Transcript for:
Threatened Error Management in Aviation

welcome to nappies mentor live program threatened error management from successful strategies used by Airlines you'll learn how to adapt the principles to your flying and instructing Paul predator is the chief instructor and examiner for a regional airline overseeing its pilot training program he has over 7500 hours as an ATP certificate with type ratings in the CL 65 and the do 328 he's the ground in gold seal flight instructor a simulator and line check Airmen an FAA air crew program designee and an FAA designated observer with 6,800 plus hours of instruction given in part 61 and 121 operations panikker maintains his commitment to general aviation instructing for 27 years sharing his extensive experience in both GA and commercial aviation as a member of the nappy professional development program committee and volunteering and many other capabilities in capacities with industry and the FAA an accomplished aviator in teacher he aims to contribute to aviation safety using his training insights to blend accepted best practices between GA and part 121 welcome to e mentor Paul Phil thank you so much for that introduction and I want to welcome all of our viewers to mentor alive it's a it's an honor to be here and I hope we have a good time to discuss you know this topic thread in error management to what it means to advance general aviation and talk about some current topics so once again I'm very pleased to be here honored to be part of the group just a quick note about the title you know I sort of a little bit of a play on words here you know 10 building what with error management will become is something that pilots can use in their toolkit or in their team to help manage risk and risk management is you know central to our you know continued safe operations so I just wanted to you know Express a way to say you know this is something that you know we can use it's a it's an active process to demand at safety and it's just part of our can be part of our team in your introduction you know you said that I spend my time between the airlines and general regulation and I you know we just like to say that I've been in your Alliance for about 18 years and I can't imagine a more dynamic period in our time right now the hiring opportunities and all facets of ammunition are tremendous you know we're in a growth economy major airlines are buying newer aircraft which of course need to be staffed you know regional airlines are hiring corporate operators are hiring there's opportunities for flight instructors it's just a it's a wonderful time to be a pilot and you know I'm happy to be a part of it and you know I think the future is good when I was thinking about you know how to introduce this you know several things came Devine about how do I introduce this topic and I I'll just tell you a story I have a very good friend of mine his name is Mike and he's a pilot friend and some years ago I what was that as a second dinner and we were just talking about you know pilots that we know or you know some experiences I had recently in training you know I have to make the comment about well you know I'm so-and-so was use a good pilot and you know Mike said to me says well what does that mean you know what what is a good pilot and I pause for a moment of course my first thought was well one like me you know I'm a good pilot but you know I try to give it a little bit more thought and I kind of narrowed it down to two things I I think a good pilot is somebody who is a true master of the aircraft you know in terms of control and smoothness of how he flies the airplane but also a good pilot is a master of the situation meaning not only do you have the good skills to you know have aircraft control but you also have an amazing ability to understand a situation that you're in or the situation that you will be in ultimate you know master of the situation combined with master of the aircraft I think is what makes a good pilot and a few days ago I had the chance to watch a movie that I had seen many times that perhaps some of you have seen this you know it's Tom Wolf's classic called the right stuff and you know if you remember there's a character in that movie you know played by Dennis Quaid but he's playing the role of the Gordon Cooper and often through the movie you know Gordon is saying you know who's the best pilot you know you've ever seen and you know whose response would be well you're looking at them and I and I thought you know I've often talked to our new higher classes when I'm making a presentation about you know their training and things like that and I'm quick to say that Gordon got it all wrong that I'm really the best pilot I've ever seen as long as I'm not flying the airplane when I'm doing observations on the airplane and a jump seat I don't really miss too much because I'm not physically engaged with the aircraft if I'm sitting in the back of a simulator doing a check ride I don't miss too much because I'm not physically involved with the aircraft now connect me to the airplane well stuff happens you know and I and I think that's what we're trying to achieve when we talk about risk management is how do we maintain good control of the airplane you know when we're dazed in the act and the art the flying and maintaining you know exquisite situational awareness of all the things that are going on around us so that's that's where we're going with this and I think we can just get started and now let's move on to the next slide so there's all good flights yeah we need a flight plan and you know these are the these are the things that we'll cover you know we will do the basics you know what is what is that air management what are you know some of the training considerations that we need to discuss when we're when we want to talk about how to retrain thread error management well jump back in history a little bit about where did where did it come from how did it get started spend a little bit of time talking about how does it relate to CRM or SRM single-pilot Resource Management of course there's a few charms associated with thread error management I'll discuss some tools you know that we use to help you know mitigate some of the threats that come our way and we'll kind of wrap up with an application to you know how we can apply this to general aviation so next slide please so you know first things first this is a common adage I mean we hear this a lot you know accidents you know rarely occur due to a single event or an error you know they may occur because there's some chain of events and we hear this from a very basic and you know primary training that you know there's an accident chain so obviously if we can take steps to break the chain then you know we can stop an incident or an accident or or you know just some event we don't want to be in and the logic of this too is that if we break the chain at the earliest point then we won't have to deal with the compounding of multiple errors so if we have multiplying effects of errors are going to be more and more difficult to manage so the sooner we can do this you know the better when we talk about events they can be anything I mean all of us can imagine you know the events that we're talking about here weather changes you know mechanical issues you know airport construction that might affect the available runways I mean all of these things are events that we have to consider and and manage in order to make and safety additionally you know our own decision-making process if if we make the wrong decision that in and of itself can become an event that we may later need to manage to help mitigate risk next slide please so let's do the basics TEM is just short for threatened error management it's a safety process that automatically assumes that we operate in a very complex environment that we will make mistakes and that we're gonna operate with some level of risk so it's important to realize that further management acknowledges the type of environments that we're in and that our continued goal