Threat and Error Management - Essay Example

KEY CHALLENGES AN ESTABLISHED AIRLINE WOULD LIKELY FACE WHEN DEVELOPING AND IMPLEMENTING A THREAT AND ERROR MANAGEMENT (TEM) TRAINING TOOL FOR THE FIRST TIME By Name Course Instructor Institution City/State Date Key Challenges an Established Airline Would Likely Face When Developing and Implementing a Threat and Error Management (TEM) Training Tool For the First Time Introduction Threat and Error Management (TEM) suggests that threats, errors, and undesired aircraft states are day-to-day events that should be managed by the flight crews in order for safety to be maintained. Basically, flight crews that manage such events successfully irrespective of an event are presumed to have improved their ability to adequately maintain safety margins. Therefore, the main objective of TEM is offering the flight crews the best possible support to successfully manage threats undesired aircraft states, and errors. The objective of this essay is to offer a critical analysis with regard to the key challenges that an established airline would possibly face when developing and implementing a Threat and Error Management (TEM) training tool for the first time. Besides that, the paper provides suggestions that could be used by the airline to effectively manage such challenges. Managing threats and errors in the airline industry has become an obvious part of skill maintenance, adaptation, and learning; therefore, the main force steering TEM is to comprehend the types of errors created under various circumstances and establishing how crews should respond to such circumstances. Using the Charkhi Dadri mid-air collision, the essay demonstrates that an error, which is detected as well as managed effectively, can help reduce the probability of a flight disaster. Contrariwise, when an error is mismanaged, the safety margins are reduced and can lead to undesired aircraft state or additional error. Therefore, TEM is crucially important because it centres on the prediction of risk conditions, which could provoke or facilitate errors. Lack of time, money and belief in TEM are some of the challenges associated with the implementation of TEM. Besides that, the issues associated with implementing TEM training tool are not technologically associated issues like standardisation, compatibility, or technological complexity, but mostly it is human and organisation associated issues, such as project mismanagement, incompatible business processes, organisational culture, and resistance to change. For TEM to be implemented successfully, airlines must take part in the five-part Line Operations Safety Assessments (LOSA) quality assurance process, which will be discussed in the essay. Analysis TEM according to Ruskin et al. (2013) is an all-encompassing safety model, whereby adverse events are defined in terms of challenges or risks that exist within the working environment (threats) as well as the specific personnel’s actions, which worsen or potentiate those errors (threats). Normally, threats reduce the safety margin and need actions do that further incidents are prevented while errors normally bring about undesired state, whereby there is limitations of options and the adverse event can only be prevented by immediate response. TEM technique was developed from LOSA program, which was designed initially with the objective of assessing the behaviour of the Crew Resource Management (CRM). The program was later expanded in order to handle other forms of errors. TEM has facilitated the determination of what causes an error, how to respond to the error, the person behind the detection of the error, and the eventual result. While examining attitude towards TEM training, ATSB (2009) observed a number of challenges associated with its implementation. The majority of the participants in the study cited that they expected to come across challenges related to resistance to change and lack of time. Normally, when a new initiative is introduced, resistance to change and objections normally emerge. Challenges associated with TEM implementation as observed by ATSB (2008) include: Lack of time since its needs a lot of time to set it up and finding time to train is also challenging. Another challenge is resistance to change because sometimes the cabin crew could be unwilling to change because of lack of involvement during the process of implementation, lack of interaction between the users and designers, and lack of support from the top management. ATSB (2008) also noted the challenge of coordinating staff and training since it is hard to organise both staff and time together at the same time. The airline could also be lacking adequate resources to successfully develop and implement TEM training tool due to commercial pressures. Other issues outlined by ATSB (2008) include issues associated with relevance and usability, training, lack of belief in the TEM training tool, and high staff turnover (see appendix one). Basically, LOSA and TEM have been widely accepted in the aviation industry in a somewhat short period; thus, this demonstrates that they are crucial tools for the modern-day efforts towards developing as well as improving the safety of the airlines. Although they are no more perceived as novel tools, Dahlström et al. (2008) posit that there are some criticisms directed towards some aspects the TEM. For instance, the TEM model