1 Background

The basics of threat management, including definitions of terms, types of threats and how threats develop were covered by the Threat Management and Error Management briefing notes, which are a prerequisite to understanding this document and should be read first.

This briefing note focuses on the point that simple texts describing threat-management strategies are not sufficient to prepare pilots to manage complex threats. It is also necessary for a pilot to understand the need for such threat-management strategies and to see how such strategies were developed and can affect real-world situations. It is relatively simple for an organization to develop threat-management schemes based on past events, but training crews to the level where they can quickly implement the schemes in the cockpit, when conditions are unfavorable and workload is high, is a more difficult undertaking.

2 Introduction

Training is one important way to improve the threat-management ability of a flight crew. This briefing note introduces training techniques for threat and risk management that are designed to improve a crew’s ability to detect and deal with unexpected threats. This is accomplished by increasing the crew’s general situational awareness, rather than by establishing a large number of rote procedures that attempt to anticipate the majority of threatening situations. This is similar to the philosophy of the traffic-alert and collision avoidance system (TCAS), which issues traffic alerts (TAs) to raise the pilot’s attention and create situational awareness, rather than simply issuing resolution alerts (RAs) that command the pilot to take corrective action. By providing the TAs, TCAS engages the crew in the situation and provides it with a broader context for accepting and executing the RA.

It would be unrealistic to attempt to train for optimal threat-management performance under all circumstances. The timing and nature of the full range of threats facing a flight crew simply cannot be defined. It is therefore necessary to focus training on developing risk tolerance by creating appropriate attitudes and problem-solving techniques that prepare a crew to face any reasonable threats. Thus, the basic philosophy of training discussed here is thoroughly pragmatic and complementary to existing training approaches.

3 Strategies for Threat Management Training

Various strategies can be used to prepare a crew to better manage threats. This is illustrated by the Airbus Crew Resource Management (ACRM) training program and the output of the Enhanced Safety through Situation Awareness Integration (ESSAI) research and development project, each of which is discussed below.

3.1 Airbus crew resource management

ACRM describes two resources a pilot must useto maintain situation control:

• Mental resources to control physical actions
• Mental resources to control situational awareness

Each of these resources has upper and lower limits with respect to the amount of mental effort that a pilot can contribute to a task and still maintain situational control. ACRM attempts to train pilots to work within a safety buffer zone that never pushes a pilot to the limits of his or her mental resources. Staying within this buffer zone helps a pilot avoid going down the risk/error spiral. This concept is similar to the design of the Airbus fly-by-wire controls that have a buffer zone that provides ample safety margins and alerts the flight crew to problems through a series of warning signals. With proper training on threat management, a pilot should be able to recognize the warning signals that he or she is reaching the limits of mental resources and things might be getting out of control.

One important aspect of threat management training involves teaching pilots how to keep track of threats and errors and learning to ask the correct questions:

• What happened? We forgot to … We reasoned wrongly on …
  • Why did we forget to ...? We were subject to time pressure … We were inattentive to …
  • Why did we reason wrongly? We had inadequate knowledge regarding a hazard.
• What can we do to avoid forgetting things? We need to manage time, prioritize tasks and use checklists.
• What did we learn from wrong reasoning? We need to make it simple; stick to standard operating procedures (SOPs).

When faced with surprises such as mode reversions, unknown aircraft behavior, undocumented procedures or technical failures that require a pilot to use the upper limits of mental resources, it is important to balance mental resources for controlling situational awareness and physical actions based on the needs of the situation. One situation may require more resources to be allotted to physical actions, while another may require more resources to be allotted to situational awareness.

Sometimes the opposite is true and demands are low, especially when automation is in use. In such situations a pilot must learn to keep mental resources balanced. Maintaining resource balance during these times will help the pilot be better prepared when action is needed for normal operations or when unexpected events occur.

Becoming proficient in balancing mental resources requires exposure to operational events specific to an aircraft type throughout the training period, paying attention to operational experience from the airlines and applying safety and risk management throughout the learning process. This is the aim of Manufacturer’s Line-Oriented Flight Training (MLOFT) that uses airline LOFT scenarios to sharpen skills, knowledge and resources.

3.2 ESSAI project

The goal of the ESSAI research and development project — funded by the European Union and completed in 2003 — was to provide workable training tools and techniques to help:

• Maintain and recover situational awareness, which is considered as an activity in context rather than as a state of being

• Perform threat management should the situation deteriorate and become potentially hazardous

It is known that situational awareness is a significant factor in aircraft accidents and incidents, playing a major role in any crew’s ability to cope with hazardous situations resulting from “expected threats” (e.g., open minimum equipment list [MEL] items, weather, terrain) and from “unexpected threats” (e.g., preoccupation or complacency with modern flight deck automation, lack of system awareness resulting from inadvertent changes or intermittent faults, workload and workload increases under time constraints, task interruptions, distractions, air traffic control [ATC] interference, ATC errors).

