T&T: Threat and Error Management

[John Baker]

Continental Airlines(the company I work for) and NASA and Univ. of Texas Human
Factors got together to develop a strategy for dealing with threats and
errors.  It is called "Threat and Error Management"...TEM.  This is the
evolution of Cockpit Resource Management(CRM).  It was such a landmark
study/"discovery" that it is used worldwide in airlines as well as other
industries(Healthcare,etc.).  It is an 82 page PDF file.  Some of it may seem
technical and some of it seems quite simple.  But I do think there is some
benefit to it as it relates to the operation of your boat and it would
obviously benefit a professional marine application.

Back in the day, the pilots were told by the company and the FAA..."don't
screw up!!!".  That philosophy brought us into the 70s but we finally admitted
that we are human, and humans make mistakes.  Why don't we examine the threats
that cause these errors and if the error has already occurred, hoe to keep it
from causing undesired consequences.  Managing threats is manageing your
future....realizing the threats to your operation and manage them in such a
way as they do not become errors.  Managing errors is managing your past....an
error is something that has already happened but manage it so it doesn't hurt
you.

Anyway, I have always wanted to share this with the boating community and have
just never got around to it.  You will have to take the aviation terms and
equipment references and "translate" them into trawler terms and equipment.

3 things that have had an incredible impact on safety in aviation:

Line Operational Safety Audit(LOSA).  This is where an observant rides along
in the jumpseat and unjudgingly observes the crew.

Flight Operations Quality Assurance(FOQA).  This is the downloading of flight
data recorders to see developing trends as they relate to certain airports
and/or operations.

Aviation Safety Action Program(ASAP)...this is the voluntary admittance of
flight crews of their mistakes to flight ops.  As long as these mistakes fall
into certain parameters(ie not intentional, no accident, etc) then no punitive
action is taken against the pilot(he becomnes immune to any action so that is
his motivation in reporting the incident)

These 3 things you will see in the presentation on the link.  They provide
extremely valuable data to use in developing strategies to mitigate certain
threats in the future.

Link to model:

http://www.flighttestsafety.org/workshops/FTSC06/threatmanagement.pdf

The first 20 pages may not be all that applicable or interesting as they just
give the history of CRM and the history of CRM at Continental.  But when you
start getting into the model and what it represents, then that is where there
is useful information as it relates to the operation of your boat.  They do
talk about risk and "time compression" but not really enough.  The coffee
filter shape of the model is to represent time compression....meaning things
do not stop happening just because they are going badly...they will continue
to happen and there will be consequences if not managed properly.

I hope this is not beyond the scope here and I hope y'all get something out of
it!!!


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