Sun-N-Fun 2023 Threat and Error Management Insights from the FAA
This seminar was presented at Sun-N-Fun, Lakeland, Florida in 2023. Air safety Investigator Mitch Mitchell covers threat and error management.
Threat and Error Management
Insights from the FAA
By: Mitch Mitchell
About Me
Aircraft and Space Accident Investigator (FAA HQ-AVP-100)
DoD Mishap Investigation Experience
ATP Rated Pilot
Commercial UAS Pilot
Airline/Corporate/Charter Experience
Masters from ERAU – Aeronautical Science/Aviation Safety
PhD studies at Liberty University
Over 15 years of Federal Service
32 Years of Aviation Experience
Threat and Error Management
What are threats?
What are errors?
How do we manage/mitigate the risks?
How do we use lessons learned and accident investigations in Threat and Error Management?
Let’s make this an open discussion!
James Reason – Swiss Cheese Model
Latent Conditions
Active Failures
Are You Threatening Me?
There are three components in the Threat and Error Management framework.
Threats - generally defined as events or errors that occur beyond the influence of the person that increase operational complexity, and must be managed to maintain the margins of safety.
Errors - generally defined as actions or inactions by the person that lead to deviations from operational intentions or expectations. Unmanaged and/or mis-managed errors frequently lead to undesired states. Errors in the operational context thus tend to reduce the margins of safety and increase the probability of an undesirable event.
Undesired states - generally defined as operational conditions where an unintended situation results in a reduction in margins of safety. Undesired states that result from ineffective threat and/or error management may lead to compromised situations and reduce margins of safety in aviation operations. Often considered the last stage before an incident or accident.
What Are Some Common Threats to Pilots?
Weather
Fit to Fly (I’M SAFE)
Task Saturation
Loss of Situational Awareness
Technology
Proficiency vs Currency
Personal Limitations
Confirmation Bias
Many More!
More???
How Do We Mitigate Threats?
Checklists (P.A.V.E.)
Pilot
Airplane
enVironment
External Pressures
REPEAT!
What are Your Biggest Threats?
Errors
Error Defined
Errs
There are 5 types of errors:
1. Intentional non-compliance errors
2. Procedural errors
3. Communication errors
4. Proficiency errors
5. Operational decision errors
Top 10 Pilot Errors
Weather
Controlled Flight into Terrain
Poor Communication
Showing Off
Inadequate Preflight Inspections
Inadequate Preflight Planning
Failure to Use a Checklist
Failure to Perform the “I’M SAFE” Checklist
Poor Fuel Management
Mismanagement of Technology
Anyone Guilty of Making an Error?
Threat and Error Management Model
Threat Management – There are two aspects to Threat Management:
- Recognizing that a threat exists.
- Coming up with a strategy to deal with the threat, so that it does not reduce safety margins or contribute to an error.
Threat and Error Management Model
Error Management – The mitigation or reduction in seriousness of the outcome.
- The resist and resolve filters or defense mechanisms may be applied to an existing error before it becomes consequential to safety.
- By applying the resist and resolve filters in the analysis of an error, you may:
Improve strategies or counter-measures to identify and manage both internal and external threats, like fatigue, condition of ground equipment, etc.
Investigations – at a Glance
WE INVESTIGATE AIRCRAFT ACCIDENTS/INCIDENTS
TO PREVENT FUTURE ACCIDENTS/INCIDENTS
FAA Accident Investigation
The FAA investigates aircraft incidents and collects and analyzes aircraft incident reports because the reports provide an excellent source of accident prevention information.
Aircraft incident investigations may result in regulatory changes, issuance of Airworthiness Directives, revised procedures, standards, policy, etc.
Support for such actions depends on facts discovered during the investigation. All relevant facts should be documented.
National Transportation Safety Board
- Conduct the Investigation, Publish Investigative Report, Recommendations, Probable Cause
- Determine the cause and contributing factors of an accident. Issue Recommendations to FAA, Operators, Manufactures, etc. to address the issues discovered.
Federal Aviation Administration
- Continued Operational Safety – 9 Areas of Responsibility
- Regulations/Oversight
- Find risk in systems or operations and mitigate the risk to prevent future accidents.
FAA Responsibilities
- FAA Facilities
- Non FAA Facilities
- Airworthiness
- Airmen/Agency Competence
- FAR Adequacy
- Airport Certification
- Security (Hazmat FAA Facilities)
- Airman Medical Qualification
- FAR Violations
FAA HQ (AVP-100) Capabilities
Flight Data Recorders – Plots and Reconstruction
Cockpit Voice Recorders – Audition and Sound Spectrum Analysis
Non-Volatile Memory download from avionics
ADS-B Download and Analysis
Simulation of Accidents
In-house (Baron G58 & 737) and OKC/ACY
Weather Products
METARs, NEXRAD Radar, Satellite imagery
SME Engagement – AVP, Flight Standards, Aircraft Certification, etc.
FAA HQ – Safety Investigations
11 Employees
200-300 NTSB requests for information or services each year
20-30 Flight data recorder downloads
70+ Major Case files opened each year
35-40 Significant air carrier accidents and incidents per year
7 Investigators
YTD 66 Fatal Accidents
YTD 117 Fatal Injuries
“Fingerprints”
We look at EVERY Accident and Incident in the NAS
Over 2,000 Accidents & Incidents in (FY22)
240 Fatal Accidents with 384 Fatalities (FY22)
73 Major Case Files Opened for FY22*
*Not an indicator trend for risk!!
Safety Recommendations Review Board
What We Do
Safety Investigation
Our mission is to find and eliminate risk
Full resources of the FAA at our disposal
Connect Industry Partners with the right elements of FAA/NTSB
We help eliminate risk/hazards
Safety Alert for Operators (SAFO)
Airworthiness Directive (AD)
Advisory Circular (AC)
Regulatory changes
FAASTeam Communications
How Do We Manage Risk?
Proper Training
Following Proper Procedures
Proper Supervision
Coordination Among Vendors
Promote a Strong Safety Culture
Policies, Processes, Procedures
Accidents – Common Themes
Failure to Follow Proper Procedures
External Pressures
Poor Recovery
Poor Decision Making
Failure to Recognize and Mitigate Risk
THANK YOU!
