Doc9803航线运行安全审计

航空

游客，如果您要查看本帖隐藏内容请回复

kmlihe

值得下载收藏学习

zhenshi13

谢谢分享！学习了

mrmmx

一般运行和飞行规则

Virgin

谢谢，楼主辛苦

航空

Klinect, J. R., J. A. Wilhelm and R. L. Helmreich. “Event and Error Management: Data from Line Operationsfficeffice" />

Safety Audits.” In Proceedings of the Tenth International Symposium on Aviation Psychology. The ffice:smarttags" />laceName w:st="on">OhiolaceName> laceType w:st="on">StatelaceType>

University, 1999, pp. 130–136.

Law, J. R., and J. A. Wilhelm. “Ratings of CRM skill markers in domestic and international operations: A

first look.” In Proceedings of the Eighth International Symposium on Aviation Psychology. Columbus, Ohio:

The laceName w:st="on">OhiolaceName> laceType w:st="on">StatelaceType> laceType w:st="on">UniversitylaceType>, 1995.

Maurino, D. E, J. Reason, A. N. Johnston and R. Lee. Beyond Aviation Human Factors. Hants, England:

Averbury Technical, 1995.

Pariès, J. “Evolution of the aviation safety paradigm: Towards systemic causality and proactive actions.” In

B. Hayward and H. Lowe (Eds.), Proceedings of the 1995 Australian Aviation Psychology Symposium. Hants,

England: Averbury Technical, 1996, pp. 39–49.

Reason, J. Managing the Risks of Organizational Accidents. Hants, England: Averbury Technical, 1998.

Taggart, W. R. “The NASA/UT/FAA Line/LOS checklist: Assessing system safety and crew performance.”

In Proceedings of the Eighth International Symposium on Aviation Psychology. Columbus, Ohio: The Ohio

State University, 1995.

Vaughan, D. The Challenger launch decision. Chicago, USA: The University of Chicago Press, 1996.

Woods, D. D., L. J. Johannesen, R. I. Cook and N. B. Sarter. Behind human error: Cognitive systems,

computers and hindsight. Wright-Patterson Air Force Base, Ohio: Crew Systems Ergonomics Information

Analysis Center (CSERIAC), 1994.

— END —

航空

Appendix Cfficeffice" />

LIST OF RECOMMENDED ffice:smarttags" />READING AND

REFERENCE MATERIAL

Amalberti, R. La conduite de systèmes a risques. Paris: Presses Universitaires de France, 1996.

Flin, R. and L. Martin. “Behavioural markers for crew resource management.” Civil Aviation Authority Paper

98005. London: laceType w:st="on">UniversitylaceType> of laceName w:st="on">AberdeenlaceName>, 1998.

Harle, P. G. “Organizational and Management Factors: A Case Study.” In International Civil Aviation

Organization (Ed.), Report of the Seventh ICAO Flight Safety and Human Factors Regional Seminar, Addis

Ababa, Ethiopia, 18–21 October 1994. Montreal, Canada, 1994, pp. 75–86.

Helmreich, R. L., R. E. Butler, W. R. Taggart and J. A. Wilhelm. “Behavioral markers in accidents and

incidents: Reference list.” NASA/UT/FAA Technical Report 95-1. Austin, Texas: The laceType w:st="on">UniversitylaceType> of laceName w:st="on">TexaslaceName> at

Austin, 1995.

Helmreich, R. L. and H. C. Foushee. “Why Crew Resource Management? Empirical and Theoretical Bases

of Human Factors Training in Aviation.” In E. Wiener, B. Kanki and R. Helmreich (Eds.), Cockpit Resource

Management. San Diego, California: Academic Press, 1993, pp. 3–45.

Helmreich, R. L., J. R. Klinect and J. A. Wilhelm. “Models of Event, error, and response in flight operations.”

In R. S. Jensen (Ed.), Proceedings of the Tenth International Symposium on Aviation Psychology. Columbus,

Ohio: The laceName w:st="on">OhiolaceName> State University, 1999, pp. 124–129.

Helmreich, R. L. and A. C. Merritt. Culture at Work in Aviation and Medicine: National, Organizational,

and Professional Influences. Aldershot, U.K.: Ashgate Publishing, 1998.

Helmreich, R. L., A. C. Merritt, and J. A. Wilhelm. “The evolution of Crew Resource Management training

in commercial aviation.” International Journal of Aviation Psychology, 9(1) (1999): 19–32.

