Contact: Nicole Baritot
American Association for Thoracic Surgery
Caption: Caption: Immediate environmental threats act on the crew and increase the probability of an error arising from them. Alternatively, errors may occur unprompted, de novo. Some errors may be inherently inconsequential. Others may be inconsequential because of error detection and appropriate rescue. However, an unintended state will occur if either: 1) the error is not detected and is not inconsequential in nature, or 2) if the error is detected but not rescued appropriately. An unintended state may in itself give rise to little or no reduction in safety margin. However, the unintended state represents a deviation from the expected flightplan and is a risk factor for additional CYCLES ("C") of unintended states and/or errors. This cycling effect amplifies the deviation from the expected and leads to progressive reduction in safety margins. Occasionally, such cycling will give rise to a major catastrophe (the "outcome," not shown). Threat and error management strategies serve to reduce and contain threats, improve error detection and rescue, and break error cycles. Crew resource management is one important part of threat and error management; there are many other additional strategies. Latent threats are the organizational, professional and management cultures which greatly modify the prevalence of threats, errors and their management.
Credit: Edward J. Hickey et al
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