Doc9803航线运行安全审计

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This was recognized by the ICAO Assembly, which in 1986fficeffice" />

adopted Resolution A26-9 on Flight Safety and Human

Factors. As a follow-up to the Assembly Resolution, the Air

Navigation Commission formulated the following objective

for the task:

“To improve safety in aviation by making States more aware

and responsive to the importance of Human Factors in civil

aviation operations through the provision of practical

Human Factors materials and measures, developed on the

basis of experience in States, and by developing and

recommending appropriate amendments to existing material

in Annexes and other documents with regard to the role of

Human Factors in the present and future operational

environments. Special emphasis will be directed to the

Human Factors issues that may influence the design,

transition and in-service use of the future ICAO CNS/ATM

systems.”

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One of the methods chosen to implement Assemblyfficeffice" />

Resolution A26-9 is the publication of guidance materials,

including manuals and a series of digests, that address

various aspects of Human Factors and its impact on aviation

safety. These documents are intended primarily for use by

States to increase the awareness of their personnel of the

influence of human performance on safety.

The target audience of Human Factors manuals and digests

are the managers of both civil aviation administrations and

the airline industry, including airline safety, training and

operational managers. The target audience also includes

regulatory bodies, safety and investigation agencies and

training establishments, as well as senior and middle nonoperational

airline management.

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This manual is an introduction to the latest informationfficeffice" />

available to the international civil aviation community on the

control of human error and the development of countermeasures

to error in operational environments. Its target

audience includes senior safety, training and operational

personnel in industry and regulatory bodies.

This manual is intended as a living document and will be

kept up to date by periodic amendments. Subsequent

editions will be published as new research results in

increased knowledge on Human Factors strategies and more

experience is gained regarding the control and management

of human error in operational environments.

(vi)

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ACRONYMS AND ABBREVIATIONSfficeffice" />

ADS Automatic Dependent Surveillance

ATC Air Traffic Control

CFIT Controlled Flight Into Terrain

CNS/ATM Communications, Navigation and Surveillance/Air Traffic Management

CPDLC Controller-Pilot Data Link Communications

CRM Crew Resource Management

DFDR Digital Flight Data Recorder

ETOPS Extended Range Operations by Twin-engined Aeroplanes

FAA Federal Aviation Administration

FDA Flight Data Analysis

FMS Flight Management System

FOQA Flight Operations Quality Assurance

ICAO International Civil Aviation Organization

LOSA Line Operations Safety Audit

MCP Mode Control Panel

QAR Quick Access Recorder

RTO Rejected Take-Off

SCP Safety Change Process

SOPs Standard Operating Procedures

TEM Threat and Error Management

ffice:smarttags" />laceName w:st="on">UTTEMlaceName> laceType w:st="on">UniversitylaceType> of Texas Threat and Error Management

(vii)

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INTRODUCTIONfficeffice" />

1. This manual describes a programme for the

management of human error in aviation operations known

as Line Operations Safety Audit (LOSA). LOSA is proposed

as a critical organizational strategy aimed at developing

countermeasures to operational errors. It is an organizational

tool used to identify threats to aviation safety, minimize the

risks such threats may generate and implement measures to

manage human error in operational contexts. LOSA enables

operators to assess their level of resilience to systemic

threats, operational risks and front-line personnel errors,

thus providing a principled, data-driven approach to

prioritize and implement actions to enhance safety.

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2. LOSA uses expert and highly trained observers tofficeffice" />

collect data about flight crew behaviour and situational

factors on “normal” flights. The audits are conducted under

strict no-jeopardy conditions; therefore, flight crews are not

held accountable for their actions and errors that are

observed. During flights that are being audited, observers

record and code potential threats to safety; how the threats

are addressed; the errors such threats generate; how flight

crews manage these errors; and specific behaviours that have

been known to be associated with accidents and incidents.

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3. LOSA is closely linked with Crew Resourcefficeffice" />

Management (CRM) training. Since CRM is essentially

error management training for operational personnel, data

from LOSA form the basis for contemporary CRM training

refocus and/or design known as Threat and Error Management

(TEM) training. Data from LOSA also provide a

real-time picture of system operations that can guide

organizational strategies in regard to safety, training and

operations. A particular strength of LOSA is that it identifies

examples of superior performance that can be reinforced and

used as models for training. In this way, training interventions

can be reshaped and reinforced based on successful

performance, that is to say, positive feedback. This is indeed

a first in aviation, since the industry has traditionally

collected information on failed human performance, such as

in accidents and incidents. Data collected through LOSA are

proactive and can be immediately used to prevent adverse

events.

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4. LOSA is a mature concept, yet a young one. LOSAfficeffice" />

was first operationally deployed following the First LOSA

Week, which was hosted by Cathay Pacific Airways in

ffice:smarttags" />laceName w:st="on">CathaylaceName> laceType w:st="on">CitylaceType>, Hong Kong, from 12 to 14 March 2001.

Although initially developed for the flight deck sector, there

is no reason why the methodology could not be applied to

other aviation operational sectors, including air traffic

control, maintenance, cabin crew and dispatch.

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5. The initial research and project definition was a jointfficeffice" />

endeavour between The University of Texas at ffice:smarttags" />Austin

Human Factors Research Project and Continental Airlines,

with funding provided by the Federal Aviation Administration

(FAA). In 1999, ICAO endorsed LOSA as the

primary tool to develop countermeasures to human error in

aviation operations, developed an operational partnership

with The laceType w:st="on">UniversitylaceType> of laceName w:st="on">TexaslaceName> at Austin and Continental

Airlines, and made LOSA the central focus of its Flight

Safety and Human Factors Programme for the period 2000

to 2004.

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6. As of February 2002, the LOSA archives containedfficeffice" />

observations from over 2 000 flights. These observations

were conducted within the ffice:smarttags" />United States and internationally

and involved four United States and four non-United States

operators. The number of operators joining LOSA has

constantly increased since March 2001 and includes major

international operators from different parts of the world and

diverse cultures.