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lei1983yu 发表于 2010-4-8 22:53:48

学习了。。。。。。。。。。。。。。

航空发表于 2010-4-12 17:11:36

Errors<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><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">2.2.6</st1:chsdate> Cockpit crew error is defined as an action or<o:p></o:p>
inaction by the crew that leads to deviations from<o:p></o:p>
organizational or flight crew intentions or expectations.<o:p></o:p>
Errors in the operational context tend to reduce the margin<o:p></o:p>
of safety and increase the probability of accidents or<o:p></o:p>
incidents. Errors may be defined in terms of non-compliance<o:p></o:p>
with regulations, Standard Operating Procedures (SOPs) and<o:p></o:p>
policies, or unexpected deviation from crew, company or<o:p></o:p>
ATC expectations. Errors observed may be minor (selecting<o:p></o:p>
the wrong altitude into the mode control panel (MCP), but<o:p></o:p>
correcting it quickly) or major (forgetting to do an essential<o:p></o:p>
checklist). Observers should record all cockpit crew errors<o:p></o:p>
that they detect.<o:p></o:p>

航空发表于 2010-4-12 17:11:49

<?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">2.2.7</st1:chsdate> Operators set up SOPs and checklists as the<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
standards for the proper and safe way to conduct flights.<o:p></o:p>
Instructors observing deviations from SOPs or checklists<o:p></o:p>
would define this as an error, and so does LOSA. If a crew<o:p></o:p>
member does not know how to execute a procedure properly<o:p></o:p>
or cannot control the aircraft in the expected manner, an<o:p></o:p>
instructor would also consider this an error, and so does<o:p></o:p>
LOSA. Deviations from expectations of ATC are also<o:p></o:p>
classified as crew errors; these would, for example, include<o:p></o:p>
altitude deviations or significant deviations around thunderstorms<o:p></o:p>
without ATC notification. There are rules in SOPs<o:p></o:p>
and/or operator manuals that, for example, specify how<o:p></o:p>
much deviation crews may make around thunderstorms<o:p></o:p>
before notifying ATC, and observers must be familiar with<o:p></o:p>
and apply these company rules when conducting observations.<o:p></o:p>
Operators also have policies that are less<o:p></o:p>

航空发表于 2010-4-12 17:11:58

航空发表于 2010-4-12 17:19:14

航空发表于 2010-4-12 17:19:26

航空发表于 2010-4-12 17:19:38

<?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">2.2.10</st1:chsdate> LOSA is predicated upon the following five<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
categories of crew errors:<o:p></o:p>
1. Intentional non-compliance error: Wilful deviation<o:p></o:p>
from regulations and/or operator procedures;<o:p></o:p>
2. Procedural error: Deviation in the execution of<o:p></o:p>
regulations and/or operator procedures. The intention<o:p></o:p>
is correct but the execution is flawed. This<o:p></o:p>
category also includes errors where a crew forgot to<o:p></o:p>
do something;<o:p></o:p>
3. Communication error: Miscommunication, misinterpretation,<o:p></o:p>
or failure to communicate pertinent<o:p></o:p>
information among the flight crew or between the<o:p></o:p>
flight crew and an external agent (for example, ATC<o:p></o:p>
or ground operations personnel);<o:p></o:p>

航空发表于 2010-4-12 17:19:49

4. Proficiency error: Lack of knowledge or<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
psychomotor (“stick and rudder”) skills; and<o:p></o:p>
5. Operational decision error: Decision-making error<o:p></o:p>
that is not standardized by regulations or operator<o:p></o:p>
2-4 Line Operations Safety Audit (LOSA)<o:p></o:p>
procedures and that unnecessarily compromises<o:p></o:p>
safety. In order to be categorized as an operational<o:p></o:p>
decision error, at least one of three conditions must<o:p></o:p>
have existed:<o:p></o:p>
• The crew must have had more conservative<o:p></o:p>
options within operational reason and decided<o:p></o:p>
not to take them;<o:p></o:p>
• The decision was not verbalized and, therefore,<o:p></o:p>
was not shared among crew members; or<o:p></o:p>
• The crew must have had time but did not use it<o:p></o:p>
effectively to evaluate the decision.<o:p></o:p>
If any of these conditions were observed, then it is<o:p></o:p>
considered that an operational decision error was made in<o:p></o:p>
the LOSA framework. An example would include the crew’s<o:p></o:p>
decision to fly through known wind shear on an approach<o:p></o:p>
instead of going around.<o:p></o:p>

航空发表于 2010-4-12 17:19:59

Definitions of crew error response<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><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">2.2.11</st1:chsdate> LOSA considers three possible responses by<o:p></o:p>
crews to errors:<o:p></o:p>
1. Trap: An active flight crew response in which an<o:p></o:p>
error is detected and managed to an inconsequential<o:p></o:p>
outcome;<o:p></o:p>
2. Exacerbate: A flight crew response in which an error<o:p></o:p>
is detected but the crew action or inaction allows it<o:p></o:p>
to induce an additional error, Undesired Aircraft<o:p></o:p>
State, incident or accident; and<o:p></o:p>
3. Fail to respond: The lack of a flight crew response<o:p></o:p>
to an error because it was either ignored or<o:p></o:p>
undetected.<o:p></o:p>

航空发表于 2010-4-12 17:20:09

Definitions of error outcomes<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><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">2.2.12</st1:chsdate> The outcome of the error is dependent upon the<o:p></o:p>
flight crew response. LOSA considers three possible<o:p></o:p>
outcomes of errors depending upon crew response:<o:p></o:p>
1. Inconsequential: An outcome that indicates the<o:p></o:p>
alleviation of risk that was previously caused by an<o:p></o:p>
error;<o:p></o:p>
2. <st1:place w:st="on"><st1:PlaceName w:st="on">Undesired</st1:PlaceName> <st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place>: An outcome in which the<o:p></o:p>
aircraft is unnecessarily placed in a compromising<o:p></o:p>
situation that poses an increased risk to safety; and<o:p></o:p>
3. Additional Error: An outcome that was the result of<o:p></o:p>
or is closely linked to a previous error.<o:p></o:p>

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