Transport Economics and Management 2 (2024) 322–330

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Transport Economics and Management

journal homepage: www.journals.elsevier.com/transport-economics-and-management

Lessons from the implementation of Threat and Error Management: A case

study of the Australian general aviation
Seung Yong Lee a,* , Paul Bates b, Patrick Murray b, Yahua Zhang a
a
UniSA Aviation, STEM Unit, University of South Australia, Australia
b
USQ Aviation, School of Business, University of Southern Queensland, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Threat and Error Management (TEM) is one of recent safety initiatives to further improve the overall aviation
General aviation safety level. In response to the recommendations of the International Civil Aviation Organisation (ICAO) for TEM
Threat and Error Management to be introduced to all pilot training syllabi, the Civil Aviation Safety Authority (CASA) in Australia mandated
Safety
TEM as an additional assessment item for various levels of flight tests and ground examinations in 2009. The
Policy implementation
current study adopted a two-pronged approach: A case study to highlight the importance of TEM training, fol­
lowed by gaining an in-depth appreciation as to how TEM was implemented and its effects of the use of TEM
training. A semi-structured interview of five highly experienced general aviation Flight Examiners (FE) was
conducted, and thematic analysis was performed for the interview data from which four main themes emerged:
1) Impracticality; 2) Lack of guidance and support; 3) TEM implementation; and 4) TEM in practice. All par­
ticipants shared the same view that TEM was not implemented well. It is expected that the findings from this
study add to the body of knowledge to better inform and provide guidance and reference for National Aviation
Authorities (NAA) to develop an implementation plan when considering the implementation of TEM training in
their regulatory framework. Our study highlights a notable disconnect in CASA’s operational workforce’s grasp
of TEM, impacting trust in the general aviation sector in its significance and application. It should be also noted
that since our study, to address this and foster innovation in safety projects, CASA has initiated comprehensive
strategies such as workforce planning and actively engaging in Technical Working Groups (TWGs) to harness
community expertise for safety improvements. Nevertheless, the findings have the potential to provide infor­
mation regarding pilot attitudes to future safety initiatives in other rapidly growing sectors such as Recreational
Aviation (RA) and Remotely Piloted Aircraft System (RPAS).

1. Introduction safety standards remain [55]. One of the ongoing safety initiatives in the
aviation sector is the recent introduction of Threat and Error Manage­
Continuous efforts to improve safety initiatives and training to ment (TEM).
address human factors issues as well as major technological advances It is often cited that approximately 70–80 % of aviation accidents are
and enhancements have resulted in civil aviation to be considered an attributed, at least partly, to human error [54]. However, given the
ultra-safe industry. According to Amalberti et al. [3], the rate of cata­ physical and psychological limitations of humans, it is unrealistic to
strophic accidents per flight is better than 1 ×10− 6, compared with other believe that errors could be entirely eliminated. Adams [1] states that
safety critical industries such as road and surgery both being 1 ×10− 4. even competent humans completing a simple task continue to make
To view this from the Australian perspective, in 2010, Australia expe­ errors and what is important is to recognise and correct them so that the
rienced 14 fatal aviation accidents, compared with 1248 fatal accidents results are inconsequential. That is, efforts have been made to not only
involving road transportation [6,44]. This is, in part, due to aviation identify errors but to develop and refine training to appropriately
being one of the most regulated industries. Although the last four de­ manage those errors to avoid or mitigate negative consequences. In
cades have seen the removal of economic controls over market entry and addition, any external factors (i.e., threats) that may increase the
exit, pricing, ownership, capacity, frequency, and so on, regulations on probability of errors should also be managed. To this end, Merritt and

* Correspondence to: University of South Australia, STEM Unit, Level 1, J Building (Reception),Mawson Lakes campus, South Australia 5095, Australia.
E-mail address: paul.lee2@unisa.edu.au (S.Y. Lee).

https://doi.org/10.1016/j.team.2024.09.007
Received 14 August 2024; Received in revised form 7 September 2024; Accepted 21 September 2024
Available online 29 September 2024
2949-8996/© 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-
nc/4.0/).
S.Y. Lee et al. Transport Economics and Management 2 (2024) 322–330

Klinect [42] argue that the overarching objective of Threat and Error demonstrated among trainees exposed to TEM [9]. TEM is one of recent
Management (TEM) provides the best possible support for flight crew in contributors to the safety and efficiency of the aviation system. TEM was
managing everyday threats and errors. initially developed while conducting audits of normal flight segments
Airlines around the world have devoted many resources to human and it has its theoretical base on Reason’s theory of accidents and in­
factors training, particularly Crew Resource Management (CRM) and cidents in complex and inconsistent environments [48]. It is one of very
Threat and Error Management (TEM). Despite the positive effects of few human factors and pilot error taxonomies that is: 1) actively in use;
extensive human factors training in the airline sector, it often appears to 2) directly used by pilots; 3) supporting human factors model of pilot
be a neglected component in general aviation. Sarter and Alexander [46] error; 4) derived from pilot terms; and 5) providing data that supports a
suggest that, to improve overall aviation safety, the focus needs to be on safety risk management system [48]. According to Merritt and Klinect
the weakest links—that is, single pilots, low-technology and less rigor­ [42], the TEM model is comprised of three major components: 1) threat;
ously trained pilots in general aviation. The lack of appropriate, formal 2) error; and 3) undesired aircraft state (UAS) as featured in Fig. 1.
human factors training within initial and recurrent pilot training offered A threat is an occurrence beyond the control of the flight crew that
in general aviation may explain as to why overall aviation safety has not consequently increases the complexity of flight operations [42]. This is
significantly improved. the first opportunity for flight crew to appropriately manage the threat
The International Civil Aviation Organisation (ICAO) acknowledged so that its outcome is inconsequential. An error, either threat induced or
the need for TEM training and recommended that TEM be introduced to spontaneous (non-threat induced), is defined as flight crew’s action or
all pilot training syllabi and the Civil Aviation Safety Authority (CASA), inaction that departs from crew or organisational intentions or expec­
the regulatory body for Australian civil aviation, mandated TEM as an tations [42]. This is the second opportunity for the adverse operational
additional assessment item for various levels of flight tests and ground potentials to be inconsequential through an error management process
examinations effective from 1 July 2009 [15]. It has been more than a of detection, localisation and correction [51]. UAS is a safety compro­
decade since the introduction of TEM training in general aviation in mising state between a normal operational state and an adverse outcome
Australia but to the best of the authors’ knowledge, there has been very (e.g., incident or accident) following an ineffective management of
limited, if any, review of such implementation. Hence, the current study threat and/or error and is the last opportunity for the flight crew to
aims to fill the gap by conducting a formal post-implementation review return to their intended and/or optimal state [32,42]. There are a
and assessment of TEM in terms of the effectiveness of TEM training and number of published works that provides further descriptions and ex­
its practices in Australian general aviation. planations on the TEM model (e.g., [42]) that readers are encouraged to
reference.
2. Literature review Despite its shorter period of existence, continued research and suc­
cess of TEM in aviation have so far resulted in the principles and con­
Threat and Error Management (TEM) is a safety management cepts of TEM being transcended into other high reliability industries
approach by proactively detecting, appropriately responding to and such as healthcare industry. Ruskin et al. [45] developed a TEM-based
managing threats and errors that are part of everyday operations so that predictive risk taxonomy applicable to anaesthesiologists that contains
a required safety margin is maintained [15]. It has been generally a list of potential threats for each stage of surgical anaesthesia to better
accepted in the airline industry as an effective method of improving prepare and manage situations that would otherwise develop into un­
flight safety. Similar was observed in the Air Traffic Management (ATM) desired patient state. The study also had an emphasis on identifying
sector where a higher achievement of post-training performance was specific threats and associated errors and their management to be

Fig. 1. TEM model. Reproduced with permission from the LOSA Collaborative.

