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航空发表于 2010-4-16 09:01:22

航空发表于 2010-4-16 09:01:33

航空发表于 2010-4-16 09:01:45

航空发表于 2010-4-16 09:01:56

Callout Errors<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
275 Omitted takeoff callouts (i.e., V-speeds)<o:p></o:p>
276 Omitted climb or descent callouts<o:p></o:p>
277 Omitted approach callouts<o:p></o:p>
Job Sequence Errors<o:p></o:p>
280 Executing the correct job procedures out of sequence<o:p></o:p>
Handling Errors<o:p></o:p>
281 Unintentional lateral deviation<o:p></o:p>
282 Unintentional vertical deviation<o:p></o:p>
286 Unintentional speed deviation<o:p></o:p>
Ground Navigation Errors<o:p></o:p>
283 Attempting or actually turning down the wrong runway<o:p></o:p>
284 Attempting or actually turning down the wrong ramp /<o:p></o:p>
taxiway / gate<o:p></o:p>
287 Attempting or actually lining up for the incorrect runway<o:p></o:p>
288 Attempting or actually lining up off C/L<o:p></o:p>
289 Failure to execute a go-around after passing procedural<o:p></o:p>
bottom lines of an unstable approach<o:p></o:p>
290 Missed runway<o:p></o:p>
291 Missed taxiway<o:p></o:p>
292 Missed gate<o:p></o:p>
SAMPLE<o:p></o:p>
FOR ILLUSTRATION PURPOSES ONLY<o:p></o:p>
A-16 Line Operations Safety Audit (LOSA)<o:p></o:p>
Copyright  2002 The University of Texas at <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place w:st="on"><st1:City w:st="on">Austin</st1:City></st1:place>. All rights reserved.<o:p></o:p>

航空发表于 2010-4-16 09:02:07

Hard Warning Errors<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
293 Failure to respond to GPWS warnings<o:p></o:p>
294 Failure to respond to TCAS warnings<o:p></o:p>
Briefing Errors<o:p></o:p>
272 Incomplete flight attendant briefing<o:p></o:p>
273 Incomplete cruise briefing<o:p></o:p>
274 Incomplete approach briefing<o:p></o:p>
295 Omitted takeoff briefing<o:p></o:p>
296 Omitted approach briefing<o:p></o:p>
297 Omitted flight attendant briefing<o:p></o:p>
298 Omitted engine-out briefing<o:p></o:p>
Other Procedural Errors<o:p></o:p>
299 Other procedural errors not listed in the code book<o:p></o:p>
SAMPLE<o:p></o:p>
FOR ILLUSTRATION PURPOSES ONLY<o:p></o:p>
Appendix A. Examples of the various forms utilized by LOSA A-17<o:p></o:p>
Copyright  2002 The University of Texas at <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place w:st="on"><st1:City w:st="on">Austin</st1:City></st1:place>. All rights reserved.<o:p></o:p>

