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民航发表于 2010-4-7 15:38:56

<?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">1.3.2</st1:chsdate> There is nothing inherently wrong or<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
troublesome with error itself as a manifestation of human<o:p></o:p>
behaviour. The trouble with error in aviation is the fact that<o:p></o:p>
negative consequences may be generated in operational<o:p></o:p>
contexts. This is a fundamental point in aviation: if the<o:p></o:p>
negative consequences of an error are caught before they<o:p></o:p>
produce damage, then the error is inconsequential. In<o:p></o:p>
operational contexts, errors that are caught in time do not<o:p></o:p>
produce negative consequences and therefore, for practical<o:p></o:p>
purposes, do not exist. Countermeasures to error, including<o:p></o:p>
training interventions, should not be restricted to avoiding<o:p></o:p>
errors, but rather to making them visible and trapping them<o:p></o:p>
before they produce negative consequences. This is the<o:p></o:p>
essence of error management: human error is unavoidable<o:p></o:p>
but manageable.<o:p></o:p>

民航发表于 2010-4-7 15:39:16

<?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">1.3.3</st1:chsdate> Error management is at the heart of LOSA and<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
reflects the previous argument. Under LOSA, flaws in human<o:p></o:p>
performance and the ubiquity of error are taken for granted,<o:p></o:p>
and rather than attempting to improve human performance,<o:p></o:p>
the objective becomes to improve the context within which<o:p></o:p>
humans perform. LOSA ultimately aims — through changes<o:p></o:p>
in design, certification, training, procedures, management<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
1-8 Line Operations Safety Audit (LOSA)<o:p></o:p>
developing analytic methods to integrate multiple and<o:p></o:p>
diverse data sources. However, most importantly, the real<o:p></o:p>
challenge for the large-scale implementation of LOSA will<o:p></o:p>
be overcoming the obstacles, presented by a blame-oriented<o:p></o:p>
industry, that will demand continued effort over time before<o:p></o:p>
normal operations monitoring is fully accepted by the<o:p></o:p>
operational personnel, whose support is essential.<o:p></o:p>

民航发表于 2010-4-7 15:40:14

民航发表于 2010-4-7 16:43:20

2-1<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Chapter 2<o:p></o:p>
IMPLEMENTING LOSA<o:p></o:p>
2.1 HISTORY OF LOSA<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">2.1.1</st1:chsdate> In 1991, The <st1:PlaceType w:st="on">University</st1:PlaceType> of <st1:PlaceName w:st="on">Texas</st1:PlaceName> at <st1:place w:st="on"><st1:City w:st="on">Austin</st1:City></st1:place><o:p></o:p>
Human Factors Research Project, with funding from the<o:p></o:p>
FAA (Human Factors Division, AAR-100), developed<o:p></o:p>
LOSA to monitor normal line operations. In its early form,<o:p></o:p>
LOSA mostly focused on CRM performance. The reason for<o:p></o:p>
this was that researchers and airlines alike wanted to know<o:p></o:p>
more about the actual practice of CRM rather than just<o:p></o:p>
formulating conclusions about its effectiveness from data<o:p></o:p>
collected within the training environment, as was the<o:p></o:p>
established practice. After LOSA audits were conducted at<o:p></o:p>
more than ten airlines in the early 1990s, it was clear that<o:p></o:p>
the actual practice of CRM was quite different than the one<o:p></o:p>
depicted within the typical training department. Most<o:p></o:p>
important, the unique insights gathered from this methodological<o:p></o:p>
approach of monitoring normal operations not<o:p></o:p>
only advanced the concepts of CRM, but also encouraged<o:p></o:p>
new ways of thinking about crew performance.<o:p></o:p>