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considered when developing or revising education programs and other e., environmental threat not managed) to be expected hence the pilot
quality improvement initiatives for current and future healthcare pro­ could better maintain his situational awareness. A series of poor in-flight
fessionals [45]. decisions was also noted where the pilot elected to continue despite
Catchpole et al. [12] examined the systemic origins of threats and deteriorating weather (i.e., error committed), being placed in a closed
errors that lead to minor and major failures in paediatric cardiac sur­ valley framed by ridgelines (i.e., undesired aircraft state), inadvertently
gery. The most frequent type of threat identified is a task-related threat, entering a cloud during the turn-back manoeuvre (i.e., additional error
often originating from equipment failure, while a non-technical error committed). Finally, the failure to effectively and adequately mitigate
such as breakdown in coordination and communication among the each threat and error management opportunity has led to the accident.
surgical team is predominantly noted [12]. Findings from the study This case study highlights the importance of on-going non-technical
support the positive effect of TEM application on improving overall skill (NTS) training opportunities that are often lacking in GA. Thomas
patient safety and more importantly, a closer examination of threat and [50] argues that the positive effects of the use of the TEM model in the
error linked to minor and major failures and lessons learned from it can training environment by incorporating types of common operational
inform recommendations on potential safety-related interventions and threats and errors will increase the realism of training and training ef­
education programs for relevant healthcare authorities [12]. It is ficiency and allow trainees to adopt systematic approaches to error
evident that adoption and appropriate modification of TEM principles management training. In response to the acknowledgement of TEM
and its training programs tailored to specific segments of industry being an effective method for improving aviation safety, it has become a
within, and outside aviation is expected to enhance overall operational mandatory assessment item for various levels of flight tests and ground
safety and efficiency. examinations [15]. The following sections provide an examination of
the ways in which the regulatory requirements for TEM training were
3. General aviation safety in Australia implemented and the industry uptake of TEM principles and opinions
regarding its effectiveness.
General aviation (GA) refers to all civilian aviation operations other
than major domestic and international passenger and freight services. 4. Methodology
Aerial work and flight training take up almost 70 per cent of total flying
time for GA [21]. Due to its diverse range of flight operations combined This paper uses a case study approach to explore the effects of
with common characteristics of GA being low technology, less rigorously implementing TEM in one of Australia’s civil aviation sectors. Case study
trained pilots and limited technical and non-technical training oppor­ research is a qualitative inquiry that can generate in-depth insights into
tunities, it is often cited as the weakest link in the overall safety of the the research questions [22,41]. It is particularly useful in exploring new
aviation system [46]. For instance, the Australian Transport Safety Bu­ safety initiatives such as TEM that has been recently introduced with
reau (ATSB) [8] found that between 2010 and 2019, over 90 per cent of limited or little prior knowledge. The sources for the case include gov­
(fatal) accidents and over 80 per cent of serious incidents involved ernment reports, Australian Bureau of Statistics, Australian Transport
aircraft operating within the GA and the number of fatalities was Safety Bureau and Australian major news websites. The case study
consistent with the 10-year average. A closer inspection of the report adopts a two-pronged approach that first describes the status of general
suggests that for the same period, while the accident rate for private and aviation safety in Australia, followed by a qualitative study in the
business flying segments decreased, the number of operational-related context of the TEM implementation process in Australian general
accidents and serious incidents involving instructional flying increased aviation.
[8]. The central purpose of this research is to gather insights on the TEM
ATSB [8] identified the contributing factors for operational-related implementation process in the Australian general aviation sector, and its
accidents that include inadequate flight preparation, poor aircraft con­ effect on the practice of TEM. The ideal candidates are those who are
trol and in-flight decision making. For instance, accidents involving CASA delegates with extensive experience in the regulatory environ­
Visual Flight Rules (VFR) pilots flying into Instrument Flight Conditions ment and flight training in general aviation. One group of potential
(IMC) have been persistently leading to a loss of control of aircraft which participants is CASA’s Flight Examiners (FE) who have delegation to
is the most frequent and deadly cause of GA accidents [26]. Following is conduct flight tests. Given the limited numbers of FEs, a total of five
a summary of a VFR-into-IMC accident that resulted in a pilot receiving a participants who all had considerable experience in both flight training
serious injury and a passenger a fatal injury. and testing with combined experience of over 180 years in Australian
On 24 December 2008, a Cessna 172 with a pilot and passenger on general aviation participated in this study. The participants’ relevant
board departed Mudgee, New South Wales (NSW) in Australia on a experience and qualifications in general aviation include: 1) Four par­
private VFR flight to Glen Innes, NSW. It was later found that the pilot ticipants previously worked for CASA; 2) Three were either a Chief
did not choose to obtain relevant aviation weather forecasts for the Flying Instructor (CFI) or a Chief Pilot (CP) when TEM was mandated; 3)
flight. After 15 minutes into the flight, the weather condition deterio­ Two also had extensive military instructional experience. All interviews
rated with increasing cloud cover above and the below the aircraft. The were conducted in 2018, and their views and opinions were verified and
pilot then decided to climb above the cloud to better assess the weather analysed in the following year with a consideration of the most recent
ahead. With a blanket of cloud below and building thunderstorms, the cases and contexts.
pilot decided to visually descend through a hole in the cloud and On the day of each semi-structured interview, the participant infor­
continued toward the intended destination rather than turning back or mation sheet and consent form were provided and discussed with each
diverting to alternative airport. When leveling out, the pilot realised the participant and the interview commenced after the consent form was
aircraft had descended into a closed valley surrounded by ridgelines. signed. On average, each interview took approximately one hour, and
After flying up the valley for a short time, the pilot decided to turn back audio recorded interviews were transcribed and sent to each respective
but during the manoeuvre, the aircraft entered into a cloud and the pilot participant via email for verification purposes. This also allowed the
became disoriented and the aircraft collided with terrain. The pilot participants to remove any transcribed conversation they did not wish to
received a serious injury while the passenger received a fatal injury [7]. be used for analysis. Two participants returned their transcripts with
Based on the accident summary, there are a number of lessons that very minor typographical errors corrected while the rest were satisfied
can be learned within the framework of the TEM model. Firstly, with the transcriptions without alteration. The rich and holistic quali­
appropriate pre-flight preparation and planning including obtaining up- tative data collected have the potential to provide in-depth appreciation
to-date weather information before and during flight is crucial. This of real issues beyond a mere description of ‘what’ and ‘how many’ [37].
would better prepare the pilot with what kind of weather conditions (i. In addition, relevant findings from two separate surveys (i.e., survey 1 in

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2018 and survey 2 in 2021), both on a 0–10 satisfaction scale (0 & 1 =

very dissatisfied/strongly disagree while 9 & 10 = very sat­
isfied/strongly agree), commissioned by CASA are also presented in this
paper to better gauge CASA’s service provision and relationship with
industry stakeholders. The surveys adopted a mixed methods
methodology.