航空发表于 2010-4-20 16:34:24

航空发表于 2010-4-20 16:34:34

航空发表于 2010-4-20 16:34:45

航空发表于 2010-4-20 16:34:57

Threat and Error Management Worksheet Codes<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Threat Codes<o:p></o:p>
Departure / Arrival Threats<o:p></o:p>
1 Adverse weather / turbulence / IMC<o:p></o:p>
2 Terrain<o:p></o:p>
3 Traffic — Air or ground congestion,<o:p></o:p>
TCAS warnings<o:p></o:p>
4 Airport — construction, signage, ground<o:p></o:p>
conditions<o:p></o:p>
5 TCAS RA/TA<o:p></o:p>
Aircraft Threats<o:p></o:p>
20 Aircraft malfunction<o:p></o:p>
21 Automation event or anomaly<o:p></o:p>
22 Communication event — radios, ATIS, ACARS<o:p></o:p>
Operational Threats<o:p></o:p>
30 Operational time pressure — delays,<o:p></o:p>
OTP, late arriving pilot or aircraft<o:p></o:p>
31 Missed approach<o:p></o:p>
32 Flight diversion<o:p></o:p>
33 Unfamiliar airport<o:p></o:p>
34 Other non-normal operation events —<o:p></o:p>
max gross wt. T/O, rejected T/O<o:p></o:p>
Cabin Threats<o:p></o:p>
40 Cabin event / distraction / interruption<o:p></o:p>
41 Flight attendant error<o:p></o:p>
ATC Threats<o:p></o:p>
50 ATC command — challenging clearances,<o:p></o:p>
late changes<o:p></o:p>
51 ATC error<o:p></o:p>
52 ATC language difficulty<o:p></o:p>
53 ATC non-standard phraseology<o:p></o:p>
54 ATC radio congestion<o:p></o:p>
55 Similar call signs<o:p></o:p>
Crew Support Threats<o:p></o:p>
80 MX event<o:p></o:p>
81 MX error<o:p></o:p>
82 Ground handling event<o:p></o:p>
83 Ground crew error<o:p></o:p>
84 Dispatch/ paperwork event<o:p></o:p>
85 Dispatch / paperwork error<o:p></o:p>
86 Crew scheduling event<o:p></o:p>
87 Manuals / charts incomplete /<o:p></o:p>
incorrect<o:p></o:p>
99 Other Threats<o:p></o:p>
Who Committed / Detected Codes Undesired Aircraft State Codes<o:p></o:p>
Flightcrew<o:p></o:p>
1 CA<o:p></o:p>
2 FO<o:p></o:p>
3 SO / FE<o:p></o:p>
4 Relief Officer<o:p></o:p>
5 Jumpseat<o:p></o:p>
Rider<o:p></o:p>
6 All crew<o:p></o:p>
members<o:p></o:p>
7 Nobody<o:p></o:p>
Other people<o:p></o:p>
8 ATC<o:p></o:p>
9 Flight attendant<o:p></o:p>
10 Dispatch<o:p></o:p>
11 Ground<o:p></o:p>
12 MX<o:p></o:p>
Aircraft<o:p></o:p>
20 Aircraft systems<o:p></o:p>
99 Other<o:p></o:p>
Configuration States<o:p></o:p>
1 Incorrect A/C configuration — flight controls,<o:p></o:p>
brakes, thrust reversers, landing gear<o:p></o:p>
2 Incorrect A/C configuration — systems (fuel,<o:p></o:p>
electrical, hydraulics, pneumatics, airconditioning,<o:p></o:p>
pressurization, instrumentation)<o:p></o:p>
3 Incorrect A/C configuration — automation<o:p></o:p>
4 Incorrect A/C configuration — engines<o:p></o:p>
Ground States<o:p></o:p>
20 Proceeding towards wrong runway<o:p></o:p>
21 Runway incursion<o:p></o:p>
22 Proceeding towards wrong taxiway / ramp<o:p></o:p>
23 Taxiway / ramp incursion<o:p></o:p>
24 Wrong gate<o:p></o:p>
Aircraft Handling States — All Phases<o:p></o:p>
40 Vertical deviation<o:p></o:p>
41 Lateral deviation<o:p></o:p>
42 Unnecessary WX penetration<o:p></o:p>
43 Unauthorized airspace penetration<o:p></o:p>
44 Speed too high<o:p></o:p>
45 Speed too low<o:p></o:p>
46 Abrupt aircraft control (attitude)<o:p></o:p>
47 Excessive banking<o:p></o:p>
48 Operation outside A/C limitations<o:p></o:p>
Approach / Landing States<o:p></o:p>
80 Deviation above G/S or FMS path<o:p></o:p>
81 Deviation below G/S or FMS path<o:p></o:p>
82 Unstable approach<o:p></o:p>
83 Continued landing - unstable approach<o:p></o:p>
84 Firm landing<o:p></o:p>
85 Floated landing<o:p></o:p>
86 Landing off C/L<o:p></o:p>
87 Long landing outside TDZ<o:p></o:p>
99 Other Undesired States<o:p></o:p>
SAMPLE<o:p></o:p>
FOR ILLUSTRATION PURPOSES ONLY<o:p></o:p>
A-20 Line Operations Safety Audit (LOSA)<o:p></o:p>
Copyright  2002 The University of Texas at <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place w:st="on"><st1:City w:st="on">Austin</st1:City></st1:place>. All rights reserved.<o:p></o:p>

