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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.
民航安全局负责澳大利亚民航运营商的安全监管，以及在澳大利亚境外注册的飞机的监管。
(cc) BY
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.
除非另有说明，本作品版权归 CASA 所有。本作品采用知识共享署名-4.0 国际许可协议进行许可，但不包括英联邦纹章、CASA 徽标、任何第三方材料、受商标保护的任何材料以及任何图像和/或照片。
Enquiries about this licence and any use of this work can be sent to Corporate Communications at PublicEnquiries@casa.gov.au. Use of any part of this work must include the following attribution: 'Source: Civil Aviation Safety Authority'. Before using any third party material in this work, you must contact the owning party directly to seek permission to use it.
有关本许可和使用本作品的任何问题，请发送电子邮件至企业交流部 PublicEnquiries@casa.gov.au。使用本作品的任何部分必须注明："来源：民航安全局"：来源：民航安全局"。在使用本作品中的任何第三方材料之前，必须直接联系拥有方，以获得使用许可。

The threat and error
威胁和错误

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
人们无法轻易避免
those actions they did not intend
他们无意采取的行动
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.
如果管理不当，这些威胁和错误有可能导致飞机出现意外状态（UAS）。管理不希望出现的飞机状态是避免不安全结果的最后机会，因此也是保持飞行操作安全系数的最后机会。
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
威胁和错误管理

  • Recognise and manage errors
    认识和管理错误
  • Recognise and manage threats
    认识和管理威胁
  • Recognise and manage undesired aircraft states
    识别和管理不希望出现的飞机状态
TEM involves: TEM 涉及
  • planning to identify threats and errors during a flight and implementing countermeasures to eliminate or minimise them
    制定计划以确定飞行中的威胁和失误，并采取对策消除或尽量减少这些威胁和失误
  • directing actions to address threats and errors, using checklists, approved procedures, and other acceptable means, including selfdirection during single-pilot operations
    使用核对表、经批准的程序和其他可接受的手段，包括在单人驾驶操作中的自我指导，指导应对威胁和错误的行动
  • 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
让我们来看看威胁、错误和非预期飞行器状态的核心组成部分

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).
威胁一般是外部的（如恶劣天气）或内部的（如生理和心理状态）。
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.
疲劳等威胁会增加出错的可能性，导致态势感知能力下降和决策失误。飞行员需要具备良好的态势感知能力，以预测、识别和管理可能出现的威胁。
For charter operations, external threats include:
对于包机运营而言，外部威胁包括
  • 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
    早出晚归
  • night operations 夜间行动
  • reduced runway length 跑道长度缩短
  • other traffic, high terrain or obstacles
    其他交通、高地形或障碍物
  • the condition of the aircraft.
    飞机的状况。
    Typical internal threats to charter operations include
    包机运营面临的典型内部威胁包括
  • fatigue 疲劳
  • inexperience 不经验
  • over-or under-confidence
    过于自信
  • isolation 孤立
  • impulsiveness 冲动
  • lack of recency and proficiency
    不及时和不熟练
  • 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
雷暴、湍流、能见度低、风切变、结冰条件、IMC
Aircraft Systems, engines, flight controls, instruments
系统、发动机、飞行控制、仪器
Airport
Poor signage, faint markings, runway/taxiway closures, poor braking action,
标志不清、标记模糊、跑道/机场跑道关闭、制动效果不佳、
contaminated runways/taxiways, condition of runway/taxiway
受污染的跑道/机场跑道，跑道/机场跑道的状况
ATC Tough-to-meet clearances/restrictions, reroutes, controller errors
难以满足的净空/限制、改道、控制器错误
Cabin Cabin events, (flight attendant errors), distractions, interruptions
机舱事件（乘务员失误）、分心、干扰
Dispatch/paperwork 调度/文书工作
Load-sheet errors, crew scheduling events, late paperwork, changes
装载单错误、机组调度事件、文书工作延迟、变更
or errors
Environmental
operational pressure 运行压力
Terrain, traffic, radio congestion
地形、交通、无线电拥塞
Ground maintenance 地面维护 Aircraft repairs on ground, maintenance log problems, maintenance errors
飞机地面维修、维修日志问题、维修错误
Ground/ramp Aircraft loading events, fuelling errors, improper ground support
飞机装载事件、加油错误、地面支持不当
Manuals/charts 手册/图表 Missing information or documentation errors
信息缺失或文件错误
Time pressure 时间压力 Delays, late arriving passengers, cargo or refueller
延误、晚到乘客、货物或加油机