of you know mitigating risk managing the threats managing the errors that are possibly made will keep us on the safe path threat error management is simply a safety process that helps us do that now risk management is an essential part of the airmen certification standards those have been put into place for some of the certificates and you know to kind of summarize the new ACS is basically adding aeronautical knowledge risk management to each pts task and you know to kind of borrow from the language of the ACS the three elements you know that comprise airman certification standards are know consider and do and the note part is obviously the knowledge the consider part is the process where we're using you know aeronautical decision-making and risk management is a key component and then the do part of course is the task itself whatever that might be now also you know from my very earliest days we were told to prioritize how we manage our flight and very simply it was a v8 navigate and communicate we still you know we teach that today in general aviation we teach it in the part 1 1 21 environment but if you look at some of the recent publications from the FAA including the FAA safety briefing there are articles in there now that talk about not only a not only aviate navigate and communicate but also mitigate then mitigate is not you know the fourth step actually but mitigate is kind of the umbrella applied to all the rest of it so that we have things to mitigate in the way we a v8 the way we navigate and the way we communicate so you know thread error management is just another way of accomplishing risk management it's something that we can train it's kind of an action-oriented process and it blends in well I think with the initiatives of the ermine certification standards because as I said they those standards have built-in risk management into the process so let's move on the police till next next slide so we we talked a little bit about you know we're trying to manage you know threats and we're trying to manage pairs and you know we can you know we toss these terms around a little bit and if we just kind of take a step back and say well you know what's a threat and what's an error well let's have a look a threat is something that's coming at us and you know there's a variety of threats that come at us and you know we'll go through and create some categories for them but all of the things that are kind of coming at us you know from the time we you know start the engines until we you know Park in at the FBO and you know call it a flight all through that we've had some threats and you know we often talk about go no-go decisions I personally I go through that process but during a flight I'm not really talking about go no-go but you're on a flight I'm doing more of a start continue because as threats come my way if I can successfully manage them of course I'll continue if I think that something is not working out by right for example unfor caste weather yeah I might make a decision to divert or do something different so again the very basics our threats come at us so what's an error well an error is something that comes from us I mean these are these are our mistakes the little caps or below this picture you know this aircraft is pulling onto the runway is the pilot saying was I supposed to hold sort of that runway well that's an odd time to be asking that because if you've already crossed the whole short line and you weren't sure that you were supposed to you just made an error it's there's the number of errors that we've all made I mean if you just try to look at any flight that we do and you say I'm gonna try to make this the perfect flight well suppose you know you're trying to hold 105 knots on your approach but you're not holding on how to intend that's an error and you just kind of deviate from perfect but of course perfect is our goal so again threats come at us arrows come from us and federal management is a way to sort of manage all that please so what this training is about is how do we how did we recognize them you know how do we recognize the threats and errors better better part of our flight what are some of the tools that we can use to manage them and you know prevent them from becoming the second you know or the third link in the accident chain and third how do we prevent what we call an undesired aircraft state in the very worst case an undesired aircraft state could be an incident or an accident but an undesired aircraft it could also be that aircraft that across the runway before he was given clearance an undesired aircraft state could be we didn't extend the flaps for landing so we're just trying to prevent those states it does not teach you how to fly I mean we've sort of already got the flying part figured out in terms of the mechanical skills and like I said what I think a good pilot is is somebody who masters his aircraft but combines that and balances that with mastering his situation or whatever that you know situation might be and exactly's so when we when we are training for error management we immediately acknowledge that we're in a complex environment and the complexity you know we can define that however we want I mean if we you're flying in busy airspace that can be part of the complex environment or going into an uncontrolled non-towered airports that you've never been to before that might in itself be a complex environment so we just start with the idea that we operate in a complex environment and it's part of our procedures and this part aircraft we have what we call hard and soft safeguards which help us with risk management but they may not actually be sufficient so let me pick up on this just a little bit when we talk about hard safeguards these are the these are the safeguards that are in the air dinner in our equipment new initiatives for a DSP by 2020 your autopilot is up as a safeguard to ensure flight path management new GPS is a piece of equipment that's a hard safeguard in the part 121 environment we have some other advanced equipment that are safeguards in terms of ground proximity warning systems so we have these hard safeguards we also have the soft safeguards which is simply you know our checklist you know the procedures the pilot operating handbook our own training you know how we conduct refunds but you know the one thing that occurs to me is that is the equipment you know what we would call the hard safeguards as it gets more and more complex that in and of itself might become a threat and if I am if I go back and use my friend Mike is an example again Mike has a very nice airplane and he lets me fly it from time to time so we can share some time unit and you decided to upgrade his panel and of course it all started with a DSP but then it developed into something you know more significant and it's wonderful technology but we both decided it would really be a good idea to take a class in this and to get some education on all of this equipment so we spent some you know time as a manufacturer's facility basically in a two day class with a desktop simulator to learn a little bit more about this equipment and it was amazingly well done it was time very well spent and I was often brought back to thinking about you know the the cockpit of an airplane is a terrible classroom if you're trying to learn a new panel by yourself I think you're gonna be very challenged even in a to that situation you have to have some division of responsibilities so that you know while somebody's trying to learn the menu options to get into the GPS somebody else is maintaining control of the aircraft so as much as I embrace and really like new technology I think we'd have to be careful that that in and of itself doesn't become a you know a threat leading to some more errors I mean this I think it's very easy if you put two pilots in an airplane for for both of you to be looking at the what's inside and you know ignore a little bit about what's going on outside yeah and of course you know somebody always has to be watching outside so I feel like I know