the latter.
For more discussion on Threat and Error Management, CRM and managing risk in High Reliability Organizations, please visit http://criticalreliability.com/blog/
Next up… Unexpected Threats
Patrick Mendenhall is a Captain for a major U.S. airline. Patrick began flying at the age of sixteen. He graduated from the University of Washington with a Bachelor of Science in Aeronautics and Astronautics in 1980, and worked for Boeing as a flight test engineer prior to joining the Navy in 1981.
He spent eight years on active duty in the U.S. Navy as a light attack pilot and retired from the Naval reserves. His duties encompassed several leadership and management positions, including a tour as an operational test pilot at VX-5 in China Lake, California. There, he was involved in various aspects of tactical and operational test and evaluation, with an emphasis on human factors integration.
He became a commercial airline pilot in 1989, where his flying experience has concentrated mostly on international, wide body operations. He is type rated on the Airbus A-330 and Boeing 767/757, Boeing 737, and has accumulated over 17,000 hours of flight time.
Patrick has been providing CRM Training to a wide variety of audiences for over 12 years and is considered a Subject Matter Expert (SME) on Human Factors, CRM, TEM, and Risk Management. He provides training for and lectures to audiences throughout the world on these topics as they pertain to high reliability and critical outcome industries.
He co-authored the book “Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety” which was published in 2013 to great acclaim. Written with renowned journalist Suzanne Gordon, and medical educator Bonnie O’Connor, PhD, this work provides valuable insight into how and why the aviation safety model has been so successful, and how these lessons can, and should, be applied to healthcare.
Patrick volunteers for the Airline Pilots Association (ALPA) as an Airport Safety Liaison and is on the Board of Advisors for the Surgical Care and Outcomes Assessment Program (SCOAP), a patient safety advocacy organization. He has been a vital content provider to several CRM training organizations including Crew Resource Management LLC, Critical Outcome Strategies LLC and TrainingPort.net.
Contact Patrick for more information or for speaking opportunities.