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.
潜在的威胁可能并不明显，可能需要通过正式的安全分析来揭示，并在组织的培训和程序中专门加以解决。

ANTICIPATED 预计

Some threats can be anticipated such as:
有些威胁是可以预见的，例如
  • thunderstorms, icing, wind shear and other forecast bad weather
    雷暴、结冰、风切变和其他恶劣天气预报
  • congested airports and landing areas
    拥挤的机场和着陆区
  • wires and other obstacles
    电线和其他障碍物
  • complex ATC clearances 复杂的空管许可
  • cross and/or downwind approaches and landings
    横向和/或顺风进场和着陆
  • outside air temperature/density altitude extremes
    外部空气温度/密度海拔极端值
  • aircraft mass and balance
    飞机质量和平衡
  • forecast or known bird/wildlife activity.
    预测或已知的鸟类/野生动物活动。

UNANTICIPATED 未分配

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:
这些都是可能在毫无征兆的情况下意外、突然发生的其他威胁。飞行员必须运用通过培训和操作经验获得的技能和知识来处理以下问题：
  • in-flight aircraft malfunctions
    飞行中飞机故障
  • automation—anomalies and over-reliance
    自动化--反常现象和过度依赖
  • unforecast weather, turbulence, icing
    未预报天气、湍流、结冰
  • ATC re-routing, unexpected congestion, non-standard phraseology, navigation aid unserviceability, confusion over similar call-signs
    空管改道、意外拥堵、非标准用语、助航设备无法使用、类似呼号混淆
  • ground handling 地面装卸
  • wires and other obstacles
    电线和其他障碍物
  • unmanned aircraft systems (drones)
    无人驾驶飞机系统（无人机）
  • unforecast bird/wildllife activity
    未预测的鸟类/野生动物活动
  • laser attacks 激光攻击
  • contaminated or sloping landing areas.
    受污染或倾斜的着陆区。

LATENT 后期

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:
有些威胁对飞行员来说可能并不直接明显，飞行员也无法观察到，可能需要通过正式的安全分析才能发现。这些被认为是潜在的威胁，可能包括组织上的弱点以及飞行员的心理和生理状态。这些威胁包括
  • organisational culture 组织文化
  • organisational change 组织变革
  • incorrect or incomplete documentation, such as poor manuals
    不正确或不完整的文件，如简陋的手册
  • equipment design issues such as landing gear and flap levers located too close to each other, or inaccurate fuel gauges
    设备设计问题，如起落架和襟翼杆距离太近，或燃油表不准确
  • operational pressures and delays, such as undue pressure to get a job done
    业务压力和延误，如完成工作的过度压力
  • perceptual illusions such as approaches to sloping runways
    知觉错觉，如接近倾斜的跑道
  • fatigue and rostering 疲劳和名册
  • lack of recent experience and proficiency
    缺乏近期经验和熟练程度
  • stress 强调
  • over-confidence or under-confidence.
    过度自信或信心不足。
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.
随着学习和经验的积累，我们能够更好地预测可能出现威胁的地点。获取和解读天气报告可以让我们为恶劣天气做好准备，而经验则有助于我们了解自己的能力和局限性。
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.
无论威胁是预期的、未预期的还是潜在的，衡量飞行员管理威胁能力的标准是能否及时发现威胁，以避免飞机出现意外状态。