Fig. 3. Final thematic map with four main themes.

4.1. A qualitative analysis of TEM implementation
4.2.1. Impracticality
The collected qualitative data was analysed using thematic analysis
According to Oxford English Dictionary [43], practicality is defined
which is arguably a “foundational method for qualitative analysis” [10]
as “a thing that is practical or that is done for practical reasons” (para.
(p. 78). Thematic analysis involves identifying, analysing, and reporting
2). General aviation is primarily a vocationally based industry. There­
themes within data and this has six phases: 1) Familiarising oneself with
fore, it is important to consider practical aspects when new safety ini­
one’s data; 2) Generating initial codes; 3) Searching for themes; 4)
tiatives such as TEM implementation are proposed and introduced.
Reviewing themes; 5) Defining and naming themes; and 6) Producing
However, all the participants expressed concerns regarding a lack of
the report [10]. The phases do not suggest a linear process, instead, it is
practically when it came to understanding the concept of TEM and
recursive, encouraging researchers/analysts to move back and forth to
implementing it in practice. Participant 3 stated that ‘CASA’s tried hard…
enable comprehensiveness and thoroughness in the analysis process
they did it very consciously, very formally and completely impractically’.
[38]. Several thematic maps were produced to organise the different
Participant 4 provided a similar observation: ‘Did we actually need to get
codes into appropriate theme piles during the process. NVivo was used
someone to put together a paper 90 % of aviation community could not un­
for the interpretative process of data analysis. Fig. 2 below displays a
derstand because they don’t have degrees?…They probably should’ve put it
preliminary thematic map with some of themes and sub-themes.
on a practical level’. This finding is consistent with a stakeholder survey
The candidate themes were further reviewed and refined using two
(Survey 1) result that an overall mean rating of 5.2 (out of 10) was re­
criteria: 1) internal homogeneity; and 2) external heterogeneity
ported on a statement: “CASA did a good job of translating participants’
whereby the former concerns internal coherence and consistency while
legal obligations into practical guidance” [11]. A subsequent stake­
the latter concerns a more global sense that considers datasets and
holder survey (Survey 2) also reported a very similar overall mean rating
themes’ distinction from one another (Pattern, 1987). Fig. 3 presents a
of 5.3 on the same statement [28]. A very small difference in two overall
final thematic map with four main themes.
mean ratings suggests a different approach may be needed to improve
when writing practical guidance.
4.2. Result and discussion Across a number of safety critical industries including mining, con­
struction and health, we observe a shared thematic underpinning: the
A re-iterative process of thematic analysis resulted in identifying four critical importance of integrating practical considerations into the
main themes: 1) impracticality; 2) lack of guidance and support; 3) TEM design and implementation of safety initiatives across various industries.
implementation; and 4) TEM in practice and these themes are somewhat Sunindijo [49] underscores the practical barriers small construction
interwoven. For instance, according to the Australian National Audit organisations face in improving safety, notably financial constraints and
Office [5], one of the six key considerations for successful imple­ the competitive bidding process. It contrasts with Cullen [23] who fo­
mentation of a policy initiative is ensuring the appropriate mix of cuses on the mining industry’s use of storytelling and case studies to
required expertise and quantity of resources available. However, it was enhance safety training’s effectiveness. This comparison highlights a
found that because of insufficient resources from CASA, there was a lack fundamental principle that practical solutions must be tailored to
of support and guidance provided to Australian general aviation pilots. address the unique challenges and cultural dynamics of each industry.
Each of four major themes is presented below with relevant discussions While Sunindijo [49] suggests structural changes such as regulation
provided. enforcement and financial support, Cullen [23] leverages cultural

Fig. 2. Preliminary thematic map of candidate themes and sub-themes for the study.

