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民航发表于 2010-4-7 15:06:26

民航发表于 2010-4-7 15:06:42

8. This manual is an introduction to the concept,<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
methodology and tools of LOSA and to the potential<o:p></o:p>
remedial actions to be undertaken based on the data<o:p></o:p>
collected under LOSA. A very important caveat must be<o:p></o:p>
introduced at this point: this manual is not intended to<o:p></o:p>
convert readers into instant expert observers and/or LOSA<o:p></o:p>
auditors. In fact, it is strongly recommended that LOSA not<o:p></o:p>
be attempted without a formal introduction to it for the<o:p></o:p>
(viii) Line Operations Safety Audit (LOSA)<o:p></o:p>
following reasons. First, the forms presented in Appendix A<o:p></o:p>
are for illustration purposes exclusively, since they are<o:p></o:p>
periodically amended on the basis of experience gained and<o:p></o:p>
feedback obtained from continuing audits. Second, formal<o:p></o:p>
training in the methodology, in the use of LOSA tools and,<o:p></o:p>
most important, in the handling of the highly sensitive data<o:p></o:p>
collected by the audits is absolutely essential. Third, the<o:p></o:p>
proper structuring of the data obtained from the audits is of<o:p></o:p>
paramount importance.<o:p></o:p>

民航发表于 2010-4-7 15:06:52

民航发表于 2010-4-7 15:07:06

10. This manual is designed as follows:<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
• Chapter 1 includes an overview on safety, and<o:p></o:p>
human error and its management in aviation<o:p></o:p>
operations. It provides the necessary background<o:p></o:p>
information to understand the rationale for LOSA.<o:p></o:p>
• Chapter 2 discusses the LOSA methodology and<o:p></o:p>
provides a guide to the implementation of LOSA<o:p></o:p>
within an airline. It also introduces a model of crew<o:p></o:p>
error management and proposes the error classification<o:p></o:p>
utilized by LOSA, which is essentially<o:p></o:p>
operational and practical.<o:p></o:p>
• Chapter 3 discusses the safety change process that<o:p></o:p>
should take place following the implementation of<o:p></o:p>
LOSA.<o:p></o:p>
• Chapter 4 introduces the example of one operator’s<o:p></o:p>
experience in starting a LOSA.<o:p></o:p>
• Appendix A provides examples of the various forms<o:p></o:p>
utilized by LOSA.<o:p></o:p>
• Appendix B provides an example of an introductory<o:p></o:p>
letter by an airline to its flight crews.<o:p></o:p>
• Appendix C provides a list of recommended reading<o:p></o:p>
and reference material.<o:p></o:p>

民航发表于 2010-4-7 15:07:16

11. This manual is a companion document to the<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Human Factors Training Manual (Doc 9683). The<o:p></o:p>
cooperation of the following organizations in the production<o:p></o:p>
of this manual is acknowledged: The University of Texas at<o:p></o:p>
Austin Human Factors Research Project, Continental<o:p></o:p>
Airlines, US Airways and ALPA, International. Special<o:p></o:p>
recognition is given to Professor Robert L. Helmreich,<o:p></o:p>
James Klinect and John Wilhelm of 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; Captains<o:p></o:p>
Bruce Tesmer and Donald Gunther of Continental Airlines;<o:p></o:p>
Captains Ron Thomas and Corkey Romeo of US Airways;<o:p></o:p>
and Captain Robert L. Sumwalt III of US Airways and of<o:p></o:p>
ALPA, International.<o:p></o:p>
1-1<o:p></o:p>

民航发表于 2010-4-7 15:07:31

Chapter 1<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
BASIC ERROR MANAGEMENT CONCEPTS<o:p></o:p>
1.1 INTRODUCTION<o:p></o:p>
<?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">1.1.1</st1:chsdate> Historically, the way the aviation industry has<o:p></o:p>
investigated the impact of human performance on aviation<o:p></o:p>
safety has been through the retrospective analyses of those<o:p></o:p>
actions by operational personnel which led to rare and<o:p></o:p>
drastic failures. The conventional investigative approach is<o:p></o:p>
for investigators to trace back an event under consideration<o:p></o:p>
to a point where they discover particular actions or decisions<o:p></o:p>
by operational personnel that did not produce the intended<o:p></o:p>
results and, at such point, conclude human error as the cause.<o:p></o:p>

民航发表于 2010-4-7 15:07:42

民航发表于 2010-4-7 15:07:57

<?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">1.1.2</st1:chsdate> It is inherent to traditional approaches to safety<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
to consider that, in aviation, safety comes first. In line with<o:p></o:p>
this, decision making in aviation operations is considered to<o:p></o:p>
be 100 per cent safety-oriented. While highly desirable, this<o:p></o:p>
is hardly realistic. Human decision making in operational<o:p></o:p>
contexts is a compromise between production and safety<o:p></o:p>
goals (see Figure 1-1). The optimum decisions to achieve the<o:p></o:p>
actual production demands of the operational task at hand<o:p></o:p>
may not always be fully compatible with the optimum<o:p></o:p>
Figure 1-1. Operational Behaviours — Accomplishing the system’s goals<o:p></o:p>
Safety Production<o:p></o:p>
1-2 Line Operations Safety Audit (LOSA)<o:p></o:p>

民航发表于 2010-4-7 15:08:10

民航发表于 2010-4-7 15:08:23

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