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a) set-up procedures;
b) operations under normal and emergency conditions; and
c) operations under equipment failure or partial failure conditions.
Step 3 Identify potential hazards that affect the ability to maintain safe separation. This is best
achieved by asking “What can go wrong?” and “What if ...?” in relation to the identified
divisions in Step 2. It is necessary to consider the impact of the procedure on all levels of
controller ability and experience.
Step 4 Identify the circumstances or incident sequence under which a hazard might occur, together
with the likelihood of occurrence. Having considered the likelihood and consequences of
occurrence, some identified hazards may be discounted as unrealistic. The reasons for
discounting must be recorded.
Step 5 Make an assessment of the hazard severity.
Step 6 Examine the hazard and incident circumstances and identify essential and desirable
measures that, when implemented, will mitigate or eliminate the hazard.
— — — — — — — —
17-APP 3-1
Appendix 3 to Chapter 17
THREAT AND ERROR MANAGEMENT (TEM) IN ATS
1. GENERAL
Under the TEM framework, a threat is not a problem as such, 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.
2. CATEGORIES OF THREATS IN AIR TRAFFIC CONTROL
2.1 Threats in ATC can be grouped into the following four broad categories:
a) internal to the ATS provider;
b) external to the ATS provider;
c) airborne; and
d) environmental.
2.2 Since awareness about these threats assists the deployment of both individual and organizational
countermeasures to maintain margins of safety during normal ATC operations, the following paragraphs
elaborate on the sources and nature of conditions which “threaten” safe air traffic services.
Internal threats to the ATS provider
2.3 Equipment is a frequent source of threat for ATC. Malfunctions and design compromises are
among the conditions that controllers have to cope with to varying degrees during everyday operations.
Other threats under this category include radio communications that may be of poor quality, and telephone
connections to other ATC centres that may not always be functioning correctly. An input to an automated
system may become a threat if the desired input is rejected by the system, and the controller has to find out
why the input was not accepted and how to remedy the situation. The lack of proper equipment is a threat in
ATC facilities in many parts of the world. A significant threat in ATC is maintenance work (scheduled or
unannounced) concurrent with normal ATC operations. In addition, maintenance activity may produce
threats that only manifest themselves when the equipment concerned is next put into service.
2.4 Workspace factors include glare, reflections, room temperature, non-adjustable chairs,
background noise, etc. A controller’s work is more difficult if there are reflections from the room lighting on
the screens. A tower controller may have problems visually acquiring traffic at night if there are reflections
17-APP 3-2 Safety Management Manual (SMM)
from the interior lighting in the windows of the tower. A high background noise level, e.g. from fans
necessary to cool the equipment, may make it more difficult to accurately understand incoming radio
messages. Similarly, it may make outgoing messages harder to understand for the receiving parties.
2.5 Procedures may also constitute threats for ATC. This applies not only to procedures for the
handling of traffic but also to procedures for internal and external communication and/or coordination.
Cumbersome or apparently unnecessary procedures may lead to shortcuts with the intent to help the traffic
but with the potential to generate errors or undesired states.
2.6 Other controllers from the same unit may be a threat as well. Proposed solutions for traffic
situations may not be accepted, intentions may be misunderstood or misinterpreted, and internal
coordination may be inadequate. Other controllers may engage in social conversation, creating a distraction
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