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practices to embed safety practices deeply within the workforce’s con­ recounts. Thus, the lack of practicality was the first barrier identified as
sciousness. Both approaches aim at enhancing safety but from different hindering the successful implementation of TEM in Australian general
angles: one through systemic changes and the other through cultural aviation.
integration [49,23]. This study and results of studies in similar safety critical industries
In health care, Houghton et al. [31] argue that the practical imple­ highlight that successful implementation of safety initiatives requires
mentation of safety initiatives is crucial, highlighting the necessity for nuanced understanding of the target industry’s operational, financial
clear communication, and training to support healthcare workers. and cultural landscape [49,23]. Practicality, in this context, does not
Similar to the aviation context, these factors in health care significantly merely refer to the feasibility of implementing safety measure but also to
influence the operational workforce ability and willingness to follow their sustainability, relevance, and acceptance within the target com­
new safety guidelines, underpinning the importance of practical, sup­ munity. Synthesising these approaches reveals a comprehensive strategy
portive measures in ensuring the effectiveness of safety initiatives. for safety initiatives success: it must be multifaceted, culturally
Theoretical knowledge and practical skills complement each other, informed, and industry-specific, blending regulator, financial and
yet they create difficulties when they need to be integrated. Based on the behavioural interventions to create a conducive environment for safety
comments from the participants, it could be well established that the practices to thrive and become ingrained within industry culture.
probable reasons for this lack of practicality may be twofold. The first It is important to note that in response to implementation challenges,
reason is likely a result of a lack of familiarity of the contemporary and enhancing awareness of industry challenges, CASA has (since our
challenges of the general aviation sector amongst senior management study) determined to address these issues by consulting industry. This
and decision makers within CASA. Participant 2 stated, ‘You’ve got all approach is evident in the General Aviation Workplan 2022 , which
these managers who do not understand their core business’. Participant 1 outlines CASA’s commitment to refining the safety framework in
supported this view that ‘CASA particularly…if you look at the profile of a collaboration with industry stakeholders [17]. By engaging directly with
lot of senior management within CASA, ones we got last probably 0–15 years those who are affected by regulatory changes, CASA appears to have
has very little expertise in aviation there’. Participant 1 added that it is transitioned to ensure regulations are proportionate to support com­
important to have a good understanding of the industry so that effective mercial sustainability and do not unduly burden the general aviation
communication methods can be established. A finding from survey 1 sector. This consultative approach alights with the Statement of Ex­
with only 29 % of participants showing their agreeance on a statement: pectations from the Minister of Infrastructure, Transport and Regional
“CASA takes the time to get to know people in the industry” [11] may Development, highlighting CASA’s priority to optimise the regulatory
provide a probable reason for CASA’s unfamiliarity with GA community. framework through open dialogue and partnership with the aviation
A participant in survey 2 commented that “We really need that direct line community [4].
of communication to ensure our issues are heard and responded to – its also a
chance for CASA exec to share their view of the world in terms of emerging 4.2.2. Lack of guidance and support
issues or risks” [28] (p.40). All participants shared very similar views that there was inadequate
The second probable reason for the lack of practicality when TEM guidance and support provided by CASA when TEM was first imple­
was mandated appeared to have occurred at the operational level. mented in Australian general aviation. Participant 1 shared their
Participant 4 felt that CASA did not have the right people in teams observation that ‘Industry needed, certainly from the outset, an education
responsible when the implementation of TEM was planned: ‘I believe at roadshow to go around the regional centres, set up workshops and explain
that time, CASA had engaged in a consultant, who I don’t think was from an what it was, what they wanted, what outcomes they wanted out of TEM
aviation background at that time. A lot of what came out made no sense implementation…If left the industry pretty much on their own devices’.
whatsoever…quite difficult to find anything aviation specific with threat and Participant 4 also shared a similar view that ‘They [CASA] have touched
error management…’. Similar observation was made when Crew on TEM in seminars…and mostly they were dealing with questions…there
Resource Management (CRM) was first introduced in the US in 1981 was no overall philosophy, except they have got to cover and demonstrate that
where the criticisms included being largely psychological in nature and you are considering threats and how you manage them’.
the associated games and exercises to illustrate concepts were unrelated The Honorable Company of Air Pilots incorporating Air Navigators,
to aviation that negatively affected overall acceptance among pilots formerly known as Guild of Air Pilots and Air Navigations (GAPAN), in
[30]. Findings from both surveys also support a poor consulting process collaboration with Australian Transport Safety Bureau (ATSB), devel­
where only 27 % (survey 1) and 28 % (survey 2) of participants show oped and conducted a ‘TEM train-the-trainer’ course for general aviation
their agreeance on a statement: ‘CASA always consults with the most and low-capacity air transport operations in 10 different locations in
appropriate people in industry when developing and reforming aviation preparation for the regulatory change [14]. Participant 4 recalled that
safety regulations’ [11,28]. ‘The GAPAN material is actually quite good, arguably miles ahead of what
Lee et al. [36] support the importance of consulting operational staff was produced by the regulator [CASA], but how many people actually
in the development of safety initiatives to support practicality. Through attended…what were their positions…actual syllabus designers…ground
systematic interviews with safety personnel and external safety con­ school instructors or the flight instructors…I would probably say less than
sultants, their study emphasizes a sociotechnical systems approach, 20 % of the industry’. According to Cheng et al. [14], approximately 312
highlight the crucial role of engaging a variety of stakeholders, including people attended the training, but this was indeed a significant
those directly involved in operations, to improve safety climate [36]. under-representation, considering there were over 20,000 licence
This approach perhaps assists in explaining the results of our study, by holders in the aeroplane category during the 2009 and 2010 periods
underlining the value of involving operational staff and their unique [16].
insights into the planning and implementing stages of safety initiatives, All five participants were flight examiners and the introduction of
ensuring these initiatives are grounded in the practical realities of the TEM would have affected the way they examined flight test candidates
workplace and are thus more likely to succeed and be sustainable over and new TEM-related flight test items. However, despite its rightly
time. deserved attention regarding how TEM items should be accurately and
It can be well established from the participants’ accounts that, when adequately examined, participant 1’s recount was somewhat different
TEM was first implemented, it was not tailored to the appropriate level where ‘…there was no separate PDP [Professional Development Program] to
for the general aviation industry. Consequently, it was viewed by many cover it to say, this is a new thing, we, CASA, have introduced to the in­
stakeholders as an additional requirement with which they needed to dustry…we really want to focus on it and…therefore we will give you separate
comply, without them appreciating the value of TEM. In addition, the training. No, they didn’t do that’. Participant 5 also shared their difficulty
findings from the stakeholder survey were similar to the participants’ in terms of examining and completing TEM elements on a flight testing

