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Safety behaviours: human factors for pilots 2 nd edition Resource booklet 8 Threat and error management
安全行为:飞行员的人为因素 2 nd 版 资料手册 8 威胁和错误管理
First edition of Safety Behaviours: Human Factors for Pilots (2009), Second edition kit (2018) ISBN: 978-1-921475-54-2
安全行为》第一版:飞行员的人为因素》(2009 年)第二版套件(2018 年)ISBN:978-1-921475-54-2
Book 1: ISBN 978-1-921475-55-9 (paperback) ISBN 978-1-921475-56-6 (pdf), Book 2: ISBN 978-1-921475-57-3 (paperback) ISBN 978-1-921475-58-0 (pdf), Book 3: ISBN 978-1-921475-59-7 (paperback) ISBN 978-1-921475-60-3 (pdf), Book 4: ISBN 978-1-921475-61-0 (paperback) ISBN 978-1-921475-62-7 (pdf), Book 5: ISBN 978-1-921475-63-4 (paperback) ISBN 978-1-921475-64-1 (pdf), Book 6: ISBN 978-1-921475-65-8 (paperback) ISBN 978-1-921475-66-5 (pdf), Book 7: ISBN 978-1-921475-67-2 (paperback) ISBN 978-1-921475-68-9 (pdf), Book 8: ISBN 978-1-921475-69-6 (paperback) ISBN 978-1-921475-70-2 (pdf), Book 9: ISBN 978-1-921475-71-9 (paperback) ISBN 978-1-921475-72-6 (pdf), Book 10: ISBN 978-1-921475-73-3 (paperback) ISBN 978-1-921475-74-0 (pdf) Workbook: ISBN 978-1-921475-75-7 (paperback) ISBN 978-1-921475-76-4 (pdf)
Book 1: ISBN 978-1-921475-55-9 (paperback) ISBN 978-1-921475-56-6 (pdf), Book 2: ISBN 978-1-921475-57-3 (paperback) ISBN 978-1-921475-58-0 (pdf), Book 3:ISBN 978-1-921475-59-7 (平装) ISBN 978-1-921475-60-3 (pdf),第 4 册:ISBN 978-1-921475-61-0 (平装) ISBN 978-1-921475-62-7 (pdf),第 5 册:ISBN 978-1-921475-63-4 (平装) ISBN 978-1-921475-64-1 (pdf),第 6 册:ISBN 978-1-921475-63-4 (平装) ISBN 978-1-921475-64-1 (pdf):ISBN978-1-921475-65-8(平装本)ISBN978-1-921475-66-5(pdf),第 7 册:ISBN978-1-921475-67-2(平装本)ISBN978-1-921475-68-9(pdf),第 8 册:ISBN978-1-921475-69-6(平装本)ISBN978-1-921475-70-2(pdf),第 9 册:ISBN978-1-921475-69-6(平装本)ISBN978-1-921475-70-2(pdfISBN 978-1-921475-71-9 (平装) ISBN 978-1-921475-72-6 (pdf), 第 10 册:ISBN 978-1-921475-73-3 (平装) ISBN 978-1-921475-74-0 (pdf) 工作手册:ISBN 978-1-921475-75-7 (平装) ISBN 978-1-921475-76-4 (pdf)
For further information or additional copies, visit CASA's website www.casa.gov.au/hf
欲了解更多信息或获取更多副本,请访问 CASA 网站 www.casa.gov.au/hf。
Notice: The information contained in this document was correct at the time of publishing and is subject to change without notice. It has been prepared by CASA Safety Promotion for educational purposes only. This guide outlines basic procedures-it should never be used as a replacement for official manuals or procedures. Reference should be made to the appropriate procedures at all times prior to the use of this information
通知:本文件中包含的信息在发布时是正确的,如有更改,恕不另行通知。本指南由 CASA 安全促进部编写,仅供教育之用。本指南概述了基本程序,但绝不能取代官方手册或程序。在使用本信息之前,应随时参考相应的程序
The Civil Aviation Safety Authority is responsible for the safety regulation of Australia's civil aviation operators, and for the regulation of Australian-registered aircraft outside Australian teritory.
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Unless noted otherwise, copyright in this work is owned by CASA. This work is licensed under a Creative Commons Attribution-4.0 International Licence, with the exception of the Commonwealth Coat of Arms; CASA's logo; any third party material; any material protected by a trademark, and any images and/ or photographs.
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The threat and error

management (TEM) concept, developed at the University of Texas in the late , looks at how airline flight crew respond to external threats and internal errors that could lead to undesired aircraft states during flight.
管理 (TEM) 概念由德克萨斯大学于晚期提出 ,研究航空公司机组人员如何对外部威胁和可能导致飞行过程中飞机出现意外状态的内部错误做出反应。
The TEM model can be used to analyse a single event, or to understand systemic patterns within a large set of events. It can also be used to help clarify human performance needs, strengths and vulnerabilities, and as a training tool to help an organisation improve the effectiveness of its training interventions, and consequently its organisational safeguards.
TEM 模型可用于分析单个事件或了解大量事件中的系统模式。它还可以用来帮助澄清人类的绩效需求、优势和弱点,并作为一种培训工具,帮助组织提高其培训干预措施的有效性,进而提高其组织保障措施的有效性。

