Doc9803航线运行安全审计

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ffice:smarttags" />3.3.3 When the airline started conducting base-linefficeffice" />

observations in 1996, the crew error-trapping rate was 15 per

cent; that is, flight crews detected and trapped only 15 per

cent of the errors they committed. After two years, following

implementation of organizational strategies aimed at error

management based on LOSA data, the crew error-trapping

rate increased to 55 per cent (see Figure 3-2).

3.3.4 Base-line observations in 1996 suggested

problems in the area checklist performance. Following

remedial interventions — including review of standard

operating procedures, checklist design and training —

checklist performance errors decreased from 25 per cent to

15 per cent, which is a 40 per cent reduction in checklist

errors (see Figure 3-3).

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Figure 3-2. Crew error-trapping ratefficeffice" />

Figure 3-3. Checklist errors

15%

55%

0%

10%

20%

40%

50%

60%

1996 1998

30%

25%

15%

0%

5%

10%

15%

20%

25%

1996 1998

40%

Reduction

Chapter 3. LOSA and the safety change process (SCP) 3-5

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ffice:smarttags" />3.3.5 Lastly, base-line observations in 1996 suggestedfficeffice" />

that 34.2 per cent of approaches did not meet all requirements

of the audit’s stabilized approach criteria, as specified

in the operator’s SOPs. Unstabilized approaches (using more

stringent criteria than during the 1996 audit) decreased to

13.1 per cent (a 62 per cent reduction) in 1998, following

remedial action through organizational interventions. The

data accessed through the operator’s flight operations quality

assurance (FOQA) programme is consistent with LOSA data

and shows a similar decline for 1998.

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ffice:smarttags" />3.3.6 How does such change take place? By adoptingfficeffice" />

a defined SCP. Following data acquisition and analysis, the

airline decided to form specific committees including a

checklist committee and an unstabilized approaches committee.

Each committee considered the problems identified

by the analysis of the LOSA data and then proposed

organizational interventions to address them. Such interventions

included modification of existing procedures,

implementation of new ones, specific training, and

redefinition of operational philosophies, among others. For

example, checklists were reviewed to ensure relevance of

contents, and clear guidelines for their initiation and

execution were promulgated. Gates and tolerances for

stabilized approaches were defined, as opposed to the

“perfect approach” parameters promulgated by the SOPs

existing at that time. Proper training and checking guidelines

were established, taking into account an error management

approach to crew coordination.

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ffice:smarttags" />3.3.7 The improved error management performance byfficeffice" />

flight crews, successful reduction in checklist performance

errors and reduction in unstabilized approaches discussed

earlier reflect the success of a properly managed SCP, based

upon data collected by observing line operations. They are

also examples of how analysis of LOSA data provides an

opportunity to enhance safety and operational human

performance.

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4-1fficeffice" />

Chapter 4

HOW TO SET UP A LOSA — US AIRWAYS EXPERIENCE

“Honest and critical self-assessment is one of the most

powerful tools that management can employ to measure

flight safety margins.”

Flight Safety Foundation Icarus Committee

May 1999

4.1 GATHERING INFORMATION

In order to decide if conducting a LOSA would be

beneficial, it is important to understand the LOSA process.

The first contact should be ICAO or The University of Texas

at Austin Human Factors Research Project. Both are able to

provide all the information needed and can discuss benefits

that have been derived from past LOSAs. They will also be

aware of other airlines currently planning or conducting a

LOSA, and it may be possible to attend those airlines’

training classes. It is also a good idea to talk with and/or visit

other airlines that have already completed a LOSA to learn

from their experiences.

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4.2 INTERDEPARTMENTAL SUPPORTfficeffice" />

ffice:smarttags" />4.2.1 When first exploring whether or not to conduct

a LOSA, it is advisable to gather representatives from all

departments that may be potentially involved. This could

include the flight operations, training and safety departments,

as well as representatives from the pilots union. If

LOSA is not supported by all concerned, the effectiveness

of LOSA will be compromised.

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ffice:smarttags" />4.2.2 As an example, a few years ago a large airlinefficeffice" />

decided to audit its line flights on a somewhat random basis.

The audit was not a LOSA but did have similarities in that

it used trained observers to ride in the airline’s cockpits. The

airline’s safety department administered the line audit, and

the data that they collected were valid and important.

However, the problem was that the flight operations and

training departments of this airline felt somewhat threatened

by the safety department telling them what “was wrong”

with the airline, and therefore they were not very receptive

to the findings of this particular line audit.

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ffice:smarttags" />4.2.3 A few years later, this same airline conducted afficeffice" />

very successful LOSA. This time, the airline emphasized

that the audit was not “owned” by the safety department, but

rather, was a product of the flight operations, training and

safety departments, along with the pilots union. Each of

these departments and organizations became members of the

“LOSA steering committee.” This airline’s LOSA was

successful for many reasons, but primarily because right

from the start, all relevant departments were involved with

the development and direction that the LOSA took. In short,

the programme had interdepartmental “buy-in”.

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4.3 LOSA STEERING COMMITTEEfficeffice" />

ffice:smarttags" />4.3.1 This buy-in and support of other departments are

crucial; therefore, consideration should be given to forming

a “LOSA steering committee.” Determining which departments

should be members varies with each organization but,

at a minimum, should include the safety, flight operations

and flight training departments and the pilots union. The role

of each of these is described below.