focuses on the ways that every pilot has at all times approached the safety of the flight, but in question forms like: What are the threats? Can these threats result in errors? What is the effective strategy towards threat and error management? Therefore, when developing TEM, the airline will find it challenging to develop a tool that will contributes to the conceptual paradigm, which pilots will apply easily. In addition, it is difficult to determine the level to which a passive and accompanying observer can detect and categorise errors. The present approaches utilised to teaching TEM emphasise replicability or performance reliability across repetitive circumstances, but with focus on the context changes. A trainer, for example, should determine whether the members of the crew are executing the approach in line with the situation and the procedures. Yet, the majority of compensation for and appreciation of the circumstance are presumed to emerge from adaptations in the competence envelope of the crew, from the judgmental as well as technical resources existing in the defined roles of the crewmembers. Woods et al. (2012) assert that this could exceedingly technicalise the threats and errors management, with a possible relapse that could limit the human components unreliability since mistakes, errors, and miscues are reduced. While developing the TEM, it is very challenging to determine how safety can inhere in the components of the system so that the system safety is not severely underdetermined. According to Woods et al. (2012) safety is concerned with retaining dynamic stability when the situations are changing. Therefore, when developing and implementing the TEM training tool, the designers should understand that safety is about what a system can do, rather than what the system has. Still, it will be difficult to make the crews recognise the developing shortage within their system’s expertise as well as developing strategies to manage the problem. Such an adaptive capacity required for such adaptation and recognition cannot only be achieved through practising technical skills, bit through recognition of the flexibility, limits and obligations of the crewmember’s role. It is at threat-and-error management could be this point where individuals tasked with teaching TEM are hindered by all the lingering essentialist suppositions regarding the nature of errors as well as threats. As mentioned by Dekker and Lundstrom (2006), threats and errors lacks immutable identity except for the social setting where knowledge regarding their manifestation. Therefore, threats and error do not exist as ready-made products that can be managed for all and sundry; rather, they are issues that have been established and analysed into negotiable irrelevancies and problems. With errors and threats being constructed socially, Dekker and Lundstrom (2006) posit that the interpersonal processes through which their creation takes place possibly outlines more regarding the ability of the crew to address adversity and diversity. An established airline would experience difficulty when trying to make the TEM training tool a discourse towards a predefined list of errors and threats. The TEM Conventional theories point out that for the effectiveness of team performance depends on the ability to match it with the context. Individuals have to acknowledge and suitably respond to events, which happen away from the flight crew influence, but heighten the complexity associated with operation and should be addressed in order for the safety margins to be maintained. For instance, the failure of both engines could create the need for decisions to be made first and also a style of leadership, which enables decisiveness as well as speed. Therefore, when developing and implementing TEM training tool it could be challenging to enable the crew members get the accurate details regarding the context, which is very important for decision-making. Yet again, the TEM would miss the persuasive context rendition when implemented for the first time. Determining the level of the immediate threat of an emergency while using the TEM tool for the first time is not easy, but after the crewmembers have been trained how to make the mayday call they will learn how to engage with the situation as a team. When implementing the TEM, it is imperative to understand that crewmembers are not only threats’ recipients, but also their constituents. Dekker and Lundstrom (2006) posit that threats do not come before the response because the threat is created by the response. Therefore, this construction consequently approves a certain repertoire of desirable or plausible countermeasures. In his study, Rantz (2002) posit that it is erroneous to think that utilising TEM and behaviour analysis could make crewmembers free from errors. It is hazardous to presume that TEM training makes someone error-free since this attitude could be conveyed from one setting to another. An established airline is inclined to experience challenges when trying to integrate the external environmental feedback, technologies, procedures, training, as well as behavioural contingencies with the TEM training tool considering that they are crucial elements for establishing error-reducing setting, where interactions between highly trained personnel take place. LOSA as cited by Rantz (2002), has exhibited that the present