Contents 目录

Introduction ..... 4 简介 .....4
What is TEM? ..... 4
什么是 TEM?.....4

Threats ..... 4 威胁 .....4
Errors ..... 6 错误 .....6
Undesired aircraft states ..... 8
非预期飞机状态 .....8

Applying TEM and countermeasures ..... 8
应用 TEM 和对策 .....8

TEM in the charter environment ..... 9
包机环境中的 TEM .....9

Consequences of poor TEM ..... 12
TEM 不佳的后果 .....12

Key points for professional pilots ..... 14
专业飞行员要点 .....14

Key points for charter operators ..... 14
包机运营商要点 .....14

Resources. ..... 15 资源。.....15
References ..... 15 参考文献 .....15
People cannot easily avoid

those actions they did not intend

to commit. 承诺。

Introduction 导言

Threat and error management (TEM) is a safety management approach which has been described as 'simply an extension of the concept of airmanship.'
威胁与失误管理(TEM)是一种安全管理方法,被称为 "航空技术概念的简单延伸"。
It is the process of detecting and responding to threats (such as adverse weather) and errors (such as unclear communication between crew members) before they compromise safety. TEM aims to maintain safety margins by training pilots and flight crews to detect and respond to threats and errors that are part of everyday operations.
它是一个在威胁(如恶劣天气)和错误(如机组成员之间沟通不畅)危及安全之前对其进行检测和应对的过程。TEM 的目的是通过培训飞行员和机组人员发现和应对日常运行中的威胁和错误,从而保持安全系数。
If not properly managed, these threats and errors have the potential to generate undesired aircraft states (UAS). The management of undesired aircreft states represents the last opportunity to avoid an unsafe outcome and thus to maintain safety margins in flight operations.
The International Civil Aviation Organization (ICAO) acknowledges TEM as a critical foundation of all pilot training regardless of the size or scope of the operation.
国际民用航空组织(ICAO)认为,无论业务规模或范围如何,TEM 都是所有飞行员培训的重要基础。
In line with ICAO's support for TEM, CASA published CAAP 5.59-1 in 2008, with key TEM principles. In 2009 CASA also incorporated TEM into the recreational pilot licence (RPL), private pilot licence (PPL), commercial pilot licence (CPL) and air transport pilot licence (ATPL) as a formal assessment requirement.
根据国际民航组织对 TEM 的支持,CASA 于 2008 年发布了 CAAP 5.59-1,其中包括 TEM 的主要原则。 2009 年,CASA 还将 TEM 纳入娱乐飞行员执照 (RPL)、私人飞行员执照 (PPL)、商业飞行员执照 (CPL) 和航空运输飞行员执照 (ATPL),作为正式的评估要求。
This booklet looks at applying TEM to single-pilot and multi-crew charter operations.
本手册介绍了如何将 TEM 应用于单驾驶员和多机组包机操作。

What is TEM? 什么是 TEM?

TEM provides a way for pilots to look for potential threats to flight operations in a structured way. They actively manage these threats and any errors that may lead to undesired aircraft states and therefore to the safety of the flight. TEM encompasses training, briefings, checklists, standard operating procedures, and human factors principles for single-pilot and multi-crew operations.
TEM 为飞行员提供了一种有条理地寻找飞行操作潜在威胁的方法。他们会积极管理这些威胁以及任何可能导致飞机出现意外状态从而影响飞行安全的错误。TEM 包括培训、简报、检查单、标准操作程序以及单人和多机组操作的人为因素原则。

Threat and error management

  • Recognise and manage errors
  • Recognise and manage threats
  • Recognise and manage undesired aircraft states
TEM involves: TEM 涉及
  • planning to identify threats and errors during a flight and implementing countermeasures to eliminate or minimise them
  • directing actions to address threats and errors, using checklists, approved procedures, and other acceptable means, including selfdirection during single-pilot operations
  • controlling the progress of events to ensure a safe outcome. This step requires monitoring progress and amending plans and actions as required, including correcting any undesired aircraft state (UAS).
    控制事件进展,确保安全结果。这一步骤要求监控进展情况,并根据需要修改计划和行动,包括纠正任何不希望出现的飞机状态 (UAS)。

TEM and risk management
TEM 和风险管理

TEM complements risk management, which is the process of deciding whether operations can be safely conducted to an acceptable level of risk, and which includes go/no-go or divert decisions. TEM applies to managing and maintaining safety during a flight.
TEM 是对风险管理的补充,后者是决定是否可以在可接受的风险水平上安全地开展业务的过程,其中包括去/不去或改道的决定。TEM 适用于飞行过程中的安全管理和维护。
Let's have a look at its core components of threats, errors and undesired aircraft states

Threats 威胁

CASA defines a threat as a situation or event that has the potential to have a negative effect on flight safety, or any influence that promotes an opportunity for pilot error/s.
CASA 将威胁定义为有可能对飞行安全产生负面影响的情况或事件,或任何助长飞行员出错机会的影响。
Threats are generally external (such as bad weather) or internal (such as physiological and psychological state).
Threats such as fatigue increase the likelihood of errors, leading to degraded situational awareness and poor decision making. Pilots need good situational awareness to anticipate, recognise and manage threats as they occur.
For charter operations, external threats include:
  • adverse weather 恶劣天气
  • weight and balance 重量和平衡
  • passenger distraction 乘客分心
  • early starts and late finishes
  • night operations 夜间行动
  • reduced runway length 跑道长度缩短
  • other traffic, high terrain or obstacles
  • the condition of the aircraft.

