Analysis of the aviation safety issues using TEM framework

This paper analyzes safety issues using Threat and Error Management (TEM) framework. Safety reports for the last decade were analyzed with special emphasis on year 2008. Causes of the accidents were determined and top three contributing factors were defined. Most common end states were identified and chains of events that led to them were analyzed. Furthermore, countermeasures were proposed in order to mitigate those safety concerns. Special care was taken to correctly identify those safety issues that stemmed from inefficient safety management systems, especially on the Operator's level. Even though there is a general industry standard regarding safety management systems, it still has to be customized and optimized by each operator in order to gain the most out of it. Organizational procedures vary significantly from one operator to the other, reflecting size and structure of the monitored fleet, size of the operator and its engineering power. Therefore, it is often hard to adapt the safety management system to fit these organizational procedures. This inconsistency is a common contributing factor to aviation accidents.