Threat & Error Mgt Training at JetBlue Airways. Captain Chris Reed Manager, AQP
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1 Threat & Error Mgt Training at JetBlue Airways Captain Chris Reed Manager, AQP
2 Outline What s TEM at JetBlue? TEM versus CRM how we think about it Description of TEM courses to we teach Overview of our TEM courses How do we use TEM in our AQP? Status of AQP at JetBlue Our TEM-based AQP Grade Scale Example of an LOE grade sheet How does it fit together? TEM fully integrated in our CQT (recurrent)
3 TEM versus CRM What is TEM? and what is CRM?... and how do they relate?? It seems to depend who you ask
4 TEM versus CRM (at JetBlue) CRM Personality profiles, styles of communication, etc Flavor is conceptual Joint Pilot & Flight Attendant Training TEM Action oriented, presents specific skills which can be taught and measured, Things you can do Flavor is practical Pilot*-Specific Training: Focused on the Flight Deck
5 TEM Training at JetBlue Initial TEM Training Basic TEM Taught to new-hire pilots (and dispatchers) during basic indoc Recurrent TEM Training Applied TEM Taught to pilots during Continuing Qualification Training (CQT)
6 A brief overview of our Basic TEM Course
7 Basic TEM Course is 3 hrs in length, and is taught using a combination of lecture, discussion, and case studies. My overview for you will be much shorter (!) Course Outline Foundational Philosophy Basic TEM Model Defenses - General TEM Tool-Kit Defenses
8 Foundational Philosophy Threats & Errors The Old School Threats can be essentially eliminated by better equipment, training, policies, etc. Human performance can be practically perfected by strict discipline, enforcement of rules, etc. Errors are abnormal hunt down and punish the guilty!
9 Foundational Philosophy Threats & Errors The Old School Threats can be essentially eliminated by better equipment, training, policies, etc. Human performance can be practically perfected by strict discipline, enforcement of rules, etc. Errors are abnormal hunt down and punish the guilty! What a crock of fertilizer!
10 Foundational Philosophy Threats & Errors The TRUTH The world is full of threats. Humans make errors. This is perfectly normal.
11 Building Our Basic TEM Model Defenses Threats Accident, Incident, Violation (We start with James Reason s Swiss Cheese model)
12 Building Our Basic TEM Model Defenses Threats Accident, Incident, Violation
13 Basic Threat & Error Management Model Defenses Threats Error Undesired Consequence Accident, Incident, Violation Prevent Trap Mitigate
14 Defenses Hardware Flows & Checklists External People What If Planning Teamwork Situational Awareness Threats Accident, Incident, Violation SOP s Other Pilot Communications & Briefings Time Management Automation Management Flying Skills
15 Defenses Hardware Flows & Checklists External People What If Planning Teamwork Situational Awareness LUCK! Threats Accident, Incident, Violation SOP s Other Pilot Communications & Briefings Time Management Automation Management Flying Skills
16 Defenses Hardware Flows & Checklists External People What If Planning Teamwork Situational Awareness Threats Accident, Incident, Violation SOP s Other Pilot Communications & Briefings Time Management Automation Management Flying Skills
17 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
18 Basic T&EM Model T&EM Tool-Kit Defenses
19 For Every Defense, Keeping the holes small is up to US! Not Proficient or Disciplined Highly Proficient and Disciplined Which makes a better defense??
20 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
21 Think Out Loud Communications Summary of Tools When you recognize a threat, say something! Ask Questions If you are wondering, ask! Be Specific Use clear language
22 Brief the Exceptions Discuss what s different Brief the Bottom Lines Briefings Summary of Tools Set and communicate the limits
23 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
24 What If Planning Summary of Tools Be Skeptical Challenge assumptions, ask what if questions Plan for the worst Always have an out Choose conservatively When in doubt, ask yourself, Do we need to be doing this?
25 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
26 Budget Available Time Time Management Summary of Tools Move tasks to low workload phases of flight when possible. Add Time Slow Down horizontally, vertically, and operationally. Set Priorities When time is limited, focus on the essentials. Fly the Airplane. Safety of Flight is always first.
