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航空发表于 2010-4-12 17:20:19

Undesired Aircraft States<?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">2.2.13 A</st1:chsdate>n “<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>” occurs when the<o:p></o:p>
flight crew places the aircraft in a situation of unnecessary<o:p></o:p>
risk. For instance, an altitude deviation is an 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> that presents unnecessary risk. An 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> may occur in response to a crew action or<o:p></o:p>
inaction (error). It is important to distinguish between errors<o:p></o:p>
and the Undesired Aircraft State that can result. If an<o:p></o:p>
Undesired <st1:place w:st="on"><st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place> is observed, there should always be<o:p></o:p>
a crew error that is responsible for this undesired state. Such<o:p></o:p>
errors may be miscommunications, lack of proficiency, poor<o:p></o:p>
decision making or wilful violation of regulations.<o:p></o:p>

航空发表于 2010-4-12 17:20:30

<?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">2.2.14</st1:chsdate> Undesired Aircraft States can also occur as a<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
result of equipment malfunction or external party errors, for<o:p></o:p>
example, a malfunctioning altimeter or flight management<o:p></o:p>
system (FMS), or an ATC command error. These are not<o:p></o:p>
associated with crew error and would be classified as<o:p></o:p>
external events.<o:p></o:p>
Crew response to Undesired Aircraft States<o:p></o:p>
<st1:chsdate IsROCDate="False" IsLunarDate="False" Day="30" Month="12" Year="1899" w:st="on">2.2.15</st1:chsdate> LOSA considers three possible crew responses<o:p></o:p>
to Undesired Aircraft States:<o:p></o:p>
1. Mitigate: An active flight crew response to an<o:p></o:p>
Undesired <st1:place w:st="on"><st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place> that results in the<o:p></o:p>
alleviation of risk by returning from the 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> to safe flight;<o:p></o:p>
2. Exacerbate: A flight crew response in which an<o:p></o:p>
Undesired <st1:place w:st="on"><st1:PlaceName w:st="on">Aircraft</st1:PlaceName> <st1:PlaceType w:st="on">State</st1:PlaceType></st1:place> is detected, but the flight<o:p></o:p>
crew action or inaction allows it to induce an<o:p></o:p>
additional error, incident or accident; and<o:p></o:p>
3. Fail to respond: The lack of an active flight crew<o:p></o:p>
response to an <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> because it<o:p></o:p>
was ignored or undetected.<o:p></o:p>

航空发表于 2010-4-12 17:20:46

Definitions of outcomes of Undesired Aircraft States<?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">2.2.16</st1:chsdate> LOSA considers three possible outcomes to<o:p></o:p>
Undesired Aircraft States:<o:p></o:p>
1. Recovery: An outcome that indicates the alleviation<o:p></o:p>
of risk that was previously caused by an 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>
Chapter 2. Implementing LOSA 2-5<o:p></o:p>
2. End State/Incident/Accident: Any undesired ending<o:p></o:p>
that completes the activity sequence with a negative,<o:p></o:p>
terminal outcome. These outcomes may be of little<o:p></o:p>
consequence, for example, a long landing or a<o:p></o:p>
landing too far to the left or right of the centre line,<o:p></o:p>
or may result in a reportable incident or in an<o:p></o:p>
accident; and<o:p></o:p>
3. Additional error: The flight crew action or inaction<o:p></o:p>
that results in or is closely linked to another cockpit<o:p></o:p>
crew error.<o:p></o:p>

航空发表于 2010-4-12 17:21:49

2.3 LOSA OPERATING CHARACTERISTICS<?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">2.3.1</st1:chsdate> LOSA is a proactive safety data collection<o:p></o:p>
programme. The data generated provide a diagnostic<o:p></o:p>
snapshot of organizational strengths and weaknesses, as well<o:p></o:p>
as an overall assessment of flight crew performance in<o:p></o:p>
normal flight operations. Therefore, the intent of LOSA is<o:p></o:p>
to aid airlines in developing data-driven solutions to improve<o:p></o:p>
overall systemic safety. The classic business principle of<o:p></o:p>
measure, implement change and measure again is pertinent<o:p></o:p>
here, with LOSA providing the metric of implementation<o:p></o:p>
effectiveness. Experience has proven that expert external<o:p></o:p>
oversight, especially on a first LOSA, is essential for<o:p></o:p>
success.<o:p></o:p>

