Change Agent

Peter N. Stein is a base chief pilot for Johnson Controls and has more than 20 years in corporate aviation, 11,000 flight hours and five jet type ratings. He is a member of the Flight Safety Foundation, Corporate Advisory Committee and currently serves as the chairman for its latest project, Threat and Error Management (TEM) for Business Aviation.

AM: What are TEM’s objectives?

PS: TEM is a systems approach to aviation safety originally developed by human factors researchers at the University of Texas. TEM has been embraced by airlines worldwide and recognized as an international best practice by, among others, the International Civil Aviation Organization, the Joint Aviation Authorities, the International Air Transport Association and the Federal Aviation Administration. TEM is a flexible and intuitive approach to practical risk management. Not only does it offer a framework for understanding and directing human performance in complex operating environments, TEM also provides aviation professionals — regardless of their organizational function or status — a risk management lexicon that supports a positive safety culture. There are several TEM models in circulation. The key guiding principle is that threats and errors must be identified and managed before they manifest themselves as an undesired state that an operator can no longer manage effectively. The common elements are threats, errors, undesired states and countermeasures. Each has its own unique definition in the context of TEM. The basic flow in all TEM models is: threat — error — outcome. Threats must be identified and managed. If not, an error may result, which through the use of error management strategies must be resisted (proactive) or resolved (reactive). If not, the outcome is an undesired state. An undesired state is not an accident, but it must be managed or a serious incident or accident will result. Admittedly, this is a gross simplification, but hopefully you get the idea.

AM: What do you see for the future of TEM?

PS: My vision is to see TEM ingrained in to the collective psyche of aviation professionals worldwide. In my experience, formal safety training, as distinguished from being trained to do things safely, is largely inaccessible to front-line personnel, in both a conceptual and practical sense. Talking about epidemiological models and multi-variate analysis is all great stuff, but it simply doesn’t translate well to the front line. Also, a great deal of proactive risk management still occurs largely within safety and management offices. TEM differs because it is easy to understand and learn, and it can be related to real-life, day-to-day work almost instantly. The best analogy was set forth by Merritt and Klinecht (two University of Texas researchers). "While you may need to be a highway or auto safety engineer to analyze and design better systems for highway safety, you don’t need to be one to understand defensive driving." I think the same is true for TEM.

AM: Please describe the education collaborative work group.

PS: My original idea was for our project team to create and administer a portable, interactive TEM course that could be taught to a broad range of aviation professionals. It became apparent that it would not be the best way, from either a practical or administrative standpoint, to educate potentially thousands of aviation professionals worldwide. The obvious alternative was to approach the training providers, on a non-exclusive basis, about offering TEM training. After taking into consideration the Flight Safety Foundation and the training providers’s respective interests, the educational collaborative work group was conceived. Any bona fide training provider with a genuine interest in offering TEM training can join the group. I should add that "training provider" is used in its broadest sense. The group’s objective is not to create a training course or commercial product; rather, it is to formulate a set of generic guidelines from which the training providers can then use to create their own unique, commercial offerings.

AM: What are some actionable items for professionals in their own operations?

PS: Once you have an understanding of the TEM model and several of its key precepts, applying it is limited only by your imagination. For example, the model can be applied prospectively as a hazard identification tool or it can be applied retrospectively as an incident analysis tool. It can also be applied to maintenance quality assurance efforts to assist with identifying threats and developing error resistance strategies. Another good application is that TEM can be integrated into maintenance human factors courses. For example, maintenance technicians can be asked to develop their own error management strategies as part of an exercise that replicates conditions that increase the likelihood of error.

AM: Are you developing a TEM course? What are the objectives and when will it launch?

PS: The TEM project steering team’s objective is not to develop a TEM course per se. Instead, we’ve adopted a three-prong approach based on awareness, outreach and engagement. We hope to increase awareness through our introductory presentations at well-known safety venues, such as the Corporate Aviation Safety Seminar and NBAA Regional Forums, and through trade publications such as yours. We’ve also reached out across the business aviation community to well-known trade groups, such as the National Air Transport Association, the National Business Aviation Association and the International Business Aviation Council to gain their support. And, we’ll continue our efforts to engage the training providers to provide integrated and stand-alone TEM training courses.

AM: How does TEM apply to a maintenance professional?

PS: Because of its generic nature, the TEM model can be readily applied to maintenance and maintenance-related activities. For example, let’s consider applying a part of the TEM model retrospectively to partially analyze a towing incident that resulted in some minor wingtip damage. After a thorough collection of the facts, the first step is to identify the threats. Recall that threat is defined broadly as anything external to the operator (i.e. the tug operator) that may reduce safety margins. Things like lighting conditions, noise levels, and proximity to other aircraft are just a few examples of threats. After you’ve identified the threats, you ask if those threats were managed or mismanaged? What, if any, threat management strategies or countermeasure were in place at the time of the incident? If the threat was mismanaged, did it manifest itself as an error? For example, if the area was subject to high noise levels, could the tug operator have heard the wing walker’s whistle? Or, was an additional wing walker not available because of a staffing shortage that day?

While this is only a partial example, the power of using the TEM model becomes evident when you consider that it does not have to be done in isolation because it uses a common framework and language that is easily understood. Rather than herding your front line personnel into a room and lecturing them about tug and towing safety, you can constructively engage them (after a bit of TEM training) in a thoughtful discussion where they not only analyze the incident but proactively identify other threats and error management countermeasures. In my view, this is the essence of a positive safety culture.

AM: Anything else you’d like to tell our readers?

PS: As safety leaders, we’re frequently asked what can be done to promote a positive safety culture within our respective organizations. Most experts would agree that a positive safety culture begins with open communication, personal commitment, and a system of shared values and beliefs. TEM embodies these attributes by providing an intuitive and flexible approach to risk management that can be easily applied - regardless of organizational function or status.

For more of Peter N. Stein’s interview, visit www.aviationmx.com.