Doc9803航线运行安全审计

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7. ICAO acts as an enabling partner in the LOSAfficeffice" />

programme. ICAO’s role includes promoting the importance

of LOSA to the international civil aviation community;

facilitating research in order to collect necessary data; acting

as a cultural mediator in the unavoidably sensitive aspects

of data collection; and contributing multicultural observations

to the LOSA archives. In line with these objectives,

the publication of this manual is a first step at providing

information and, therefore, at increasing awareness within

the international civil aviation community about LOSA.

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8. This manual is an introduction to the concept,fficeffice" />

methodology and tools of LOSA and to the potential

remedial actions to be undertaken based on the data

collected under LOSA. A very important caveat must be

introduced at this point: this manual is not intended to

convert readers into instant expert observers and/or LOSA

auditors. In fact, it is strongly recommended that LOSA not

be attempted without a formal introduction to it for the

(viii) Line Operations Safety Audit (LOSA)

following reasons. First, the forms presented in Appendix A

are for illustration purposes exclusively, since they are

periodically amended on the basis of experience gained and

feedback obtained from continuing audits. Second, formal

training in the methodology, in the use of LOSA tools and,

most important, in the handling of the highly sensitive data

collected by the audits is absolutely essential. Third, the

proper structuring of the data obtained from the audits is of

paramount importance.

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9. Therefore, until extensive airline experience isfficeffice" />

accumulated, it is highly desirable that LOSA training be

coordinated through ICAO or the founding partners of the

LOSA project. As the methodology evolves and reaches full

maturity and broader industry partnerships are developed,

LOSA will be available without restrictions to the

international civil aviation community.

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10. This manual is designed as follows:fficeffice" />

• Chapter 1 includes an overview on safety, and

human error and its management in aviation

operations. It provides the necessary background

information to understand the rationale for LOSA.

• Chapter 2 discusses the LOSA methodology and

provides a guide to the implementation of LOSA

within an airline. It also introduces a model of crew

error management and proposes the error classification

utilized by LOSA, which is essentially

operational and practical.

• Chapter 3 discusses the safety change process that

should take place following the implementation of

LOSA.

• Chapter 4 introduces the example of one operator’s

experience in starting a LOSA.

• Appendix A provides examples of the various forms

utilized by LOSA.

• Appendix B provides an example of an introductory

letter by an airline to its flight crews.

• Appendix C provides a list of recommended reading

and reference material.

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11. This manual is a companion document to thefficeffice" />

Human Factors Training Manual (Doc 9683). The

cooperation of the following organizations in the production

of this manual is acknowledged: The University of Texas at

Austin Human Factors Research Project, Continental

Airlines, US Airways and ALPA, International. Special

recognition is given to Professor Robert L. Helmreich,

James Klinect and John Wilhelm of The University of

ffice:smarttags" />Texas at Austin Human Factors Research Project; Captains

Bruce Tesmer and Donald Gunther of Continental Airlines;

Captains Ron Thomas and Corkey Romeo of US Airways;

and Captain Robert L. Sumwalt III of US Airways and of

ALPA, International.

1-1

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Chapter 1fficeffice" />

BASIC ERROR MANAGEMENT CONCEPTS

1.1 INTRODUCTION

ffice:smarttags" />1.1.1 Historically, the way the aviation industry has

investigated the impact of human performance on aviation

safety has been through the retrospective analyses of those

actions by operational personnel which led to rare and

drastic failures. The conventional investigative approach is

for investigators to trace back an event under consideration

to a point where they discover particular actions or decisions

by operational personnel that did not produce the intended

results and, at such point, conclude human error as the cause.

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The weakness in this approach is that the conclusion isfficeffice" />

generally formulated with a focus on the outcome, with

limited consideration of the processes that led up to it. When

analysing accidents and incidents, investigators already

know that the actions or decisions by operational personnel

were “bad” or “inappropriate”, because the “bad” outcomes

are a matter of record. In other words, investigators

examining human performance in safety occurrences enjoy

the benefit of hindsight. This is, however, a benefit that

operational personnel involved in accidents and incidents

did not have when they selected what they thought of as

“good” or “appropriate” actions or decisions that would lead

to “good” outcomes.

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ffice:smarttags" />1.1.2 It is inherent to traditional approaches to safetyfficeffice" />

to consider that, in aviation, safety comes first. In line with

this, decision making in aviation operations is considered to

be 100 per cent safety-oriented. While highly desirable, this

is hardly realistic. Human decision making in operational

contexts is a compromise between production and safety

goals (see Figure 1-1). The optimum decisions to achieve the

actual production demands of the operational task at hand

may not always be fully compatible with the optimum

Figure 1-1. Operational Behaviours — Accomplishing the system’s goals

Safety Production

1-2 Line Operations Safety Audit (LOSA)

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decisions to achieve theoretical safety demands. Allfficeffice" />

production systems — and aviation is no exception —

generate a migration of behaviours: due to the need for

economy and efficiency, people are forced to operate at the

limits of the system’s safety space. Human decision making

in operational contexts lies at the intersection of production

and safety and is therefore a compromise. In fact, it might

be argued that the trademark of experts is not years of

experience and exposure to aviation operations, but rather

how effectively they have mastered the necessary skills to

manage the compromise between production and safety.

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Operational errors are not inherent in a person, although thisfficeffice" />

is what conventional safety knowledge would have the

aviation industry believe. Operational errors occur as a result

of mismanaging or incorrectly assessing task and/or situational

factors in a specific context and thus cause a failed

compromise between production and safety goals.