you and I talked about this earlier something to say about that you know there are a couple of things Paul I think to sort of summarize what you're saying and expanded a bit is in general aviation I think we tend to take the presence of just some mixture of equipment as okay that's what we're flying today we're in reality the variation from airplane airplane in itself is a pretty significant threat and how might you suggest addressing that when you're instructing different airplanes same make and model but with it's quite different configurations of navigation and avionics and so on yeah it's some I'll bring this up in a you know in the later slide it's about you know we've all probably had the experience of teaching in an unfamiliar aircraft and that's sometimes that's not so easy I mean we it's an airplane right we should be able to do this but as you said fill the panel layouts are different there's instrumentation that we made ourselves not be familiar with and these are the sort of things that as a flight instructor we can start compounding the problems and it you know gets in the way of mitigating our you know the risk that we're trying to deal with just to pick up a little bit bomb to solve safeguards like I said these are just the things that you know are available to us you know checklists procedures training you know briefings you know if you have a to pilot crew or you know student and instructor I think it's very important that we you know conduct a thorough briefing about how we intend the flight to go and what you know the expectations are when we say there's no such thing as the perfect flight I have administered about 1,100 port 121 check rides I can tell you that there is no such thing as a perfect check ride and there's no such thing as a perfect flight even though you know we say they're perfect it is to go but that is really kind of the essence of Threatened error management is to say it's not going to be perfect but you know as pilots who are mastering the aircraft or master in our situation we can keep the errors to a minimum and you know enhance the safety of the operation so yeah I think something that you said there goes back to something you said earlier that's also a point that occasionally gets missed you talked about how threat and error management is a process and yet I've had so many pilots have phone with her train that will start through and they have a triggering event something may happen that was a little unexpected and they'll go through their mental checklist but they get to a hard stop until something else happens and I think one of the key points and threaten error management management of the differences that can occur in an airplane just on a random basis is you have to have some sort of baseline mental checklist that you're constantly running in flight that you're you're considering you're just checking in every minute or two or three or what the appropriate time in Raqqah lives to say okay how are we doing on fuel how are we doing on a flight plan how are we doing on our avionics and equipment State and so on and I think that's really important to have that as a process that repeats and doesn't simply wait for event to occur and then apply it that's exactly right you know for owners of their own aircraft you know they're intimately familiar with her with their aircraft and I think that in time you get so comfortable that you you might not start paying attention to some of these things because you just have a comfort level my plan always works what could possibly go wrong it's a beautiful day but you're right I mean when we talk about I often talk to people about you know a scam you know we all know the instruments can that we're talking about but in reality this the scan is much broader than that it's not just up your instruments but it's of the entire situation where are we you know in time and space as you said the fuel just monitoring things you know on a fairly regular basis just to stay ahead of things I mean we're really trying to prevent things from happening you know not as you said not react to them after they happen you know when I've talked about situational awareness again you know somebody said well give me in another example of that I would say well you know if you're on an instrument flight plan um and you're kind of got the other frequencies in your headset and you know you start hearing about holding instructions at some Airport that you happen to be going to that's to tell you something you know let's you tell you that perhaps I need to start planning to hold how will I do that do I have the fuel for this and if you know about that you know 20 miles ahead rather than two miles ahead it just puts your father in the game so it's um it's it's another way to you know just say we have to you know maintain our situation to you know keep the risk keep the risk low and not let the errors creep in next slide please so this is an easy one if you just want it to have a quick way of looking at what thread error management really is I would say it's defensive driving for pilots you know it is we've all seen offensive drivers we know what that looks like the thing that you know makes us safe is to be a you know defensive you know driver and be on guard at all the time times you know kind of expecting the worst my former flight instructor for many years ago always said you know just expect the unexpected and you know if you keep that in mind you know you can maintain a margin of safety question we've had come in from an audience on that it's partly for what you're just saying now and asks what can I do to help remember the tasks at the right time so that's a very good question I myself and feel free to you know share your own advice on this bill but I generally tried to look at phase of flight and after some transitional event you know a level off from a climb a level off from a descent crossing over of you are taking up a new course every time I have kind of a transitional event I'll go back and kind of rescan to make sure that everything that I want to do and everything that you know is in front of me is set up correctly you know we rely so much on our you know GPS and you know the magenta line to say well let's just go direct I always make sure that if I make a course change to a real art or an intersection that I'm always using my GPS to make sure that it shows that I'm in fact in there I don't make those assumptions so again transitional events or comes is what triggers it for me you know there's certain things we do when we level off terms of mixture adjust in the mixture prop throttle maybe the Cal flaps with certain things we do and we're leveling off from a descent when we start getting into the approach place I think we all you know use it as a trigger to you know it's time to change the radios and it is not a one-size-fits-all for everybody you know it's aircraft dependent situation dependent but I think all of us can kind of develop our own system to dress like Islander said you know and I think that ties back to what we'd said earlier and that's to have the sort of continual checklist that's running all the time it it can pace differently based on it but a transition event occurs and that's the time to run that checklist as a bare minimum exactly next slide please so this is not me on that motorcycle my garage and for those of you who perhaps enjoy motorcycles I think you can imagine and relate to the fact that a motorcycle and the act of riding a motorcycle is the ultimate in threat error management because everything is out to get you you've got your own skills you've got mechanical issues certainly you have weather obstructions other vehicles the list can go on and on and on and I'd have to say that I'd I'd have sort of a young I wouldn't say love-hate relationship with my motorcycle but it's something close to that when I'm not on it I think about getting on and riding when I am on it I think about getting hurt because everything is your you're so exposed but I've actually thought you know could I write