Threat and error management : an analysis of reported safety occurences to the Civil Aviation Authority of New Zealand 1998-2007 : a thesis presented in partial fulfilment of the requirements for the degree of Master of Aviation at Massey University, Palmerston North, New Zealand
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Date
2010
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Massey University
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Abstract
Current safety reports indicate a rise in the number of reported incidents involving both medium and small aeroplanes and helicopters. The purpose of this study is to identify specific threats, errors and Undesirable Aircraft States (UAS), present in safety-related occurrences reported to the Civil Aviation Authority of New Zealand (CAANZ).
Threat and Error Management (TEM) is used to improve safety margins in aviation operations through the practical integration of human factors knowledge. The TEM framework is used to guide the investigation of reported safety-related occurrences in a way that systematically identifies specific threats, errors and UAS.
This research employs the predictive safety method by investigating reported historical events, followed by analysing each event to list threats, errors and UAS. If a threat, error or UAS is identified in an occurrence, it is then marked ‘present’ under the corresponding column of the TEM taxonomic. After the completion of the classifications, solutions can be developed to prevent similar occurrences in the future.
To test for accuracy and consistency of threat, error and UAS classifications, ten randomly chosen occurrences were provided to ten aviation professionals. These tests included Cohen’s Kappa test and a percentage of agreement test. Cohen’s Kappa results reached significant agreement with half of the respondents and an overall percentage of agreement of 68 per cent compared with the researcher’s classifications.
Results from the TEM classifications show the majority of threats had environmental influences and procedural errors. The most common UAS resulted mainly from Ground Navigation and Aircraft Handling operational conditions.
The TEM technique enabled a focus on the events that contributed to an incident rather than an accident. By applying the results from this TEM taxonomic, it is hoped that pilots will benefit from a better understanding of the importance of TEM and how frequently threat and errors contribute to incidents. This research would then help flight operators and pilots better prepare themselves to react to the likelihood of specific threats or errors, if and when they occur.
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Error management, Near misses (Aeronautics), Safety measures, Aviation psychology, New Zealand