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form: ‘Especially on the test form for the flight tests. It’s just got three very sharing and innovation but also ensures that safety standards are met
basic items…that is probably too broad and too general…unless you really and exceeded through the effective project implementation. The studies
had a thorough knowledge of what threat and error management is’. These of Cengiz and Demirci [13] and Watkins et al. [53] collectively support
comments shed some lights on a finding from other study that the trainer the notion that in the highly technical and safety-critical aviation sector,
group did not strongly feel that TEM was appropriately assessed during trust in the technical expertise and knowledge of management, project
flight tests [35]. teams and the safety regulator is indispensable for achieving innovation
The importance of guidance and support in the implementation of and ensuring safety outcomes.
new safety initiatives is underscored by the insights derived from Far­
okhzadian et al. [27] and Maliha et al. [39]. Both studies emphasise the 4.2.3. Threat and Error Management (TEM) implementation
multifaceted challenges encountered when striving to enhance patient Oxford English Dictionary [43] defines implementation as ‘the pro­
safety culture within healthcare settings. Farokhzadian et al. [27] cess of putting a decision or plan into effect’ and, needless to say, any
elaborate on the critical roles of leadership effectiveness, organizational implementation requires a thoughtful process. The Australian National
infrastructure, and a supportive work environment in fostering safety Audit Office [5] provided a guide that identified six key considerations
culture. The findings suggest that the successful implementation of ‘when implementing a policy initiative—the act of translating policy
safety initiatives is contingent upon an environment that values into reality—so that indented benefits are realised’ (p. 3). The consid­
continuous learning, open communication, and the empowerment of erations are: 1) Governance; 2) Managing risk; 3) Engaging stake­
staff. Similarly, Maliha et al. [39] delineate the intricate dynamics of holders; 4) Planning; 5) Resources and monitoring; and 6) Review and
integrating innovative safety measures, highlighting the necessity for a evaluation [5]. Based on the general consensus among all participants so
comprehensive approach that encompasses training, resources, and an far was that the implementation of TEM was problematic. Participant 2
organizational ethos conducive to change. The insight from the studies commented that ‘…they’ve introduced threat and error management, which
helps to explain the perceived lack of support identified in our study. is a fantastic idea, but…it’s been poorly introduced and therefore there’s no
Collectively, these studies underscore the imperative for a holistic and value’. Participant 1 also recalled that ‘It was mandated by CASA…Nobody
supportive approach to the adoption of safety measures, one that tran­ really understood what it was CASA wanted and nobody really clearly
scends mere procedural changes to encapsulate a transformation of defined it and it was not very well implemented’.
culture and mindset. The first key consideration, governance, refers to the arrangements
Some participants offered possible reasons regarding why there was and practices that enable the achievement of expected outcomes and
a lack of guidance provided by CASA. Participant 4 stated that ‘It was a sound governance arrangements require a committed executive and a
lack of understanding…of threat and error management within the regulator senior responsible officer to either possess the appropriate skills or have
[CASA] themselves’. This was supported by participant 3 that ‘When they access to such skills to oversee the entire implementation process [5].
were introducing it, they were sort of say things like, we’re only still trying to However, based on some of the participants’ recounts in Sections 5.1.1
find out how to do it. Even later, I spoke to a senior manager at CASA, and he and 5.1.2, it was evident that a sound governance arrangement was not
said, we have no idea what it’s about, so we were enforcing something that we well established.
didn’t understand’. Participant 5 added that ‘To this day, I would be fairly Kjulavkovska et al. [52] explored the significant role of
confident in saying that you could ask 15 inspectors at CASA, and you’ll have competency-based training (CBT) within civil aviation authorities
15 different opinions on threat and error management and their under­ (CAAs) in Europe, highlighting its influence on the training and per­
standing’. This lack of adequate guidance and support from CASA then formance management of civil aviation inspectors. The research un­
logically leads to examine how TEM was implemented which is the next derscores the integration of CBT into organisational management
main theme. This is supported by a finding from the survey 1 and 2 that systems as a means to address skill gaps and improve workforce com­
only 34 % and 37 % of participants showed their agreeance on a state­ petency, thereby enhancing productivity and employee engagement.
ment: “CASA inspectors have a consistent understanding of regulations Despite CBT’s growing popularity and its critical role in ensuring a
and apply rules consistently” [11,28]. A participant from the survey 2 highly skilled aviation workforce, the study identifies a gap in research
also commented that “I can give you evidence of four different emails about concerning the training and performance management of civil aviation
the same subject and it will have four different answers regarding the same inspectors specifically. By conducting a pilot study involving eleven
regulation” [28] (p.38). European CAAs, Kjulavkovska et al. [52] aimed to understand the
The studies by Cengiz and Demirci [13] and Watkins et al. [53] application of CBT in this context, benchmarking against a framework
explore the critical role of trust, particularly competence-based trust, in for integrating training and performance management systems through
the aviation industry, emphasizing its importance in the successful CBT. The findings reveal general consistency in CBT elements applied
implementation of safety-related projects. Both studies highlight the across CAAs but also highlight inconsistencies and gaps in implementing
necessity of social capital, encompassing strong internal networks, trust, recommended elements fully. This highlights the need for improved and
and tacit knowledge exchange within organizations. Cengiz and Demirci harmonized training management practices to support successful safety
[13] focus on the dynamics of social capital in facilitating radical initiatives. The implications of the Kjulavkovska et al. [52] study for
innovation efforts, showing how internal social networks and future research and training management practices within European
competence-based trust among team members significantly contribute CAAs emphasize the importance of competent inspectors and an effec­
to creative and innovative outcomes. Similarly, Watkins et al. [53] delve tive governance structure in aviation safety regulation.
into the impact of social capital on organisational innovation, under­ It is clear that since our study, CASA is proactively steering towards
scoring the reliance on tacit knowledge and the strength of ties fostered an enhanced understanding and identification of skill gaps and future
by trust in technical competence. skill requirements within its inspectorate. The strategic orientation, as
The findings in our study indicate a perception across industry that delineated in their Corporate Plan for 2022–2023, underscores a
there was a lack of tacit knowledge from the CASA operational work­ commitment to rigorous workforce planning [18]. By doing so, CASA
force relating to TEM and this has impacted on the sector’s trust in the not only acknowledges the pivotal role of a proficient and well-quipped
relevance and implementation process. The work of Cengiz and Demirci workforce in upholding the stringent standards of aviation regulation
[13] and Watkins et al. [53] assists in explaining the findings of our but also demonstrated foresight in adapting to the evolving needs and
research. It is evident that competence-based trust in management challenges of the aviation industry. The initiative represents a signifi­
teams’ technical knowledge is paramount for the aviation industry’s cant step forward in ensuring that CASA remains at the forefront of
innovation processes, especially concerning safety-related projects. This global aviation safety. Through this forward-looking approach, CASA
form of trust not only fosters an environment conducive to knowledge appears to be setting a benchmark for aviation safety regulators,

