Errors in Air Traffic Control
One of the premises in TEM is that perspectives on errors as portrayed by traditional views on human error do not properly reflect the realities of operational contexts. Operational personnel in ultrasafe industries, of which aviation is a perfect example, do not adopt courses of action merely by choosing between a good and a bad outcome. Rather they adopt courses of action that seem to be the best in the light of their training, experience and understanding of the situation. They make sense of the operational context in which they are immersed, based upon cues and clues provided by the context of the situation. Only afterwards, when the result of such attempt at making sense is known (the outcome), is it possible to suggest, with the benefit of hindsight, that a different view would probably have resulted in a more desirable outcome.
Under TEM, a threat is not a problem as such in and of itself, but it could develop into one if
not managed properly. Not every threat leads to an error, and not every error leads to an undesired state, yet the potential is there and so should be recognized. For example, visitors in an ATC operations room are a "threat": their presence in itself is not a dangerous situation, but if the visitors engage in discussions with the ATC crew or otherwise distract them, they might lead the controller to make an error. Recognizing this situation as a threat will enable the controllers to manage it accordingly, thereby minimizing or preventing any distraction and thus not allowing the safety margins in the operational context to be reduced. Specific examples of errors in air traffic control from the perspective of TEM are included hereunder. The list is illustrative and not comprehensive.
Source By Threats and Error Management DOC
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