The use of the TEM model helps to illustrate to flight crews that when the aircraft is in an undesired state, the basic task of the flight crew is undesired "aircraft state management" instead of "error management". It also illustrates how easy it is to get locked into the error management phase.


An example would be as follows: A stabilized approach (normal operational state) turns into an un-stabilized approach (undesired aircraft state), which results in a runway excursion (outcome).


Once the undesired aircraft state becomes an "outcome" -- recovery of the situation, return to a normal operational state, and restoration of margins of safety, is not possible.


Remember: Identify and Recover Layers of Protection:


Within the flight operation, there should be built-in layers of protection designed to catch threats and errors before ever reaching an undesired airplane state. By utilizing and recognizing the layers of protection and appropriate CRM elements, a crewmember can close the holes that may lead to recurring or critical errors.


The following list the layers of protection, which can be compared to the links in the error chain: • • • • •


Flight Manual/FARs Pilots/GSC


Airplane Resources CRM/TEM Skills SOPs


Enhanced TEM is the product of the combined use of systemic-based and individual and team countermeasures.


9 CRM 2, TEM, Fatigue


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