Flight threat and error management

Threat is an external situation that cockpit crew must deal with in daily flight. The following is what I share with you about flight threats and error management. Welcome to read and browse.

I. Overview of threats and errors

threaten

Threat is an external situation that cockpit crew must deal with in daily flight. This situation increases the complexity of flight operation and poses a threat to flight safety to some extent. Threats are predictable (such as judging the weather ahead from the shape of clouds), so the crew can inform them in advance; Threats may also be unexpected (such as bumps in the clear sky), because things happen suddenly without warning. External threats are big or small.

Errors made by non-cockpit personnel are considered as external threats. For example, if the cockpit personnel find that the command issued by the ground commander is wrong, it will be recorded as an external threat, not an error, and the crew is not the source of the error (although they must deal with it, just as they will deal with any external threat). Examples of non-cockpit personnel's mistakes being recorded as external errors include: the error of the commander's release instruction found by the crew, the error of the ground personnel refueling, and the error that the aircraft equipment status is inconsistent with the aircraft record book.

mistake

Cockpit crew error is defined as the deviation from the intention or expectation of the organization or crew caused by the behavior or negligence of the crew. Errors in flight often reduce the safety factor and increase the probability of accidents or accident symptoms. Errors can be defined as non-compliance with regulations, standard operating procedures and policies, and deviation from the expectations of crew members, flight departments or flight controllers. So the error may be small (the air pressure value was picked up, but it was quickly corrected) or large (I forgot to make an important checklist).

We regard standard operating procedures and checklists as the standard for correct and safe flight. If flight inspectors observe deviations from standard operating procedures or checklists, they will define such deviations as errors. If a pilot doesn't know how to execute a program correctly, or can't control the plane in the expected way, the flight inspector will also think it is a mistake.

Deviation from the commander's expectations is also defined as crew error. However, sometimes the crew members deviate from the commander's intention (for example, when landing on the ground, they deliberately fly the three sides a little longer, leaving more redundancy for the adjustment of the five sides), which does not increase the danger and will not be considered as a mistake. However, if the crew violates the operation regulations or the commander's intention and unnecessarily increases the flight risk, it will be considered as a mistake. In training flight, many standard operating procedures do not define decision points, but as long as the decisions made by the crew unnecessarily increase the flight risks, they will be defined as crew errors.

Errors in this unit may not have any consequences. In addition, mistakes may be intentional or unintentional. By definition, if the action of the unit is appropriate or specified in the standard operating procedure, the omission will also be defined as an error.

According to the types of errors, we can divide the errors in this unit into five categories:

& lt 1 & gt； Deliberately deviate from regulations or flight procedures (for example, deliberately deviate from the route).

& lt2> Procedural error, deviation in implementing regulations or flight procedures, correct intention, but defective implementation (such as wrong flap angle). This kind of mistake also includes the mistake that the crew forgot to do something.

& lt3> communication error. There are communication errors, interpretation errors or failure to communicate relevant information between crew members or with external institutions.

& lt4> proficiency error. Knowledge or mental movement (stick rudder technology) skills defects.

& lt5> operation decision error. Unnecessary crisis safety errors that are not standardized in conditions or carrier procedures. To be classified as an operational decision error, there must be at least one of the following three situations:

(1) Company had a more reasonable and conservative choice in operation, but decided not to adopt it;

(2) The decision was not expressed, so it was not shared among the crew;

(3) The unit should have time, but this time has not been effectively used to evaluate the decisions made.

Three possible responses of units to errors:

& lt 1 & gt； Stop: the flight crew responded positively, and the error was detected and controlled within the scope of irrelevant consequences.

& lt2> Aggravation: The flight crew's response is to find out the error, but the crew's actions or omissions lead to new errors, unexpected aircraft state, accident symptoms or accidents.

& lt3> No response: The unit did not respond to this error because it was either ignored or not found.

The error consequence depends on the response of the unit, and three kinds of error consequences may be induced according to the response of the unit.

& lt 1 & gt； It doesn't matter: this is a result, and the danger caused by mistakes has been reduced.

& lt2> Unexpected aircraft state: This is the result that the aircraft is unnecessarily in danger, thus increasing the safety risk.

& lt3> Add Error: This is caused by or closely related to the previous error.

When the crew puts the aircraft in unnecessary danger, it will produce unexpected aircraft conditions, such as the deviation of altitude or track, which constitutes unnecessary danger. The crew's behavior or negligence (error) may lead to unexpected aircraft conditions.

If there is an unexpected plane situation, there will always be crew mistakes that cause this unexpected situation. This kind of mistake may be communication error, inexperience, low decision-making level or intentional violation. The unexpected state of the plane may also be due to equipment failure and the wrong command of the commander. These have nothing to do with unit error and are regarded as external events.

Three possible flight crew responses to unexpected aircraft conditions;

& lt 1 & gt； Relieve the crew from actively responding to the unexpected aircraft state, thereby reducing the danger and returning the aircraft from the unexpected aircraft state to the safe flight state.

& lt2> intensified. The crew's response is to find out the unexpected aircraft state, but the crew's behavior or omission leads to the state inducing new errors, accidents or accident symptoms.

