Doc9803航线运行安全审计

航空

How did the crew manage or mismanage the threat?fficeffice" />

T 1 Runway and taxiway construction on

their departing runway (final ffice:smarttags" />2000’)

4 1 No Threat mismanaged — CA failed to talk about the construction and

closures in his brief. No plans in place in the event of a RTO.

T 2 Late ATC runway change — changed

runway to 24R from 25L due to a slow

moving aircraft on 25L

50 4 Yes Threat managed — CA reprogrammed the FMC, handled the

radios, and placed emphasis on the FO to fly the aircraft.

T 3 ATC called back and told the crew that

it was at their discretion to land on 24R

or 25L

50 4 Yes Threat managed — CA asked for the FO’s preference. They

mutually decided to continue the approach into 24R because it was

already in the box.

T 4 Heavy congestion going into LAX 3 4 Yes Threat managed — The crew closely monitored the traffic with

the help of ATC and TCAS.

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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

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ATC Threatsfficeffice" />

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

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-11

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

Error Management Worksheet Error ID

Error Description Error Response / Outcome

Describe the crew error and associated

undesired aircraft states

Phase of flight

1 Predepart/Taxi

2 Takeoff/Climb

3 Cruise

4 Des/App/Land

5 Taxi-in

Error Type

1 Intentional

Noncompliance

2 Procedural

3 Communication

4 Proficiency

5 Decision

Error

Code

Use

Code

Book

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Whofficeffice" />

committed

the error?

Who

detected

the error?

Crew Error

Response

1 Trap

2 Exacerbate

3 Fail to Respond

Error

Outcome

1 Inconsequential

2 Undesired state

3 Additional error

E 1 FO failed to set his airspeed bugs. 1 2 211 2 7 3 3

Error ID

Error Management Undesired ffice:smarttags" />laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>

Associated

with a

threat?

(If Yes, enter

Threat ID)

How did the crew manage or mismanage the error? Undesired

Aircraft

State

Code

Who

detected

the state?

Crew Undesired

State Response

1 Mitigate

2 Exacerbate

3 Fail to Respond

Undesired

laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>

Outcome

1 Inconsequential

2 Additional error

E 1 No Error chain to E2

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Who Committed /fficeffice" />

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

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Aircraft Handling States — All Phasesfficeffice" />

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-12 Line Operations Safety Audit (LOSA)

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

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感谢LZ分享

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Error Management Worksheet Error IDfficeffice" />

Error Description Error Response / Outcome

Describe the crew error and associated

undesired aircraft states

Phase of flight

1 Predepart/Taxi

2 Takeoff/Climb

3 Cruise

4 Des/App/Land

5 Taxi

Error Type

1 Intentional

Noncompliance

2 Procedural

3 Communication

4 Proficiency

5 Decision

Error

Code

Use

Code

Book

Who

committed

the error?

Who

detected

the error?

Crew Error

Response

1 Trap

2 Exacerbate

3 Fail to Respond

Error

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Outcomefficeffice" />

1 Inconsequential

2 Undesired state

3 Additional error

E ffice:smarttags" />2 In running the Before Takeoff Checklist, the

FO skipped the takeoff data item. 1 2 200 2 7 3 1

E 3 FO called “flaps up” prior to the flap

retraction speed. 2 2 299 2 1 1 1

Error ID

Error Management Undesired laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>

Associated

with a

threat?

(If Yes, enter

Threat ID)

How did the crew manage or mismanage the error? Undesired

Aircraft

State

Code

Who detected

the

state?

Crew Undesired

State Response

1 Mitigate

2 Exacerbate

3 Fail to Respond

Undesired

laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>

Outcome

1 Inconsequential

2 Additional error

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E 2 Nofficeffice" />

Errors mismanaged — The bug error should have been caught with the

Before Takeoff Checklist, but the FO unintentionally skipped that item.

All checklists during this phase were poorly executed. The FO caught

the error during the takeoff roll.

E 3 No Error managed — CA saw that the aircraft was not at the proper speed

and waited to retract the flaps. Good monitoring in this case.

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-13

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