    Typical internal threats to charter operations include
  • fatigue 疲劳
  • inexperience 不经验
  • over-or under-confidence
  • isolation 孤立
  • impulsiveness 冲动
  • lack of recency and proficiency
  • press-on-itis. 压迫性炎症。
External threats 外部威胁 Examples
Adverse weather 恶劣天气 Thunderstorms, turbulence, poor visibility, wind shear, icing conditions, IMC
Aircraft Systems, engines, flight controls, instruments
Poor signage, faint markings, runway/taxiway closures, poor braking action,
contaminated runways/taxiways, condition of runway/taxiway
ATC Tough-to-meet clearances/restrictions, reroutes, controller errors
Cabin Cabin events, (flight attendant errors), distractions, interruptions
Dispatch/paperwork 调度/文书工作
Load-sheet errors, crew scheduling events, late paperwork, changes
or errors
operational pressure 运行压力
Terrain, traffic, radio congestion
Ground maintenance 地面维护 Aircraft repairs on ground, maintenance log problems, maintenance errors
Ground/ramp Aircraft loading events, fuelling errors, improper ground support
Manuals/charts 手册/图表 Missing information or documentation errors
Time pressure 时间压力 Delays, late arriving passengers, cargo or refueller

Managing threats 管理威胁

The TEM model includes three threat categories: anticipated, unanticipated and latent. All three can reduce safety margins.
TEM 模型包括三个威胁类别:预期威胁、非预期威胁和潜在威胁。这三种威胁都会降低安全系数。
Latent threats may not be clear and may need to be uncovered by formal safety analysis and specifically addressed in your organisation's training and procedures.


Some threats can be anticipated such as:
  • thunderstorms, icing, wind shear and other forecast bad weather
  • congested airports and landing areas
  • wires and other obstacles
  • complex ATC clearances 复杂的空管许可
  • cross and/or downwind approaches and landings
  • outside air temperature/density altitude extremes
  • aircraft mass and balance
  • forecast or known bird/wildlife activity.


These are other threats that can occur unexpectedly, suddenly and without warning. Pilots must apply the skills and knowledge they have acquired through training and operational experience to deal with issues such as:
  • in-flight aircraft malfunctions
  • automation—anomalies and over-reliance
  • unforecast weather, turbulence, icing
  • ATC re-routing, unexpected congestion, non-standard phraseology, navigation aid unserviceability, confusion over similar call-signs
  • ground handling 地面装卸
  • wires and other obstacles
  • unmanned aircraft systems (drones)
  • unforecast bird/wildllife activity
  • laser attacks 激光攻击
  • contaminated or sloping landing areas.


Some threats may not be directly obvious to, or observable by, pilots and may need to be discovered through formal safety analysis. These are considered latent threats and may include organisational weaknesses and the psychological and physiological state of the pilot. They include:
  • organisational culture 组织文化
  • organisational change 组织变革
  • incorrect or incomplete documentation, such as poor manuals
  • equipment design issues such as landing gear and flap levers located too close to each other, or inaccurate fuel gauges
  • operational pressures and delays, such as undue pressure to get a job done
  • perceptual illusions such as approaches to sloping runways
  • fatigue and rostering 疲劳和名册
  • lack of recent experience and proficiency
  • stress 强调
  • over-confidence or under-confidence.
As we learn and gain experience we are better able to predict where threats may occur. Obtaining and interpreting a weather report allows us to prepare for bad weather, while experience helps us to understand our capabilities and limitations.
Regardless of whether threats are anticipated, unanticipated, or latent, a measure of a pilot's ability to manage threats is whether they are detected in time to avoid an undesired aircraft state.

