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An aircraft departs from a major airport. According to the pre-flight brief, the Commander flies the departure procedure and the Co-Pilot monitors speed, level, and communications. After departure, due to the distraction caused by ATC transmissions, the Co-Pilot retracts the flaps without noticing that the speed is below that required for flap retraction. While responding to the subsequent speed warning, the Commander allows the aircraft to climb above its cleared altitude. What are the error types illustrated in this scenario?

1. Communication error: Co-Pilot fails to inform the Commander of the speed before retracting the flaps
2. Communication error: Co-Pilot fails to tell the Commander about the altitude deviation
3. Handling error: Commander fails to control the speed and fails to control the rate of climb
4. Procedural error: Co-Pilot fails to monitor the speed and altitude
5. Procedural error: Commander fails to achieve the correct flap retraction speed
6. Procedural error: Commander and Co-Pilot fail to level the aircraft at the cleared altitude

  • A

    1, 2, 3, and 5.

  • B
    1, 4 and 5.
  • C

    2, 5, and 6.

  • D
    3 and 4.

The Threat and Error Management (TEM) model is a conceptual framework that assists in understanding, from an operational perspective, the inter-relationship between safety and human performance in dynamic and challenging operational contexts.

The TEM model classifies errors based upon the primary interaction of the pilot or flight crew at the moment the error is committed. Thus, in order to be classified as aircraft handling error, the pilot or flight crew must be interacting with the aircraft (e.g. through its controls, automation or systems). In order to be classified as procedural error, the pilot or flight crew must be interacting with a procedure (e.g. checklists; SOPs; etc). In order to be classified as communication error, the pilot or flight crew must be interacting with people (ATC; groundcrew; other crewmembers, etc).






Aircraft Handling errors
  • Manual handling/flight controls: vertical/lateral and/or speed deviations, incorrect flaps/speedbrakes, thrust reverser or power settings. (Commander)
  • Automation: incorrect altitude, speed, heading, autothrottle settings, incorrect mode executed, or incorrect entries.
  • Systems/radio/instruments: incorrect packs, incorrect anti-icing, incorrect altimeter, incorrect fuel switches settings, incorrect speed bug, incorrect radio frequency dialled.
  • Ground navigation: attempting to turn down wrong taxiway/runway, taxi too fast, failure to hold short, missed taxiway/runway.




Procedural errors
  • SOPs: failure to cross-verify automation inputs. (Co-pilot)
  • Checklists: wrong challenge and response; items missed, checklist performed late or at the wrong time.
  • Callouts: omitted/incorrect callouts
  • Briefings: omitted briefings; items missed.
  • Documentation: wrong weight and balance, fuel information, ATIS, or clearance information recorded, misinterpreted items on paperwork; incorrect logbook entries, incorrect application of MEL procedures.


Communication errors
  • Crew to external: missed calls, misinterpretations of instructions, incorrect read-back, wrong clearance, taxiway, gate or runway communicated.
  • Pilot to pilot: within crew miscommunication or misinterpretation

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