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
    偏离机组或组织的意图或期望
  • reduced safety margins 安全系数降低
  • increased probability of adverse operational events on the ground and during flight.
    增加了在地面和飞行过程中发生不利运行事件的概率。
Adverse operational events can be handling errors, procedural errors or communications errors.
不良操作事件可能是处理错误、程序错误或通信错误。
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.
错误可能是一时注意力转移（失误）的结果，也可能是预期或意料之外的威胁导致记忆失败（失效）的结果。也有更多蓄意的、故意的违规错误。这些错误通常是为了提高操作效率而采取的捷径，但却违反了标准操作程序。
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.
疏忽和失误是指在执行预定行动时出现的失误。失误是指没有按计划进行的行动，而失误则是指记忆失败。例如，拉动混合气而不是化油器加热就是失误。忘记加热化油器则是失误。
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.
错误是行动计划的失败；即使计划执行正确，也不可能实现预期结果。
While errors may be inevitable, we need to identify and manage them before safety margins are compromised. Typical errors in charter operations include:
虽然失误在所难免，但我们需要在安全系数受到影响之前识别和管理这些失误。包机运营中的典型错误包括
  • incorrect performance calculations (mistakes)
    不正确的性能计算（错误）
  • inaccurate flight and fuel planning (slips, lapses)
    飞行和燃料计划不准确（失误、疏忽）
  • non-standard communication (mistakes, violations)
    非标准交流（错误、违规）
  • aircraft mishandling (slips)
    飞机误操作（滑行）
  • incorrect systems operation or management (slips, lapses, mistakes)
    系统操作或管理不正确（失误、疏忽、错误）
  • checklist errors (slips, lapses)
    核对错误（疏忽、失误）
  • failure to meet flight standards, such as poor airspeed control (slips).
    未达到飞行标准，如空速控制不良（滑行）。
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
飞机操作失误 		Examples
Flight control 飞行控制 Incorrect flaps or power settings
襟翼或动力设置不正确
Ground navigation 地面导航
Attempting to turn down wrong taxiway/runway, missed
试图转入错误的滑行道/跑道，错过
taxiway/runway/gate, failure to hold short
滑行道/跑道/门，未保持短距离
Manual flying 手动飞行 Hand flying vertical, lateral, or speed deviations
手动飞行垂直、横向或速度偏差
Systems/radio/instruments
系统/无线电/仪器
Incorrect GPS, altimeter, fuel switch, transponder or radio
GPS、高度计、燃料开关、应答器或无线电不正确
frequency settings 频率设置
Procedural errors 程序错误 Examples
Briefings
Missed items in the brief, omitted departure, take-off,
简报中的遗漏项目，遗漏了出发、起飞、
approach, or handover briefing
或移交简报
Callouts Omitted take-off, descent, or approach callouts
遗漏起飞、下降或进场呼号
Checklist
Performed checklist from memory or omitted checklist,
凭记忆执行核对表或遗漏核对表、
missed items, performed late or at wrong time
遗漏项目、迟到或在错误时间执行
Documentation
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
清关记录，误读文书项目
Other procedural 其他程序
Other deviations from regulations, flight manual
其他偏离规定、飞行手册的情况
requirements or standard operating procedures
要求或标准操作程序
Communication errors 通信错误 Examples
Pilot to external 试点到外部
Missed calls, misinterpretation of instructions, or
漏接电话、误解指示，或
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
已通知登机口或跑道
Pilot to pilot 飞行员对飞行员 Internal crew miscommunication or misinterpretation
船员内部沟通不畅或误解
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.
错误管理的目的是让飞行员发现错误并迅速做出反应，从而使错误在操作上变得无关紧要，并将安全风险降至最低。
A mismanaged error is one which is linked to or induces an additional error or undesired aircraft state.
管理不善的误差是指与额外误差或不希望出现的飞机状态相关联或诱发额外误差的误差。