training system is less likely to reduce crewmembers errors on the flight deck. Therefore, when implementing the TEM training tool the airline should understand that errors cannot be eliminated completely since they are an outcome of integrating human into the system. Integrating behaviour analysis with TEM could be beneficial since it can balance and improve the training initiatives. At first, determining the antecedents and organising behaviours’ reinforcing values for anti-error behaviour would be challenging, but would be crucial for the development and retention of anti-error behaviours. An effective TEM training tool is the one that shapes, identifies, as well as strengthens the suitable contingencies of anti-error behaviour. Normally, error originates from humans’ psychological and physiological limitations, and they are caused by workload, poor interpersonal communications, poor decision making, fatigue, cognitive overload, fear, and flawed information processing. The ability of the airline to train crewmembers how to use teamwork is important because it could improve safety. Managing threat and error effectively depend on the crewmembers ability to understand the extent and nature of error, changing error-inducing conditions, and identifying behaviours that mitigate or prevent error (Helmreich, 2000). Resistance to implementation of TEM could be attributed to the change agents, especially when they break agreements when making the changes and being unsuccessful to restore trust within the crewmembers. In this case, the agreements would entail implied and psychological, which are breached or broken every time the airline’s agents deliberately or unintentionally break their promise. Basically, breaches can take place when changes are made during the distribution of procedures, the processes and resources or when there is interaction between individuals with greater authority (management team) and those having lesser authority (crewmembers). When crewmembers feel they are treated fairly, they are inclined to develop behaviours and attitudes related to successful TEM training. Still, when they experience a betrayal or injustice, they are likely to develop negative behaviours such less cooperation and could result in erosion of trust between them and the top management. If the airline fails to create awareness before implementing the TEM, then there is high probability that the crewmembers will consider the action as mistreatment as well as injustice. Perceiving the introduction of TEM as an injustice could result in resistance. The airline can lessen resistance to change by ensuring that the crewmembers are involved in the change process. Without a doubt, encouraging the crewmembers to partake in the change process can be extremely beneficial to the airline because participation would improve the crewmembers’’ knowledge regarding TEM; therefore, reducing fear. Besides that, participation could improve ego and make the crewmembers feel appreciated and needed at the airline. More importantly, participation will encourage the crewmembers to have faith in the TEM system. Therefore, involving the crewmembers in the development and implementation of TEM training tool will undoubtedly reduce change resistance. Aside from change resistance, the airline’s structures as well as the existing culture could induce reluctance to the utilisation of TEM, particularly if the crewmembers realise that it needs extra effort. The implementation of TEM must be communicated to crewmembers and items like expectations, benefits and status must be offered. Furthermore, the airline management should communicate the ‘what’ and ‘why’ of the TEM implementation so as to enable the staffs understand the changes, which will take place and what the airline expects from them. This can be achieved effectively if the nature of change is defined and the crewmembers are told how they will be affected by the change professionally and personally. The airline should communicate to the crewmembers about TEM through the company website, staff briefings, newsletters, or email. More importantly, the communication regarding the TEM training tool has to be tailored to the different roles and levels in the Airline since every affected person will respond differently to the changes. The airline managers should communicate openly with the employees so as to effectively encourage their acceptance of TEM and reduce possible resistance. There is high likelihood that internal conflict will happen in the airline when the TEM training tool is implemented. Normally, when an airline introduces something new, the management creates proposal which is then reviewed, consented and executively sanctioned prior to its full implementation. Therefore, before the implementation of TEM the airline should first prepare by carrying out original research regarding TEM, which includes documenting the reasons why the airline needs TEM and how it will be aligned with the organisational goals. In addition, the preparation must include the evaluation of pros and cons of TEM, contingency and estimated costs, and ways to reduce conflict that could arise after its implementations. For instance, an opinion difference between the airline management and crewmembers could result in delay and perhaps communication breakdown. Therefore, the best course of action could be collecting perspectives