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Operating a flight
Published in Peter J. Bruce, Yi Gao, John M. C. King, Airline Operations, 2018
Procedural compliance is essential to ensure continual safe and effective operations. Many airlines prioritize this, as well as the message of safety, as a core brand value, for example, ‘Safety is our first priority’.29 There are typically two types of inspections or oversight regimes used by airlines to determine operational safety compliance and subsequent violations by Cabin Crew. These include the check/inspection process of upholding mandatory standards and the operational audit program known as Line Operational Safety Audit (LOSA), predominantly with a view of the Human Factors (HFs) and behavioural elements observed within the interaction of the crew, their environment and the various systems/standard operating procedures. LOSA has the objective of observing behaviours in both full and reduced narrative, recording, coding, sanitizing and collating data from observational audits of crew performance over regular flight stages. In accordance with the Threat and Error Management (TEM) framework, this data is used to evaluate and measure procedural effectiveness, safety compliance and organizational efficiency. To this extent, based on final analysis of the data, procedural variations are monitored and can lead to prescribed changes in future and/or amendments to existing company policy. LOSA forms part of audit compliance under the standards and controls of the IOSA program, where member airlines register these activities as part of their IATA compliance, forming part of their risk identification and management strategies within the airlines safety management system.
Improving Healthcare Communication: Lessons from the Flightdeck
Published in Christopher P. Nemeth, Improving Healthcare Team Communication, 2017
Monitor and Manage Problems and Errors One critical reason for establishing a positive crew climate is to create an atmosphere in which crew members are willing to raise issues of concern that may influence safety. In the introductory section we cited several crashes in which failures of “monitoring and challenging” contributed to the accident. What needs to be monitored is not only the aircraft systems, weather, traffic, and ATC, but also the activities and apparent understanding of the other pilot. The current generation of CRM training emphasizes “threat and error management” (Helmreich, Klinect and Wilhelm 1999). Threats tend to be events in the aircraft or environment that pose a challenge to the crew, whereas errors typically are made by the flight crew, but also may be made by ATC or others in the system. (Monitoring external threats has been discussed already in the first section on building shared situation models.) Errors, which must be detected before they can be corrected, can be of several types: slips, lapses, mistakes, and violations (Norman 1981; Reason 1990). Slips include mishearing clearances, entering incorrect data into the flight management computer, or misreading a chart or a checklist item. Lapses include forgetting to enter data or make a call-out. Correcting these types of error may be straightforward since one can specify a clearly correct behavior. More difficult types of corrections involve mistakes that are grounded in professional judgment, or violations, willful disregard of the rules.
Epilogue
Published in R. Kurt Barnhart, Douglas M. Marshall, Eric J. Shappee, Introduction to Unmanned Aircraft Systems, 2021
Threat and error management strategies began evolving in the 1970s with the beginning of “cockpit resource management” (CRM) to assist crew interactions with regard to communication, crew coordination, team building, and decision-making. The work of James Reason, Douglas Wiegmann, Thomas Shappell, and others further identified ways to classify errors and contributing causes, with the intent to identify trends and develop effective countermeasures. Shappell and Wiegmann’s publication of the human factors analysis and classification system (HFACS) provided a framework to identify and classify errors and contributing factors.
The impact of power on health care team performance and patient safety: a review of the literature
Published in Ergonomics, 2021
Erin L. Stevens, Adam Hulme, Paul M. Salmon
In response, Crew Resource Management (CRM) and Threat and Error Management (TEM) training programmes were developed to level out the authority gradient between the captain and co-pilot on the flight deck (Helmreich 2000; Gross et al. 2019). CRM and TEM training programmes sought to shift the culture of safety in the aviation industry to allow airline crew to challenge each other on safety decisions, irrespective of seniority or experience, without fear of retribution (Green et al. 2017; Gerstle 2018; Bennett 2019). Given the contribution of CRM and TEM approaches in aviation, similar training was introduced to the health care sector in the late 1980s, however its increasing application in the medical domain through standardised professional team training is a direct outcome of the Institute of Medicine’s 2000 report ‘To Err Is Human’ (Donaldson, Corrigan, and Kohn 2000; Gross et al. 2019). This report was instrumental in increasing the recognition of ‘error’ within health care teams and its impact on patient mortality and morbidity in US hospitals (Green et al. 2017). Whilst the existence of power within health care teams is acknowledged in the report, there was limited consideration of its role in adverse medical events (Donaldson, Corrigan, and Kohn 2000).
What went right? An analysis of the protective factors in aviation near misses
Published in Ergonomics, 2019
Brian Thoroman, Natassia Goode, Paul Salmon, Matthew Wooley
Error-handling models describe the processes by which front-line operators identify and address errors to generate near misses rather than accidents. Kontogiannis (1999) discusses the types of recovery made by operators at various stages of a work process. Similarly, research on error recovery (van der Schaaf 1995; Rizzo, Ferrante, and Bagnara 1995; Kanse et al. 2006) identifies the stages through which operators detect, explain and correct errors. In aviation, the Threat and Error Management (TEM) model (Helmreich 1999; Klinect 2003) extends error handling to the identification and management of threat and error within flight crews (Helmreich 2001). The error-handling models do not, however, identify the system-wide factors which lead to the management of threats and errors.