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Threat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. Within the TEM framework, and according to ICAO Annex 1 on Personnel Licensing, error is defined as..
  • A
    an intentional deviation by an operational person from a known process or procedures with undesired consequences.
  • B
    an event that occurs beyond the influence of an operational person that must be managed to maintain the margin of safety.
  • C
    an action or inaction by an operational person that leads to deviations from organisational or the operational person’s intentions or expectations.
  • D
    an erroneous, perception, belief or mental state by an operational person that does not conform to an organisation’s objective reality.

ICAO Annex 1

Error. An action or inaction by an operational person that leads to deviations from organizational or the operational person's intentions or expectations.


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.
  • 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.
  • 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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