of every person that could be affected by the implementation of TEM so that an outline is developed that is approved by the majority to facilitate successful implementation of the TEM training tool. Another challenge associated with TEM implementation is emotional barriers such as risk-aversion (fear of failing or making mistakes). Besides that, the crewmembers could be unable to process contradictory or incomplete information such as solving multifarious issues. For instance, incomplete information could result in the reduction of promising ideas. In addition, some crewmembers could prefer examining the existing ideas rather than creating new ones. As pointed out by Helmreich (2004), failure to utilise the basic CRM behaviours like cross checking or monitoring as error countermeasures could pose some challenges when using the TEM training tool. Furthermore, there are some communications errors related to TEM; therefore the airline must ensure that the TEM is calibrated effectively to reduce the probability of such errors occurring. Both communication and decision errors if unchecked can render TEM ineffective and may fail to reduce human-induced accidents such as Charkhi Dadri mid-air collision that happened in 1996. The accident is considered as the worst mid-air crash to ever happen in the aviation history. On 12th November 1996, Saudi Arabian Airlines Flight 763 and Kazakhstan Airlines Flight 1907 collided at an altitude of approximately 14,000 feet leading to the death of 349 passengers. According to Purohit and Suthar (2012), the disaster was caused by communication errors, particularly in the Kazakhstani plane. All of the crewmembers in the Kazakhstani flight crew apart from the radio operator could not speak English; therefore, the entirely depended on the radio operator for effective communication with the air traffic control. The situation was exacerbated by the fact that the radio operator had no set of instruments; therefore, he would check the pilots’ shoulders so as to get information, like the height of the aircraft. As a result, Flight 1907 failed to maintain its assigned altitude (15,000 feet); instead it was flying on an altitude of 14,000 feet. Upon noticing the descent, the radio operator informed the crew to ascend the aircraft to the assigned altitude. Unfortunately, this placed Flight 1907 squarely in the path that Flight 763 was flying on leading to a collision that demolished the stabiliser and left wing of Flight 763. This led to the death of all passengers and crewmembers in both planes. If Kazakhstan Airlines had implemented the TEM training tool, the crewmembers would have been able to establish the looming threat, the radio operator’s error as well as the undesired states. As pointed out by Langer and Braithwaite (2016), interruptions and obstructions can be handled effectively if TEM is implemented successfully. The Charkhi Dadri mid-air collision illustrates the essence of implementing the TEM framework since as mentioned by Thomas (2004) it enables the crewmembers to avoid opportunities for error or threats. In addition, TEM could have enabled the Kazakhstan Airlines’ crewmembers to detect new errors or threats and reduce the potential effects. According to Wagener and Ison (2014), TEM training enables the pilots to achieve an improved performance level, which enables them to manage the growing challenges related to maintaining safe flying operations. If the crewmembers in both flights had identified the threat successfully as red flags, they could have addressed the threat and make it insignificant. As opined by Thorogood and Crichton (2014), airlines should organise around expertise by giving technical decisions to suitable specialists. For an airline to successfully implement the TEM training tool, Merritt (2006) suggest that they must participate in the five-part LOSA process of quality assurance. First, as mentioned earlier, the airline must reach an agreement with the pilots’ association so as to make sure that every data will be confidential, de-identified as well as conveyed to LOSA Collaborative directly for examination. Secondly, after LOSA presents results, both parties (the airline and pilot associations) are expected to utilise the data in order to ensure that safety is improved. The airline should accept assistance in the selection of motivated and diverse group of observers. As pointed out by Merritt (2006), an observer team should typically be represented by different departments in the airline, like flight crew association, training, flight operations, as well as safety. The trainers should then be trained for five days in the observation methodology, the TEM framework, as well as the LOSA software tool utilised in the organisation of the data input. Thirdly, after their training, the observers should carry out sample observations before convening again for recalibration sessions. At this time, observers get feedback (one-on-one) on their observations quality as well as approved to carry on as the projects’ observers. Merritt (2006) mentions that observer recalibration and training are crucial for consistent LOSA dataset and the succeeding observations should be carried out over the subsequent 28 to 56 days. Fourthly, after sending the encrypted observations to the LOSA Collaborative, the observers’ flight narratives are read and checked by the analysts to make sure