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航空发表于 2010-4-12 17:29:28

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.4.3</st1:chsdate> The number of observers needed depends, as<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
already discussed, on the intended scope of the audit. For<o:p></o:p>
example, an airline might want to audit 50 flight crews in<o:p></o:p>
each of 2 domestic fleets, for a total of 100 segments. A<o:p></o:p>
conservative rule of thumb to scope this audit would be<o:p></o:p>
2 domestic observations per day per observer. The goal is<o:p></o:p>
thus expressed in terms of flight crews observed, rather than<o:p></o:p>
segments. Should an airline want to audit an international<o:p></o:p>
fleet, the first step is to determine how many international<o:p></o:p>
observations can be made in a day, and this depends on the<o:p></o:p>
length of the segments. For a domestic LOSA, a workable<o:p></o:p>
rule of thumb suggests the need for 50 person/days of work<o:p></o:p>
for the actual audit phase of the LOSA. Using line pilots for<o:p></o:p>
a month of observations, each might be requested to spend<o:p></o:p>
10 days conducting observations, plus 4 days training/<o:p></o:p>
travelling. This requires 14 days per observer. Thus, there<o:p></o:p>
would be a need for 4 observers for this hypothetical audit,<o:p></o:p>
2-8 Line Operations Safety Audit (LOSA)<o:p></o:p>
and this should easily meet the audit’s goals. It is important<o:p></o:p>
to be conservative in the estimates since sometimes it will<o:p></o:p>
be necessary to observe a crew for more than one segment.<o:p></o:p>This counts as one crew, not two.

航空发表于 2010-4-12 17:29:43

<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p> </o:p>
2.5 ONCE THE DATA IS COLLECTED<o:p></o:p>
The data acquired through the observations must be<o:p></o:p>
“verified” and prepared for analysis, and the time involved<o:p></o:p>
in this process should not be underestimated. Once the<o:p></o:p>
various LOSA forms have been collected, the airline is ready<o:p></o:p>
to begin a lengthy process. It typically takes longer to<o:p></o:p>
prepare the LOSA data for analysis and ulterior action than<o:p></o:p>
it does to collect it. The steps that must be followed in this<o:p></o:p>
process include data entry, data quality/consistency checks<o:p></o:p>
and final aggregation.<o:p></o:p>

航空发表于 2010-4-12 17:29:59

2.6 WRITING THE REPORT<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.6.1</st1:chsdate> The last stage of LOSA is a written report that<o:p></o:p>
presents the overall findings of the project. With a large<o:p></o:p>
database like the one generated from a LOSA, it is easy to<o:p></o:p>
fall into the trap of trying to present too much information.<o:p></o:p>
The author needs to be concise and present only the most<o:p></o:p>
significant trends from the data. If the report does not<o:p></o:p>
provide a clear diagnosis of the weaknesses within the<o:p></o:p>
system for management to act upon, the objective of the<o:p></o:p>
LOSA will be unfulfilled.<o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.6.2</st1:chsdate> Writing the report is where “data smarts” enters<o:p></o:p>
into the process. Although certain types of comparisons will<o:p></o:p>
seem obvious, many analyses will be based upon the<o:p></o:p>
“hunches” or “theories” of the writer. The usefulness of the<o:p></o:p>
result has to be the guiding principle of this effort. If the<o:p></o:p>
writer knows how fleets and operations are managed,<o:p></o:p>
comparisons that reflect this structure can be made. If the<o:p></o:p>
author knows the kinds of information that might be useful<o:p></o:p>
to training, safety or domestic/international flight operations,<o:p></o:p>
results can be tailored to these particular aspects of<o:p></o:p>
the operation. Feedback from various airline stakeholders is<o:p></o:p>
critical during this stage of writing the report. Authors<o:p></o:p>
should not hesitate to distribute early drafts to key people<o:p></o:p>
familiar with LOSA to verify the results. This not only helps<o:p></o:p>
validate derived trends, but it gives other airline personnel,<o:p></o:p>
besides the author, ownership of the report.<o:p></o:p>