Undesired aircraft states
飞机意外状态

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.
飞机的非预期状态（UAS）是指飞行员引起的飞机位置或速度偏差、飞行控制的错误应用或与安全裕度降低有关的不正确系统配置。
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.
为了保证飞行安全，我们必须在飞机出现意外状态导致失控或不受控制地飞入地形之前，迅速识别并恢复飞机状态。
Examples of errors and associated undesired aircraft states in charter operations include:
包机运行中的错误和相关的不希望出现的飞机状态包括
  • mismanagement of aircraft systems (error), resulting in aircraft anti-ice not turned on during icing conditions (state)
    飞机系统管理不善（错误），导致飞机在结冰条件下未开启防冰功能（状态）
  • inappropriate scan of aircraft instruments (error), resulting in an unusual aircraft attitude (state)
    不适当地扫描飞机仪器（错误），导致飞机姿态（状态）异常
  • flying a final approach below appropriate threshold speed (error), resulting in excessive deviations from specified performance (state).
    以低于适当临界速度（误差）飞行最终进场，导致与规定性能（状态）偏差过大。
    Table 4 Examples of undesired aircraft states
    表 4 飞机非预期状态示例
Undesired
aircraft state 飞机状态
Examples
Aircraft handling 飞机操作
Vertical, lateral or speed
垂直、横向或速度
deviations
Unnecessary weather 不必要的天气
penetration
Unstable approach 不稳定的方法
Long, floated, firm or
长、浮动、坚固或
off-centreline landings 偏离中心线着陆
Ground
navigation
Runway/taxiway incursions
跑道/行车道入侵
Wrong taxiway, ramp, gate,
走错滑行道、匝道或登机口、
or hold spot
Taxi above speed limit
出租车超速
Incorrect aircraft 不正确的飞机
configuration
Automation, engine, flight
自动化、发动机、飞行
control, systems, or weight/
控制、系统或重量
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:
对策有三种：
  • Planning countermeasures including flight planning, briefing, and contingency planning.
    规划应对措施，包括飞行计划、简报和应急计划。
  • Execution countermeasures including monitoring, cross-checking, workload and systems management.
    执行对策，包括监测、交叉检查、工作量和系统管理。
  • Review countermeasures including evaluating and modifying plans as the flight proceeds, and enquiry and assertiveness to identify and address issues in a timely way.
    审查应对措施，包括在飞行过程中评估和修改计划，以及通过询问和自信及时发现和解决问题。
Once you recognise an undesired aircraft state, you must use the correct countermeasure rather than fixate on the error.
一旦发现飞机出现不希望看到的状态，就必须采取正确的应对措施，而不是纠缠于错误。
So how do we do this in practice?
那么，我们在实践中如何做到这一点呢？
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.
您为每次飞行所做的准备工作，包括解释航行通告和气象信息以及检查燃油，都应考虑到哪些行动、条件或事件可能会导致错误和潜在威胁，以及适当的应对措施。例如，如果出现无法预测的天气变化，您建议采取什么行动。
Identifying threats can reduce your in-flight workload, as you have already prepared yourself to deal with them.
识别威胁可以减少飞行中的工作量，因为您已经做好了应对这些威胁的准备。
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).
在起飞和开始任何重要的飞行程序（如飞往不熟悉的机场）之前，飞行简报（自我简报、机组人员和乘客）应包括计划程序、预期威胁和应对措施。
During flight you should:
在飞行过程中，您应该
  • continuously monitor and cross-check visual and instrument indications and aircraft energy state to maintain situational awareness
    持续监控和交叉检查目视和仪表指示以及飞机能量状态，以保持对态势的了解
  • prioritise tasks and manage workload to avoid being overloaded, and to maintain situational awareness
    确定任务的轻重缓急，管理工作量，避免超负荷工作，并保持对情况的了解
  • identify and manage threats and errors
    识别和管理威胁和错误
  • 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
    当遇到威胁和/或错误时，对飞机进行配置，使其尽可能容易地保持控制，包括设置正确的飞行路线
  • monitor the progress of every sequence and abort if necessary
    监控每个序列的进度，并在必要时中止
  • not fixate on threat or error management to the detriment of aircraft control
    不专注于威胁或误差管理，以免影响飞机控制
  • identify and manage any undesired aircraft state
    识别和管理任何不希望出现的飞机状态
  • return to planned flight and normal safety margins before dealing with other problems.
    在处理其他问题之前，先恢复计划飞行和正常的安全系数。
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:
环境威胁超出了飞机运营商的控制范围；飞行员必须在可用时间内处理这些威胁。包机运营中环境威胁的例子包括
  • weather, such as turbulence, ice, wind, fog, storms, driving rain
    天气，如湍流、冰、风、雾、风暴、暴雨
  • aerodrome conditions, such as congestion, complex surface navigation, poor signage/ markings, and unprepared landing strips
    机场条件，如拥堵、复杂的地面导航、标志/标记不清和未准备好的着陆场
  • air traffic control issues, such as non-standard phraseology and complex clearances
    空中交通管制问题，例如非标准用语和复杂的许可问题
  • terrain, such as mountains, valleys and built-up areas.
    地形，如山脉、山谷和建筑密集区。
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.
组织威胁往往是潜在的，运营者可以通过安全管理系统、疲劳风险管理系统、标准操作程序、检查单、地勤支持和运营健康与安全程序加以控制或减少。然而，作为飞行员，你往往是最后一道防线。
Examples of organisational threats in charter operations include:
包机运营中组织威胁的例子包括
  • pressures such as tight turn-around times
    周转时间紧迫等压力
  • poor aircraft serviceability
    飞机适用性差
  • maintenance errors 维护错误
  • incorrect documentation such as incorrect or expired charts, an incomplete or erroneous maintenance release, or inaccurate fuel logs.
    不正确的文件，如不正确或过期的图表、不完整或错误的维护记录或不准确的燃料记录。

