Doc9803航线运行安全审计

航空

ffice:smarttags" />2.4.3 The number of observers needed depends, asfficeffice" />

already discussed, on the intended scope of the audit. For

example, an airline might want to audit 50 flight crews in

each of 2 domestic fleets, for a total of 100 segments. A

conservative rule of thumb to scope this audit would be

2 domestic observations per day per observer. The goal is

thus expressed in terms of flight crews observed, rather than

segments. Should an airline want to audit an international

fleet, the first step is to determine how many international

observations can be made in a day, and this depends on the

length of the segments. For a domestic LOSA, a workable

rule of thumb suggests the need for 50 person/days of work

for the actual audit phase of the LOSA. Using line pilots for

a month of observations, each might be requested to spend

10 days conducting observations, plus 4 days training/

travelling. This requires 14 days per observer. Thus, there

would be a need for 4 observers for this hypothetical audit,

2-8 Line Operations Safety Audit (LOSA)

and this should easily meet the audit’s goals. It is important

to be conservative in the estimates since sometimes it will

be necessary to observe a crew for more than one segment.

This counts as one crew, not two.

航空

fficeffice" /> 

2.5 ONCE THE DATA IS COLLECTED

The data acquired through the observations must be

“verified” and prepared for analysis, and the time involved

in this process should not be underestimated. Once the

various LOSA forms have been collected, the airline is ready

to begin a lengthy process. It typically takes longer to

prepare the LOSA data for analysis and ulterior action than

it does to collect it. The steps that must be followed in this

process include data entry, data quality/consistency checks

and final aggregation.

航空

2.6 WRITING THE REPORTfficeffice" />

ffice:smarttags" />2.6.1 The last stage of LOSA is a written report that

presents the overall findings of the project. With a large

database like the one generated from a LOSA, it is easy to

fall into the trap of trying to present too much information.

The author needs to be concise and present only the most

significant trends from the data. If the report does not

provide a clear diagnosis of the weaknesses within the

system for management to act upon, the objective of the

LOSA will be unfulfilled.

2.6.2 Writing the report is where “data smarts” enters

into the process. Although certain types of comparisons will

seem obvious, many analyses will be based upon the

“hunches” or “theories” of the writer. The usefulness of the

result has to be the guiding principle of this effort. If the

writer knows how fleets and operations are managed,

comparisons that reflect this structure can be made. If the

author knows the kinds of information that might be useful

to training, safety or domestic/international flight operations,

results can be tailored to these particular aspects of

the operation. Feedback from various airline stakeholders is

critical during this stage of writing the report. Authors

should not hesitate to distribute early drafts to key people

familiar with LOSA to verify the results. This not only helps

validate derived trends, but it gives other airline personnel,

besides the author, ownership of the report.

航空

ffice:smarttags" />2.6.3 General findings from the survey, interview andfficeffice" />

observational data should serve as the foundation in

organizing the final report. A suggested outline for the report

follows:

Introduction — Define LOSA and the reasons why it

was conducted.

Executive Summary — Include a text summary of the

major LOSA findings (no longer than two pages).

Section Summaries – Present the key findings from each

section of the report including:

I — Demographics

II — Safety Interview Results

III — External Threats and Threat Management

Results

IV — Flight Crew Errors and Error Management

Results

V — Threat and Error Countermeasure Results

Appendix — Include a listing of every external threat

and flight crew error observed with the proper coding

and an observer narrative of how each one was managed

or mismanaged.

航空

Tables, charts and explanations of data should be providedfficeffice" />

within each section of the report.

ffice:smarttags" />2.6.4 It is important to remember that the author’s

primary job is to present the facts and abstain from outlining

recommendations. This keeps the report concise and

objective. Recommendations and solutions may be given

later in supporting documentation after everyone has had the

chance to digest the findings.

