Threat And Error Management Revisited

Abstract

Threat and error management (TEM) is considered a key responsibility of pilots, flight instructors and flight examiners. This study presents a new model for teaching threat and error management related to flight instruction that is based on the system-theoretic process analysis (STPA) (Leveson, 2011). Currently a linear threat and error management model is used which lacks critical aspects related to the control hierarchy and multiple control. With STPA complex processes involving hierarchy, multiple controllers, non-linear relationships or feedback, that are typical for flight instruction can be modelled. This model includes the higher-level controllers in the hierarchy of the aviation system such as company management, authorities and industry associations that shape the interactions among flight instructor, trainee, automation and environment. The new model shows that each control instance in the system can contribute to threat and error management. Thus, the people from every control instance of the hierarchy can be better prepared to anticipate and deal with hazards related to their work. The STPA-based TEM model can be used for safety training, instructor training, for developing requirements, standards and for hazard analysis and prevention of instructional incidents and accidents.