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.
通过承认错误的发生，我们将重点从错误预防转向错误识别和管理。由于未管理或管理不善的错误可能会导致不希望出现的飞机状态，因此我们需要时刻保持警惕，及早发现并纠正错误。
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.
    飞行员在结束了一天的长途飞行后回到家中，感觉疲惫不堪，难以保持精力充沛。
  • 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.
    当时有很大的横风，他担心自己的横风技术不过关。他已经很久没有练习过侧风着陆了。

Errors 错误

  • The pilot was interrupted during his descent checklist and did not complete it.
    飞行员在进行下降检查时被打断，没有完成检查。
  • He was surprised by the late runway change and did not complete his descent or before-landing checklists.
    他对跑道晚换感到惊讶，没有完成下降或着陆前检查单。
  • He was having difficulty making the crosswind correction for the pattern on the second runway.
    他在为第二跑道上的模式进行横风修正时遇到了困难。

Error management 错误管理

  • The pilot did not attempt to complete the descent checklist.
    飞行员没有尝试完成下降检查单。
  • He did not attempt to complete the beforelanding checklist.
    他没有尝试填写着陆前检查清单。
  • He was barely managing the errors he was making correcting for the crosswind.
    他在纠正横风时几乎无法控制自己的失误。

Undesired states 不希望出现的状态

  • The aircraft engine was running hot because the descent checklist wasn't completed.
    由于没有完成下降检查单，飞机发动机正在发热。
  • The gear wasn't down because the beforelanding checklist wasn't completed.
    装备没有放下是因为着陆前检查表没有完成。
  • The flaps were not configured for landing.
    襟翼没有为着陆而配置。
  • The aircraft wasn't lined up with the runway.
    飞机没有对准跑道。
  • Undesired state management nil.
    非预期状态管理为零。

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.
    由于这一事件序列，飞机以机腹着陆，需要更换新发动机和新螺旋桨。修复机腹需要大量的机械工作。幸运的是，飞行员和乘客都没有受伤。
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.
那么，如何防止错误成倍增加，使飞机处于不受欢迎的状态呢？在这种情况下，绕飞可以提供时间，让我们把所有事情都集中起来，理清头绪。
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.
考虑一下您如何能够预见到这一天的威胁和失误，并对自己进行简要介绍，以及您可以采取哪些应对措施来控制局面，避免出现您无法控制的意外飞机状态。

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.
这样的计划应能回答以下有关运营商飞行员的问题。
  • Do they recognise, assess and manage potential threats?
    他们是否认识、评估和管理潜在威胁？
  • Do they diligently follow standard operating procedures and show evidence of situational awareness to avoid and trap errors?
    他们是否严格遵守标准操作程序，是否有证据表明他们具有情景意识，能够避免和避免错误？
  • Do they apply strategies to manage and mitigate the effects of any errors?
    他们是否采用策略来管理和减轻任何错误的影响？
  • Do they manage any undesired aircraft state and return to normal operations successfully?
    它们是否能管理任何不希望出现的飞机状态并成功恢复正常运行？
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:
在评估飞行中，合格的飞行员不太可能会进入不希望的飞机状态，或者即使出现这种情况也无法纠正。因此，可能有必要设置一个理论情况。例如
  • create a scenario that will be analysed during the pre-flight briefing
    创建一个情景，并在飞行前简报中进行分析
  • when approaching a destination airport, simulate a thunderstorm over the airfield
    在接近目的地机场时，在机场上空模拟雷雨天气
  • simulate a radio failure approaching a reporting point or entering a control zone
    模拟无线电故障接近报告点或进入控制区
  • simulate a precautionary or forced landing
    模拟预防性着陆或迫降
  • simulate an instrument or display failure.
    模拟仪器或显示屏故障。
The following list of competencies may be useful as a starting point for an assessment program:
以下能力清单可作为评估计划的起点：

Maintains effective lookout
保持有效瞭望

  • Maintains lookout and traffic separation using a systematic scan technique determined by traffic density, visibility and terrain.
    使用根据交通密度、能见度和地形确定的系统扫描技术，保持瞭望和交通隔离。
  • Maintains radio listening watch and interprets transmissions to determine traffic location and intentions of traffic.
    保持无线电监听并解读信号，以确定交通位置和交通意图。
  • Performs airspace-cleared procedure before commencing any manoeuvres.
    在开始任何操作前执行空域清理程序。

