Doc9803航线运行安全审计

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ffice:smarttags" />3.1.4 The following would be some of the typicalfficeffice" />

expected actions, in no particular order, by an airline

following a LOSA:

• Modifying existing procedures or implementing new

ones;

• Redefining operational philosophies and guidelines;

• Arranging specific training in error management and

crew countermeasures;

• Reviewing checklists to ensure relevance of the

content and then issuing clear guidelines for their

initiation and execution; and

• Defining tolerances for stabilized approaches, as

opposed to the “perfect approach” parameters

promoted by existing SOPs.

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ffice:smarttags" />3.2 A CONSTANTLY CHANGING SCENEfficeffice" />

3.2.1 Airlines are continually involved in changes that,

at some point or other, have an effect upon safety. Factors

underlying this continuous change process include, among

others, regulatory changes (airworthiness directives, advisory

circulars, etc.); changes in national or international

airspace systems (automatic dependent surveillance (ADS),

data link/controller-pilot data link communications

(CPDLC), reduced vertical separation, extended range

operations by twin-engined aeroplanes (ETOPS), etc.);

changes to improve operational efficiencies (reduction of

costs, improvement of on-time performance, etc.); operational

events (diversions, rejected take-offs, etc.); and

progress (route expansion, fleet modernization, new

technologies, etc.)

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ffice:smarttags" />3.2.2 Virtually everyone in an airline is somehowfficeffice" />

involved in these changes. For example, Chief Executive

Officers and their staff decide to buy new equipment;

marketing opens up new routes; engineering must install

new components; flight operations faces new staffing

requirements and adjustments to line procedures; flight

standards must define new policies and procedures; and

flight training faces acquisition of new simulators.

3.2.3 These changes are achieved and monitored both

through established formal and informal mechanisms

underlying change processes. Formal mechanisms include

meetings (daily, weekly, monthly and quarterly), reports and

reviews at all levels of the organization. Informal

3-2 Line Operations Safety Audit (LOSA)

mechanisms include crosstalk, spontaneous information

transfer, and sharing in general by everyone in the

organization. Both mechanisms work toward actively

maintaining focus on the changes affecting safety.

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ffice:smarttags" />3.2.4 Therefore, when in spite of these formal andfficeffice" />

informal mechanisms an airline experiences an accident or

an incident, the immediate question arises: What is

happening “out there”? The fact is that system changes and

organizational responses to these changes generate active

and latent threats to daily line operations. Active and latent

threats themselves constantly change in a manner proportional

to system changes. Active and latent threats

become the breeding grounds of crew errors. Many organizations

are not aware of these active and latent threats for

a number of reasons, including the following:

• The “big picture” of flight operations is constantly

changing because of the constantly changing scene;

• Crews may not report threats, fearing punishment;

• Crews may not report threats because they do not

receive any feedback on their reports;

• Crews operate unsupervised most of the time;

• Line Checks (supervised performance) are poor

indicators of normal operations; and

• Management may have difficulty screening out valid

reported crew concerns from over-reported crew

complaints.

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ffice:smarttags" />3.2.5 Active and latent threats are the precursors tofficeffice" />

accidents and incidents. Threats cannot be identified through

the investigation of accidents and incidents until it is too late.

Most threats, however, can be proactively identified through

LOSA (and other safety data collection programmes such as

flight data analysis) and considered as targets for enhancement.

For example, following a LOSA, an airline might

identify the following targets for enhancement:

• Stabilized approaches

• Checklists

• Procedural errors

• Automation errors

• ATC communications

• International flight operations guide

• Captain leadership (intentional non-compliance

errors)

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ffice:smarttags" />3.2.6 To sustain safety in a constantly changingfficeffice" />

environment, data must be collected and analysed on a

routine basis to identify the targets for enhancement and then

a formal safety change process (SCP) must occur in order

to bring about improvement. The basic steps of the SCP

include the following and are also shown in Figure 3-1.

• Measurement (with LOSA) to obtain the targets

• Detailed analysis of targeted issues

• Listing of potential changes for improvement

• Risk analysis and prioritization of changes

• Selection and funding of changes

• Implementation of changes

• Time allocation for changes to stabilize

• Re-measurement

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ffice:smarttags" />3.2.7 Airlines need a defined SCP to keep thefficeffice" />

organization working together to achieve the same safety

objectives. A well-defined SCP keeps the organization from

getting into “turf” issues, by clearly specifying who and

what impacts flight operations. An SCP also contributes to

improving the safety culture by maximizing the capabilities

of current and future safety programmes. Last, but not least,

an SCP provides a principled approach to target limited

resources.

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ffice:smarttags" />3.2.8 In the past, SCPs were based on accident andfficeffice" />

incident investigations, experience and intuition. Today,

SCPs must be based on the “data wave”, the “data

warehouse” and the “drill-down” analysis. Measurement is

fundamental, because until an organization measures, it can

only guess. In the past, SCPs dealt with accidents. Today,

SCPs must deal with the precursors of accidents.

3.3 ONE OPERATOR’S EXAMPLE

OF AN SCP

3.3.1 This section briefly presents some of the very

positive results obtained by one airline that pioneered LOSA

in international civil aviation. The examples represent a

two-year period, between 1996 and 1998, and include

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

aggregate data collected during 100 flight segments. During

this two-year period, 85 per cent of the crews observed made

at least one error during one or more segments, and 15 per

cent of the crews observed made between two and five

errors. Errors were recorded in 74 per cent of the segments

observed, with an average of two errors per segment (see

Chapter 2 for a description of the error categories in LOSA).

These data, asserted as typical of airline operations,

substantiated the pervasiveness of human error in aviation

operations, while challenged beyond question the illusion of

error-free operational human performance.

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ffice:smarttags" />3.3.2 LOSA observations indicated that 85 per cent offficeffice" />

errors committed were inconsequential, which led to two

conclusions. First, the aviation system possesses very strong

and effective defences, and LOSA data allow a principled

and data-driven judgement of which defences work and

which do not, and how well defences fulfil their role.

Second, it became obvious that pilots intuitively develop ad

hoc error management skills, and it is therefore essential to

discover what pilots do well so as to promote safety through

organizational interventions, such as improved training,

procedures or design, based on this “positive” data.

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Figure 3-1. Basic steps of the safety change processfficeffice" />

Re-measurement

Measurement

Risk analysis and

prioritization of changes

Listing of

potential changes

Analysis of

targets

Time allocation

for changes

Implementation

of changes

Selection and

funding of changes

LOSA

3-4 Line Operations Safety Audit (LOSA)