The project prepared an inventory of skills to develop a structure of well-identified competencies from which skill interrelationships could be made clear. Situational awareness and threat management skills were each broken down into four competencies that reflect iterative steps in the thinking process.

Translated into aviation terminology, concepts were grouped into four training modules:

• Think ahead into future phases of flight in order to maintain situational awareness instead of simply noticing events
• Avoid threats instead of waiting to contain or mitigate their consequences
• Perceive loss of situational awareness, speak up if behind, with or ahead of the aircraft, and act on that knowledge
• Perceive turbulent and weak signals that are indicative of potentially risky situations and apply situational control (i.e., the skill to effectively balance mental as well as flying workload between crewmembers)

This methodology offers a very effective means of training all required skills. The proposed training consists of a DVD, exercises and simulator sessions. The effectiveness of the training was evaluated in a Level D simulator experiment, where eight reference crews received the ESSAI training and eight reference crews did not. Otherwise, the simulator sessions were identical for both groups.

The DVD’s main menu consists of three central sections preceded by an introduction and concluded by a summary of key learning points:

• Planning: Define situational awareness levels and elements, and focus on building high crew situation awareness
• Operating: Threat management and situation control; operating under stress, turbulent signals, signs of loss of situational awareness
• Reviewing: Why and how; the learning process

The first two concepts describe situational awareness and threat management and the third describes situation control. These provide insight as to how situational awareness and threat management are influenced by high workload and how to help cope with such situations as an individual and as a crew. Lastly, the training reviews how pilots can recognize their own or fellow crewmembers’ loss of situational awareness and strategies for how to try to recover it. All concepts are explained with concrete examples using video material specifically filmed for the project in an A320 simulator using crews from ESSAI partner airlines. The three concepts are discussed below.

Situational awareness

The words perceive, comprehend and project were changed into more everyday language — notice, understand and think ahead. The first and most basic level of situational awareness is noticing, for example, an area of cumulonimbus (CB) activity on the weather radar. The next level of situational awareness is reached with understanding what this actually means. In this example, thunderstorms equate with turbulence, lightning strikes, etc. Having understood the implications of the CB activity, we move on to the higher level of situational awareness — thinking ahead, which here could be to negotiate a re-route or different approach with ATC.

Threat management

Using the University of Texas model, the first and most effective defense is to identify potential threats and avoid them. But all threats cannot be predicted, so another level of threat management must be used when they slip through the “avoid” layer. In these circumstances, current threats that are developing can be trapped and corrected. If a threat slips through the “trap” layer, then the final strategy is to mitigate its effect. This involves identifying threats that have occurred and limiting the damage.

Situation control

This concept aims to help pilots picture how they apply their mental resources in different situations. It helps us to prioritize the allocation of our mental resources. It is a concept, not an exact procedure. A pilot has to pay attention to turbulent and weak signals and speak up if he or she is getting behind the aircraft. Examples of identifiers to recognize loss of (-) or gain of situational awareness (+) are short-listed in ESSAI and include the pilot:

• asking for information (-)
• asking for feedback (-)
• asking open questions (-)
• showing discomfort, hesitation or distraction (-)
• speaking up about feeling unhappy (-)
• dwelling on past events (-)
• remaining fixated on task (-)
• failing to complete briefings (-)
• showing confusion over data sources (-)
• having unresolved confusion (-)
• sharing situational awareness with crewmembers (+)
• using effective prioritization (e.g., telling cabin crew to wait) (+)
• sharing tasks positively (e.g., discussing who does what) (+)
• using low workload periods to share situational awareness (+)

Similar to ACRM, this training breaks situation control into two dimensions:

• Mental resources to control resources to take action (e.g., fly the aircraft)
• Mental resources to control resources to think (e.g., situational awareness)

Within these dimensions, a conceptual workload envelope can be plotted, showing where sufficient mental resources are available to deal with both thinking and flying to effectively balance workload among crewmembers. This represents the “in control” or “ahead of the aircraft” region, where demands on mental resources can be met by the available brainpower.

Results indicate that situational awareness and threat management increased as a result of the training across all methods of measurement. Observations showed that especially the briefing quality for the approach and landing phase, as well as the management of distractions, can be significantly improved by means of ESSAI training. The roles of situational awareness and threat management skills as reviewed by ESSAI are summarized as follows:

The process of threat management is certainly a cyclical and adaptive process depending on such external factors as situation complexity, time pressure, workload and associated risks, and such internal ones as crew expertise and experience that need to be balanced.