2.7 SUCCESS FACTORS FOR LOSA

The best results are achieved when LOSA is conducted in

an open environment of trust. Line pilots must believe that

there will be no repercussions at the individual level;

otherwise, their behaviour will not reflect daily operational

reality and LOSA will be little more than an elaborate line

check. Experience at different airlines has shown that several

strategies are key to ensuring a successful, data-rich LOSA.

These strategies include:

航空

• Using third-party oversight: One way to build trustfficeffice" />

in the LOSA process is to seek a credible but neutral

third party who is removed from the politics and

history of the airline. Data can be sent directly to this

third party, who is then responsible for the objective

analyses and report preparation. The University of

ffice:smarttags" />Texas at Austin Human Factors Research Project

provides, for the time being, such third party

oversight;

Chapter 2. Implementing LOSA 2-9

• Promoting LOSA: Use group presentations, media

clippings, experience from other airlines and intraairline

communications to discuss the purpose and

logistics of a LOSA audit with management, pilots

and any pilots associations. Experience shows that

airlines often underestimate the amount of communication

required so they must be persistent in

their efforts;

航空

• Stressing that observations cannot be used forfficeffice" />

discipline purposes: This is the key issue and must

be stated as such in the letter of endorsement;

• Informing the regulatory authority of the proposed

activity: It is as much a courtesy as it is a way of

communicating the presence of LOSA;

• Choosing a credible observer team: A line crew

always has the prerogative to deny cockpit access to

an observer; hence the observer team is most

effective when composed of credible and wellaccepted

pilots from a mix of fleets and departments

(for example, training and safety). This was achieved

at one airline by asking for a list of potential

observers from the management and the pilots

association; those pilots whose names appeared on

both lists were then selected as acceptable to

everyone;

航空

• Using “a fly on the wall” approach: The bestfficeffice" />

observers learn to be unobtrusive and nonthreatening;

they use a pocket notebook while in the

cockpit, recording minimal detail to elaborate upon

later. At the same time, they know when it is

appropriate to speak up if they have a concern,

without sounding authoritarian;

• Communicating the results: Do not wait too long

before announcing the results to the line or else

pilots will believe nothing is being done. A summary

of the audit, excerpts from the report and relevant

statistics will all be of interest to the line; and

• Using the data: The LOSA audit generates targets

for enhancement, but it is the airline that creates an

action plan. One airline did this by creating a

committee for each of the central concerns, and they

were then responsible for reviewing procedures,

checklists, etc., and implementing change, where

appropriate.

航空

3-1fficeffice" />

Chapter 3

LOSA AND THE SAFETY CHANGE PROCESS (SCP)

3.1 INTRODUCTION

ffice:smarttags" />3.1.1 When an airline commits to LOSA, it must also

commit to acting upon the results of the audit. LOSA is but

a data collection tool. LOSA data, when analysed, are used

to support changes aimed at improving safety. These may be

changes to procedures, policies or operational philosophy.

The changes may affect multiple sectors of the organization

that support flight operations. It is essential that the organization

has a defined process to effectively use the analysed

data and to manage the changes the data suggest.

航空

ffice:smarttags" />3.1.2 LOSA data should be presented to managementfficeffice" />

in at least the areas of operations, training, standards and

safety, with a clear analysis describing the problems related

to each, as captured by LOSA. The LOSA report should

clearly describe the problems the analysed data suggest but

should not attempt to provide solutions. These will be better

provided through the expertise in each of the areas in

question.

3.1.3 LOSA directs organizational attention to the

most important safety issues in daily operations and it

suggests what questions should be asked; however, LOSA

does not provide the solutions. The solutions lie in

organizational strategies. The organization must evaluate the

data obtained through LOSA, extract the appropriate

information and then carry out the necessary interventions

to address the problems thus identified. LOSA will only

realize its full potential if the organizational willingness and

commitment exist to act upon the data collected and the

information such data support. Without this necessary step,

LOSA data will join the vast amounts of untapped data

already existing throughout the international civil aviation

community.