Errors 错误

As humans we all make errors. In TEM, errors are defined as flight crew actions or inactions which lead to:
作为人类,我们都会犯错误。在 TEM 中,失误被定义为导致以下结果的机组人员行为或不行为:
  • a deviation from crew or organisational intentions or expectations
  • reduced safety margins 安全系数降低
  • increased probability of adverse operational events on the ground and during flight.
Adverse operational events can be handling errors, procedural errors or communications errors.
Errors can be the result of momentary diversion of attention (slip), or memory failure (lapse) induced by an expected or unexpected threat. There are also more deliberate, intentional non-compliance errors. These are often shortcuts used to increase operational efficiency, but in violation of standard operating procedures.
Slips and lapses are failures in the execution of an intended action. Slips are actions that do not go as planned, while lapses are memory failures. For example, pulling the mixture instead of the carburettor heat is a slip. Forgetting to apply the carburettor heat is a lapse.
Mistakes are failures in the plan of action; even if execution of the plan was correct, it would not have been possible to achieve the intended outcome.
While errors may be inevitable, we need to identify and manage them before safety margins are compromised. Typical errors in charter operations include:
  • incorrect performance calculations (mistakes)
  • inaccurate flight and fuel planning (slips, lapses)
  • non-standard communication (mistakes, violations)
  • aircraft mishandling (slips)
  • incorrect systems operation or management (slips, lapses, mistakes)
  • checklist errors (slips, lapses)
  • failure to meet flight standards, such as poor airspeed control (slips).
Figure 1 Basic error types
图 1 基本错误类型
From Reason, 1991 摘自《理性》,1991 年
Table 3 Examples of error types
表 3 错误类型示例
Aircraft handling errors
Flight control 飞行控制 Incorrect flaps or power settings
Ground navigation 地面导航
Attempting to turn down wrong taxiway/runway, missed
taxiway/runway/gate, failure to hold short
Manual flying 手动飞行 Hand flying vertical, lateral, or speed deviations
Incorrect GPS, altimeter, fuel switch, transponder or radio
frequency settings 频率设置
Procedural errors 程序错误 Examples
Missed items in the brief, omitted departure, take-off,
approach, or handover briefing
Callouts Omitted take-off, descent, or approach callouts
Performed checklist from memory or omitted checklist,
missed items, performed late or at wrong time
Wrong weight and balance, fuel information, ATIS, or
错误的重量和平衡、燃料信息、ATIS 或
clearance recorded, misinterpreted items on paperwork
Other procedural 其他程序
Other deviations from regulations, flight manual
requirements or standard operating procedures
Communication errors 通信错误 Examples
Pilot to external 试点到外部
Missed calls, misinterpretation of instructions, or
incorrect read-backs to ATC, wrong clearance, taxiway,
不正确地向 ATC 回读、错误的许可、滑行道、
gate or runway communicated
Pilot to pilot 飞行员对飞行员 Internal crew miscommunication or misinterpretation
The aim of error management is to have pilots detect errors and respond quickly to them, so that the errors become operationally inconsequential and the risk to safety is minimised.
A mismanaged error is one which is linked to or induces an additional error or undesired aircraft state.

Undesired aircraft states

Undesired aircraft states (UAS) are pilotinduced aircraft position or speed deviations, misapplications of flight controls, or incorrect systems configurations associated with a reduced margin of safety.
For safe flight we must quickly recognise and recover from an undesired aircraft state before it leads to a loss of control or uncontrolled flight into terrain.
Examples of errors and associated undesired aircraft states in charter operations include:
  • mismanagement of aircraft systems (error), resulting in aircraft anti-ice not turned on during icing conditions (state)
  • inappropriate scan of aircraft instruments (error), resulting in an unusual aircraft attitude (state)
  • flying a final approach below appropriate threshold speed (error), resulting in excessive deviations from specified performance (state).

    Table 4 Examples of undesired aircraft states
    表 4 飞机非预期状态示例
aircraft state 飞机状态
Aircraft handling 飞机操作
Vertical, lateral or speed
Unnecessary weather 不必要的天气
Unstable approach 不稳定的方法
Long, floated, firm or
off-centreline landings 偏离中心线着陆
Runway/taxiway incursions
Wrong taxiway, ramp, gate,
or hold spot
Taxi above speed limit
Incorrect aircraft 不正确的飞机
Automation, engine, flight
control, systems, or weight/
balance events 平衡事件

Applying TEM and countermeasures
应用 TEM 和对策

Threats and errors occur during every flight. Data from airline operations suggests that nearly half of flight-crew errors are not detected or responded to. is very likely that this will be no better for charter operations.
每次飞行都会遇到威胁和失误。航空公司的运营数据表明,近一半的机组错误没有被发现或采取应对措施。 ,包机运营的情况很可能也不会好到哪里去。
TEM involves anticipating and calling out potential threats and errors as well as planning countermeasures in the self-briefing process at each stage of flight to prevent threats and errors becoming an undesired aircraft state. This needs to be done in a structured and simple way, without becoming complacent about commonlyencountered threats such as weather, traffic, and terrain.
TEM 包括预测和指出潜在的威胁和错误,以及在每个飞行阶段的自我通报过程中计划应对措施,以防止威胁和错误成为飞机的不良状态。这需要以结构化和简单的方式进行,不能对天气、交通和地形等常见威胁掉以轻心。
There are three kinds of countermeasures:
  • Planning countermeasures including flight planning, briefing, and contingency planning.
  • Execution countermeasures including monitoring, cross-checking, workload and systems management.
  • Review countermeasures including evaluating and modifying plans as the flight proceeds, and enquiry and assertiveness to identify and address issues in a timely way.
Once you recognise an undesired aircraft state, you must use the correct countermeasure rather than fixate on the error.
So how do we do this in practice?
Your preparation for every flight, including interpreting NOTAMs and meteorological information, and checking fuel, should consider which actions, conditions or events are likely to promote errors and potential threats, and the appropriate countermeasures. An example is the action you propose if there are unpredicted weather changes.
Identifying threats can reduce your in-flight workload, as you have already prepared yourself to deal with them.
In-flight briefings (self-brief, crew and passengers) should include planned procedures, anticipated threats and countermeasures before take-off and commencing any significant flight sequence (such as an approach to an unfamiliar airport).
During flight you should:
  • continuously monitor and cross-check visual and instrument indications and aircraft energy state to maintain situational awareness
  • prioritise tasks and manage workload to avoid being overloaded, and to maintain situational awareness
  • identify and manage threats and errors
  • when confronted by threats and/or errors, configure the aircraft to make it as easy as possible to maintain control, including setting the correct flight path
  • monitor the progress of every sequence and abort if necessary
  • not fixate on threat or error management to the detriment of aircraft control
  • identify and manage any undesired aircraft state
  • return to planned flight and normal safety margins before dealing with other problems.
Post flight you should take a few minutes to go over any threats, errors and/or undesired aircraft states you encountered during the flight. Ask yourself how well they were managed and what you could do differently to improve their management. Note these and discuss them with your fellow pilots to develop improved TEM strategies for next time.
飞行结束后,您应该花几分钟时间回顾一下在飞行过程中遇到的任何威胁、错误和/或不希望出现的飞机状态。问问自己对这些状态的处理效果如何,以及您可以采取哪些不同的方法来改进对这些状态的处理。将这些问题记录下来,并与其他飞行员讨论,为下次制定更好的 TEM 战略。