an article for a motorcycle magazine call it threat error management you know for motorcycles from the pilot's perspective and apply some of these same concepts because you know as I said those of you who have written motorcycles know but you're the threats are significant and your own errors of the errors of other people are significant when when I get in an airplane the thought of having an an incident or an accident never never occurs to me when I'm on a motorcycle about every mile to get a Babbage so it's just it's just another way to express you know this concept of risk risk management so you what about you failed you have a motorcycle no I have never been attracted to the motorcycle I figured airplanes or a good place to start and stop I've been advised that I should do the same alright next slide please well where did all this start it goes back in time a little bit back in in the mid 1990s some researchers at the University of Texas at Austin went into a cooperative study where they major airline at that time and what they wanted to do was to come up with a way to measure procedural compliance and crew resource management and they put together a program call that Llosa which stands for line operational safety on it and in the way that works because there's in the 121 environment there's still opportunities to do that but basically you you put trained observers in the jump seat of your aircraft and they basically watch you know a flight from A to B and they collect data I'm exactly what they saw in terms of procedural compliance non-compliance where the CRM still sufficient so that's kind of where it started and they used at that time they used thread error management as the model to measure the errors so if I could you know just expand on this a little bit we in our training in the 121 environment and our training and checking events we have a measuring scale is just a simple five-point scale but it's all based on predator management and you know to run through the basics if if you're if a particular task for example you know taxiing the aircraft if if everything was done to procedure and was done correctly then the pilot or the crew would get a five the scale keeps going down of course you know you know a four would be that there were some threats or there were some errors but they were trapped in other words because of some threat and you know an error was made but it was immediately caught you can imagine wrong frequency on the radio initially bugged the wrong altitude but you caught it so these are all what we call track errors the next part of the scale was you had a an untracked error which means you made a mistake it didn't catch it but there were no safety consequences because of it the next part of this would be you had an untracked error with a safety consequence and the last part of the scale was if if if there was not some intervention on the part of a crew member you could be leading yourself towards you know a violation or this event or an accident so they used this kind of a scale to measure what they saw in terms of procedural compliance and how effective crew resource management became but pretty early on in all of this they decided that not only should threader management be the measuring tool but it should also be part of the strategy to mitigate risk so from a just a purely historical perspective that's how all this happened and it's this and variations that are still being used today you know 1:21 environment of course I'm trying to make the case for saying that you know we can use it in the general aviation world to do exactly the same thing hey there's a question there can you introduce that Phil yes Roger says I missed checklist items of most flight I missed something typically small things but it bothers me how do you suggest a person minimized the checklist misses so I wish that I knew in the environment that Roger was working and I'm assuming it might be single pilot sometimes what I what I do is or what I have found is that sometimes the checklist itself can become a distraction because you're kind of moving before you you know you're going from the checklist items to whatever the item is and you're kind of doing it back and forth I've always thought you know flows you know the way you start in aircraft you do a certain flow the way you set up for an approach you do a certain flow but you back it up with a checklist to make sure that what you thought you did you actually accomplished I mean many of us certainly when I first learned to fly we were sort of taught to use Flo's mnemonics you know we're memory aids that we were used and then and then back that up with a checklist so that the checklists itself and your your interaction where it didn't become a distraction you know in in the 121 environment we we cannot live without checklist and checklist work great but the reason they work great is those two of us doing them somebody's accomplishing the task and somebody else is verifying it with a checklist and the single pilot environment I sort of see that the flow followed by the checklist is a better way of accomplishing it let me ask you a question about that in GA training I've only seen a handful of instructors over the years and in my environment and general aviation they utilized flows would you recommend using that with the smaller much less sophisticated air points I like them I like I like flows because like I said I've seen cases where a checklist might become a distraction and as Roger says he sometimes misses things you're you're in good company though Roger I can assure you that in even in the two-person environment things get missed especially if they're if we're responding to a normal or emergency procedures you know we have checklists there to prevent that he is a battle sometimes you know we do miss things I like flows followed by checklist it might not be appropriate for everybody or every aircraft of course the challenge is you you're not gonna find I know in your aircraft flight manual you're gonna have to come up with a float yourself and then have to have the checklist to follow it and I'm glad you got to that because I was sort of what I found works well is to help the student develop a set of flows here on 152 or 172 basic airplane and then allow them the time to use that rather than jumping in when something happens and start getting frustrated that well we're supposed to have a two-hour lesson but we've already eaten up 15 minutes by delay for takeoff and just skip that and go to go to the lesson I think that's one of the things that's really important on the instructional side is to say with the discipline of how you use flows if you're using them in how you use checklist when you use them yeah exactly and you know the there there are different checklist philosophies we have checklists that we refer to as read and do you read it you go do it but we have other checklists that are more challenge response and the challenge response is really designed for a crew type environment where one crew member you know will issue the challenge and the other crew member will respond with whatever the action was there's not a reason in the world in my opinion that you can't apply a challenge response to the flow checklist scenario because I'm a gun connection and now you're challenging yourself to make sure and especially at the bottom end of aviation the GA they're like singles and like twins I think that's one of the discipline that would really help the the overall accent rate would be if we develop the discipline to do that much more consistently than it's been my experience yeah exactly it's a good question next slide please so just just chat for a little bit weird a CRM kind of play you know with with TEM you know since I've been in aviation I've heard CRM referred to as cockpit resource management I've heard crew resource management I've heard a variation of a call company resource management it's its resources and however you define them and you know CRM in general is about recognizing the you know resources