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航空发表于 2010-4-12 17:31:50

航空发表于 2010-4-12 17:33:34

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chmetcnv w:st="on" TCSC="0" NumberType="1" Negative="False" HasSpace="True" SourceValue="3.2" UnitName="a">3.2 A</st1:chmetcnv> CONSTANTLY CHANGING SCENE<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.2.1 A</st1:chsdate>irlines are continually involved in changes that,<o:p></o:p>
at some point or other, have an effect upon safety. Factors<o:p></o:p>
underlying this continuous change process include, among<o:p></o:p>
others, regulatory changes (airworthiness directives, advisory<o:p></o:p>
circulars, etc.); changes in national or international<o:p></o:p>
airspace systems (automatic dependent surveillance (ADS),<o:p></o:p>
data link/controller-pilot data link communications<o:p></o:p>
(CPDLC), reduced vertical separation, extended range<o:p></o:p>
operations by twin-engined aeroplanes (ETOPS), etc.);<o:p></o:p>
changes to improve operational efficiencies (reduction of<o:p></o:p>
costs, improvement of on-time performance, etc.); operational<o:p></o:p>
events (diversions, rejected take-offs, etc.); and<o:p></o:p>
progress (route expansion, fleet modernization, new<o:p></o:p>
technologies, etc.)<o:p></o:p>

航空发表于 2010-4-12 17:34:14

<?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">3.2.2</st1:chsdate> Virtually everyone in an airline is somehow<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
involved in these changes. For example, Chief Executive<o:p></o:p>
Officers and their staff decide to buy new equipment;<o:p></o:p>
marketing opens up new routes; engineering must install<o:p></o:p>
new components; flight operations faces new staffing<o:p></o:p>
requirements and adjustments to line procedures; flight<o:p></o:p>
standards must define new policies and procedures; and<o:p></o:p>
flight training faces acquisition of new simulators.<o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.2.3</st1:chsdate> These changes are achieved and monitored both<o:p></o:p>
through established formal and informal mechanisms<o:p></o:p>
underlying change processes. Formal mechanisms include<o:p></o:p>
meetings (daily, weekly, monthly and quarterly), reports and<o:p></o:p>
reviews at all levels of the organization. Informal<o:p></o:p>
3-2 Line Operations Safety Audit (LOSA)<o:p></o:p>
mechanisms include crosstalk, spontaneous information<o:p></o:p>
transfer, and sharing in general by everyone in the<o:p></o:p>
organization. Both mechanisms work toward actively<o:p></o:p>
maintaining focus on the changes affecting safety.<o:p></o:p>

航空发表于 2010-4-12 17:34:25

<?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">3.2.4</st1:chsdate> Therefore, when in spite of these formal and<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
informal mechanisms an airline experiences an accident or<o:p></o:p>
an incident, the immediate question arises: What is<o:p></o:p>
happening “out there”? The fact is that system changes and<o:p></o:p>
organizational responses to these changes generate active<o:p></o:p>
and latent threats to daily line operations. Active and latent<o:p></o:p>
threats themselves constantly change in a manner proportional<o:p></o:p>
to system changes. Active and latent threats<o:p></o:p>
become the breeding grounds of crew errors. Many organizations<o:p></o:p>
are not aware of these active and latent threats for<o:p></o:p>
a number of reasons, including the following:<o:p></o:p>
• The “big picture” of flight operations is constantly<o:p></o:p>
changing because of the constantly changing scene;<o:p></o:p>
• Crews may not report threats, fearing punishment;<o:p></o:p>
• Crews may not report threats because they do not<o:p></o:p>
receive any feedback on their reports;<o:p></o:p>
• Crews operate unsupervised most of the time;<o:p></o:p>
• Line Checks (supervised performance) are poor<o:p></o:p>
indicators of normal operations; and<o:p></o:p>
• Management may have difficulty screening out valid<o:p></o:p>
reported crew concerns from over-reported crew<o:p></o:p>
complaints.<o:p></o:p>

航空发表于 2010-4-12 17:34:40

航空发表于 2010-4-12 17:34:49

航空发表于 2010-4-12 17:34:59

航空发表于 2010-4-12 17:35:16

<?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">3.2.8</st1:chsdate> In the past, SCPs were based on accident and<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
incident investigations, experience and intuition. Today,<o:p></o:p>
SCPs must be based on the “data wave”, the “data<o:p></o:p>
warehouse” and the “drill-down” analysis. Measurement is<o:p></o:p>
fundamental, because until an organization measures, it can<o:p></o:p>
only guess. In the past, SCPs dealt with accidents. Today,<o:p></o:p>
SCPs must deal with the precursors of accidents.<o:p></o:p>
3.3 ONE OPERATOR’S EXAMPLE<o:p></o:p>
OF AN SCP<o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">3.3.1</st1:chsdate> This section briefly presents some of the very<o:p></o:p>
positive results obtained by one airline that pioneered LOSA<o:p></o:p>
in international civil aviation. The examples represent a<o:p></o:p>
two-year period, between 1996 and 1998, and include<o:p></o:p>
Chapter 3. LOSA and the safety change process (SCP) 3-3<o:p></o:p>
aggregate data collected during 100 flight segments. During<o:p></o:p>
this two-year period, 85 per cent of the crews observed made<o:p></o:p>
at least one error during one or more segments, and 15 per<o:p></o:p>
cent of the crews observed made between two and five<o:p></o:p>
errors. Errors were recorded in 74 per cent of the segments<o:p></o:p>
observed, with an average of two errors per segment (see<o:p></o:p>
Chapter 2 for a description of the error categories in LOSA).<o:p></o:p>
These data, asserted as typical of airline operations,<o:p></o:p>
substantiated the pervasiveness of human error in aviation<o:p></o:p>
operations, while challenged beyond question the illusion of<o:p></o:p>
error-free operational human performance.<o:p></o:p>

航空发表于 2010-4-13 16:41:18

航空发表于 2010-4-13 16:41:36

Figure 3-1. Basic steps of the safety change process<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Re-measurement<o:p></o:p>
Measurement<o:p></o:p>
Risk analysis and<o:p></o:p>
prioritization of changes<o:p></o:p>
Listing of<o:p></o:p>
potential changes<o:p></o:p>
Analysis of<o:p></o:p>
targets<o:p></o:p>
Time allocation<o:p></o:p>
for changes<o:p></o:p>
Implementation<o:p></o:p>
of changes<o:p></o:p>
Selection and<o:p></o:p>
funding of changes<o:p></o:p>
LOSA<o:p></o:p>
3-4 Line Operations Safety Audit (LOSA)<o:p></o:p>

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