Flight crews still remain the last line of defence, but there are earlier opportunities for these threats to be mitigated by aviation organisations themselves. Organisational threats are usually latent in nature. Organisational threats, on the other hand, can be controlled (i.e., removed or, at least, minimised) at source by aviation organisations. Some environmental threats can be planned for and some will arise spontaneously, but they all have to be managed by flight crews in real time. Environmental threats occur due to the environment in which flight operations take place. Table 1 presents examples of threats, grouped under two basic categories derived from the TEM model. As threat managers, flight crews are the last line of defense to keep threats from impacting flight operations. Threat management provides the most proactive option to maintain margins of safety in flight operations, by voiding safety-compromising situations at their roots. Although the threat-error linkage is not necessarily straightforward, although it may not be always possible to establish a linear relationship, or one-to-one mapping between threats, errors and undesired states, archival data demonstrates that mismanaged threats are normally linked to flight crew errors, which in turn are oftentimes linked to undesired aircraft states. Threat management is a building block to error management and undesired aircraft state management. Regardless of whether threats are expected, unexpected, or latent, one measure of the effectiveness of a flight crew’s ability to manage threats is whether threats are detected with the necessary anticipation to enable the flight crew to respond to them through deployment of appropriate countermeasures. Examples of latent threats include equipment design issues, optical illusions, or shortened turn-around schedules. Lastly, some threats may not be directly obvious to, or observable by, flight crews immersed in the operational context, and may need to be uncovered by safety analysis. In this case, flight crews must apply skills and knowledge acquired through training and operational experience. Some threats can occur unexpectedly, such as an in-flight aircraft malfunction that happens suddenly and without warning. For example, flight crews can anticipate the consequences of a thunderstorm by briefing their response in advance, or prepare for a congested airport by making sure they keep a watchful eye for other aircraft as they execute the approach. Some threats can be anticipated, since they are expected or known to the flight crew. The TEM model considers these complexities as threats because they all have the potential to negatively affect flight operations by reducing margins of safety. Such complexities would include, for example, dealing with adverse meteorological conditions, airports surrounded by high mountains, congested airspace, aircraft malfunctions, errors committed by other people outside of the cockpit, such as air traffic controllers, flight attendants or maintenance workers, and so forth. During typical flight operations, flight crews have to manage various contextual complexities. Threats are defined as “events or errors that occur beyond the influence of the flight crew, increase operational complexity, and which must be managed to maintain the margins of safety”. Undesired aircraft state management largely represents the last opportunity to avoid an unsafe outcome and thus maintain safety margins in flight operations. Undesired state management is an essential component of the TEM model, as important as threat and error management. Flight crews must also manage undesired aircraft states, since they carry the potential for unsafe outcomes. The model proposes that threats and errors are part of everyday aviation operations that must be managed by flight crews, since both threats and errors carry the potential to generate undesired aircraft states. There are three basic components in the Threat and Error Management (TEM) model, from the perspective of flight crews: threats, errors and undesired aircraft states (UAS).
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