Friday, March 25, 2016

Threats and Errors

Wind Lines has so many cool stories about adventurous flights in paradise. This is not one of those. But, it may change the way you fly and make you a better pilot. This is an article about a safety system that is practical and that works. You might wonder how a guy like me comes up with something like this. I've made mistakes and I'm certainly no pillar of safety. But, I do have the advantage of 30+ years of Air Force and airline training. Although not everything applies to our simple solo pilot pursuit, some things do. This approach to safety applies directly and I think free flight can really benefit from it. You probably already apply these principles, but applying them within this systems approach will greatly improve your decision-making skills as a pilot. This is intended to be used before you launch and while you fly. It's also effective in understanding why things sometimes go wrong and how to prevent them from recurring.

As we all know, risk is inherent in aviation and the only way to achieve risk avoidance is to avoid flying. Sometimes, that’s the correct course of action. However, when the choice to fly is made, the risk that comes with it has to be managed. It’s true that it could be ignored, and some have done this and gotten away with it. But, eventually this method fails horribly. Risk management is essential in maintaining safety margins.

But what is risk? Some might say it’s the probability or chance that harm will come. If the probability of harm is high and/or the potential harm is severe, avoid the risk. If you're like me, that all sounds good, but I need something tangible. I can't think like an insurance assessor or a bookie when I fly.

Instead of focusing on risk, focus on the cause-effect relationship that creates risk. The how and why that lead to bad things happening are things you can get your arms around; they are threats and errors.

Definition of threats: conditions or events that occur outside the influence of the pilot that increase the complexity of a flight and require pilot management if safety margins are to be maintained. Examples of threats aren’t hard to come up with. Some of the obvious ones are strong wind, snags on launch, turbulent air, knots or "death sticks" in lines, congestion approaching the LZ when setting up to land, social banter while setting up to launch, pilot fatigue, complacency, mistakes made by other pilots, etc.

Definition of errors: pilot actions or inactions that lead to a deviation from intentions or expectations, reduce safety margins, and increase the probability of adverse events. Examples of errors aren’t difficult either; spinning the wrong way on a reverse launch, forgetting to buckle in to the harness before launch, misjudging glide angle, incorrect determination of wind direction on landing, excessive use of brakes, etc.

Threats are omnipresent. They can increase workload, increase skill requirements and rush decision-making. They can be seemingly benign as well. Errors can occur spontaneously (no external cause), but more often, they are induced by threats. Obviously, we don’t want to make any mistakes when we fly. If we are trained well and have good basic skills and there are no complexities, the flight will very likely be safe. However, threats lead to complexities and these induce error. Threat and Error Management (TEM) focuses on threats primarily. If the threats aren't managed effectively, they can often induce error. Errors can be repaired once they are realized. However, uncorrected errors can lead to an undesirable aircraft state (UAS), and if there is no UAS recovery, this can lead to an accident or incident. In a nutshell, this is TEM. The blue is what you do to stay in the green.

(Note: CRM on the diagram above is Crew Resource Management. It relates to the communication and coordination between two or more crew members. Unless you are on a radio with your instructor or flying tandem with another contributing pilot, CRM is limited in free flight.)

As you can see by the diagram, TEM works from the top-down. Safe operations is the goal, and it begins by managing threats. If threats are properly managed before and during flight, you can expect to have a good, pleasant flight - in the green. So, the initial focus for any flight should be on threat management.

As you can imagine, threat awareness is paramount. If you're unaware, you are flying “fat, dumb and happy”. Every site has its particular resident threats that have caused errors and eventually lead to incidents and accidents. The locals are generally well aware of these and know how to manage them. Anyone new to a site stands to learn about these the hard way if they don't get a thorough site brief. Although site familiarity gives a pilot a leg up on managing threats, non-resident threats can surface and surprise the locals as well. We need to be vigilant, constantly assess changing conditions and communicate threat awareness to other pilots.

So let's assume you are aware of a given threat. You might not be surprised after an encounter, but unless you understand how and why it can lead to errors (and an eventually UAS), you won't know what to do about it. How can the threat make the environment more complex? As a result of the complexity, what skills or performance will be required to avoid error? What kinds of errors are likely? Is there enough time (altitude) and skills to repair these potential errors before they lead to a UAS? Stepping through this process will help you understand each threat in your environment. This requires thought, discussion and in some cases experience (not just your own). Understanding the threats is really important.

Finally, we need to have a plan. In most cases, avoidance is a simple and effective course of action. Unavoidable threats that are anticipated and understood can be dealt with, depending on their severity. Simply realizing scenarios that lead to potential errors and any kind of UAS is enough to keep them from developing down that path. Certain defensive measures may put you in a position to avoid impending errors, should an anticipated threat be encountered. You might make use of a small adjustment, a skill set, an exit plan, etc. There can be multiple ways to deal with a given threat. Your plan may not be perfect, but something is better than nothing in most cases.