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emphasizing the importance of continuous learning, skill development, formulation and implementation of comprehensive and effective avia­
and strategic workforce planning in maintaining and enhancing aviation tion planning policies. Both studies collectively emphasise that mean­
safety and regulation. ingful stakeholder engagement is not merely beneficial but essential for
The second key consideration, risk management, is about the the advancement of aviation regulation and policy initiatives that are
dispersion of expected outcomes [5] that ensures a proper introduction, both effective and sustainable while acknowledging the complexity and
practice and assessment of TEM. However, as established in Sections multiplicity of stakeholder interests in the dynamic field of aviation.
5.1.1 and 5.1.2, poor teaching and inconsistent assessment of TEM were Since our study, the Civil Aviation Safety Authority [17] has adjusted
evident. This is consistent with findings from the two CASA surveys with its approach to actively implement stakeholder engagement though its
an average rating of 5.2 and 5.5 (out of 10) on a statement: “CASA ex­ Technical Working Groups (TWGs), which are essential for providing
plains the regulations and how they affect industry stakeholders in a high level advice on aviation safety. These groups are part of the Avia­
clear and succinct manner”, suggesting significant scope for further tion Safety Advisory Panel (ASAP), drawing expertise from the aviation
improvement in this area [11,28]. A result of poorly introduced new community on current and significant issues that could impact aviation
regulations and/or safety initiatives is highlighted in a participant’s safety. CASA’s commitment to working cooperatively with the aviation
comment from the survey 2 that ‘I can tell you every single day I’m industry and community is evident in their approach to maintaining and
breaking a rule, I just don’t know what rule I’m breaking’ [28]. enhancing aviation safety, as they invite industry members, technical
Emerson and Blake [25] and Schooner [47] contribute significantly expert, and other interested individuals to participate in TWGs through
to the ongoing discussion on the effectiveness of plain language in reg­ an Expression of interest process [19].
ulatory contexts. Emerson and Blake [25] delve into the nuances of The fourth key consideration of planning is to provide ‘a map of how
implementing plain language guidelines within regulatory frameworks, an initiative will be implemented, addressing matters such as timeframe,
emphasising the correlation between clear, accessible language and dependencies with other policies or activities, program logic, phases of
improved compliance and enforcement outcomes. This aligns with the implementation, roles and responsibilities, resourcing and compliance
foundational premise of Schooner [47], which critically examines the with legal and policy requirements’ [5] (p.43). It has been well estab­
broader implications of adopting plain language for regulatory lished from relevant comments above that more thorough planning
communication, highlighting its potential to enhance governance would have led to more successful implementation of TEM. Participant 4
transparency and public engagement. Emerson and Blake [25] and highlighted the importance of in-depth planning by commenting that ‘…
Schooner [47] assist in explaining the Australian context. It is apparent the first question…is, What is this? Is this actually something new or is this
that adoption of plain language in regulatory drafting is not merely a something we’re already doing…If it did already exist, what was actually
stylistic preference but a strategic approach to enhance regulatory wrong with the way it’s been…run a series of training sessions, practically
effectiveness. By making regulations more understandable, regulatory focused training session, showing threat and error management in practice…
authorities can achieve higher compliance rates, thereby advancing the what are plausible management strategies…If you did that way, you probably
safety and well-being of the public. Both studies conclude that the would’ve had a greater pick up and a greater success’.
strategic implementation of plain language guidance is pivotal in Denney et al. [24] emphasize the criticality of structured method­
enhancing the clarity and effectiveness of safety regulations, thereby ologies and safety architectures in aviation safety cases. This approach
contributing to improved regulatory outcomes and public safety [25, underlines a comprehensive strategy to mitigate risks associated with
47]. unmanned aircraft systems. However, the features of the paper provide
Since our study, the Civil Aviation Safety Authority (CASA) has been insights into our study’s findings by elaborating on the integration of
proactive in developing plain language guides to aid the industry in safety measures both at the design phase and during operational phases,
understanding and adhering to aviation safety regulations. These guides ensuring a robust framework for risk management. This insight aligns
translate the Civil Aviation Safety Regulations (CASR) into plain En­ with the necessity for a strong purpose and a scaffolded approach to
glish, using practical information and examples to simplify complex implementing safety initiatives, highlighting the importance of
regulations. Covering a range of topics, including general operations, well-defined and iterative processes that adapt to evolving safety re­
flight rules, fatigue management, visual flight rules, and training and quirements and standards. By fostering a detailed and structured
checking, these resources aim to make aviation safety regulations more approach, Denney et al. [24] support the notion that careful planning,
accessible and understanding [20]. through analysis, and continuous improvement are fundamental to the
The third key consideration, engaging stakeholders, requires a clear effective implementation of safety measures in aviation.
objective for consultation and the identification of key stakeholders The remaining key considerations are to ensure an appropriate mix
while maintaining clear and timely communication to wider commu­ of required expertise and quality of resources available and the estab­
nities [5]. Participant 1, however, recalled that ‘…TEM was a buzzword. lishment of ongoing active management that comprises well-
It was pushed out there and it was required by CASA to be introduced to flight coordinated monitoring, review, and evaluation processes [5]. Laszlo
schools, and nobody really had a clear understanding of what it was, its (1998) emphasises the need for adequate allocation of resources, with a
components or elements’. This suboptimal level of effective stakeholder top priority being training key personnel on the project to be imple­
engagement was again identified in both CASA stakeholder surveys mented, followed by cascading training down, based on organisational
where only 33 % (both survey 1 and 2) of participants showed their structure. However, inadequate training opportunities highlighted in
agreeance on a statement: “CASA is actively involved in relevant com­ Section 5.1.2 suggest that there is a disconnect between an under­
mittees and events” [11,28], suggesting a significant improvement on standing of regulations at a head-office level and staff operating at the
the stakeholder engagement is urgently needed. ground-level [28].
Amaeshi and Crane [2] highlight the crucial role of stakeholder The relevant recounts from the participants already presented
engagement as a mechanism for achieving sustainable aviation, against all six key considerations suggest that TEM implementation in
emphasising that understanding and integrating the perspectives of Australian general aviation was perceived by many as laissez-faire.
various stakeholders are essential for developing effective and sustain­ Despite the poor implementation of TEM, however, it became a
able aviation policies. Similarly, Kivits and Charles [34] explore aviation mandatory flight test item in 2009 and hence it was required to be
planning policy in Australia, demonstrating that the identification and taught, assessed, and practised.
consideration of diverse stakeholder frames of reference facilitate better
navigation through complex policy landscapes. Kivits and Charles [34] 4.2.4. Threat and Error Management in practice
underscore the necessity of recognizing and addressing the distinct The final main theme is how TEM has been taught and practised (i.e.,
perspectives held by stakeholders in the aviation sector to ensure the TEM in practice) since its implementation in 2009. According to