available to you you know in in the airlines we actually have it pretty easy you know we'd have dispatchers who were helping us with weather and flight planning we have air traffic control of course you know if the airplane breaks we just call maintenance you know go get coffee let me fix it so you know we have a variety of resources you know that we can use in general aviation we still have resources um flight service stations of course air traffic control is a huge resource to us you know your partner pilot passenger is a resource to you and let's not forget the all of the wonderful flight planning tools we have I mean everything that's deployed on an iPad I mean I consider that if I'm single pilot I consider my iPad part of my part of my career I mean it's it's a resource to me that you know I have access to so CRM is you know traditionally been about personality profiles styles of communication it's not really about you know do two people get along that's not really you know what's involved it is more about are we using the resources effectively so I would say that you know crew resource management is more conceptual in nature threader management as I think we're trying to develop here it's more of an action oriented it gives you things that you can do that we can teach that we can measure and you know compared to CRM I think it's more you know practical in nature I sort of see you know threader and management as the umbrella for how we you know manage a flight and CRM is one of those elements is under the umbrella as a tool to be used it's just like we brought up earlier the aviate navigate communicate mantra really now as an umbrella has mitigated over it it's just another way expressing you know risk management so let's move on please so get down to a few more of the terms here we've already said that threats are something that come at us we can you know further define them as you know they occur you know outside the pie less ability to influence they absolutely increase the complexity to fly it and and usually they increase the complexity of the flight because it just takes time to manage you know all the time we spend managing things that are coming at us means we might not be managing something else and of course you know threats requires some kind of attention you know in order to you know maintain our safety margins they couldn't be divided you know into three categories sort of you know film this into operational threats which are you know things that are kind of coming from our airplane malfunctions for example and the malfunctions can either you know some piece of equipment that's not essential to the airplane may not be working before we leave or you know we have a malfunction in flight you know which is a little bit more of an issue or you know maybe it's just poor procedures or maybe the you know the cockpit layout it's not ideal so there's some things that just come to us it's kind of part of the operation the environmental threats of course are the obvious ones whether air traffic control you know we can we can imagine all kinds of scenarios about changing weather you know the whole VMC entire IMC scenarios whether it's not as forecast bills are obvious threats to US air traffic controllers as well complicated procedures communication I mean we've all dealt with the controllers that talk so fast it you know we can't keep up I mean that in and of itself you know it's a threat if we can manage that and then the last category of threats are you know what we call mismanage you know it's might be a stretch to think that you know in a twin and a light twin aircraft if you've had an engine failure that you might shut down the wrong one but I've seen accident data to suggest that that has happened more likely you know if you're doing twin-engine training if the engine quits you might be stepping on the wrong rudder so you know if we don't manage the threats well then they just simply become mismanaged obviously for some more consequences next slide please so we may not always be able to see you know all of the threats I mean we we certainly have the observable ones I mean if you look out you know if the distance and see a thunderstorm and you see it in time well you can you can mitigate that by you know deviating or diverting or whatever the strategy might be so there are known observable threats but of course unexpected you know an unexpected threat you know engine failure would certainly be part of that scenario but we also have what I would call latent threats things like how your cockpit is laid out maybe the fuel gauges are blocked from your view you you've got some equipment design the shoes that are not optimal the air traffic system you know around the country my impression is air traffic is getting a little bit more complicated because of some of the procedures but again as I mentioned earlier even if you're flying into a non-towered you know I'm control the airport there could be complications which is transitioning from you know control to uncontrolled airspace and how are you gonna do that I know if you live in a Washington DC area you're challenged by the special flight rules that surround our nation's capital and that is something that constantly has to be managed to make sure that you're you're you know we're not in the wrong place the other kind of lady threat if you're part of a you know a flight school or an organization there may be you know some threats associated with that in terms of you know student load you know you have a lot of students you know there might be some pressure to get get more people trained or more people signed off so there could be some organizational culture in that environment you know that we put into the category of Eleni threat next time please so the errors you know and as I said arrows are things that come from us they they lead to a deviation from you know operational intentions or expectations most errors produce safety margins to some extent and you know that increase the probability of some you know adverse event either in flatter on the ground like threats errors come into three categories you know the simplest of just aircraft handling there's you're not on the speed you would like to be at you're not configured properly you know you haven't put the flaps down for landing you haven't put the flaps down for takeoff you're you crossed the whole short line I mean that means you you have had an aircraft handling a mistake if you're having aircraft not where it's intended to be and of course there's automation errors I mean as much as I said earlier I really love and embrace technology the more complexity gets the more chances are you may make an error in just managing the automation procedural errors these you know you know these can either be intentional or non-intentional you know deviations from you know a regulation a rule your pilot operating handbook the airplane flight manual I've done some work with the NTSB and they published the material about procedural compliance and they've published a paper some years ago but I think it's very valid it says that if a pilot or a crew intentionally deviates from a procedure that they're going to be seven times more likely to continue doing that and that's obviously a slippery slope you know that we want to try to avoid sterile cockpit I mean I have a feeling that that's one of the most broken rules you know in aviation yes having non-essential conversation you know during some critical phase of flight but there can be other things I hope descending below minimums is an example there's other things that you could probably think of and it just shows that if you intentionally deviate you you might start walking down the path of continuing that and that's the path you know we try to avoid the last errors communication errors my goodness you know we make them all the time right read back things incorrectly so we have communication errors with our air traffic controllers those communication errors between the pilot and instructor and they just have to be you know managed