TEM as an TEM as an Analytical Tool Analytical Tool Bert Ruitenberg Bert Ruitenberg Flight Safety and Human Factors – Flight Safety and Human Factors – ICAO ICAO First ICAO Global Symposium on TEM First ICAO Global Symposium on TEM & NOSS in ATC & NOSS in ATC Luxembourg Luxembourg 9 – 10 November 2005 9 – 10 November 2005
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TEM as an Analytical Tool Bert Ruitenberg Bert Ruitenberg Flight Safety and Human Factors – ICAO First ICAO Global Symposium on TEM & NOSS in ATC Luxembourg.
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TEM as an Analytical ToolTEM as an Analytical Tool
Bert RuitenbergBert RuitenbergFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAO
First ICAO Global Symposium on TEM & NOSS in ATCFirst ICAO Global Symposium on TEM & NOSS in ATCLuxembourgLuxembourg
9 – 10 November 20059 – 10 November 2005
Presentation OverviewPresentation Overview
• The TEM Framework explained• Definitions• Examples
• TEM Case Study• Ueberlingen mid-air collision
• Integrated Threat Analysis• The Added Value of TEM
TEM Terminology for ATCTEM Terminology for ATC Threats: Events or errors that occur
beyond the influence of the air traffic controller, increase operational complexity, and which must be managed to maintain the margins of safety
Errors: Actions or inactions by the air traffic controller that lead to deviations from organisational or controller intentions or expectations
Undesired States: operational conditions where an unintended traffic situation results in a reduction in margins of safety
Threats (TWR)Threats (TWR)
WeatherWeather
MaintenanceMaintenance
AirspaceAirspacerestrictionsrestrictions
VisitorsVisitors
Runway crossingsRunway crossingsComsfailure/Comsfailure/sticking mikesticking mike
Unique to monitoring normal operations Transient in nature – exists for limited
time only "When the traffic is not doing what you
want it to do" An Undesired State is often the first
indication to a controller that an earlier threat or error was not adequately managed
Undesired States - ExamplesUndesired States - Examples
• On the ground:• Aircraft continuing taxiing when/where it should
stop; aircraft stopping when/where it should continue taxiing
• Aircraft entering a taxiway that it shouldn’t use; aircraft not entering a taxiway that it should use
• In the air:• Aircraft not turning when it should; aircraft turning
when it should not; aircraft turning in direction other than planned
• Aircraft climbing/descending to another flight level/altitude than it should; aircraft not climbing or descending to the flight level/altitude where it should
TEM Terminology - ExampleTEM Terminology - Example
RTORTO Night operationsNight operations Proficiency Proficiency and and
proceduralprocedural issues issues
ConclusionConclusion
Controllers, pilots and other aviation professionals have intuitively been familiar with Threats (and Errors, and Undesired States) throughout their careers – the TEM framework provides a structured way to look at them
The TEM framework adds a valuable dimension to the analysis of safety data