Maintains situational awareness
保持态势感知

  • Monitors all aircraft systems using a systematic scan technique.
    使用系统扫描技术监控所有飞机系统。
  • Collects information to facilitate ongoing system management.
    收集信息，促进系统的持续管理。
  • Monitors flight environment for deviations from planned operations.
    监控飞行环境，以防偏离计划运行。
  • Collects flight environment information to update planned operations.
    收集飞行环境信息，更新计划运行。

Assesses situations and make decisions
评估情况并做出决定

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

Assesses solutions and risks
评估解决方案和风险

  • Decides on a course of action.
    决定行动方案。
  • Communicates plans of action (if appropriate).
    传达行动计划（如适用）。
  • Allocates tasks for action (if appropriate).
    分配任务，以便采取行动（如有必要）。
  • Takes actions to achieve optimum outcomes for the operation.
    采取行动，为业务取得最佳成果。
  • Monitors progress against plan.
    对照计划监测进展情况。
  • Re-evaluates plan to achieve optimum outcomes.
    重新评估计划，以取得最佳成果。

Sets priorities and manages tasks
确定优先事项并管理任务

  • Organises workload and priorities to ensure completion of all tasks relevant to the safety of the flight.
    安排工作量和优先次序，确保完成与飞行安全有关的所有任务。
  • Puts the safe and effective operation of the aircraft ahead of competing priorities and demands.
    将飞机的安全和有效运行放在优先事项和需求之前。
  • Plans events and tasks to occur sequentially.
    计划按顺序发生的事件和任务。
  • Anticipates critical events and tasks to ensure completion.
    预测关键事件和任务，确保完成。
  • Uses technology to reduce workload and improve cognitive and manipulative activities.
    利用技术减少工作量，改善认知和操作活动。
  • Avoids fixation on single actions, tasks or functions.
    避免专注于单一行动、任务或功能。

Maintains effective communications and interpersonal relationships
保持有效的沟通和人际关系

  • Establishes and maintains effective and efficient communications and interpersonal relationships with all stakeholders to ensure the safe outcome of the flight.
    与所有利益相关者建立并保持有效、高效的沟通和人际关系，确保飞行安全。
  • Defines and explains objectives to applicable or involved parties.
    确定目标并向适用方或相关方解释。
  • Demonstrates a level of assertiveness that ensures the safe completion of the flight.
    表现出一定程度的自信，确保安全完成飞行。
  • Encourages passengers to participate in and contribute to the safe outcome of the flight.
    鼓励乘客参与并促进飞行安全。

Recognises and manages threats
认识并管理威胁

  • Identifies relevant environmental or operational threats that are likely to affect the safety of the flight.
    确定可能影响飞行安全的相关环境或运行威胁。
  • Develops and implements countermeasures to manage threats.
    制定并实施管理威胁的对策。
  • Monitors and assesses flight progress to ensure a safe outcome.
    监控和评估飞行进度，确保安全结果。
  • Modifies actions when a safe outcome is not assured.
    在无法确保安全结果时，修改行动。

Recognises and manages errors
认识并管理错误

  • 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.
    应用核对表和标准操作程序，防止飞机操作、程序或通信错误，并在安全受到影响或飞机进入不希望的状态之前找出已犯的错误。
  • Monitors aircraft systems, flight environment and crewmembers, collects and analyses information to identify potential or actual errors.
    监控飞机系统、飞行环境和机组人员，收集和分析信息以发现潜在或实际错误。
  • Implements countermeasures to prevent errors, or acts in the time available to correct errors before the aircraft enters an undesired state.
    采取应对措施防止出错，或在飞机进入不希望出现的状态之前及时纠正错误。

Recognises and manages UAS
识别和管理无人机系统

  • 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.
    操纵飞机控制装置或系统，或修改行动或程序，以保持对飞机的控制，并在可用时间内恢复正常飞行操作。

Key points for professional pilots
专业飞行员要点

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.
制定战略或对策（如计划、审查或修改计划）的飞行员往往会减少处理不当的威胁，减少失误，减少飞机的意外状态。

Key points for charter operators
包机运营商的要点

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

FURTHER READING 更多阅读

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

KEY TERMS 关键术语

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)
威胁和错误管理（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.
检测和应对威胁和错误的过程，以确保随之而来的结果是无关紧要的，即结果不是错误、进一步的错误或不希望出现的状态。
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.
飞行员引起的飞机位置或速度偏差、飞行控制误操作或系统配置错误，导致安全系数降低。

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