航空发表于 2010-4-20 16:35:08

LOSA Crew Interview<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
1. Training<o:p></o:p>
a) Is there a difference in how you were trained, and how things really go in line operations?<o:p></o:p>
b) If so, why?<o:p></o:p>
2. Standardization<o:p></o:p>
a) How standardized are other crews that you fly with?<o:p></o:p>
b) If there is a lack of standardization, what do you think is the reason(s) for procedural non-compliance?<o:p></o:p>
3. Automation<o:p></o:p>
a) What are the biggest automation “gotchas” for this airplane?<o:p></o:p>
4. Overall safety improvements – concerns and suggestions for improvement<o:p></o:p>
a) Flight Ops<o:p></o:p>
b) Dispatch<o:p></o:p>
c) Airports and ATC<o:p></o:p>
d) SOPs<o:p></o:p>
SAMPLE<o:p></o:p>
FOR ILLUSTRATION PURPOSES ONLY<o:p></o:p>
B-1<o:p></o:p>
Appendix B<o:p></o:p>
EXAMPLE OF AN INTRODUCTORY LETTER<o:p></o:p>
BY AN AIRLINE TO ITS FLIGHT CREWS<o:p></o:p>
To: All US Airways Pilots<o:p></o:p>
From: Captain Ed Bular<o:p></o:p>
Senior Director, Flight Operations<o:p></o:p>
Captain Ron Schilling<o:p></o:p>
Director, Flight Training and Standards<o:p></o:p>
Captain Pete Eichenlaub<o:p></o:p>
Director, US Airways Flight Safety and Quality Assurance<o:p></o:p>
Captain Terry McVenes<o:p></o:p>
Chairman, ALPA Central Air Safety Committee<o:p></o:p>
Subject: Line Operations Safety Audit (LOSA)<o:p></o:p>
Date: October 1, 2000<o:p></o:p>
Beginning mid-October and continuing for approximately five weeks, US Airways will conduct a Line<o:p></o:p>
Operations Safety Audit (LOSA). For this audit, we will use US Airways pilots to conduct cockpit jumpseat<o:p></o:p>
observations, along with three observers from the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place w:st="on"><st1:PlaceType w:st="on">University</st1:PlaceType> of <st1:PlaceName w:st="on">Texas Human Factors Research Project</st1:PlaceName></st1:place> (a.k.a.<o:p></o:p>
“NASA/UT Aerospace Crew Research Project.”<o:p></o:p>
LOSA observations are no-jeopardy events, and all data are confidential and de-identified. LOSA data go<o:p></o:p>
directly to the UT Human Factors Research Program for data entry and analysis. Be assured that these<o:p></o:p>
observations are not checkrides. Although some LOSA observers may be US Airways check airmen, they<o:p></o:p>
are not there to critique your performance — their mission is to be an unobtrusive observer and to fill out<o:p></o:p>
data collection forms after the flight is completed.<o:p></o:p>
Early on, it was decided that the ultimate customer of the audit should be the US Airways line pilot. By<o:p></o:p>
that, the audit should help us identify problem areas so that we can correct them and make your job easier.<o:p></o:p>
Did you ever see a procedure that could be done better, but didn’t feel like you had a way to feed that idea<o:p></o:p>
into the system for possible change? Are some procedures better than others as far as helping avoid, trap<o:p></o:p>
and mitigate errors? LOSA should help us identify the strengths and weaknesses of our crew procedures,<o:p></o:p>
and with that information, management is committed to making necessary changes to continually improve<o:p></o:p>
the way that we do business.<o:p></o:p>
In short, we’re doing a LOSA so that we can improve the system to better support you. After the audit is<o:p></o:p>
completed, we’re committed to telling you how it went, and how we plan to make improvements.<o:p></o:p>
B-2 Line Operations Safety Audit (LOSA)<o:p></o:p>
In addition to using US Airways pilots as LOSA observers, we will also use three observers from UT Human<o:p></o:p>
Factors Research Program. These gentlemen are very experienced LOSA observers, having worked with the<o:p></o:p>
UT program for many years. They are John Bell, Roy Butler and James Klinect, and their credentials can<o:p></o:p>
be verified by your requesting that they present a copy of their FAA jumpseat authorization.<o:p></o:p>
Please extend your usual professional courtesies to the LOSA observation team, and thank you for your<o:p></o:p>
unfailing cooperation.<o:p></o:p>
Sincerely,<o:p></o:p>
Captain Ed Bular<o:p></o:p>
Senior Director, Flight Operations<o:p></o:p>
Captain Ron Schilling<o:p></o:p>
Director, Flight Training and Standards<o:p></o:p>
Captain Pete Eichenlaub<o:p></o:p>
Director, Flight Safety and Quality Assurance<o:p></o:p>
Captain Terry McVenes<o:p></o:p>
Chairman, ALPA Central Air Safety Committee<o:p></o:p>
C-1<o:p></o:p>

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