Doc9803航线运行安全审计

航空

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

航空

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 4 CA and FO failed to verify multiple altitude

changes. 2 1 140 1 6 3 1

E 5

FO, who was new to the aircraft, let it slip

a little to the left during the final approach.

Resulted in landing left of the centerline.

4 4 402 2 6 1 2

航空

Error IDfficeffice" />

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

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

Code

Who

detected

the state?

Crew Undesired

State Response

1 Mitigate

2 Exacerbate

3 Fail to Respond

Undesired

laceName w:st="on">AircraftlaceName> State

Outcome

1 Inconsequential

2 Additional error

航空

E 4 No No error management — intentional errorfficeffice" />

E 5 No

Error mismanaged — FO tried to correct but still landed left of the

centerline. Approach was stable and they made the first high-speed

taxiway. The CA did not verbalize the deviation during the approach.

86 6 1 1

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

A-14 Line Operations Safety Audit (LOSA)

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

航空

Intentional Noncompliance Error Codesfficeffice" />

Sterile Cockpit Errors

100 Sterile cockpit violation

Callout Errors

104 Omitted takeoff callouts (i.e., V-speeds)

105 Omitted climb or descent callouts

106 Omitted approach callouts

Crew to ATC Errors

109 Altitude deviation without ATC clearance

110 Course or heading deviation without ATC clearance

(deviation more than 20 degrees)

111 Use of nonstandard ATC phraseology

112 Omitted position report to ATC

113 Omitted non-radar environment report to ATC

114 Omitted call signs to ATC

航空

Checklist Errorsfficeffice" />

120 Checklist performed from memory

121 Completed checklist not called "complete"

122 Checklist not performed to completion

123 Use of nonstandard checklist protocol (i.e., use of

nonstandard responses)

124 Omitted checklist

125 Self-performed checklist — no challenge or response

126 Omitted abnormal checklist

127 Self initiated checklist — not called for by PF

128 Self initiated checklist — not called for by CA

129 Checklist performed late or at wrong time

航空

Cross-Verification Errorsfficeffice" />

140 Failure to cross-verify MCP / altitude alerter changes

141 Failure to cross-verify FMC/CDU changes before

execution

142 Failure to cross-verify altimeter settings

Hard Warning Errors

160 Failure to respond to GPWS warnings

161 Failure to respond to TCAS warnings

162 Failure to respond to overspeed warning

Briefing Errors

170 Omitted takeoff briefing

171 Omitted approach briefing

172 Omitted flight attendant briefing (only for the first flight

of a trip or crew change)

173 Omitted engine-out briefing

179 Intentional failure to arm spoilers

航空

Approach Errorsfficeffice" />

180 Failure to execute a go-around after passing procedural

bottom lines of an unstable approach

181 Speed deviation without ATC clearance

183 Intentionally flying below the G/S

184 PF makes own flight control settings

Automation and Instrument Setting Errors

185 PF makes own MCP changes

186 PF makes own FMC changes

187 Failure to set altitude alerter

189 Setting altimeters before the transition altitude

190 Using equipment placarded inoperative

Other Noncompliance Errors

195 Taxi-in or out without a wing walker

ffice:smarttags" />196 A/C operation with unresolved MEL item

199 Other noncompliance errors not listed in the code

book

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-15

Copyright  2002 The University of Texas at Austin. All rights reserved.

航空

Procedural Error Codesfficeffice" />

Checklist Errors

200 Missed checklist item

201 Wrong checklist performed

202 Checklist performed late or at the wrong time

203 Forgot to call for checklist

206 Wrong response to a challenge on a checklist (i.e., item

not checked that was responded to as “checked”)

207 Completed checklist not called "complete"

209 Omitted checklist

233 Omitted abnormal checklist

Primary Instrument or Panel Errors

210 Wrong altimeter settings

211 Wrong bug settings (i.e., airspeed or altimeter)

212 Failure to set altitude alerter

213 Failure to cross-verify altimeter settings

214 Failure to cross-verify altitude alerter

航空

Lever and Switch Errorsfficeffice" />

215 Failure to extend the flaps on schedule

216 Failure to retract the flaps on schedule

217 Wrong display switch setting

218 Failure to leave thrust reversers extended

219 Failure to lower the landing gear on schedule

220 Failure to bring up the landing gear on schedule

221 Failure to extend the speed brakes on landing

222 Failure to retract the speed brakes

223 Failure to engage thrust reversers on landing

224 Failure to retract thrust reversers after landing

225 Failure to turn on the landing lights

226 Wrong fuel switch setting

227 Failure to turn on TCAS

228 Failure to turn on the fasten seat belt sign

229 Failure to arm spoilers

230 Failure to turn on the A/C packs (no pressurization)

231 Wrong panel setup for an engine start

278 Wrong power settings for T/O

279 Wrong autobrake setting

232 Other incorrect switch or lever settings