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participant 5, their pre-flight briefing structure was modified by ‘… adversely affected the way TEM was taught and practised in Australian
putting TEM as an addition to the briefing…at the end of the briefings’. general aviation. Since our study, however, it is encouraging to note that
Participant 4 agreed that it is more appropriate to be covered as part of a CASA has been proactively fostering continuous skill development and
pre-flight briefing prior to flight because ‘we are able to actually consider strategic workforce planning in enhancing aviation safety and regula­
environmental factors of the day…the actual condition of the aircraft in tory initiatives. In addition, CASA has adjusted its approach to actively
which we are flying on that day’. implement stakeholder engagement through its Technical Working
After TEM demonstration became a flight test requirement, TEM Groups by inviting industry members, technical experts and other
briefings were incorporated into relevant in-flight briefings and partic­ interested aviation community members to work cooperatively with the
ipant 3 highlighted that the briefings were not given the deserved aviation industry. These efforts are expected to have a positive impact
attention and consideration nor completed the way they are intended to on well-informed policy development and implementation that are
be by commenting, ‘the ritual chant to please the gods’. Participant 5 made relevant, responsive and sustainable for the Australian GA industry.
a similar comment that ‘Just the old parrot fashion…some of them just rote, The International Civil Aviation Organisation (ICAO) has recom­
just rattle it off…unfortunately, they are not practised conscientiously’. mended that TEM training be a requirement for all levels of pilot licences
Participant 2 also agreed that ‘They mouth this off, but they don’t really as well as initial and recurrent flight crew training. Despite this, not all
understand what they are actually telling you’. Participant 3 explained that ICAO contracting states have mandated TEM training in their regulatory
flight test candidates had to verbalise these briefings because ‘…the way requirements. Therefore, it is expected that the findings from this study
of doing all that was, unless I can hear you say something that shows me that add to the body of knowledge to better inform and provide a guidance
you are doing it, I can’t tick that box’. Participant 3 continued to express a and reference for National Aviation Authorities (NAA) to develop an
safety concern with the prevalence of poor briefing practices that ‘… implementation plan and to enhance education and training material in
they’ve given me whole this spiel and I’m sitting there and I’m watching this the area of TEM and human factors when considering the implementa­
aircraft, converging on us from my right…but he was so busy with saying his tion of TEM training in their regulatory framework. In addition, the
spiels, he wasn’t actually doing threat and error management by keeping his findings have the potential to provide information regarding pilot atti­
eyes open…so the whole briefing meant nothing’. tudes to future safety initiatives in other rapidly growing sectors such as
Based on the participants’ comments, it was again evident that poor Recreational Aviation (RA) and Remotely Piloted Aircraft System
TEM implementation has negatively affected the way TEM is taught and (RPAS).
practised in Australian general aviation. The participants’ main criticism
involved individuals verbalising a series of briefings without conscien­ CRediT authorship contribution statement
tiously thinking about the real-life situation. Daily practice of these
artificial briefings that may not be appropriate to actual conditions on a Seung Yong Lee: Writing – review & editing, Writing – original
particular day is the area that is particularly a safety concern which draft, Validation, Project administration, Methodology, Investigation,
needs immediate attention. Despite the overall poor implementation, Formal analysis, Data curation, Conceptualization. Paul Bates: Writing
findings from the two CASA surveys show that the majority of partici­ – review & editing, Supervision, Methodology, Conceptualization. Pat­
pants (63 % and 65 % respectively) agree on the statement: “Regula­ rick Murray: Writing – review & editing, Supervision, Methodology,
tions play a key role in ensuring I operate safely”. This suggests that Conceptualization. Yahua Zhang: Writing – review & editing.
there is a potential for TEM to be valued and practised as intended by GA
communities. Declaration of Competing Interest
The research insights from Kearns and Sutton [33], Helmreich [29],
and Maurino [40] underscore the pivotal role of TEM in operational The authors declare that they have no known competing financial
aviation safety and the indispensable function of regulations in its interests or personal relationships that could have appeared to influence
effective implementation. Helmreich [29] draws lessons from aviation the work reported in this paper.
to advocate error management strategies that include understanding
error, changing conditions to reduce error, and training personnel in Data Availability
error mitigation, asserting the influence of regulations in standardizing
these processes. Kearns and Sutton [33] highlight the use of naturalistic The interview data are no longer accessible.
stories as a method to inform TEM training, emphasizing the integration
of human factors knowledge through narrative. Maurino [40], coordi­ References
nating flight safety at ICAO, discusses TEM as a safety concept evolving
from industry experience, emphasizing operational context – organisa­ [1] D. Adams, A Layman’s Introduction to Human Factors in Aircraft Accident and
Incident Investigation, B2006/0094, Australian Transport Safety Bureau, Canberra,
tional, regulator, and environmental factors – as crucial to human per­ Australia, 2006.
formance in aviation, thereby linking regulations directly to safety [2] K.M. Amaeshi, A. Crane, Stakeholder engagement: a mechanism for sustainable
improvements. Together, these studies have provided pillars to address aviation, Corp. Soc. Responsib. Environ. Manag. 13 (5) (2006) 245–260.
[3] R. Amalberti, Y. Auroy, D. Berwick, P. Barach, Five system barriers to achieving
the possible past implementation limitations in the Australian context, ultrasafe health care, Ann. Intern Med 142 (9) (2005). Doi: 10. 7326/0003-4819-
by delineating how regulations not only underpin but are integral to the 142-9-200505030-00012.
successful application of TEM in aviation, suggesting a symbiotic rela­ [4] Australian Government (2023) Statement of Expectations for the Civil Aviation
Safety Authority from 1 July 2023 to 30 June 2025 〈https://www.legislation.gov.
tionship between regulator frameworks and the operationalization of
au/F2023L00920/latest/text〉.
TEM principles for advancing safety. [5] Australian National Audit Office, Successful Implementation of Policy Initiatives:
Better Practice Guide, Commonwealth of Australia, Canberra, Australia, 2014.
[6] Australian Transport Safety Bureau, Aviation Occurrence Statistics: 2006 – 2015,
5. Conclusion AR-2016-122, Commonwealth of Australia, Canberra, Australia, 2017.
[7] Australian Transport Safety Bureau, Accidents Involving Visual Flight Rules Pilots
The central focus of this study was to better understand how TEM in Instrument Meteorological Conditions, AR-2011-050, Commonwealth of
Australia, Canberra, Australia, 2019.
was implemented in Australian general aviation. We reviewed relevant
[8] Australian Transport Safety Bureau, Aviation Occurrence Statistics: 2010 – 2019,
case study materials and conducted our own interviews. Four themes AR-2020-047, Commonwealth of Australia, Canberra, Australia, 2020.
arose from the analysis emerged: impracticality, lack of support and [9] T. Bove, Development and Validation of a Human Error Management Taxonomy in
guidance, TEM implementation and TEM in practice. All participants Air Traffic Control (Riso-R-1378[EN]), Roso National Laboratory, Roskilde,
Denmark, 2002.
shared the same view that TEM was not implemented properly as had [10] V. Braun, V. Clarke, Using thematic analysis in psychology, Qual. Res. Psychol. 3
been hoped. It was evident that the first three themes would have (2) (2006) 77–101.