航空发表于 2010-4-12 17:22:17

航空发表于 2010-4-12 17:22:28

2. Joint management / pilot sponsorship: In order for<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
LOSA to succeed as a viable safety programme, it<o:p></o:p>
is essential that both management and pilots<o:p></o:p>
(through their professional association, if it exists)<o:p></o:p>
support the project. The joint sponsorship provides<o:p></o:p>
a “check and balance” for the project to ensure that<o:p></o:p>
change, as necessary, will be made as a result of<o:p></o:p>
LOSA data. When considering whether to conduct<o:p></o:p>
a LOSA audit, the first question to be asked by<o:p></o:p>
airline management is whether the pilots endorse the<o:p></o:p>
project. If the answer is “No”, the project should not<o:p></o:p>
be initiated until endorsement is obtained. This issue<o:p></o:p>
is so critical in alleviating pilot suspicion that the<o:p></o:p>
existing LOSA philosophy is to deny airline<o:p></o:p>
assistance if a signed agreement is not in place<o:p></o:p>
before commencing a LOSA. A LOSA steering<o:p></o:p>
committee is formed with representatives from both<o:p></o:p>
groups and is responsible for planning, scheduling,<o:p></o:p>
observer support and, later, data verification (see<o:p></o:p>
Point 8).<o:p></o:p>

航空发表于 2010-4-12 17:22:37

3. Voluntary crew participation: Maintaining the<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
integrity of LOSA within an airline and the industry<o:p></o:p>
as a whole is extremely important for long-term<o:p></o:p>
success. One way to accomplish this goal is to<o:p></o:p>
collect all observations with voluntary crew<o:p></o:p>
participation. Before conducting LOSA observations,<o:p></o:p>
an observer must first obtain the flight<o:p></o:p>
crew’s permission to be observed. The crew has the<o:p></o:p>
option to decline, with no questions asked. The<o:p></o:p>
observer simply approaches another flight crew on<o:p></o:p>
another flight and asks for their permission to be<o:p></o:p>
observed. If an airline conducts a LOSA and has an<o:p></o:p>
unreasonably high number of refusals by crews to be<o:p></o:p>
observed, then it should serve as an indicator to the<o:p></o:p>
airline that there are critical “trust” issues to be dealt<o:p></o:p>
with first.<o:p></o:p>

航空发表于 2010-4-12 17:22:47

4. De-identified, confidential and safety-minded data<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
collection: LOSA observers are asked not to record<o:p></o:p>
names, flight numbers, dates or any other<o:p></o:p>
information that can identify a crew. This allows for<o:p></o:p>
a level of protection against disciplinary actions. The<o:p></o:p>
purpose of LOSA is to collect safety data, not to<o:p></o:p>
punish pilots. Airlines cannot allow themselves to<o:p></o:p>
squander a unique opportunity to gain insight into<o:p></o:p>
their operations by having pilots fearful that a LOSA<o:p></o:p>
observation could be used against them for<o:p></o:p>
disciplinary reasons. If a LOSA observation is ever<o:p></o:p>
used for disciplinary reasons, the acceptance of<o:p></o:p>
LOSA within the airline will most probably be lost<o:p></o:p>
forever. Over 6 000 LOSA observations have been<o:p></o:p>
conducted by 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><o:p></o:p>
Human Factors Research Project and not one has<o:p></o:p>
ever been used to discipline a pilot.<o:p></o:p>

航空发表于 2010-4-12 17:25:02

5. Targeted observation instrument: The current data<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
collection tool to conduct a LOSA is the LOSA<o:p></o:p>
Observation Form. It is not critical that an airline use<o:p></o:p>
this form, but whatever data collection instrument is<o:p></o:p>
used needs to target issues that affect flight crew<o:p></o:p>
performance in normal operations. An example of<o:p></o:p>
2-6 Line Operations Safety Audit (LOSA)<o:p></o:p>
the LOSA Observation Form is shown in<o:p></o:p>
Appendix A. The form is based upon the UTTEM<o:p></o:p>
Model and generates data for a variety of topics,<o:p></o:p>
including the following:<o:p></o:p>
• Flight and crew demographics such as city pairs,<o:p></o:p>
aircraft type, flight time, years of experience<o:p></o:p>
within the airline, years of experience within<o:p></o:p>
position, and crew familiarity;<o:p></o:p>
• Written narratives describing what the crew did<o:p></o:p>
well, what they did poorly and how they<o:p></o:p>
managed threats or errors for each phase of the<o:p></o:p>
flight;<o:p></o:p>

航空发表于 2010-4-12 17:25:21

• CRM performance ratings using researchdeveloped<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
behavioural markers;<o:p></o:p>
• Technical worksheet for the descent/approach/<o:p></o:p>
land phases that highlights the type of approach<o:p></o:p>
flown, landing runway and whether the crew met<o:p></o:p>
airline stabilized approach parameters;<o:p></o:p>
• Threat management worksheet that details each<o:p></o:p>
threat and how it was handled;<o:p></o:p>
• Error management worksheet that lists each<o:p></o:p>
error observed, how each error was handled and<o:p></o:p>
the final outcome; and<o:p></o:p>
• Crew interview conducted during low workload<o:p></o:p>
periods of the flight, such as cruise, that asks<o:p></o:p>
pilots for their suggestions to improve safety,<o:p></o:p>
training, and flight operations.<o:p></o:p>

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