Helmreich, R. L. and J. A. Wilhelm. “Outcomes of Crew Resource Management training.” International

Journal of Aviation Psychology, 1(4) (1991): 287–300.

Helmreich, R. L., J. A. Wilhelm, J. R. Klinect and A. C. Merritt. “Culture, error, and Crew Resource

Management.” In E. Salas, C. A. Bowers, and E. Edens (Eds.), Applying resource management in

organizations: A guide for professionals. Hillsdale, New Jersey: Erlbaum (In press).

International Civil Aviation Organization. Human Factors Digest No. 10 — Human Factors, Management

and Organization (Circular 247). Montreal, Canada, 1993.

Johnston, A. N. “Blame, Punishment and Risk Management.” In C. Hood, D. Jones, N. Pidgeon and B. Turner

(Eds.), Accident and Design. London, U.K.: University College Press, 1996, pp. 72–83.

C-2 Line Operations Safety Audit (LOSA)

Klein, G. A, J. Orasanu, R. Calderwood and C. E. Zsambok. Decision making in action: Models and methods.

Norwood, New Jersey: Ablex Publishing Corporation, 1993.

航空

LOSA Crew Interviewfficeffice" />

1. Training

a) Is there a difference in how you were trained, and how things really go in line operations?

b) If so, why?

2. Standardization

a) How standardized are other crews that you fly with?

b) If there is a lack of standardization, what do you think is the reason(s) for procedural non-compliance?

3. Automation

a) What are the biggest automation “gotchas” for this airplane?

4. Overall safety improvements – concerns and suggestions for improvement

a) Flight Ops

b) Dispatch

c) Airports and ATC

d) SOPs

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

B-1

Appendix B

EXAMPLE OF AN INTRODUCTORY LETTER

BY AN AIRLINE TO ITS FLIGHT CREWS

To: All US Airways Pilots

From: Captain Ed Bular

Senior Director, Flight Operations

Captain Ron Schilling

Director, Flight Training and Standards

Captain Pete Eichenlaub

Director, US Airways Flight Safety and Quality Assurance

Captain Terry McVenes

Chairman, ALPA Central Air Safety Committee

Subject: Line Operations Safety Audit (LOSA)

Date: October 1, 2000

Beginning mid-October and continuing for approximately five weeks, US Airways will conduct a Line

Operations Safety Audit (LOSA). For this audit, we will use US Airways pilots to conduct cockpit jumpseat

observations, along with three observers from the ffice:smarttags" />laceType w:st="on">UniversitylaceType> of laceName w:st="on">Texas Human Factors Research ProjectlaceName> (a.k.a.

“NASA/UT Aerospace Crew Research Project.”

LOSA observations are no-jeopardy events, and all data are confidential and de-identified. LOSA data go

directly to the UT Human Factors Research Program for data entry and analysis. Be assured that these

observations are not checkrides. Although some LOSA observers may be US Airways check airmen, they

are not there to critique your performance — their mission is to be an unobtrusive observer and to fill out

data collection forms after the flight is completed.

Early on, it was decided that the ultimate customer of the audit should be the US Airways line pilot. By

that, the audit should help us identify problem areas so that we can correct them and make your job easier.

Did you ever see a procedure that could be done better, but didn’t feel like you had a way to feed that idea

into the system for possible change? Are some procedures better than others as far as helping avoid, trap

and mitigate errors? LOSA should help us identify the strengths and weaknesses of our crew procedures,

and with that information, management is committed to making necessary changes to continually improve

the way that we do business.

In short, we’re doing a LOSA so that we can improve the system to better support you. After the audit is

completed, we’re committed to telling you how it went, and how we plan to make improvements.

B-2 Line Operations Safety Audit (LOSA)

In addition to using US Airways pilots as LOSA observers, we will also use three observers from UT Human

Factors Research Program. These gentlemen are very experienced LOSA observers, having worked with the

UT program for many years. They are John Bell, Roy Butler and James Klinect, and their credentials can

be verified by your requesting that they present a copy of their FAA jumpseat authorization.

Please extend your usual professional courtesies to the LOSA observation team, and thank you for your

unfailing cooperation.