航空发表于 2010-4-12 17:30:15

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.6.3</st1:chsdate> General findings from the survey, interview and<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
observational data should serve as the foundation in<o:p></o:p>
organizing the final report. A suggested outline for the report<o:p></o:p>
follows:<o:p></o:p>
Introduction — Define LOSA and the reasons why it<o:p></o:p>
was conducted.<o:p></o:p>
Executive Summary — Include a text summary of the<o:p></o:p>
major LOSA findings (no longer than two pages).<o:p></o:p>
Section Summaries – Present the key findings from each<o:p></o:p>
section of the report including:<o:p></o:p>
I — Demographics<o:p></o:p>
II — Safety Interview Results<o:p></o:p>
III — External Threats and Threat Management<o:p></o:p>
Results<o:p></o:p>
IV — Flight Crew Errors and Error Management<o:p></o:p>
Results<o:p></o:p>
V — Threat and Error Countermeasure Results<o:p></o:p>
Appendix — Include a listing of every external threat<o:p></o:p>
and flight crew error observed with the proper coding<o:p></o:p>
and an observer narrative of how each one was managed<o:p></o:p>
or mismanaged.<o:p></o:p>

航空发表于 2010-4-12 17:30:26

Tables, charts and explanations of data should be provided<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
within each section of the report.<o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.6.4</st1:chsdate> It is important to remember that the author’s<o:p></o:p>
primary job is to present the facts and abstain from outlining<o:p></o:p>
recommendations. This keeps the report concise and<o:p></o:p>
objective. Recommendations and solutions may be given<o:p></o:p>
later in supporting documentation after everyone has had the<o:p></o:p>
chance to digest the findings.<o:p></o:p>
2.7 SUCCESS FACTORS FOR LOSA<o:p></o:p>
The best results are achieved when LOSA is conducted in<o:p></o:p>
an open environment of trust. Line pilots must believe that<o:p></o:p>
there will be no repercussions at the individual level;<o:p></o:p>
otherwise, their behaviour will not reflect daily operational<o:p></o:p>
reality and LOSA will be little more than an elaborate line<o:p></o:p>
check. Experience at different airlines has shown that several<o:p></o:p>
strategies are key to ensuring a successful, data-rich LOSA.<o:p></o:p>
These strategies include:<o:p></o:p>

航空发表于 2010-4-12 17:30:38

• Using third-party oversight: One way to build trust<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
in the LOSA process is to seek a credible but neutral<o:p></o:p>
third party who is removed from the politics and<o:p></o:p>
history of the airline. Data can be sent directly to this<o:p></o:p>
third party, who is then responsible for the objective<o:p></o:p>
analyses and report preparation. The University of<o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:State w:st="on"><st1:place w:st="on">Texas</st1:place></st1:State> at Austin Human Factors Research Project<o:p></o:p>
provides, for the time being, such third party<o:p></o:p>
oversight;<o:p></o:p>
Chapter 2. Implementing LOSA 2-9<o:p></o:p>
• Promoting LOSA: Use group presentations, media<o:p></o:p>
clippings, experience from other airlines and intraairline<o:p></o:p>
communications to discuss the purpose and<o:p></o:p>
logistics of a LOSA audit with management, pilots<o:p></o:p>
and any pilots associations. Experience shows that<o:p></o:p>
airlines often underestimate the amount of communication<o:p></o:p>
required so they must be persistent in<o:p></o:p>
their efforts;<o:p></o:p>