TEM in the charter environment
包机环境中的 TEM

The TEM model distinguishes between environmental and organisational threats.
TEM 模型区分了环境威胁和组织威胁。
Environmental threats are beyond the control of the aircraft operator; the pilot must manage these in the time available. Examples of environmental threats in charter operations include:
  • weather, such as turbulence, ice, wind, fog, storms, driving rain
  • aerodrome conditions, such as congestion, complex surface navigation, poor signage/ markings, and unprepared landing strips
  • air traffic control issues, such as non-standard phraseology and complex clearances
  • terrain, such as mountains, valleys and built-up areas.
Organisational threats, which are often latent, can be controlled by the operator or reduced through safety management systems, fatigue risk management systems, standard operating procedures, checklists, ground handling support and operational health and safety procedures. However, as the pilot you tend to be the last line of defence.
Examples of organisational threats in charter operations include:
  • pressures such as tight turn-around times
  • poor aircraft serviceability
  • maintenance errors 维护错误
  • incorrect documentation such as incorrect or expired charts, an incomplete or erroneous maintenance release, or inaccurate fuel logs.

Error management 错误管理

By acknowledging that errors will occur, we change our focus from error prevention to error recognition and management. Because unmanaged or mismanaged errors may result in an undesired aircraft state we need to be constantly alert to recognise and fix them early.
Once you recognise an error, it is important you focus on managing any resulting undesired aircraft state. In trying to manage an error, we can become fixated on its cause and forget firstly to 'aviate, navigate and communicate'.
一旦发现错误,就必须集中精力处理由此导致的飞机不良状态。在尝试管理错误时,我们可能会专注于错误的原因,而忘记了首先要 "飞行、导航和沟通"。
For example, if you become uncertain of your position, you need to make a timely decision to perform a 'lost procedure'. You may be tempted to ascertain why you became lost and blunder on regardless (undesired aircraft state), rather than initiating a logical procedure to re-establish your position, seek assistance from other aircraft or ATC or plan a precautionary landing.
例如,如果您不确定自己的位置,您需要及时决定执行 "迷航程序"。您可能很想确定自己为什么会迷失方向,然后不管不顾地继续前进(不希望出现的飞机状态),而不是启动合理的程序来重新确定自己的位置、寻求其他飞机或 ATC 的帮助或计划预防性着陆。
An effective tool for a post-flight TEM debrief is to use a simple timeline with the following steps:
飞行后 TEM 汇报的一个有效工具是使用一个简单的时间表,包括以下步骤:

Threat  威胁

- Pilot response (R)
- 试点响应 (R)

  • Outcome (O) Inconsequential or consequential? Inconsequential means that there was no adverse outcome, i.e. there was no error.
    结果 (O) 无后果还是有后果?无后果是指没有不良后果,即没有错误。

Error (  错误 (

- Pilot response (R)
- 试点响应 (R)

  • Outcome (O) Inconsequential or consequential? This time a consequential outcome may be a further error, or an undesired state.
    结果 (O) 不重要还是重要?这次的后果可能是进一步出错,也可能是不希望出现的状态。

Undesired Aircraft State (U)
非预期飞行器状态 (U)

- Pilot response (R)
- 试点响应 (R)

  • Outcome (O) Inconsequential or consequential? Again, a consequential outcome may be a further error, or an undesired state.
    结果 (O) 不重要还是重要?同样,后果性结果可能是进一步的错误,也可能是不希望出现的状态。
Figure 2 TEM triangle
图 2 TEM 三角形
While the basic concept of TEM is simple, including it into your standard practices is more challenging. But if you do, you will see the benefit of a planned and structured approach to staying ahead of the aircraft—and staying safe.
虽然 TEM 的基本概念很简单,但将其纳入您的标准实践更具挑战性。但是,如果您这样做了,您就会发现有计划、有条理地保持领先于飞机--并确保安全的方法所带来的好处。
After the following gear-up accident in a Cessna 210 in the US, the pilot described the lead-up to the accident. Despite his training and the gear horn warning, he had failed to put the gear down before landing. Here's his analysis using the TEM model of the threat and error triangle pathway (see diagram above).
在美国发生了一起塞斯纳 210 型飞机挂挡事故后,飞行员描述了事故发生的前因后果。尽管他接受过培训,而且齿轮喇叭也发出了警告,但他还是没有在着陆前放下齿轮。以下是他使用威胁和错误三角路径的 TEM 模型进行的分析(见上图)。

Threat management 威胁管理

  • The pilot was coming home from a long flight and long day, feeling fatigued and struggling to keep on top of things.
  • On arrival at his destination, ATC switched runways on him at the last minute. He became flustered as he had planned and briefed landing on runway 36 , and now had to quickly switch to runway 27.
    到达目的地后,空管在最后一刻为他调换了跑道。由于他计划在 36 号跑道着陆并做了简况报告,现在不得不迅速切换到 27 号跑道,因此他感到非常慌乱。
  • There was a significant crosswind and he was concerned that his crosswind skills were not up to par. He hadn't practised crosswind landings for a long time.