that all threats and errors have been accurately coded. This would help ensure that the data of the airline are within the quality and standard of the other airlines within the LOSA Archive. Lastly, after the analysts have checked the airline’s initial data integrity, the representatives of the airline participate in a data-cleaning discussion together with the analysts from the LOSA Collaborative, where the data is reviewed against the policies, manuals, and procedures of the airline so as to ensure correct coding of the errors and events. After the discussions, the data set should be signed off by the representatives of the airline as the accurate version of errors and threats. Then the final report analysis start and implementation of TEM is more likely to become successful. Aside from the five-part LOSA process of quality assurance, the airline should ensure that the presumed differences between non-technical and technical skills have been deconstructed so as to facilitate integrated methods of training. In addition, identifying types of TEM training interventions should facilitate the cognitive skills development. Still, failure to solve the misconceptions associated with TEM training could result in additional challenges. It is the duty of the airline management team to enlighten the crewmembers managers regarding what TEM training could do to the airline. Conclusion In conclusion, the essay has offered a critical analysis with regard to the key challenges that an established airline would possibly face when developing and implementing a Threat and Error Management (TEM) training tool for the first time. The key challenge to TEM implementation as mentioned in the essay is resistance to change, which normally happens when the airline fail to communicate effectively to the crewmembers the importance and value of TEM. The change resistance can also come about when the airline fails to follow the five-part LOSA process of quality assurance or commit fewer resources to change. Inept strategies to TEM training can accelerate resistance from the crewmembers. As pointed out in the essay, the corrective action to change resistance is offering sufficient information regarding the change process to the affected and convincing them the TEM tool would be beneficial both to the company. Other challenges mentioned in the essay include poor supervision, lack of time, staff availability, lack of sufficient resources, training issues and lack of belief in the new system. TEM is a suitable way of reducing the human error opportunity in the aviation industry by improving the detection as well as mitigation of threats and errors. The Charkhi Dadri mid-air collision demonstrates the significance of implementing the TEM framework since it would have enabled the crewmembers to avoid opportunities for error or threats. More importantly, the five-part LOSA process of quality assurance is the most effective way of ensuring successful development and implementation of TEM training tool. The airline must reach an agreement with the pilots’ association to reduce the likelihood of change resistance. The data from both parties is sent to LOSA Collaborative for analysis before sending back the results that are used to ensure that safety is improved. Generally, following the five-part LOSA process of quality assurance, TEM training would enable the pilots to achieve an improved performance level and be able to manage the growing challenges related to maintaining safe flying operations. References ATSB, 2009. Threat and Error Management: Attitudes towards training and applicability of TEM to general aviation and low capacity air transport operations. Safety Report. Canberra: ATSB Australian Transport Safety Bureau. Dahlström, N., Laursen, J. & Bergström, J., 2008. Crew Resource Management, Threat and Error Management and Assessment of CRM skills – current situation and development of knowledge, methods and practice. Reserach Paper. Lund, Sweden: Swedish Civil Aviation Authority Lund University School of Aviation. Dekker, S.W.A. & Lundstrom, J., 2006. From Threat and Error Management (TEM) to Resilience. Human Factors and Aerospace Safety, vol. 6, no. 3, pp.261-73. Helmreich, R.L., 2000. On error management: lessons from aviation. 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Using Applied Behavior to Complement Error Management in Crew Resource Management Education. Journal of Aviation/Aerospace Education & Research, vol. 11, no. 3, pp.41-47. Ruskin, K.J. et al., 2013. Threat and error management for anesthesiologists: a predictive risk taxonomy. Current Opinion in Anesthesiology, vol. 26, no. 6, pp.707–13. Thomas, M.J.W., 2004. Error Management Training Defining Best Practice. Woodville SA: ATSB University of South Australia. Thorogood, J. & Crichton, M., 2014. Threat-and-Error Management: The Connection Between Process Safety and Practical Action at the Worksite. In IADC/SPE Drilling Conference and Exhibition. Fort Worth, Texas, 2014. Wagener, F. & Ison, D.C., 2014. Crew Resource Management Application in Commercial Aviation. Journal of Aviation Technology and Engineering, vol. 3, no. 2, pp.2–13. Woods, D.D., Leveson, N. & Hollnagel, E., 2012. Resilience Engineering: Concepts and Precepts. Aldershot, UK: Ashgate Publishing, Ltd. Appendix Common Challenges Associated With the Development and Implementation of TEM Training Tool Read More