Doc9803航线运行安全审计

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Safety departmentfficeffice" />

ffice:smarttags" />4.3.2 Ideally, the safety department should be the

department to administer the LOSA. There are several

reasons for this. For one, conducting audits is typically a job

function of the safety department. Another important reason

4-2 Line Operations Safety Audit (LOSA)

is that the safety department often holds the trust of the line

pilots regarding confidential information. It is the safety

department that typically administers confidential incident

reporting systems and the FOQA Programme or digital

flight data recorder monitoring programmes.

Flight operations and training departments

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ffice:smarttags" />4.3.3 The flight operations and training departmentsfficeffice" />

must be integrally involved with implementing a LOSA for

several reasons. First, they are at the centre of the operation

and have first-hand information about what is and is not

working well. These departments often know of specific

areas on which they would like the LOSA to concentrate.

Additionally, these departments can provide valuable input

and suggestions for the smooth conduct of the LOSA. They

will also be able to help provide the much needed personnel.

Possibly the most important reason for their involvement is

that ultimately many of the problem areas and the potential

benefits that are identified during a LOSA must be

“corrected” or implemented by these departments. As with

the example of the airline above, if these departments do not

support the LOSA, then there could be possible resistance

to the findings from the LOSA. However, if these departments

take an active part in the process, implementation of

LOSA enhancements becomes much more probable.

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Pilots unionfficeffice" />

ffice:smarttags" />4.3.4 The importance of having the pilots union

involved with and support the LOSA must not be

overlooked. If the line pilots believe that their union supports

this endeavour, they will more readily accept observation

flights. Additionally, if pilots believe this is a process that

they can support, they will be more forthcoming and candid

with their views and safety concerns. On the other hand, if

the pilots view LOSA as a management tool to spy on them,

then the results will not be as productive. The pilots union

can also help disseminate the results of the LOSA and

inform the pilots of any company decisions as a result of the

LOSA. Hopefully, the union will agree with the

enhancements and endorse them.

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4.4 THE KEY STEPS OF A LOSAfficeffice" />

ffice:smarttags" />4.4.1 To help provide focus for the LOSA, the LOSA

steering committee should first look at problems that have

been identified in the past by all involved departments. With

this information in hand, the committee can then decide

what they expect to gain from the LOSA and use that to form

goals and an action plan. It must be kept in mind that the

goals and action plan may have to be modified depending

on the LOSA findings.

Goals

4.4.2 The LOSA steering committee should meet to

determine what they would like to achieve from the LOSA.

This will vary among airlines, but the following are some

goals established by one airline:

• To heighten the safety awareness of the line pilot

• To obtain hard data on how crews manage threats

and errors

• To measure and document what is happening “on the

line”

— What works well

— What does not work well

• To provide feedback to the system so that

enhancements can be made

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• To inform end users WHY enhancements are beingfficeffice" />

made, especially if the enhancements are a result of

end user feedback

• To monitor results of LOSA enhancements

ffice:smarttags" />4.4.3 One airline stated up front that they wanted their

line pilots to be the “customer” of the LOSA, meaning that

whatever problems were identified, they would work to

correct them to make the system safer and more efficient for

their pilots.

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Action planfficeffice" />

ffice:smarttags" />4.4.4 Figure 4-1 shows a flow chart of the key steps

to LOSA. Steps 1 to 6 are covered below. Notice that the

actual LOSA observations are not the end of the project but,

in fact, are only a part of an entire process to help improve

system safety at an airline. Steps 7 to 9 have already been

covered earlier in this manual.

Step 1: Form initial development team

This team may be the same as the LOSA steering committee

or just a few core individuals who can bring the committee

up to date.

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Chapter 4. How to set up a LOSA — US Airways experience 4-3fficeffice" />

Figure 4-1. The key steps to LOSA

STEP 5: Schedule audit dates,

select observers and

schedule training

STEP 8: Provide feedback to system

and carry out improvements to system

STEP 9: Develop enhanced policies,

procedures and a safer operational

environment for the line pilot

STEP 4: Determine how

many segments to observe

STEP 6: Conduct observer training

STEP 7: Analyse audit findings

AUDIT

STEP 3: Identify what to look at

STEP 2: Gather information

STEP 1: Form initial

development team

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SAFER OPERATION!fficeffice" />

Develop data collection forms and

observer training

Refine data collection forms

as needed

Recalibrate observers

4-4 Line Operations Safety Audit (LOSA)

Step 2: Gather information

In order to conduct a LOSA, the initial development team

must understand how LOSAs have been carried out in the

past and they should be aware of the benefits that have been

derived. They should, therefore, gather information on the

LOSA process.

Step 3: Identify what to look at

To conduct the most efficient LOSA, it is best to focus on

specific aspects. One common mistake is to try to tackle too

much at one time. When doing this, the effort can be

enormous and the data findings can be overwhelming.

A more manageable approach may be to narrowly focus on

or target specific things to be observed. Are there certain

airports that have more hazards or threats compared to other

airports? Do certain aircraft fleets have more instances of tail

strikes? Are unstabilized approaches something your

operation is struggling with?

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The decisions about what to observe should be based on datafficeffice" />

and not just instincts. For example, if an airline utilized an

FOQA Programme or a confidential incident reporting

system, these sources would be excellent places to help

pinpoint areas on which efforts should be focused.

It should be remembered that LOSA is not designed to look

at the entire operation, but really just provide a

representative sampling or “slice” of the operations. One

large international carrier decided to focus their first LOSA

on their domestic operations, but had plans to later conduct

a LOSA that focused on their international operations.

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Step 4: Determine how many segments to observefficeffice" />

The number of flights that will be observed is a function of

the number of people who will act as LOSA observers. Also

to be considered is the need to collect enough data to provide

a statistically valid sample of the operation. For example,

statisticians at The University of Texas at Austin Human

Factors Research Project have determined that if an airline

wanted to evaluate a specific airport, then that airline should

observe at least ten flights into and out of that airport. For

a specific operation or fleet, the LOSA should observe at

least 50 flights on that operation or fleet.