27 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
28 Balance Task Loading Teamwork Summary of Tools Divide up the workload within the cockpit. Be ready to reassign tasks. Off-Load Tasks Get help from outside the cockpit. ATC, In-Flight Crew, Dispatch, etc. may all be able to help
29 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
30 Levels of Automation - Terminology Level General Definition 4 A/P, Controlled by FMS [Managed] 3 A/P, Controlled by GP (E190) or FCU (A320) [Selected] 2 F/D Only 1 No Automation at all. (A/P & F/D Off)
31 Automation Management Summary of Tools Use the 3 Rules of Thumb Immediate maneuvering Reduce Level Automation is the problem Reduce Level Workload high Increase Level (if automation is not the problem) Use Active Monitoring Visualize, Act, Compare
32 T&EM Toolkit Defenses Communications & Briefings Time Management Automation Management Threats Accident, Incident, Violation What If Planning Teamwork Situational Awareness
33 Situational Awareness Summary of Tools Use The 3 R s SA Loss Defense 1. Recognize Take your Gut Feel seriously Look for the Flags 2. React Immediately ensure safe flight path & energy state Add Time 3. Regain Rebuild your SA Communicate
34 Situational Awareness Summary of Tools Use Memory Joggers (physical, visual, or aural) To remember to do something in the future which is outside of your normal habits Use The 3 R s SA Loss Defense 1. Recognize Take your Gut Feel seriously Look for the Flags 2. React Immediately ensure safe flight path & energy state Add Time 3. Regain Rebuild your SA Communicate
35 Situational Awareness Summary of Tools SA Loss Defense ( 3 R s ) 1. Recognize Take your Gut Feel seriously Look for the Flags 2. React Immediately ensure safe flight path & energy state Add Time (Slow Down) 3. Regain Rebuild your S.A. Communicate (Ask Questions & Think Out Loud) SA Flags Not Communicating Not Addressing Discrepancies Ambiguity No One Flying the Aircraft (or not looking outside) Failure to Meet Targets Deviating From Standards, Violating Minimums Preoccupation or Fixation Confusion
36 Threat & Error Management Identify Threats, Place Defenses!
37 Recurrent TEM Training
38 Applied TEM Course taught during CQT (recurrent) and is 2 hrs long Course Content Begins with a brief review of the material from Basic TEM For the rest of the class period, scenarios are presented to allow the class to practice applying TEM skills to real-world scenarios. Key point: The scenarios tie in with the CQT training objectives. I.e., we intentionally choose scenarios directly from the LOE. Here s an example
39 Applied TEM Example Scenario Pre-Departure You ve been assigned a late night ferry flight for aircraft repositioning. Threats Unfamiliarity with Ferry Flight tasks Departing with incorrect performance calculations Task loading Defenses Comm&Brief: Verbalize the threat(s), brief the exceptions Time Mgt: Slow down as needed to manage task loading Teamwork: Offload tasks might want to get dispatcher on the phone?
40 TEM is the heart AQP at JetBlue
41 How goes our AQP transition? We are in phase IV (Initial Operations) We re still early in the game Just now completing our first year of operation We transitioned all of our recurrent training into AQP CQT for both of our fleets (A320 & E190) in the first year We conduct CQT on a 9/18 interval (9 month evaluation periods, 18 month qualification cycle) QT programs (Initial, transition, upgrade) still to be done
42 Using our TEM model to build our AQP Grade Scale
43 AQP requires grades to reflect CRM how should we deal with this? Some airlines grade CRM skills separately from technical skills Some airlines integrate CRM and technical skills into the grading scale Allows for a single grade Eliminates potential dilemmas when technical skills are great but CRM skills are deficient (or vice versa) JetBlue chose the integrated method. To do this, we used our Threat and Error Management model
44 Applying T&EM to Grading Defenses Threats Error Undesired Consequence Accident, Incident, Violation Prevent Trap Mitigate
45 Applying T&EM to Grading No Errors Errors occur, but are trapped Errors not trapped Consequences not mitigated YES Threats Error Undesired Consequence Accident, Incident, Violation Attitude, Skill, Knowledge? NO Prevent Trap Mitigate 1 Consequences not mitigated
46 How does our grading model account for standards? The FARs, Practical Test Standards (PTS), OpSpec, Flight Ops Manual (FOM), and aircraft Flight Crew Ops Manual (FCOM), provide the basis for our standards Let s go back to the model
47 Standard maintains objectivity The FARs, Practical Test Standards (PTS), OpSpec, Flight Ops Manual (FOM), and aircraft Flight Crew Ops Manual (FCOM), provide the basis for our standards The technical aspects of these standards are incorporated in our TEM model via the SOP and Flying Skills defenses The CRM aspects of these standards are incorporated in our TEM model via the six TEM Tool-Kit defenses
