Document Type


Publication Date





For an operator, a high level of understanding regarding procedures enables appropriate defenses to be built into a robust Threat and Error Management (TEM) framework. Currently, airline flightdeck crewmember training and reference information is concentrated heavily on what and how procedures are performed, but not on why they must be performed a standard way. This missing component of certainty invites misinterpretation of the standards and induces error. I propose a Crew-Centered TEM (CC/TEM) approach designed to arm flight crewmembers with more depth of procedural understanding than that currently afforded. A recent accident where human error was identified as a probable cause is used as an example of how a CC/TEM approach may have prevented the occurrence. CC/TEM solutions have further application within other safety-critical domains, such as medicine and emergency response.