The following skills were defined to be aware of, to identify and to manage threats:

4 Strategies Based on Crew Operational Techniques

4.1 Threat and error management to ‘stay well ahead of the situation’

In this strategy, threat and error management (TEM) focuses on prevention versus reactive and tactical error management approaches.

• It aims to give crews strategic decision-making skills to stay well ahead of the aircraft by:
  • Perceiving the situation, the nature of threats and problems, and the risks and time to respond
  • Developing, sharing and executing plans
  • Monitoring results
  • Selecting a course of action

(Continental Airlines CRM TEM Concept)

• This scheme attempts to cultivate elements of leadership throughout training and flight operations by focusing on some key commitments:
  • Setting the example
  • Staying well ahead
  • Being adaptable and receptive
  • Taking initiative and influencing
• It then moves progressively toward error resistance provided by the hardware and software before humans ever come into play (e.g., ground-proximity warning system, TCAS, training manuals, SOPs, checklists, automation)
• It then moves toward the stage of error resolution by including what the human

brings to the system (e.g., proficiency, vigilance, assertiveness, monitoring and cross-checking, decision making, experience, leadership, situation assessment, checklist discipline)

• The scheme finally deals with tactics in response to undesirable aircraft states

This scheme insists that pilots verbalize, verify and monitor threat appearance, and review crew proficiency with regard to TEM during line operations safety audits when the collection and accumulation of threat lists are being refined.

4.2 Threat and error management to ‘stay in the context of the situation’

This strategy positions TEM as a context of CRM and appropriately focuses CRM on a set of countermeasures for managing threats and errors in the language of pilots:

• TEM is the framework for CRM, and it outlines propagation and breach of human error (threat-error-undesired crew state-incident)
• TEM is as a detour back to CRM beginnings, returning to the foundations of flight operations, that is the management of operational threats and errors.

CRM skill training focuses on developing countermeasure competencies in group climate, team planning, execution, and review/modification to manage threats and errors with the TEM framework in the background.

5 Deploying human factors resources when facing an operational situation or threat

As understood from the various TEM models, there is a need for mental resources to guide pilot cognition and behavior in the right direction. Faced with familiar or unfamiliar threats or with challenging operational situations, pilots are expected to adopt an attitude that guides them in the correct direction and to follow golden rules. This attitude may have to encompass the full scope of human factors to mingle technical and non-technical interactions, which is a highly demanding requirement that is not easily achieved without some quality aids.

The various notions involved here must not be remembered as declarative or literary knowledge, but rather as an operative and pragmatic resource ready to be invoked when facing an operational situation (i.e., an operational context, a practice to deal with the context, a defense to utilize, preserve and manage).

6 Key Points

• Threats must effectively be identified, assessed and countered. This process has to happen in context and is structured
• ACRM describes two resources a pilot can use to maintain situation control:
  • Mental resources to control physical actions
  • Mental resources to control situational awareness
• Maintaining mental resource balance is critical for identifying and managing threats.
• First, attempt to avoid threats. If a threat cannot be avoided, attempt to trap it. If the threat cannot be trapped, attempt to mitigate its effects.
• CRM skill training focuses on developing countermeasure competencies in group climate, team planning, execution, and review/modification to manage threats and errors with the TEM framework in the background.

7 Associated OGHFA Materials

Briefing Notes:

• Managing Interruptions and Distractions
• Error Management
• Organizational Threat Management
• Enhancing Situational Awareness

Situational Examples:

• Fuel Leak and Confirmation Bias
• In-flight Pilot Incapacitation
• Threat and Error Management Preventing CFIT
• Wind Shear Encounter During Go-Around

8 Regulatory References

• International Civil Aviation Organization (ICAO). Accident Prevention Manual (Doc 9422).
• ICAO. Human Factors Training Manual (Doc 9683).
• ICAO. FCLT/P, State Letter AN 12/1.1-05/62.
• ICAO. FCLT/P, Annex 6, Operation of Aircraft.
• ICAO. Line Operations Safety Audit (Doc AN/761).

9 Industry References

• ESSAI. Final Report. Feb. 4, 2003.
• International Air Transport Association (IATA). Safety Report 2004, Ref. no 9049-05 ISBS: 92-9195-468-3, April 2005
• Joint Aviation Authorities Safety Strategy Initiative (JSSI): Analysis Capabilities Specification Document MOR — Occurrences Data Analysis Working Group.
• ICAO/IATA: Proceedings of the First ICAO-IATA LOSA and TEM Conference. Dublin, Ireland, November 2003.

10 Additional Reading Material

• Maurino, Daniel; Reason, James; Johnston, Neil. Lee, Rob. Beyond Aviation Human Factors/ Avebury Aviation, 1995, 629.13 ISBN: 0-291-39822-7.

Related Skybrary Articles

• Threat and Error Management (TEM);