Errors 错误

  • The pilot was interrupted during his descent checklist and did not complete it.
  • He was surprised by the late runway change and did not complete his descent or before-landing checklists.
  • He was having difficulty making the crosswind correction for the pattern on the second runway.

Error management 错误管理

  • The pilot did not attempt to complete the descent checklist.
  • He did not attempt to complete the beforelanding checklist.
  • He was barely managing the errors he was making correcting for the crosswind.

Undesired states 不希望出现的状态

  • The aircraft engine was running hot because the descent checklist wasn't completed.
  • The gear wasn't down because the beforelanding checklist wasn't completed.
  • The flaps were not configured for landing.
  • The aircraft wasn't lined up with the runway.
  • Undesired state management nil.

End state 结束状态

  • Because of this event sequence, the aircraft landed on its belly, necessitating a new engine and new propeller. Extensive mechanical work was needed to fix the belly. Luckily there were no injuries to the pilot or his passengers.
So, how do you prevent errors from multiplying and putting you in an undesired aircraft state? In this case, a go-around would have provided time to get everything together and sort things out.
Consider how you could have anticipated and briefed yourself for the threats and errors on this day and the countermeasures that you could have put in place to manage the situation and avoid an undesired aircraft state you couldn't control.

Consequences of poor TEM
不良 TEM 的后果

The following example describes a series of events which led to the death of a patient. While it is from the health sector, it illustrates how unmanaged threats and errors can lead to disaster.
下面的例子描述了导致一名病人死亡的一系列事件。 虽然这只是一个卫生部门的例子,但它说明了未经管理的威胁和错误是如何导致灾难的。

Assessing the application of TEM
评估 TEM 的应用

Let's conclude by considering how a charter operator could develop a simple program to assess the practical application of TEM.
最后,让我们考虑一下包机运营商如何开发一个简单的程序来评估 TEM 的实际应用。
Such a program should answer the following questions about an operator's pilots.
  • Do they recognise, assess and manage potential threats?
  • Do they diligently follow standard operating procedures and show evidence of situational awareness to avoid and trap errors?
  • Do they apply strategies to manage and mitigate the effects of any errors?
  • Do they manage any undesired aircraft state and return to normal operations successfully?
Assessors need evidence that threat and error management is being practised; they can't assume that competent TEM was used just because a flight was completed safely.
评估人员需要证据来证明威胁和错误管理正在实施;他们不能因为一次飞行安全完成就认为使用了合格的 TEM。
Since observation is the only way to gather this evidence, it is important to actively question the pilot pre-flight, in-flight and post-flight to understand why specific TEM techniques were applied. However, the assessor should not distract the pilot.
由于观察是收集这些证据的唯一方法,因此必须在飞行前、飞行中和飞行后积极询问飞行员,以了解为什么要使用特定的 TEM 技术。不过,评审员不应分散飞行员的注意力。
On an assessment flight it is unlikely a competent pilot will get into an undesired aircraft state or, if it occurs, fail to correct it. It may therefore be necessary to set up a theoretical situation. For example:
  • create a scenario that will be analysed during the pre-flight briefing
  • when approaching a destination airport, simulate a thunderstorm over the airfield
  • simulate a radio failure approaching a reporting point or entering a control zone
  • simulate a precautionary or forced landing
  • simulate an instrument or display failure.
The following list of competencies may be useful as a starting point for an assessment program:

Maintains effective lookout

  • Maintains lookout and traffic separation using a systematic scan technique determined by traffic density, visibility and terrain.
  • Maintains radio listening watch and interprets transmissions to determine traffic location and intentions of traffic.
  • Performs airspace-cleared procedure before commencing any manoeuvres.

Maintains situational awareness

  • Monitors all aircraft systems using a systematic scan technique.
  • Collects information to facilitate ongoing system management.
  • Monitors flight environment for deviations from planned operations.
  • Collects flight environment information to update planned operations.

Assesses situations and make decisions

  • Identifies problems. 发现问题。
  • Analyses problems. 分析问题。
  • Identifies solutions 确定解决方案

Assesses solutions and risks

  • Decides on a course of action.
  • Communicates plans of action (if appropriate).
  • Allocates tasks for action (if appropriate).
  • Takes actions to achieve optimum outcomes for the operation.
  • Monitors progress against plan.
  • Re-evaluates plan to achieve optimum outcomes.

Sets priorities and manages tasks

  • Organises workload and priorities to ensure completion of all tasks relevant to the safety of the flight.
  • Puts the safe and effective operation of the aircraft ahead of competing priorities and demands.
  • Plans events and tasks to occur sequentially.
  • Anticipates critical events and tasks to ensure completion.
  • Uses technology to reduce workload and improve cognitive and manipulative activities.
  • Avoids fixation on single actions, tasks or functions.