Sincerely,

Captain Ed Bular

Senior Director, Flight Operations

Captain Ron Schilling

Director, Flight Training and Standards

Captain Pete Eichenlaub

Director, Flight Safety and Quality Assurance

Captain Terry McVenes

Chairman, ALPA Central Air Safety Committee

C-1

航空

Threat and Error Management Worksheet Codesfficeffice" />

Threat Codes

Departure / Arrival Threats

1 Adverse weather / turbulence / IMC

2 Terrain

3 Traffic — Air or ground congestion,

TCAS warnings

4 Airport — construction, signage, ground

conditions

5 TCAS RA/TA

Aircraft Threats

20 Aircraft malfunction

21 Automation event or anomaly

22 Communication event — radios, ATIS, ACARS

Operational Threats

30 Operational time pressure — delays,

OTP, late arriving pilot or aircraft

31 Missed approach

32 Flight diversion

33 Unfamiliar airport

34 Other non-normal operation events —

max gross wt. T/O, rejected T/O

Cabin Threats

40 Cabin event / distraction / interruption

41 Flight attendant error

ATC Threats

50 ATC command — challenging clearances,

late changes

51 ATC error

52 ATC language difficulty

53 ATC non-standard phraseology

54 ATC radio congestion

55 Similar call signs

Crew Support Threats

80 MX event

81 MX error

82 Ground handling event

83 Ground crew error

84 Dispatch/ paperwork event

85 Dispatch / paperwork error

86 Crew scheduling event

87 Manuals / charts incomplete /

incorrect

99 Other Threats

Who Committed / Detected Codes Undesired Aircraft State Codes

Flightcrew

1 CA

2 FO

3 SO / FE

4 Relief Officer

5 Jumpseat

Rider

6 All crew

members

7 Nobody

Other people

8 ATC

9 Flight attendant

10 Dispatch

11 Ground

12 MX

Aircraft

20 Aircraft systems

99 Other

Configuration States

1 Incorrect A/C configuration — flight controls,

brakes, thrust reversers, landing gear

2 Incorrect A/C configuration — systems (fuel,

electrical, hydraulics, pneumatics, airconditioning,

pressurization, instrumentation)

3 Incorrect A/C configuration — automation

4 Incorrect A/C configuration — engines

Ground States

20 Proceeding towards wrong runway

21 Runway incursion

22 Proceeding towards wrong taxiway / ramp

23 Taxiway / ramp incursion

24 Wrong gate

Aircraft Handling States — All Phases

40 Vertical deviation

41 Lateral deviation

42 Unnecessary WX penetration

43 Unauthorized airspace penetration

44 Speed too high

45 Speed too low

46 Abrupt aircraft control (attitude)

47 Excessive banking

48 Operation outside A/C limitations

Approach / Landing States

80 Deviation above G/S or FMS path

81 Deviation below G/S or FMS path

82 Unstable approach

83 Continued landing - unstable approach

84 Firm landing

85 Floated landing

86 Landing off C/L

87 Long landing outside TDZ

99 Other Undesired States

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

A-20 Line Operations Safety Audit (LOSA)

Copyright  2002 The University of Texas at ffice:smarttags" />Austin. All rights reserved.

航空

Operational Decision Error Codesfficeffice" />

Descent and Approach Errors

500 Failure to execute a go-around before reaching

procedural bottom-lines

501 Unnecessary low maneuver on approach

502 Approach deviation (lateral or vertical) by choice

503 Decision to start the descent late

520 Operating at the edge of the performance envelope

(no buffer for error)

Navigation Errors

510 Navigation through known bad weather that

unnecessarily increased risk (i.e., thunderstorms or wind

shear)

512 Decision to navigate to the wrong assigned altitude

513 Decision to navigate on the incorrect heading or course

514 Decision to navigate without ground clearance

521 Speed too high for operating environment

ATC Errors

530 Accepting instructions from ATC that unnecessarily

increased risk

531 Making a request to ATC that unnecessarily

increased risk

532 Failure to verify ATC instructions

533 Altitude deviation without ATC notification

534 Course or heading deviation without ATC clearance

535 Accepting a visual in nonvisual conditions

Crew Interaction Errors

540 Non-essential conversation at inappropriate times

Automation Errors

550 FMC over-reliance — used at inappropriate times

551 FMC under-reliance — not used when needed

552 Heads down FMC operation

553 Discretionary omission of FMC data (e.g., winds)

Instrument Errors

560 Lack of weather radar use

Checklist Errors

570 Failure to complete a checklist in a timely manner (i.e.,

after takeoff checklist)

Paperwork Errors

590 Failure to cross-verify documentation or paperwork

Other Operational Decision Errors

599 Other operational decision errors not listed in the

code book

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-19

Copyright  2002 The University of Texas at ffice:smarttags" />Austin. All rights reserved.