航空发表于 2010-4-12 17:30:48

• Stressing that observations cannot be used for<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
discipline purposes: This is the key issue and must<o:p></o:p>
be stated as such in the letter of endorsement;<o:p></o:p>
• Informing the regulatory authority of the proposed<o:p></o:p>
activity: It is as much a courtesy as it is a way of<o:p></o:p>
communicating the presence of LOSA;<o:p></o:p>
• Choosing a credible observer team: A line crew<o:p></o:p>
always has the prerogative to deny cockpit access to<o:p></o:p>
an observer; hence the observer team is most<o:p></o:p>
effective when composed of credible and wellaccepted<o:p></o:p>
pilots from a mix of fleets and departments<o:p></o:p>
(for example, training and safety). This was achieved<o:p></o:p>
at one airline by asking for a list of potential<o:p></o:p>
observers from the management and the pilots<o:p></o:p>
association; those pilots whose names appeared on<o:p></o:p>
both lists were then selected as acceptable to<o:p></o:p>
everyone;<o:p></o:p>

航空发表于 2010-4-12 17:31:00

• Using “a fly on the wall” approach: The best<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
observers learn to be unobtrusive and nonthreatening;<o:p></o:p>
they use a pocket notebook while in the<o:p></o:p>
cockpit, recording minimal detail to elaborate upon<o:p></o:p>
later. At the same time, they know when it is<o:p></o:p>
appropriate to speak up if they have a concern,<o:p></o:p>
without sounding authoritarian;<o:p></o:p>
• Communicating the results: Do not wait too long<o:p></o:p>
before announcing the results to the line or else<o:p></o:p>
pilots will believe nothing is being done. A summary<o:p></o:p>
of the audit, excerpts from the report and relevant<o:p></o:p>
statistics will all be of interest to the line; and<o:p></o:p>
• Using the data: The LOSA audit generates targets<o:p></o:p>
for enhancement, but it is the airline that creates an<o:p></o:p>
action plan. One airline did this by creating a<o:p></o:p>
committee for each of the central concerns, and they<o:p></o:p>
were then responsible for reviewing procedures,<o:p></o:p>
checklists, etc., and implementing change, where<o:p></o:p>
appropriate.<o:p></o:p>

航空发表于 2010-4-12 17:31:12

3-1<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Chapter 3<o:p></o:p>
LOSA AND THE SAFETY CHANGE PROCESS (SCP)<o:p></o:p>
3.1 INTRODUCTION<o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.1.1</st1:chsdate> When an airline commits to LOSA, it must also<o:p></o:p>
commit to acting upon the results of the audit. LOSA is but<o:p></o:p>
a data collection tool. LOSA data, when analysed, are used<o:p></o:p>
to support changes aimed at improving safety. These may be<o:p></o:p>
changes to procedures, policies or operational philosophy.<o:p></o:p>
The changes may affect multiple sectors of the organization<o:p></o:p>
that support flight operations. It is essential that the organization<o:p></o:p>
has a defined process to effectively use the analysed<o:p></o:p>
data and to manage the changes the data suggest.<o:p></o:p>

航空发表于 2010-4-12 17:31:25

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.1.2</st1:chsdate> LOSA data should be presented to management<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
in at least the areas of operations, training, standards and<o:p></o:p>
safety, with a clear analysis describing the problems related<o:p></o:p>
to each, as captured by LOSA. The LOSA report should<o:p></o:p>
clearly describe the problems the analysed data suggest but<o:p></o:p>
should not attempt to provide solutions. These will be better<o:p></o:p>
provided through the expertise in each of the areas in<o:p></o:p>
question.<o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.1.3</st1:chsdate> LOSA directs organizational attention to the<o:p></o:p>
most important safety issues in daily operations and it<o:p></o:p>
suggests what questions should be asked; however, LOSA<o:p></o:p>
does not provide the solutions. The solutions lie in<o:p></o:p>
organizational strategies. The organization must evaluate the<o:p></o:p>
data obtained through LOSA, extract the appropriate<o:p></o:p>
information and then carry out the necessary interventions<o:p></o:p>
to address the problems thus identified. LOSA will only<o:p></o:p>
realize its full potential if the organizational willingness and<o:p></o:p>
commitment exist to act upon the data collected and the<o:p></o:p>
information such data support. Without this necessary step,<o:p></o:p>
LOSA data will join the vast amounts of untapped data<o:p></o:p>
already existing throughout the international civil aviation<o:p></o:p>
community.<o:p></o:p>

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