Maintains effective communications and interpersonal relationships

  • Establishes and maintains effective and efficient communications and interpersonal relationships with all stakeholders to ensure the safe outcome of the flight.
  • Defines and explains objectives to applicable or involved parties.
  • Demonstrates a level of assertiveness that ensures the safe completion of the flight.
  • Encourages passengers to participate in and contribute to the safe outcome of the flight.

Recognises and manages threats

  • Identifies relevant environmental or operational threats that are likely to affect the safety of the flight.
  • Develops and implements countermeasures to manage threats.
  • Monitors and assesses flight progress to ensure a safe outcome.
  • Modifies actions when a safe outcome is not assured.

Recognises and manages errors

  • Applies checklists and standard operating procedures to prevent aircraft handling, procedural or communication errors and identifies committed errors before safety is affected or aircraft enters an undesired state.
  • Monitors aircraft systems, flight environment and crewmembers, collects and analyses information to identify potential or actual errors.
  • Implements countermeasures to prevent errors, or acts in the time available to correct errors before the aircraft enters an undesired state.

Recognises and manages UAS

  • Recognises UAS. 承认无人机系统。
  • Prioritises tasks to ensure management of UAS.
    确定任务的轻重缓急,确保 UAS 的管理。
  • Manipulates aircraft controls or systems or modifies actions or procedures to maintain control of the aircraft and return to normal flight operations, in the time available.

Key points for professional pilots

The threat and error management (TEM) approach recognises that making errors is a normal part of human behaviour that can and should be managed. It promotes a philosophy of anticipation or 'thinking ahead'.
威胁与错误管理(TEM)方法认为,犯错误是人类行为的正常部分,可以而且应该加以管理。它倡导一种预测或 "超前思考 "的理念。
The three basic components of the TEM model are threats, errors and undesired aircraft states (UAS). It is important that crews know when to switch from error management to undesired aircraft state management.
TEM 模型的三个基本组成部分是威胁、错误和不期望的飞机状态 (UAS)。重要的是,机组人员要知道何时从错误管理切换到不良飞机状态管理。
Pilots who develop strategies or countermeasures such as planning, and review or modification of plans, tend to have fewer mismanaged threats, commit fewer errors, and have fewer undesired aircraft states.

Key points for charter operators

Charter operators can develop simple programs to develop and assess the practical application of TEM by their flight crews and to provide assurance that their flight training, checking and standard operating procedures are working effectively to manage safety.
包机运营商可以制定简单的计划,以发展和评估机组人员对 TEM 的实际应用,并保证其飞行培训、检查和标准操作程序能够有效地管理安全。
TEM programs are designed to question and observe pilots before, during and after flights to determine whether pilots recognise, assess and manage potential threats; diligently follow standard operating procedures; demonstrate situational awareness to avoid and trap errors; apply strategies to mitigate the effects of any errors; and manage any undesired aircraft state to successfully return to normal operations.
TEM 计划的目的是在飞行前、飞行中和飞行后对飞行员进行询问和观察,以确定飞行员是否认识、评估和管理潜在威胁;是否认真遵守标准操作程序;是否具有避免和避免失误的态势感知能力;是否采用了减轻失误影响的策略;以及是否管理了任何不希望出现的飞机状态以成功恢复正常运行。
Operators should seek evidence that TEM is being routinely practised rather than assuming it is. They should focus on making TEM training and observations a positive shared learning and continuous improvement experience for their people and their organisation.
运营者应寻找证据,证明 TEM 已被常规化,而不是假设它已被常规化。他们应集中精力,使 TEM 培训和观察成为员工和组织共同学习和持续改进的积极体验。