329
S.Y. Lee et al. Transport Economics and Management 2 (2024) 322–330

[11] Colmar Brunton, Civil Aviation Safety Authority: Stakeholder Relationship Health, [34] R. Kivits, M.B. Charles, Aviation planning policy in Australia: Identifying frames of
Colmar Brunton Social Research, QLD, Australia, 2018. reference to support public decision making, J. Air Transp. Manag. 47 (2015)
[12] K.R. Catchpole, A.E.B. Giddings, M.R. de Laval, G.J. Peek, P.J. Godden, M. Utley, 102–111.
S. Gallian, G. Hirst, T. Dale, Identification of systems failures in successful [35] S.Y. Lee, P.R. Bates, P.S. Murray, W.L. Martin, An exploratory study on the post-
paediatric cardiac surgery, Ergonomics 49 (5) (2006). Doi: 10.1080/ implementation of threat and error management training in Australian general
00140130600568865. aviation, Int. J. Train. Res. 15 (2) (2017) 136–147.
[13] A.A. Cengiz, A.E. DEMİRCİ, Impact of social capital on radical innovation efforts of [36] J. Lee, Y.-H. Huang, M.J. Dainoff, Y. He, Where to focus? Insights from safety
the organizations: a case in the aviation industry, Ege Acad. Rev. 12 (1) (2012) personnel and external safety consultants on lessons learned about safety climate
53–66. interventions – A qualitative approach, J. Saf. Res. 79 (2021) 51–67, https://doi.
[14] K. Cheng, M. Inglis, S.T. Godley, Threat and Error Management: Attitudes Towards org/10.1016/j.jsr.2021.08.005.
Training and Applicability of TEM to General Aviation and Low-capacity Air [37] M.B Miles, A.M. Huberman, J.Saldana, 2014, Qualitative data analysis: a methods
Transport Operations (AR-2006-156, Australian Transport Safety Bureau, s2014, Sourcebook, 3rd ed.)., Sage, Thousand Oaks, CA.
Canberra, Australia, 2009. [38] M. Maguire, B. Delahunt, Doing a thematic analysis: a practical, step-by-step guide
[15] Civil Aviation Safety Authority, Teaching and Assessing Single-pilot Human for learning and teaching scholars, AISHE-J. 8 (3) (2017) 3351–33514.
Factors and Threat and Error Management (CAAP 5.59-1), Author, Canberra, [39] G. Maliha, S. Gerke, G. Cohen, R.B. Parikh, Artificial Intelligence and liability in
Australia, 2008. medicine: Balancing safety and innovation, The Milbank Quarterly 99 (3) (2021)
[16] Civil Aviation Safety Authority, Annual Report 2009-2010, Author, Canberra, 629–647.
Australia, 2010. [40] D. Maurino, C.A.S. Seminar, Threat and error management (TEM) (April), Can.
[17] Civil Aviation Safety Authority (2022a) General Aviation Work Plan 〈https://www. Aviat. Saf. Semin. (CASS) (2005) 18–20.
casa.gov.au/sites/default/files/2022-06/general-aviation-workplan-printable. [41] J.A. Maxwell, M. Chmiel, Generalization in and from qualitative analysis, in:
pdf〉. U. Flick (Ed.), The SAGE handbook of qualitative data analysis, SAGE, US, 2014,
[18] Civil Aviation Safety Authority (2022b) Corporate Plan 2022-2023 〈https://previe pp. 540–553.
wapi.transparency.gov.au/delivery/assets/80a82ed1-3e33-027b-b7e0-6493f97f [42] Merritt, A., & Klinect, J. (2006). Defensive flying for pilots: An introduction to
18f8/3629ad7e-0fd6-4183-8894-fe9b5f9030b6/2022-23_civil_aviation_safety_aut Threat and Error Management. The University of Texas Human Factors Research
hority_corporate_plan.pdf〉. Project: The LOSA Collaborative. Austin, Texas.
[19] Civil Aviation Safety Authority. (n.d.). CASA Consultative Hub. 〈https://consulta [43] Oxford University Press (2023). English: Oxford English Dictionary. Retrieved from
tion.casa.gov.au/〉. 〈https://www.oed.com/dictionary/practicality_n?tl=true〉.
[20] Civil Aviation Safety Authority. (n.d.). Plane English Guides. 〈https://www.casa. [44] B. Pink, 2012 Year Book Australia (No. 1301.0), Australian Bureau of Statistics,
gov.au/search-centre/plain-english-guides〉. Canberra, Australia, 2012.
[21] Commonwealth of Australia, Aviation Green Paper: Towards 2050, Author, [45] K.J. Ruskin, M.P. Stiegler, K. Park, P. Guffey, V. Kurup, T. Chidester, Threat and
Canberra, Australia, 2023. error management for anesthesiologiests: a predictive risk taxonomy, Curr. Opin.
[22] J.W. Creswell. Qualitative inquiry and research design: Choosing among five Anesthesiol. 26 (6) (2013). Doi: 10/1097/ACO.0000000000000014.
traditions, Sage, London, 1998. [46] N.B. Sarter, H.M. Alexander, Error types and related error detection mechanisms in
[23] E.T. Cullen, Tell me a story using stories to improve occupational safety training, aviation domain: An analysis of aviation safety reporting system incident reports,
Prof. Saf. 53 (07) (2008). Int. J. Aviat. Psychol. 10 (2) (2000). Doi: 10.1207/S15327108IJAP1002_5.
[24] E. Denney, G. Pai, I. Whiteside, The role of safety architectures in aviation safety [47] S.L. Schooner, Communicating governance: will plain english drafting improve
cases, Reliab. Eng. Syst. Saf. 191 (2019) 106502. regulation, Geo. Wash. L. Rev. 70 (2002) 163.
[25] Emerson, B., & Blake, C. (2017, December). Plain language in regulatory drafting. [48] A.J. Stolzer, J.J. Goglia. Safety Management Systems in Aviation, 2nd ed.).,
In Administrative Conference of the United States (December). 〈https://www〉. acus. Ashgate, Abingdon, Oxon, 2016.
gov/sites/default/files/documents/Plain% 5C% 20Regulatory% 5C% 20Drafting_ [49] R.Y. Sunindijo, Improving safety among small organisations in the construction
Final% 5C% 20Report. pdf. industry: Key barriers and improvement strategies, Procedia Eng. 125 (2015)
[26] European Union Aviation Safety Agency, General aviation loss of control – in flight 109–116.
fact sheet, Author, Cologne, Germany, 2016. [50] M.J.W. Thomas, Error management training: Defining best practice (No. 2004/
[27] J. Farokhzadian, N. Dehghan Nayeri, F. Borhani, The long way ahead to achieve an 2005 - ATSB Aviation Safety Research Grant Scheme Project), University of South
effective patient safety culture: challenges perceived by nurses, BMC Health Serv. Australia, Adelaide, SA, 2004.
Res. 18 (2018) 1–13. [51] van der Schaaf, T.W. (1995). Human recovery of errors in man-machine systems.
[28] Faster Horses CASA stakeholder satisfaction research, Faster Horses Consulting In: Proceedings of the 6th IFAC/IFIP/IFORS/IEA Symposium on the Analysis,
2021 WA, Australia. Design and Evaluation of Man-Machine system, June 1995, Cambridge, MA.
[29] R.L. Helmreich, On error management: lessons from aviation, Bmj 320 (7237) [52] M. Vaskova Kjulavkovska, G.O. Serafini, L.T. Szamosi, Integrating training and
(2000) 781–785. performance management of civil aviation inspectors: A pilot study of the
[30] R.L. Helmreich, A.C. Merritt, J.A. Wilhelm, The evolution of crew resource mediating role of competency-based training, Int. J. Train. Dev. 26 (1) (2022)
management training in commercial aviation, in: International Journal of Aviation 29–54.
Psychology, 9, Routledge, 1999, pp. 19–32. [53] D. Watkins, J.M. Newcomer, M.P. Earnhardt, J.W. Marion, R.A. Opengart, A.
[31] C. Houghton, P. Meskell, H. Delaney, M. Smalle, C. Glenton, L.M. Biesty, Barriers M. Glassman, A cross-sectional investigation of the relationships education,
and facilitators to healthcare workers’ adherence with infection prevention and certification, and experience have with knowledge, skills, and abilities among
control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative aviation professionals, Int. J. Aviat., Aeronaut., Aerosp. 3 (1) (2016) 6.
evidence synthesis, Cochrane Database Syst. Rev. 2020 (8) (1996). [54] D. Wiegmann, S. Shappell, A Human Error Approach to Aviation Accident Analysis:
[32] International Civil Aviation Organisation, Threat and Error Management (TEM) in The Human Factors Analysis and Classification System, Ashgate, Aldershot, UK,
air traffic control, Author, Montreal, Canada, 2005. 2003.
[33] S. Kearns, J.E. Sutton, Exploring the experiences of pilots within Canadian general [55] Y. Zhang, C.C.H. Law, A. Zhang, The efficiency performance of full-service carriers
aviation flight operations, Coll. Aviat. Int 30 (1) (2012) 16–31. in East and Southeast Asia amid increasing air transport liberalisation and LCC
presence, in: K. Button (Ed.), Airlines and developing countries, Emerald
publishing, UK, 2023, pp. 137–151.

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