and mitigated next slide please so the other term is we addressed this briefly undesired aircraft state it's basically another error or you know safety safety compromise an event called an undesired aircraft study it just simply means that the aircraft is not in a position speed altitude or configuration that you want it to be yet it's almost always going to reduce safety margin to some extent and it's primarily our own fault you know I mean it's gonna be from our own you know errors actions or inactions next one please so this is a good news bad news thing the bad news it is that humans are the problem but the good news is that we're also the solution most most of our threats are caused by you know other humans errors but most of the errors you know especially our own sometimes go undetected and if they go undetected long enough then you know we could lead to a undesired aircraft state threader man is for training absolutely recognizes that if you're trying to eliminate all errors you just signed up permission impossible you can't it's just if you can't the challenge is set before is to have this broad situational awareness this says well I just met a mistake now I have to go fix it now we're the solution obviously and you know this bullet point ahead of you says the pilots are the last line of defense let's think about what that means for a moment I think think about it in terms of what being a P I Siemens the apic means that we are the final authority as to the safe operation of the flight so you know for example we trust our mechanics to do the work that there was a sign for them to do but it is up to us to make sure that we pre flight the aircraft properly and to make sure all the paperwork is done we trust the fuel guy to top off four tanks but it's up to us to make sure he did we trust ATC you know to make sure they're doing their job but sometimes they make mistakes and in fact I heard an interesting statistic a few weeks ago that was presented by the FAA that 48% of air traffic controllers are in training well that you know tells you right there that the air traffic control system just like the pilots there could be opportunities for mistakes so even though we have trusted in the mechanic we have trust in the fuel guy we have trust in ATC the bottom line is we're the last line of defense to make sure that we're catching all these things and I and I guess I the best way I could describe this in a relationship you know we're there with these outside influences is an expression they I suspect you'll recognize fill expression that came out of the 80s trust but verify and deed so so I think that's our I think that's our role you know we trust these people to do the work but there's the last line of defense berea because we're the pse so it's probably a good place to put in a question we just got Roger ask from management point of view how do you promote threatener management with students well I think I think that it's it's best promoted by you know going through a you know not necessarily this presentation but by taking some of these things away from this presentation and sort of saying that every flight we're going to if you're in a single pilot situation or you know how a student instructor situation or a two pilot situation every flight you'll actually make a list of the things that are potential threat the weather for example changing weather all of the things that you know could be coming out here that you potentially know about once you're in the flight I think as we've talked about fill this kind of continual kind of review of how things are going I think will help present you know threats to us once we identified the threats all we have to do is to stay on guard to prevent those things from turning into errors my goal and you know this sort of presentation would be to you know suggest a way to create some guidelines and some curriculum for general aviation pilots to be able to take these same principles and just apply it to our general aviation world I do think by just having an awareness of some of these things we've talked about it will just heighten you know your your senses about what to expect and what to do if you see something that comes to unexpected so I'm all for trying to you know bring these principles into into you know the world because there's so many opportunities here one of the ways that we used to in the flight school that I own for a number of years back in Long Island it was more in the risk management era but I think what we were doing applies and that is we had about once every 18 months or so I would take some of the mid-level instructors ones who were just beginning to take supervisory or managerial positions before moving on and put them together in a team of four or five people to go back and do a review of exactly the kind of things that you're talking about and it gave them a sense of what they're doing but they almost invariably would also bring some of their students into the discussion informally but it really helped get that idea done in a way that we paid him a few bucks they made some extra money on it so Leah I couldn't usually did it during an off period in Long Island that was November December you could usually count on getting some days to work on it and folks liked it and it seemed to work pretty well very good next slide please so did some specific tools basically it's there's three of them anticipation recognition and recovery and anticipation is probably you know is the key to success because you you expect you know expect the unexpected if you're always on guard then you know your level of vigilance will be at a higher level and I think vigilance is one of the biggest keys to being successful with this but also think it's the hardest thing to maintain you know as I said before you get into your own airplane time after time after time everything is easy you build makeup on the same between the same two airports you know what could possibly go wrong if you have this idea that something might go wrong and you keep your vigilance at a high level I think you have a better chance to succeed leaving anticipation and going to recognition that's another strategy here is that it's one thing to be on the wrong heading or the wrong altitude or the wrong frequency you have to recognize that once you recognize it then that's a then obviously you have to recover and apply whatever corrective action you have to do you know one twenty one world and you know if we program for something into the flight management system and all of a sudden you know we're saying to each other what's it doing now you have to turn it off you can't wonder what's it gonna do when it's not doing what you expect you have to disengage resume manual control and then go figure it out later so anticipation recognition and recovery to me are you know the essential tools for how to apply these concepts I also think that in the student-instructor relationship we have to be on guard as instructors because as time goes on with our students we get comfortable with them we see them progress we know their skill set but that doesn't mean we can let our own guard down as an instructor you know we still have to be vigilant I'm I think that's probably where the concept of sweating only on one side of your face comes from you know you don't want to you don't let your students see you sweat but it's okay if you're sweating a little bit I think that means you're doing your job because you're all guard next slide please so these tools anticipation is strategy I mean that's the strategies for success that prepares for you know what threats and errors been becoming other strategies you know include you know briefings for example and I'm a big you know I'm a big fan on briefing especially in a student instructor relationship because I've I've had you know people say to me that you know well my instructor told me to just go pre-flight the airplane and he'll come out but they haven't really brief what they're gonna do and that's really kind of a disservice to the entire process