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Old 07-03-2008, 10:41 AM   #1
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Threat and error management

Continental Airlines(the company I work for) and NASA and Univ. of Texas Human Factors got together to develop a strategy for dealing with threats and errors.* It is called "Threat and Error Management"...TEM.* This is the evolution of Cockpit Resource Management(CRM).* It was such a landmark study/"discovery" that it is used worldwide in airlines as well as other industries(Healthcare,etc.).* It is an 82 page PDF file.* Some of it may seem technical and some of it seems quite simple.* But I do think there is some benefit to it as it relates to the operation of your boat and it would obviously benefit a professional marine application.

Back in the day, the pilots were told by the company and the FAA..."don't screw up!!!".* That philosophy brought us into the 70s but we finally admitted that we are human, and humans make mistakes.* Why don't we examine the threats that cause these errors and if the error has already occurred, hoe to keep it from causing undesired consequences.* Managing threats is manageing your future....realizing the threats to your operation and manage them in such a way as they do not become errors.* Managing errors is managing your past....an error is something that has already happened but manage it so it doesn't hurt you.

Anyway, I have always wanted to share this with the boating community and have just never got around to it.* You will have to take the aviation terms and equipment references and "translate" them into trawler terms and equipment.

3 things that have had an incredible impact on safety in aviation:

Line Operational Safety Audit(LOSA).* This is where an observant rides along in the jumpseat and unjudgingly observes the crew.

Flight Operations Quality Assurance(FOQA).* This is the downloading of flight data recorders to see developing trends as they relate to certain airports and/or operations.

Aviation Safety Action Program(ASAP)...this is the voluntary admittance of flight crews of their mistakes to flight ops.* As long as these mistakes fall into certain parameters(ie not intentional, no accident, etc) then no punitive action is taken against the pilot(he becomnes immune to any action so that is his motivation in reporting the incident)

These 3 things you will see in the presentation on the link.* They provide extremely valuable data to use in developing strategies to mitigate certain threats in the future.

Link to model:

http://www.flighttestsafety.org/work...management.pdf

The first 20 pages may not be all that applicable or interesting as they just give the history of CRM and the history of CRM at Continental.* But when you start getting into the model and what it represents, then that is where there is useful information as it relates to the operation of your boat.* They do talk about risk and "time compression" but not really enough.* The coffee filter shape of the model is to represent time compression....meaning things do not stop happening just because they are going badly...they will continue to happen and there will be consequences if not managed properly.

I hope this is not beyond the scope here and I hope y'all get something out of it!!!

-- Edited by Baker at 11:53, 2008-07-03
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Old 07-04-2008, 04:39 AM   #2
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RE: Threat and error management

"Back in the day, the pilots were told by the company and the FAA..."don't screw up!!!". That philosophy brought us into the 70s but we finally admitted that we are human, and humans make mistakes. "

Having been on the receiving side of CRM , most folks thought it was a needed reaction to the mistake of hiring single seat pilots.

At least 2 UAL crashes were traced to the fighter pilot mentality (I don't need anyone on the cockpit , neither co-pilot or then a flight engineer, I make ALL the decisions and need no input from anyone).

The company loved heavy multiengine with at least 2000 hours TT and 1000 in command.

When that well ran dry they hired military rotor heads (the co would teach them to fly fixed wing)who at least had worked with a crew.

Bottom of the bucket was the usually un-trainable single seat jocks.

But expansion was expansion so some got hired.

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Old 07-04-2008, 09:39 AM   #3
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RE: Threat and error management

How does this apply to boats???

Threats:

Weather...current...traffic...restricted channel/water depth(terrain)...a known problem with the boat(broken radar, etc)...darkness....fatigue...poor health of the helmsman(ie poor eyesight or night vision, etc.) The list could go on and on.

Every single one of these is a threat and every single one of these should be considered. You should definitely develop strategies to cope with them and mitigate their risk. If the risk is acceptable to you, then you continue on. If it is not, then you figure a different strategy or don't continue.

Okay so now you are coming to a bend in the channel. There is a barge with about 3 long and double wide(damn near 1000ft long). Coming around the bend as well. You don't call to coordinate with him which is your first error. You keep to the "right side of the road" and he is trying to stay to his side. The one thing you didn't realize(another error) is that you are down wind of him and the wind is a solid 15 with may higher gusts. You realize he is getting out of shape. You are running out of water on the downwind side of him. You see seagulls 20 feet away in ankle deep water!!! What are you gonna do??? Luckily the pilot of the tow manages his load and gets out of the pickle and you scoot around the back of him with about 5ft of water under you.

The debrief portion(LOSA,FOQA,ASAP) of this is to brief how you screwed up. The first thing would have been to have called the tow captain. There are many people who just don't think the tow captains want to talk to us....that is a very false assumption. They will rarely tell you how to run your boat but they will suggest very strongly what they would recommend. I guarantee you in this case he would have told what he was doing and most likely would have preferred you to pass on the upwind side(2 whistle...starboard to starboard) because he was well aware of the threat that the wind and the bend in the channel posed to his operation. With experiences like this you will now realize that steering a 1000ft long load is not a science...but an art and you will respect that next time.

What would you have done had he not regained control???
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Old 07-05-2008, 03:52 AM   #4
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RE: Threat and error management

The modern lock will hold a barge pack 3 barges wide and 5 barges long.

Where we mostly travel Long Island Sound , the fun is the tugs tow barges on 500 ft trail.

Eats a few sailboats & marine motorists every foggy summer, again communication would help.

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Old 07-11-2008, 09:49 PM   #5
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RE: Threat and error management

Baker,
After a few GIWW trips I have also learned to read the barges- empty or loaded. Loaded is low in the water, lots of weight- and very little windage. Empty barges carry the threat of swinging a lot more than you would think. It pays to know on your chart which way the channel turns and what the direction of the wind is during your error management.
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Old 07-11-2008, 09:56 PM   #6
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RE: Threat and error management

I agree. "Empties" are much harder for the tow captains to manage. I have seen them doing 360s at Rollover Pass because they would lose control. I have also seen them at Red Can Bend near Tiki Island run aground simply because they could not keep it in the channel.
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Old 07-14-2008, 09:39 AM   #7
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RE: Threat and error management

Many thanks for an excellent thread.
I spent many years in underground mining and, until we could admit that we could learn something from every failure we just kept repeating, and attending funerals.
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Old 07-15-2008, 02:52 AM   #8
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RE: Threat and error management

The study of errors and ways to avoid them and apply solutions is possible in a corporate environment like an airline, and can certainly be done in a similar way by a shipping company.
However to find a way to apply the same principles in a hobby/ pleasure / individual / personal situation would be rather daunting.

It would be like trying to lift driving standars on the road.
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Old 07-15-2008, 08:31 AM   #9
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RE: Threat and error management

Quote:
Marc1 wrote:

The study of errors and ways to avoid them and apply solutions is possible in a corporate environment like an airline, and can certainly be done in a similar way by a shipping company.
However to find a way to apply the same principles in a hobby/ pleasure / individual / personal situation would be rather daunting.

It would be like trying to lift driving standars on the road.
I disagree and don't follow your logic.* The main message here is to identify the threats and try to* manage them in such a way so they don't become errors.* And to also realize your errors and make sure you manage them in such a way so they don't produce harmful consequences.

Do you realize that your chartplotter/nav computer*can be a threat?
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Old 07-16-2008, 03:58 AM   #10
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RE: Threat and error management

Prior Planning Precludes Piss Poor Performance.

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