& lt3> did not respond. The flight crew did not respond positively to the unexpected aircraft state, because the state was either ignored or not found.

Three possible consequences of an unexpected aircraft condition;

& lt 1 & gt； Recover. This is the result of indicating that the danger previously caused by unexpected aircraft conditions has been alleviated.

& lt2> Final status/accident symptoms/accident. End any unexpected end of the activity sequence with a final negative result.

& lt3> error added. The action or omission of the flight crew leads to another error of the cockpit crew or an error closely related to it.

Importance of threat and error management in flight

In the aviation system, threats can lead to mistakes. What if there is no right? Threats? Effective management will lead to mistakes; If the error is not managed in time and effectively, it will continue to expand as time goes by. A simple and unconscious mistake may trigger a chain reaction, leading to unsafe events.

The negative impact of mistakes will lead to new mistakes after the conditions change, which will form a chain reaction and eventually lead to accidents.

According to Heine's law, the chain reaction among accidents, accident symptoms and critical errors can be expressed in proportion, and the ratio of accidents, accident symptoms and critical errors is 1: 29: 300.

Since threats may lead to mistakes and mistakes may lead to accidents, pilots should be able to manage threats and mistakes. In the aviation operation system, standardized error management tools include standard operating procedures, simple commands, checklists, publicity, cross-checking, ground proximity warning systems, etc. , which can effectively manage errors. But once the mistakes go through layers? Obstacles, accident signs or accidents will happen.

The so-called threat and error management in flight is to discuss the threat and error problems in flight through human factors. Therefore, it is the most important task to find out all kinds of methods to prevent accidents through various practices, and then choose the best method for Excellence, and finally achieve the purpose of improving safety standards.

Secondly, SHEL is used to classify threats in flight.

SHEL model: four aspects that must be contacted and influenced in flight.

List threats and mistakes in flight.

Threats: bad weather, terrain, air or ground traffic congestion, aircraft failure, automatic equipment problems or failures, communication problems, go-around, maneuvering flight, take-off interruption, commander's orders, harsh instructions, commander's mistakes, commander's language difficulties, commander's nonstandard terminology, radio congestion, similar call signs, maintenance errors, ground personnel errors and other threats.

Errors: incorrect aircraft configuration flight control, flaps, landing gear, incorrect aircraft configuration fuel booster pump, landing lights, instruments, incorrect aircraft configuration automatic equipment, wrong runway, wrong taxiway, vertical deviation, lateral deviation, too high or too low speed, violent aircraft control, too steep slope, unstable approach, continuous landing, high, drifting, jumping landing, landing deviating too much from the centerline,

SHEL model is used to classify common threats in flight.

Personal hardware:. Aircraft failure (engine and other hardware failure).

Personal software: there is a problem or malfunction of automatic equipment and communication problems.

Human environment: bad weather, terrain, traffic, air or ground congestion.

Everyone: maneuvering flight, interrupted take-off, commander's orders, demand instructions, commander's mistakes, commander's language difficulties, commander's terminology is not standard, radio congestion, similar call signs, maintenance mistakes, and ground personnel's mistakes.

The mistake is the pilot's own mistake, not his own reason.

Third, the management methods of threats and errors in flight

According to the threats and mistakes that often appear in flight training, the following methods of threat and error management in flight training are summarized.

(1) Strive to improve the comprehensive quality of pilots.

& lt 1 & gt； Ideological quality. Make them establish a correct outlook on life, world outlook and values, and develop good professional ethics and professionalism.

& lt2> psychological quality. In the air, especially in the take-off and landing of aircraft, pilots always struggle with deviations, mistakes, difficulties and even dangers. He must be brave, decisive, witty and flexible. Don't be chaotic in times of crisis, don't be surprised in times of crisis? Psychological quality.

& lt3> technical quality. Strengthen the training of pilots on the aircraft simulator, arrange the key, difficult and special training subjects in a planned way according to the characteristics of the aircraft simulator, and be familiar with the specific environment and various factors where special situations occur.

(2) Strengthening the construction of work style. Against everything? Loose? 、? Lazy? 、? Scattered? Phenomenon, put an end to the resulting human error. Thoroughly correct the bad style of unruly, blind and reckless, just trying to save trouble and lacking a sense of responsibility.

(3) Strengthen organization and management. From the perspective of overall and macro control of aviation flight driving safety, when considering human errors, we should change the management mode that is often considered and analyzed from the individual rather than the whole, and more importantly, we should analyze and find out the defects and loopholes from the management system and find out the root causes of the errors.

(4) Strengthen the assessment system. Improve the assessment standards.

(5) Strengthen training guidance. In the process of inspection and guidance, it is important to pay attention to: quality control, find problems and correct them in time; To pass, to help, to be careful with; Solve technical difficulties; Explore the law, replace the surface with points, and sum up experience.

There is no shortcut to flight threat and error management. There is only one way to go, that is, to accept and digest the experiences and lessons of others in a large number and systematically; Thoroughly study, summarize and master the objective laws of aviation flight, carefully analyze the actual situation of the unit, take active and effective measures, and resolutely implement them.

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