48 Our TEM model includes SOP s & Flying Skills defenses this covers the technical standards Hardware Flows & Checklists External People What If Planning Teamwork Situational Awareness Threats Accident, Incident, Violation SOP s Other Pilot Communications & Briefings Time Management Automation Management Flying Skills
49 Our TEM model includes our Tool-Kit defenses this covers the CRM standards Hardware Flows & Checklists External People What If Planning Teamwork Situational Awareness Threats Accident, Incident, Violation SOP s Other Pilot Communications & Briefings Time Management Automation Management Flying Skills
50 Applying T&EM to Grading No Errors Errors occur, but are trapped Errors not trapped Consequences not mitigated YES Threats Error Undesired Consequence Accident, Incident, Violation Attitude, Skill, Knowledge? NO Prevent Trap Mitigate 1 Consequences not mitigated Our Standard
51 Scenario Approach & Landing Approaching KBTV late at night, tower is closed, weather is VMC. Threats Defenses Terrain Lack of ATC vectoring capability Responsibility for choosing own approach Planning workload Time Mgt: Budget time in cruise to fully review the issues Think Out Loud Teamwork: Watch for unbalanced task loading. What If Planning: Be skeptical and conservative in choosing approach
52 Specific Threats & Defenses Identified for each Event Set Leg 1 Event Set 7 Approach Event Set Summary: Crew cleared for chosen approach from the BTV VOR, either (1) Visual, or (2) ILS 15 with PT, or (3) direct IAF for RNAV 15. Non-Towered airport operations Threats: - Terrain (CFIT) - Night - Non-tower environment workload - Pilot-controlled lighting distractions - Black Hole approach - SA Loss (esp. position & terrain awareness) Pilot 1 Flying Seat: O Left O Right Defenses - Technical: - SOP non-tower operations, approach procedures - Flying Skills standards met; use of glide path information (PAPI and electronic if available) - Hardware EGPWS displayed, FMS properly set up and used. Defenses TEM: - Automation Management: use 3 rules of thumb, esp. workload high increase level (AP left on as long as it s helpful), and automation problem decrease level (if automation problem, crew reduces level) - Time Management: Add time slow down; goaround if in doubt - What If Planning: Make conservative choices Do we need to be doing this? - SA: Use 3R s -- Recognize (Look for flags), if any are noted immediately React
53 Threat & Error Management Identify Threats, Place Defenses!
54 How this all fits together in the LOE Grade-Sheet/Job Aid
55 Excerpt from LOE Grade Sheet
56 Crew Grade, Reason Code, & Comments Graded Item Crew Grade 1-5 Reason Code Circle A, S and/or K Database Comments Pre-Departure Planning 1 A S K Receiving Checklist 2 A S K Cockpit Preparation 3 A S K Before Start (To the line) 4 A S K Before Start (Below the line) 5 A S K
57 Excerpt from LOE Grade Sheet
58 Event-Set Header Section Specific Threats & Defenses Identified Leg 1 Event Set 1 Pre-Departure Planning Event Set Summary: Crew preps for a middle-of-the-night ferry flight. Ballast fuel required. Threats: Departing with incorrect performance calculations, departing without clear understanding of destination plan. Unfamiliarity with tasks (ferry flight, ballast fuel, and non-towered ops rarely done) Higher than normal task loading Night operations Defenses Technical: SOPs use of FOM guidance ferry flights, non-tower operations Flows and Checklists use of QRH for Ballast fuel, use of QRH for ferry Hardware hard-tune BOS for the SID Defenses TEM: Comm&Brief think out loud about threats, brief exceptions (esp. SID, and unfamiliar procedures). Teamwork contact with dispatcher for briefing Time Mgt Add time as necessary to manage pre-departure task loading Pilot 1 Flying Seat: O Left O Right
59 Next Steps for our TEM Program Integrating TEM into our QT development Plan to follow the same strategy as we re using in CQT Identifying threats how do you do that? Recognition-Primed Decision-Making, based on Experience- Primed Recognition Expansion of TEM outside of Flight Operations Other departments interested Flight Attendants already using some of the material Strong interest from Maintenance, Dispatch, and even HR!
60 Concluding Recap
61 Recap of Key Points At JetBlue, TEM is about things you can do Basic TEM course taught to new-hires during indoc Concepts of TEM TEM Tool-Kit Applied TEM taught during CQT (recurrent) Brief review of the Basic TEM material Scenarios (coordinated with LOE) used to practice use of the tool-kit TEM is the heart of our AQP TEM model used to construct our Grade Scale TEM skills taught and checked along with technical skills
62 Threat & Error Management Identify Threats, Place Defenses!
63 Questions?
64 Thank you for your kind attention
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