民航发表于 2010-4-7 16:43:30

民航发表于 2010-4-7 16:43:44

2.2 THE THREAT AND ERROR<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
MANAGEMENT MODEL<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">2.2.1</st1:chsdate> LOSA is premised on The University of Texas<o:p></o:p>
Threat and Error Management (UTTEM) Model (see<o:p></o:p>
Figure 2-1). Essentially, the model posits that threats and<o:p></o:p>
errors are integral parts of daily flight operations and must<o:p></o:p>
be managed. Therefore, observing the management or mismanagement<o:p></o:p>
of threats and errors can build the desired<o:p></o:p>
systemic snapshot of performance. Pilots quickly grasp the<o:p></o:p>
concepts of external threats once they are explained, and the<o:p></o:p>
idea of managing the threats has great relevance to them,<o:p></o:p>
more so than error management, which still retains negative<o:p></o:p>
connotations despite attempts to acknowledge its ubiquity<o:p></o:p>
and necessity in human intelligence and information<o:p></o:p>
processing. Crew countermeasures are then seen as the tools<o:p></o:p>
that pilots develop to handle these daily threats and errors.<o:p></o:p>
The UTTEM Model has been successfully incorporated into<o:p></o:p>
training programmes and in some cases has replaced<o:p></o:p>
existing CRM training.*<o:p></o:p>

民航发表于 2010-4-7 16:43:55

<?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">2.2.2</st1:chsdate> The UTTEM Model provides a quantifiable<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
framework to collect and categorize data. Some questions<o:p></o:p>
that can be addressed using this framework include the<o:p></o:p>
following:<o:p></o:p>
• What type of threats do flight crews most frequently<o:p></o:p>
encounter? When and where do they occur, and what<o:p></o:p>
types are the most difficult to manage?<o:p></o:p>
• What are the most frequently committed crew errors,<o:p></o:p>
and which ones are the most difficult to manage?<o:p></o:p>
• What outcomes are associated with mismanaged<o:p></o:p>
errors? How many result in an Undesired Aircraft<o:p></o:p>
State?<o:p></o:p>
• Are there significant differences between airports,<o:p></o:p>
fleets, routes or phases of flight vis-à-vis threats and<o:p></o:p>
errors?<o:p></o:p>

民航发表于 2010-4-7 16:44:06

民航发表于 2010-4-7 16:44:15

Figure 2-1. The Threat and Error Management Model<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Threats<o:p></o:p>
Inconsequential Threat management<o:p></o:p>
Crew error<o:p></o:p>
Crew error responses<o:p></o:p>
Undesired<o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place w:st="on"><st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place><o:p></o:p>
Crew Undesired<o:p></o:p>
<st1:place w:st="on"><st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place><o:p></o:p>
responses<o:p></o:p>
Chapter 2. Implementing LOSA 2-3<o:p></o:p>

民航发表于 2010-4-7 16:44:25

the flight and pose a safety risk to the flight at some level.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Threats may be expected or anticipated and, therefore, the<o:p></o:p>
crew may brief in advance. Threats may also be unexpected.<o:p></o:p>
As they occur suddenly and without any warning, there is<o:p></o:p>
no possibility for the crew to brief in advance. External<o:p></o:p>
threats may be relatively minor or major. Observers should<o:p></o:p>
record all external threats that are on the code sheet or any<o:p></o:p>
others that may be considered significant.<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">2.2.5</st1:chsdate> Errors originated by non-cockpit personnel are<o:p></o:p>
considered external threats. For example, if the cockpit crew<o:p></o:p>
detects a fuel loading error made by ground staff, it would<o:p></o:p>
be entered as an external threat, not an error. The crew was<o:p></o:p>
not the source of the error (although they must manage it,<o:p></o:p>
as they would any other external threat). Other examples of<o:p></o:p>
non-cockpit crew errors that would be entered as external<o:p></o:p>
threats are errors in Air Traffic Control (ATC) clearances<o:p></o:p>
discovered by the crew, dispatch paperwork errors and<o:p></o:p>
discrepancies in passenger boarding counts by cabin<o:p></o:p>
attendants.<o:p></o:p>

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