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While traditional training focuses on the physical and technical understanding of an aircraft, TEM focuses mainly on psychological processes. It represents a systematic means of introducing logic into the sometimes reflexive nature of decision-making.
The development of CRM/SRM be- gan the long arc toward the multidisci- plinary field of Human Factors, which utilizes everything from psychology to statistics. Before this, aviation safety largely focused on two goals: eliminate pilot error and develop more resilient aircraft systems. While the second goal has largely been achieved, pilot error as a root cause of accidents has remained persistent. The core tenant of Human Factors is that we all make errors. I have participated in hundreds of training events (both as an applicant and as an evaluator), and I have yet to witness a perfect check ride. A high- performance aircraft is complex by nature, with many different systems and operating parameters to manage. Toss in an external environment that includes adverse weather, ATC conges- tion and mechanical issues, and you have a recipe for distraction. Every f light requires a particular series of steps to be taken in order to achieve a successful outcome. Errors can occur at any point but are much more likely to develop when a pilot is startled by an unexpected scenario. The com- pression of time that occurs during flight greatly increases the odds that
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those errors will lead to an undesirable aircraft state.
The Swiss cheese model is one of the better-known allegories used to describe the process of capturing er- rors. The holes in the cheese represent the threats and errors that we experi- ence every f light. The cheese slices represent the barriers that we utilize to resist those errors. A checklist is a prime example of a barrier. Used properly, it ensures that an error is recognized prior to a critical phase of flight. If a runway change necessi- tates a new aircraft configuration after the takeoff checklist has already been performed, the slice of cheese has a potential hole (which can be solved by running the checklist again). Forget- ting to actually run the checklist is another hole. It is worth noting that the “error” holes become larger or smaller depending upon workload. When task saturated, the “holes in the cheese” can be nearly the size of the slice itself. The goal of Threat and Error Management (TEM) is to produce enough “slices of cheese” so that all errors will be trapped prior to a complete loss of situational awareness.
While flight training programs largely focus on the pilot’s role in managing risks and mitigating er- rors, the final solution involves other working groups as well. Have you ever wondered why ATC requires fuel re- maining to be reported in hours and minutes following the declaration of an emergency? Knowing the total amount of fuel onboard is obviously useful for firefighters in understand- ing the potential for a post-accident blaze, but this is something more ef- ficiently accomplished by reporting in pounds or gallons. During the event with United Airlines flight 173, the captain reported fuel remaining in pounds. Had ATC instead required him to report fuel remaining in min- utes, he would have rapidly figured out that “three thousand pounds of fuel” actually meant 13 minutes of endur- ance. Confronted by this, he would have undoubtedly requested an im- mediate approach. The requirement to report fuel as a time-sensitive re- source orients a pilot towards landing before a greater crisis develops, and it provides ATC with a comprehensive understanding in order to back up a potentially task-saturated individual.
Over the past two decades, the NTSB has found pilots at fault in approxi- mately 85 percent of aviation acci- dents. The FAA has understandably placed emphasis on teaching TEM during regular aviation training cycles. While traditional training focuses on the physical and technical understand- ing of an aircraft, TEM focuses mainly on psychological processes. It repre- sents a systematic means of introduc- ing logic into the sometimes ref lexive nature of decision-making. One vital element of TEM is to acknowledge threats explicitly before takeoff and landing. Even if you are flying alone, it is a good idea to perform these brief- ings verbally. Talking to yourself feels silly, but it is calming and provokes critical thinking.
Talking is also quite useful in en- suring the completion of checklists. Nearly all pilots develop a “beat and tempo” when verbalizing a checklist. If you inadvertently miss an item, it dis- rupts the tempo and brings it to your attention. If you are a single-occupant, discussing the flight with a weather briefer introduces a dispassionate third-party opinion (a conversation