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航空发表于 2010-4-13 16:41:49

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">3.3.3</st1:chsdate> When the airline started conducting base-line<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
observations in 1996, the crew error-trapping rate was 15 per<o:p></o:p>
cent; that is, flight crews detected and trapped only 15 per<o:p></o:p>
cent of the errors they committed. After two years, following<o:p></o:p>
implementation of organizational strategies aimed at error<o:p></o:p>
management based on LOSA data, the crew error-trapping<o:p></o:p>
rate increased to 55 per cent (see Figure 3-2).<o:p></o:p>
<st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">3.3.4</st1:chsdate> Base-line observations in 1996 suggested<o:p></o:p>
problems in the area checklist performance. Following<o:p></o:p>
remedial interventions — including review of standard<o:p></o:p>
operating procedures, checklist design and training —<o:p></o:p>
checklist performance errors decreased from 25 per cent to<o:p></o:p>
15 per cent, which is a 40 per cent reduction in checklist<o:p></o:p>
errors (see Figure 3-3).<o:p></o:p>

航空发表于 2010-4-13 16:42:01

Figure 3-2. Crew error-trapping rate<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Figure 3-3. Checklist errors<o:p></o:p>
15%<o:p></o:p>
55%<o:p></o:p>
0%<o:p></o:p>
10%<o:p></o:p>
20%<o:p></o:p>
40%<o:p></o:p>
50%<o:p></o:p>
60%<o:p></o:p>
1996 1998<o:p></o:p>
30%<o:p></o:p>
25%<o:p></o:p>
15%<o:p></o:p>
0%<o:p></o:p>
5%<o:p></o:p>
10%<o:p></o:p>
15%<o:p></o:p>
20%<o:p></o:p>
25%<o:p></o:p>
1996 1998<o:p></o:p>
40%<o:p></o:p>
Reduction<o:p></o:p>
Chapter 3. LOSA and the safety change process (SCP) 3-5<o:p></o:p>

航空发表于 2010-4-13 16:42:11

航空发表于 2010-4-13 16:42:21

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">3.3.6</st1:chsdate> How does such change take place? By adopting<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
a defined SCP. Following data acquisition and analysis, the<o:p></o:p>
airline decided to form specific committees including a<o:p></o:p>
checklist committee and an unstabilized approaches committee.<o:p></o:p>
Each committee considered the problems identified<o:p></o:p>
by the analysis of the LOSA data and then proposed<o:p></o:p>
organizational interventions to address them. Such interventions<o:p></o:p>
included modification of existing procedures,<o:p></o:p>
implementation of new ones, specific training, and<o:p></o:p>
redefinition of operational philosophies, among others. For<o:p></o:p>
example, checklists were reviewed to ensure relevance of<o:p></o:p>
contents, and clear guidelines for their initiation and<o:p></o:p>
execution were promulgated. Gates and tolerances for<o:p></o:p>
stabilized approaches were defined, as opposed to the<o:p></o:p>
“perfect approach” parameters promulgated by the SOPs<o:p></o:p>
existing at that time. Proper training and checking guidelines<o:p></o:p>
were established, taking into account an error management<o:p></o:p>
approach to crew coordination.<o:p></o:p>

航空发表于 2010-4-13 16:42:31

航空发表于 2010-4-13 16:42:42

4-1<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Chapter 4<o:p></o:p>
HOW TO SET UP A LOSA — US AIRWAYS EXPERIENCE<o:p></o:p>
“Honest and critical self-assessment is one of the most<o:p></o:p>
powerful tools that management can employ to measure<o:p></o:p>
flight safety margins.”<o:p></o:p>
Flight Safety Foundation Icarus Committee<o:p></o:p>
May 1999<o:p></o:p>
4.1 GATHERING INFORMATION<o:p></o:p>
In order to decide if conducting a LOSA would be<o:p></o:p>
beneficial, it is important to understand the LOSA process.<o:p></o:p>
The first contact should be ICAO or The University of Texas<o:p></o:p>
at Austin Human Factors Research Project. Both are able to<o:p></o:p>
provide all the information needed and can discuss benefits<o:p></o:p>
that have been derived from past LOSAs. They will also be<o:p></o:p>
aware of other airlines currently planning or conducting a<o:p></o:p>
LOSA, and it may be possible to attend those airlines’<o:p></o:p>
training classes. It is also a good idea to talk with and/or visit<o:p></o:p>
other airlines that have already completed a LOSA to learn<o:p></o:p>
from their experiences.<o:p></o:p>

航空发表于 2010-4-13 16:42:52

航空发表于 2010-4-13 16:43:02

航空发表于 2010-4-13 16:43:12

航空发表于 2010-4-13 16:43:21

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