because we have to brief you know what the lessons gonna be about and once we're in the aircraft we have to brief about you know the expected outcome and how things are gonna go in our in the 121 environment you know we rely on briefings a lot because what we're trying to do is to create what I call a shared mental model so if you create a shared mental model about how this flight is gonna be then everybody's on the same page and you can enhance you know crew resource management so anticipation is a type of strategy the recognition and recovery or simply countermeasures so you know countermeasures of things like trapping you know a threat or an error and try to keep it from you know having a multiple compounding effect next slide please so use these terms before just let me bring up a couple of you know examples you know a trap error is absolutely the first step in reducing the ER chain if you have an untracked error it could lead to a safety if you or not it depends a little bit on the situation just go to the next slide for another example let's suppose you know you're you're gonna fly a misterben approach to you know some Airport and you we failed to note or grief or program or set the missed approach altitude well failing to set the missed approach altitude is the error if you don't do anything about it that becomes an untracked error but if you don't miss then it doesn't really matter you know there's no safety consequence of that if you do miss and you find yourself at an altitude that's not appropriate because you didn't set the correct altitude now you have a safety problem so that's a little bit how we you know we break down the trap and untrap there's whether or not they lead to safety consequences or not next slide so I'm sitting here in the heart of Wisconsin so of course I've got to talk about cheese right then the Swiss cheese model is certainly not about something that's new it's a fairly common expression about how to look at the accident chain the whole idea is if you get too many holes to line up you know you've had some threats that turned into errors that maybe became on trapped you didn't mitigate them and now you have some undesired aircraft state so I just have to throw a plug in for our you know the Dairyland stage so next slide before we go on yeah not to ask a cheesy question but Dan asks have threat checklist been developed so to my knowledge in in the in the GA world I haven't seen them I will tell you that in the 1:21 environment we talked about known threats as part of our briefings take a simple example you had a fairly busy airport but there's there's taxiway construction and the taxiway construction means that you're not going to be taxing along a route that you're more familiar with that tax away construction is briefed as a threat just like hot spots on the taxiway diagram those are briefed as threats so that as you get near the hot spot everybody's kind of got their head on the swivel to make sure you're not gonna have an incursion I think that the key to this is to just whether you're single pilot or not I think you can make notes about this and say these are the things that I know about and if you know about those you're in a better position to mitigate them so we're just going for general aviation I mean obviously I feel that it has a wide adaptability to flight instruction I'm single pilot general aviation ops multi pilot but for the moment let's just have a look at flight instruction next slide please so this is a near copy of the pave model you know the pave pide model is something that is popular in general aviation combined with some other things about you know we ready do we understand what's coming at us it's likely I'm safe checklist and basically I took that modified it slightly and said that there are four threats in general in our flight instructing world the pilot himself instead of personal like I put in pilot is still set or lack of skill the aircraft you know which is us you know an example of maybe mechanical malfunctions the environment of course weather Airport and then there are external pressures you know maybe completion pressure from the student so let's look at the pilot ones on the next slide please certainly the experience level has to be considered as a threat if you have a brand-new student who's never been in an airplane before I mean that's gonna cause you to manage that flight a lot differently than if you you know have somebody with quite a bit of experience so I think experience level through the gamut needs to be you know recognized and managed and I think we also have to be careful not to assume I mean I've done flight instruction you know with people who have more time than I do you know you get in a 172 RG and you know the gentleman needs a flight review and he's got all kinds of time and you think oh this will be easy you can't make that assumption really you know you know just because somebody has a commercial multi-engine land certificate that doesn't tell you the experience it just tells you the certificate more MORE you know we I know the flight schools our language skills you know or our threat and I you know from the instructor standpoint you know where is the threat well it's between the student and the instructor and I think too mitigated it as instructors you know we just have to use more precise language we try not to speak in colloquialisms or jokes or slang just try to be precise and do pilots speak you know in clear terms but just because you know you do that doesn't necessarily mean your students understood you have to do some checking and maybe ask questions to verify the understanding so you know we see this in the 121 environment as well is this more foreign nationals coming to the country because it's less expensive to train near mrs. Sanford all the people that are coming into you know the four-year program amps many many of those individuals have English as their second language and it's something that has to be managed the other you part of the threats that come from pilots or just you know behavior you know attitudes learning styles you know sometimes in our new higher classes we may open that we may have a newer candidate here some in his late 50s and everybody other candidate who is twenty thirty and I can tell you that the older individual was very happy to be in the classroom discussion environment and the younger individual basically wants us to give it everything to them on this iPad and send them out so and in the you know in the cockpit mmm there's certainly differences about how we should relate to one another I know fills you and I were talking about that a little bit earlier maybe you could elaborate on that on which point oh you know the older the new oh yeah with the instructors you have that and I think an example that I've used a long time ago and it always got a perk of the year and the I from FA and other folks but that would be to go out and a lot of the airport meetings and FA meetings of the general community we'd be talking and I'd listen to with her is coming up with all these complex plans and how they're gonna solve some problem the hot spot issue is one that actually came out of Farmingdale where I was and part of that solution and what really got the attention was when everybody said yeah we'll do this and this and this and I said you know I represent the least competent pilots on this airplane Airport and everybody gave me a strange look with that I said they're all students they're brand new they don't know what they're doing we can't be building these really complex procedures the guys have about eight ten thousand hours can easily adapt to we've got people over here they're soloing with in our school probably 20 22 24 hours at a very busy Airport and I think when you take that perspective it really draws out how you have different issues with the old pilots and the new pilots and how you approach it and and we're not in you know one size fits all in terms of training I mean as instructors I think we really need to do our job to you know