Adopting TEM to Your Flying

Forensics: I challenge everyone to list five or six accidents or incidents for which you have detailed knowledge. Remember that a close call is an incident. Treat it as an accident because one day, the same threats and errors may make it one. Be careful with your own events, as you may have some emotional input that could distort the process. Work backwards. Begin by identifying the accident or incident. Then determine what kind of UAS immediately preceded the event. Now determine what errors were made in producing the UAS. There may be just one. There may be a chain of errors. Begin to write down each external influence or threat that may have induced each error. Once you have your threats identified, start asking yourself questions. Was there threat awareness? Was the connection between threat and error understood? Could the threat have been avoided, assuming there was awareness? Was there a defensive action possible that would have avoided or reduced the threat? Were errors recognized? Were errors repaired? Was there an opportunity to recover from the UAS that preceded the accident/incident?

The takeaway from your forensic exercise should be a list of threats and errors. You should know that these can and often will resurface. This time, you will be watching for them and when they present themselves, you will better understand how they can negatively affect you. You should also have a plan for how to avoid them or minimize their effect. It's really important to talk about these with other pilots as well. A variety of different experiences will often increase understanding and insight. We often focus on poor decision-making when analyzing an accident. Good decisions are easy in the aftermath. Instead, try to focus on threat awareness and the errors they induce as the flight develops.

This is a very basic introduction to TEM. There are books written on this subject, so it doesn't end with this short article. I think that when bad things happen (including close calls), we can push the events through this system and come up with tangible threats. Remember that threat mitigation is the first element in TEM and threat awareness is the first step in mitigating these threats. My hope is that we can collectively generate a list of threats, understand how and why they can bite us and come up with various methods of mitigation for each.

We will get better at TEM by using the system, and it's not just limited to flying. Use it for driving, boating, biking, hiking, working around the home, etc. It's an effective safety system that applies to just about everything we do.


firedave2 said...


I saw this article and couldn't wait to read it. Once I started reading it I couldn't wait for it to end. Did you copy this from your United Flight Manual? I found no real insight here, just a technical treatise on risk assessment, mildly directed at paragliding. It is a great piece, but not geared toward the average pilot who needs safety tips like ' land standing up' and ' watch the inside wingtip for spin while turning on final', or something like that. I know you hold a lot of tips anyone can use. Let's have it.

And thanks for letting me rag on you. You know I think highly of you.

JK said...

Thanks Dave! I appreciate the candid input and you have my respect. Before your post, it was just crickets and I wasn't sure what the impact was. I knew this article would be unglamorous. It's intended as a setup for the stories that will hopefully follow (forensics). I think those will be much more interesting and should generate some thought and more replies.

I'm busy in the next few weeks, but I plan to write one after the dust settles. If anyone wants to take a crack at my "challenge", I will be happy to review what you have. I submitted this article to USHPA, but my guess is that it won't be published without more practical examples.

Alex said...

JK, I know you put a lot of effort into this, and it is clearly far from a copy and paste operation! Thanks for sharing your ideas. Personally, I am fascinated by the idea of how free flyers can learn from the lessons of professional aviation safety. The odds of an airplane accident are incredibly low because professional pilots are trained in threat and error management. Whereas the odds of a paragliding accident are undeniably high, especially if you look at last year's statistics. But I also understand Dave's point. None of us wants to think that hard about safety unless we are forced to by our airline employer! I often think of paragliding as a strange hybrid of skateboarding and aviation, and I think many of us relate more closely to the skateboarding side. Unfortunately we are skateboarding at some pretty dangerous heights. I think free flyers like the idea that we are able to have more fun and fly more freely than professional airline pilots! We don't want to imagine we have to implement some boring corporate safety protocols! But obviously there is something to learn from those protocols. I think this article provides some general clues to start that learning process.

Thom said...

Well, seeing as I am one of the paragliding statistics. I think this article can be pertinent. Yes we do fly for fun and yes many of our brains are no more than skateboarders. Yes, it is a long read, but so are our meetings which do have minutes of relevance. But some of these safety protocols should not have to be thought up during flight. They should be automatic, ingrained, second nature and frankly just plain obvious. I'm glad you wrote this it has inspired me to finally get my ASS going on writing up my incident report which I will hope Save some other pilot from going through what I am.

Thanks JK

Brazilian Ray said...

everybody has got a good point here! I believe we all manage risk in different ways, some better than others and some more TECHNICAL than others.... Like Thom mention, it is second nature for some. A good example of this is when you kite and launch a paraglider: we don't think about every detail, we just do it. we do a million corrections per second to get it right. Now try to explain (teach) someone how to do it and you will find it is not so simple. A beginner pilot has to have more technical input on what to do to get it right... it comes with experience and practice.
a few pilots speak the technical language and this could be one more tool in the shed to keep someone safe. This is a good approach on good judgment.
JK, the CRM might include briefings and debriefings, before and after flights not necessarily on radio, right?
stay on the green

Brazilian Ray

firedave2 said...

I like the phrase: Good judgement comes from experience, which comes from bad judgement.

The important thing is it doesn't have to be your bad judgement to learn from it.

Skater Dave

JK said...

Bottom line: Be aware of your threats, understand how and why they are threats, and have a plan to deal with them. Nuff said.

Illustrative examples to follow.

Keep it safe. - JK