Resources 资源


Australian Transport Safety Bureau (ATSB) (2006). Threat and Error Management: Attitudes towards training and applicability of TEM to general aviation and low capacity air transport operations. Aviation Research and Analysis-AR-2006-156(1) Final. See: https://www.atsb.gov.au/media/625596/ AR2006156_1.pdf
澳大利亚运输安全局 (ATSB)(2006 年)。威胁与错误管理:对培训的态度以及 TEM 对通用航空和低容量航空运输业务的适用性。航空研究与分析-AR-2006-156(1)最终版。参见:https://www.atsb.gov.au/media/625596/ AR2006156_1.pdf
European Helicopter Safety Team (EHEST) (2014). The Principles of Threat and Error Management (TEM) for Helicopter Pilots, Instructors and Training Organisations. Training Leaflet HE 8. See: https:// uww.easa.europa.eu/sites/default/files/dfu/HE8.pdf
欧洲直升机安全小组 (EHEST)(2014 年)。直升机飞行员、教官和培训机构的威胁和错误管理原则 (TEM)。培训手册 HE 8。参见:https:// uww.easa.europa.eu/sites/default/files/dfu/HE8.pdf
Helmreich, R., Klinect, J. and Wilhelm, J. (1999). Models of event, error and response in flight operations. In Jensen, R. S. (ed.) Proceedings of the Tenth International Symposium on Aviation Psychology, pp. 124-129. The Ohio State University, Columbus, Ohio, USA.
Helmreich, R., Klinect, J. and Wilhelm, J. (1999).飞行操作中的事件、错误和反应模型。In Jensen, R. S. (ed.) Proceedings of the Tenth International Symposium on Aviation Psychology, pp.美国俄亥俄州哥伦布市俄亥俄州立大学。
Helmreich, R., Klinect, J. and Wilhelm, J. (2003). Managing threat and error: Data from line operations. In Edkins, G. and Pfister, P. (eds) Innovation and consolidation in aviation. Ashgate Publishing, Aldershot, England.
Helmreich, R., Klinect, J. and Wilhelm, J. (2003).管理威胁和错误:来自航线运营的数据。In Edkins, G. and Pfister, P. (eds) Innovation and consolidation in aviation.Ashgate Publishing, Aldershot, England.
International Civil Aviation Organization (ICAO) (2006). Proceedings of the Fourth ICAO-IATA LOSA and TEM Conference. Toulouse, France, 16-17 November 2006.
国际民用航空组织(ICAO)(2006 年)。第四届国际民航组织-空运协会 LOSA 和 TEM 会议记录。法国图卢兹,2006 年 11 月 16-17 日。
Merritt, A. and Klinect, J. (2006). Defensive Flying for Pilots: An Introduction to Threat and Error Management. The University of Texas Human Factors Research Project, The LOSA Collaborative. See: https://www.skybrary.aero/bookshelf/ books/1982.pdf
Merritt, A. and Klinect, J. (2006).飞行员的防御性飞行:威胁和错误管理简介》。德克萨斯大学人为因素研究项目,LOSA 合作项目。参见:https://www.skybrary.aero/bookshelf/ books/1982.pdf
Skybrary (2017). Threat and Error Management (TEM) in Flight Operations. See: https://www. skybrary.aero/index.php/TEM_in_Flight_Operations
天空图书馆(2017 年)。飞行操作中的威胁和错误管理(TEM)。参见:https://www. skybrary.aero/index.php/TEM_in_Flight_Operations


error Flight crew actions or inactions that lead to a deviation from crew or organisational intentions or expectations, reduce safety margins or increase the probability of adverse operational events on the ground and during flight.
错误 飞行机组的行为或不行为导致偏离机组或组织的意图或预期,降低安全系数或增加地面和飞行期间发生不利运行事件的概率。
human factors (HF) Optimising the relationship within systems between people, activities and equipment.
人为因素(HF) 优化系统内人、活动和设备之间的关系。
non-technical skills (NTS) Specific human factors competencies, such as look out, situational awareness, decision making, task management and communication.
非技术技能 (NTS) 具体的人为因素能力,如观察力、情景意识、决策制定、任务管理和沟通。
threat Events which occur beyond the influence of the flight crew, increase operational complexity and which must be managed to maintain the margin of safety.
威胁 事件的发生超出了机组人员的影响范围,增加了运行的复杂性,必须加以管理以保持安全系数。

threat and error management (TEM)

The process of detecting and responding to threats and errors to ensure that the ensuing outcome is inconsequential, i.e. the outcome is not an error, further error or undesired state.
undesired aircraft state (UAS) Pilot induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration, associated with a reduced margin of safety.

References 参考资料

1 Maurino, D. (2005). Threat and Error Management (TEM). Canadian Aviation Safety Seminar (CASS). Vancouver, Canada, 18-20 April 2005. See: https://mww.skybrary.aero/bookshelf/ books/515.pdf
1 Maurino, D. (2005)。威胁与错误管理(TEM)。加拿大航空安全研讨会(CASS)。加拿大温哥华,2005 年 4 月 18-20 日。参见:https://mww.skybrary.aero/bookshelf/ books/515.pdf
2 Tait, B. (2009) Human Performance and Limitations. See https:// www.bobtait.com.au/files/pdf/errata/HPL_TEM_2010.06.10.pdf
2 Tait, B. (2009)《人的表现与局限》。见 https:// www.bobtait.com.au/files/pdf/errata/HPL_TEM_2010.06.10.pdf
3 Civil Aviation Safety Authority (CASA) (2008). Teaching and assessing single-pilot human factors and threat and error management (CAAP 5.59-1). Canberra, Australia.
3 民航安全局(CASA)(2008 年)。教学和评估单人驾驶的人为因素以及威胁和错误管理(CAAP 5.59-1)。澳大利亚堪培拉。
4 Civil Aviation Safety Authority (CASA) (2017). Advisory Circular (AC) 61-08 Teaching and assessing non-technical skills for single-pilot operations. See: https://www.casa.gov.au/files/ ac6108pdf
4 Civil Aviation Safety Authority (CASA) (2017)。Advisory Circular (AC) 61-08 Teaching and assessing non-technical skills for single-pilot operations.参见:https://www.casa.gov.au/files/ ac6108pdf
5 Mitchell, P. (2013). Safer Care Human Factors for Healthcare: Trainer's Manual. Swan and Horn, UK. See: http://patientsafety. health.org.uk/sites/default/files/human_factors_in_healthcare_ trainer_manual_en_march_2013.pdf
5 Mitchell, P.(2013)。更安全的护理:医疗保健中的人为因素》:培训师手册》。Swan and Horn,英国。参见:http://patientsafety. health.org.uk/sites/default/files/human_factors_in_healthcare_ trainer_manual_en_march_2013.pdf