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Doc9803航线运行安全审计 [复制链接]

Rank: 9Rank: 9Rank: 9

181#
发表于 2010-4-16 09:01:22 |只看该作者

Mode Control Panel Errorsfficeffice" />

234 Failure to cross-verify MCP / altitude alerter changes

235 Wrong MCP altitude setting dialed

236 Wrong MCP vertical speed setting dialed

237 Wrong MCP speed setting dialed

238 Wrong MCP course setting dialed

239 Wrong MCP heading setting dialed

240 Wrong setting on the MCP autopilot or FD switch

241 Wrong MCP mode executed

242 Wrong MCP mode left engaged

243 Manual control while a MCP mode is engaged

244 Failure to execute a MCP mode when needed

245 Wrong MCP navigation select setting

(NAV/GPS/ILS/VOR switch)

246 PF makes own MCP changes

247 Wrong MCP setting on the auto-throttle switch

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182#
发表于 2010-4-16 09:01:33 |只看该作者

Flight Management Computer / Control Display Unitfficeffice" />

Errors

249 Failure to cross-verify FMC/CDU changes / position

250 Wrong waypoint / route settings entered into the FMC

251 Failure to execute a FMC mode when needed

252 Wrong mode executed in the FMC

253 Wrong mode left engaged in the FMC

254 Wrong present position entered into the FMC

255 Wrong weights / balance calcs entered into the FMC

256 Wrong speed setting entered into the FMC

257 PF makes own FMC changes

258 Wrong FMC format for input

205 Wrong approach selected in the FMC

204 Other wrong CDU entries / settings

259 Wrong nav radio frequency

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183#
发表于 2010-4-16 09:01:45 |只看该作者

Radio Errorsfficeffice" />

260 Wrong ATIS frequency dialed

261 Wrong ATC frequency dialed

262 Wrong squawk

Documentation Errors

263 Wrong ATIS information recorded

264 Wrong runway information recorded

265 Wrong V-speeds recorded

266 Wrong weights and balance information recorded

267 Wrong fuel information recorded

268 Missed items on the documentation (flight plan,

NOTAMS, or dispatch release)

269 Misinterpreted items on the documentation (flight plan,

NOTAMS, or dispatch release)

270 Wrong time calculated in the flight plan

271 Wrong clearance recorded

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184#
发表于 2010-4-16 09:01:56 |只看该作者

Callout Errorsfficeffice" />

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

276 Omitted climb or descent callouts

277 Omitted approach callouts

Job Sequence Errors

280 Executing the correct job procedures out of sequence

Handling Errors

281 Unintentional lateral deviation

282 Unintentional vertical deviation

286 Unintentional speed deviation

Ground Navigation Errors

283 Attempting or actually turning down the wrong runway

284 Attempting or actually turning down the wrong ramp /

taxiway / gate

287 Attempting or actually lining up for the incorrect runway

288 Attempting or actually lining up off C/L

289 Failure to execute a go-around after passing procedural

bottom lines of an unstable approach

290 Missed runway

291 Missed taxiway

292 Missed gate

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

A-16 Line Operations Safety Audit (LOSA)

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

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185#
发表于 2010-4-16 09:02:07 |只看该作者

Hard Warning Errorsfficeffice" />

293 Failure to respond to GPWS warnings

294 Failure to respond to TCAS warnings

Briefing Errors

272 Incomplete flight attendant briefing

273 Incomplete cruise briefing

274 Incomplete approach briefing

295 Omitted takeoff briefing

296 Omitted approach briefing

297 Omitted flight attendant briefing

298 Omitted engine-out briefing

Other Procedural Errors

299 Other procedural errors not listed in the code book

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-17

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

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186#
发表于 2010-4-20 16:34:24 |只看该作者

Communication Error Codesfficeffice" />

Crew to ATC Errors

300 Wrong readbacks or callbacks to ATC

301 Missed ATC calls

302 Omitted call signs to ATC

303 Failure to give readbacks or callbacks to ATC

305 Omitted position report to ATC

306 Omitted non-radar environment report to ATC

307 Misinterpretation of ATC instructions

309 Crew omitted ATC call

310 Missed instruction to hold short

Crew to Crew Errors

319 Wrong airport communicated

320 Wrong taxiway communicated

321 Wrong runway communicated

322 Wrong takeoff callouts communicated

323 Wrong climb and descent callouts communicated

324 Wrong approach callouts communicated

325 Wrong gate assignment communicated

335 Crew miscommunication that lead to a misinterpretation

336 Wrong engine out procedures stated

Other Communication Errors

350 Misinterpretation of ATIS

399 Other communication errors not listed in the code

book

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187#
发表于 2010-4-20 16:34:34 |只看该作者

Proficiency Error Codesfficeffice" />

400 Lack of systems knowledge

401 Lack of automation knowledge

402 Lack of stick and rudder proficiency

403 Lack of knowledge to properly contact ATC

404 Lack of procedural knowledge

405 Lack of weather knowledge

406 Lack of knowledge of standard ATC phraseology

407 Lack of knowledge to contact company (i.e., gate

assignments)

499 Other knowledge or proficiency based errors not

listed in the code book

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

A-18 Line Operations Safety Audit (LOSA)

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

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188#
发表于 2010-4-20 16:34:45 |只看该作者

