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Threat And Error Management Revisited

Table 1:

Control Action (CA) CA causes hazard Lack of CA causes hazard CA too early/ too late/ wrong sequence CA too long or too short causes hazard
Government, Regulatory Agencies Provides inadequate laws, regulations and standards for approval and operation; Approves inadequate organisations;Conducts inadequate investigations and audits of the certified training organization; Does not provide regulations and standards for critical aspects of flight training; Laws and regulations fail to promote a just culture (e.g. Janezic, 2016); Does not amend, limit, suspend or revoke the company’s training certificate when the conditions according to which it was issued are no longer fulfilled Provides laws, regulations and standards too late;Conducts investigations and audits of the certified training organization of the company too late;Amends, limits, suspends or revokes the company’s training certificate too late -
Associations Provide inadequate recommendations, reports Do not provide required recommendations, reports Provide recommendations, report too late -
Company Management Provides inadequate safety policy, standards, resources; Promotes a blame culture; Excessive pressure to fulfil concurrent goals on costs of safety Does not promote a safety culture (e.g., Ioannou et al., 2017);Does not provide necessary resources; Provides resources and standards too late -
Operations management Provides inadequate procedures, resources, staff planning/ scheduling Lack of procedures, resources, oversight; Provides resources, procedures and standards too late -
Flight Instructor Provides conflicting or uncoordinated control inputs;Provides inadequate instruction or CAs Does not follow the procedures when required; Does not provide CAs or does not take over the control Provides control inputs too late; Takes over the control too late Provides too short or too long control inputs; too short instruction before and after practical sessions; too long verbal instructions during practical flight
Trainee Providesinadequate CAs  Does not perform a required CA;Does not followthe instructor’scommand Provides CA tooearly, too fast, too late or in the wrong sequence Provides too short or too long CAs
Automation Providesinadequate CAs  Does not provide a required CA Provides CA tooearly, too fast, too late or in the wrong sequence Provides too short or too long controlinputs
Other controllers CA causes hazard Lack of CA causes hazard CA too early/ too late/ wrong sequence CA too long or too short
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