listen and tailor our training to the individual so next slide please so obviously this right that's from an aircraft you know read the mechanical problems that we're going to start out with our mechanical problems that develop in flight for me you know teaching in an unfamiliar aircraft is something that I'm very careful with I don't like getting into a airplane I'm not really familiar with you know even though just you know the person that'll SC might say well MPIC I'll say I understand that but I still want to you know have some familiarity with you with the aircraft and you know the cockpit layouts and things like that the same we're flying into an unfamiliar airport you know I think that's always a threat in our instructional world or you know two-person environment or by ourselves the picture on the right is you know you're going in kind of a mountainous terrain icy snow maybe that means there's something on the runway so all of these things you know kind of threats that are coming to us from the aircraft but if we know about them we're in a better position to you know manage them I think you know the other part of this is we have to make sure that we don't get complacent I mean checking weather checking modems you know doing it - doing it the right way every time you know we'll build a pattern you know that will lead to continued success you know just because you go to the same Airport doesn't mean that the next time you go to it something won't be there or something will be different and if you didn't check the notice and you could find yourself you know trying to manage the safety issue next slide so you know these are obvious we have an aircraft that's you know on top of the deck and possibly in a PFR situation so whether you know in the structural environment we have to keep track of the weather a TC and nurse face challenges especially the more complicated airspace and then just there are four conditions I mean even to the point of you know being familiar with where the hangar buildings are on a windy day so that you can anticipate maybe some low-level turbulence close to the ground I mean if you have that kind of a picture you're in a better position next slide so this one's a you know a little bit tougher to deal with because you know that's external pressures you know as you develop a relationship with your student you know you might become friends you want to see them succeed but you have to make sure that you don't let your friendship you know get in the way of making sure you're doing the right thing I've worked with students who've said I've got you know financial constraints I need to get signed off or or I need to get signed off so I can you know move on to my new job you know I think we need to remember that this students I'm sorry as instructors and examiner's that you know our main mission is safety these these other factors we have to manage and realize that at the end of the day safety is the only thing we should you know really care about you know you might have pressure from your flight school in terms of schedules the number of students high student lines can contribute to fatigue I mean we've all been there you know we've all we've all flown we're tired but it's again recognized that that is a threat so that you're in a better position to deal with it our next slide please so we're near the end here this is the main thing from an instructor standpoint remember all the things that we talked about we're going to make errors we know our students will make errors you know a good instructor is somebody who can anticipate the errors that the student is about to make so that you're in a better position to mitigate them the problem is our students errors become our new threats so we have to constantly be on guard to watch that I was at a presentation in Arizona a few weeks ago and my very good friend Susan parson from the FAA he was making a presentation on the errant certification standards and was kind of reviewing the progress that's been made and then noted that she put up a slide about the instructor ACS which is not yet done but she said you know the instructor ACS that's a different that's a different kind of a cat because not only are we trying to teach people how to manage our students and manage that risk we still have to keep our own skills together and Phil I know you've been involved in that and maybe you have some comments now that was one of the most interesting parts from my participation in the ACS I'd worked on the private the instrument and the CFI and the first - really pretty straightforward it was going through and basically burnishing the thing and coming up into the structure we used Singh but when we got into the white instructor we got about two-thirds the way down the path and then it started bothering me and a couple of other people they said I was leaving something really big out of this we're saying what the instructor has to convey to the student but we also have a whole different arena that with the instructors the pilot and command on most activities in an instructional situation it's your responsibility to keep it safe and so you've really got this dual responsibility in the airplane that has presented an interesting challenge going forward and how the instructor ACS is going to be written we think we've addressed it pretty well by very specifically spelling out the risk management elements and dividing those into the ones that are specifically applicable to the student and then the ones that are the instructor role when the student is playing that role in the checker I'd of keeping it safe but it is a challenge it's one reason that the instructor ACS is quite a bit past the original date we hope to have it out on the street we are looking getting the prototype thing either done in June though so they were back on on schedule very good thanks for that insight Phil I appreciate it so just you know a quick review we've covered this before but you know threats are those things that come at us you know there are three categories eras are all the things that are coming from us as a result of the threat very important is that a trap terror is absolutely the first step in breaking the chain you know towards I yeah I'm sorry our trusty vigilance is probably the most important key to standing on guard but it's also the most difficult to maintain over time and as flight instructors have to strive to prevent our student errors from becoming our next week in the Train next slide so if anybody wishes to you know correspond with me or contact me there's two email addresses that would work and it's been a privilege to be part of this Phil you're an excellent host and I appreciate your contributions and I hope everybody stay safe out there thank you Paul and very glad you could be a part of the presentation and like to invite you anytime you want to get involved in the future be more than happy to have your input have your program or whatever contribution you might like to make we have developed at NASA those program is an ongoing program developing a database of various programs on various topics that will be available to people in the industry and folks that are going through instructional process so again want to thank you for coming in and taking the time to put this together and we'll say good night with that did you Oh missing Mike you here for the FAA wings course link remember you want to do that you've got to do the completion of it and you can go on to the web site and click on the line and it'll take you through to finish your work and of course our course evaluation link we would love the feedback we make programs it's difficult to be effective if you don't get feedback from the studio students in a classroom that's pretty easy but in a situation like this we really need your suggestions anything you had an issue with her questions you have we could try to respond to some of those perhaps if you give us contact information and any evaluation would be very helpful to us so again thank you and we will see you next month