Operational Decision Error Codesfficeffice" />

Descent and Approach Errors

500 Failure to execute a go-around before reaching

procedural bottom-lines

501 Unnecessary low maneuver on approach

502 Approach deviation (lateral or vertical) by choice

503 Decision to start the descent late

520 Operating at the edge of the performance envelope

(no buffer for error)

Navigation Errors

510 Navigation through known bad weather that

unnecessarily increased risk (i.e., thunderstorms or wind

shear)

512 Decision to navigate to the wrong assigned altitude

513 Decision to navigate on the incorrect heading or course

514 Decision to navigate without ground clearance

521 Speed too high for operating environment

ATC Errors

530 Accepting instructions from ATC that unnecessarily

increased risk

531 Making a request to ATC that unnecessarily

increased risk

532 Failure to verify ATC instructions

533 Altitude deviation without ATC notification

534 Course or heading deviation without ATC clearance

535 Accepting a visual in nonvisual conditions

Crew Interaction Errors

540 Non-essential conversation at inappropriate times

Automation Errors

550 FMC over-reliance — used at inappropriate times

551 FMC under-reliance — not used when needed

552 Heads down FMC operation

553 Discretionary omission of FMC data (e.g., winds)

Instrument Errors

560 Lack of weather radar use

Checklist Errors

570 Failure to complete a checklist in a timely manner (i.e.,

after takeoff checklist)

Paperwork Errors

590 Failure to cross-verify documentation or paperwork

Other Operational Decision Errors

599 Other operational decision errors not listed in the

code book

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

Appendix A. Examples of the various forms utilized by LOSA A-19

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

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189#
发表于 2010-4-20 16:34:57 |只看该作者

Threat and Error Management Worksheet Codesfficeffice" />

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

ATC Threats

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

Who Committed / 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

Aircraft Handling States All Phases

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-20 Line Operations Safety Audit (LOSA)

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

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190#
发表于 2010-4-20 16:35:08 |只看该作者

LOSA Crew Interviewfficeffice" />

1. Training

a) Is there a difference in how you were trained, and how things really go in line operations?

b) If so, why?

2. Standardization

a) How standardized are other crews that you fly with?

b) If there is a lack of standardization, what do you think is the reason(s) for procedural non-compliance?

3. Automation

a) What are the biggest automation “gotchas” for this airplane?

4. Overall safety improvements – concerns and suggestions for improvement

a) Flight Ops

b) Dispatch

c) Airports and ATC

d) SOPs

SAMPLE

FOR ILLUSTRATION PURPOSES ONLY

B-1

Appendix B

EXAMPLE OF AN INTRODUCTORY LETTER

BY AN AIRLINE TO ITS FLIGHT CREWS

To: All US Airways Pilots

From: Captain Ed Bular

Senior Director, Flight Operations

Captain Ron Schilling

Director, Flight Training and Standards

Captain Pete Eichenlaub

Director, US Airways Flight Safety and Quality Assurance

Captain Terry McVenes

Chairman, ALPA Central Air Safety Committee

Subject: Line Operations Safety Audit (LOSA)

Date: October 1, 2000

Beginning mid-October and continuing for approximately five weeks, US Airways will conduct a Line

Operations Safety Audit (LOSA). For this audit, we will use US Airways pilots to conduct cockpit jumpseat

observations, along with three observers from the ffice:smarttags" />laceType w:st="on">UniversitylaceType> of laceName w:st="on">Texas Human Factors Research ProjectlaceName> (a.k.a.

“NASA/UT Aerospace Crew Research Project.”

LOSA observations are no-jeopardy events, and all data are confidential and de-identified. LOSA data go

directly to the UT Human Factors Research Program for data entry and analysis. Be assured that these

observations are not checkrides. Although some LOSA observers may be US Airways check airmen, they

are not there to critique your performance — their mission is to be an unobtrusive observer and to fill out

data collection forms after the flight is completed.

Early on, it was decided that the ultimate customer of the audit should be the US Airways line pilot. By

that, the audit should help us identify problem areas so that we can correct them and make your job easier.

Did you ever see a procedure that could be done better, but didn’t feel like you had a way to feed that idea

into the system for possible change? Are some procedures better than others as far as helping avoid, trap

and mitigate errors? LOSA should help us identify the strengths and weaknesses of our crew procedures,

and with that information, management is committed to making necessary changes to continually improve

the way that we do business.

In short, we’re doing a LOSA so that we can improve the system to better support you. After the audit is

completed, we’re committed to telling you how it went, and how we plan to make improvements.

B-2 Line Operations Safety Audit (LOSA)

In addition to using US Airways pilots as LOSA observers, we will also use three observers from UT Human

Factors Research Program. These gentlemen are very experienced LOSA observers, having worked with the

UT program for many years. They are John Bell, Roy Butler and James Klinect, and their credentials can

be verified by your requesting that they present a copy of their FAA jumpseat authorization.

Please extend your usual professional courtesies to the LOSA observation team, and thank you for your

unfailing cooperation.

Sincerely,

Captain Ed Bular

Senior Director, Flight Operations

Captain Ron Schilling

Director, Flight Training and Standards

Captain Pete Eichenlaub

Director, Flight Safety and Quality Assurance

Captain Terry McVenes

Chairman, ALPA Central Air Safety Committee

C-1

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