Doc9803航线运行安全审计

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ffice:smarttags" />1.3.2 There is nothing inherently wrong orfficeffice" />

troublesome with error itself as a manifestation of human

behaviour. The trouble with error in aviation is the fact that

negative consequences may be generated in operational

contexts. This is a fundamental point in aviation: if the

negative consequences of an error are caught before they

produce damage, then the error is inconsequential. In

operational contexts, errors that are caught in time do not

produce negative consequences and therefore, for practical

purposes, do not exist. Countermeasures to error, including

training interventions, should not be restricted to avoiding

errors, but rather to making them visible and trapping them

before they produce negative consequences. This is the

essence of error management: human error is unavoidable

but manageable.

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ffice:smarttags" />1.3.3 Error management is at the heart of LOSA andfficeffice" />

reflects the previous argument. Under LOSA, flaws in human

performance and the ubiquity of error are taken for granted,

and rather than attempting to improve human performance,

the objective becomes to improve the context within which

humans perform. LOSA ultimately aims — through changes

in design, certification, training, procedures, management

 

 

1-8 Line Operations Safety Audit (LOSA)

developing analytic methods to integrate multiple and

diverse data sources. However, most importantly, the real

challenge for the large-scale implementation of LOSA will

be overcoming the obstacles, presented by a blame-oriented

industry, that will demand continued effort over time before

normal operations monitoring is fully accepted by the

operational personnel, whose support is essential.

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ffice:smarttags" />1.5.2 Despite the challenges and barriers, the aviationfficeffice" />

system has more to gain by moving forward to system-wide

implementation of LOSA than by denying progress because

that is not the way business has been done in the past or by

decrying the difficulties involved. The following chapters

present an overview of how to tackle these challenges and

barriers.

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2-1fficeffice" />

Chapter 2

IMPLEMENTING LOSA

2.1 HISTORY OF LOSA

ffice:smarttags" />2.1.1 In 1991, The laceType w:st="on">UniversitylaceType> of laceName w:st="on">TexaslaceName> at Austin

Human Factors Research Project, with funding from the

FAA (Human Factors Division, AAR-100), developed

LOSA to monitor normal line operations. In its early form,

LOSA mostly focused on CRM performance. The reason for

this was that researchers and airlines alike wanted to know

more about the actual practice of CRM rather than just

formulating conclusions about its effectiveness from data

collected within the training environment, as was the

established practice. After LOSA audits were conducted at

more than ten airlines in the early 1990s, it was clear that

the actual practice of CRM was quite different than the one

depicted within the typical training department. Most

important, the unique insights gathered from this methodological

approach of monitoring normal operations not

only advanced the concepts of CRM, but also encouraged

new ways of thinking about crew performance.

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ffice:smarttags" />2.1.2 After several years of development andfficeffice" />

refinement, LOSA has turned into a strategy of systematic

line observations to provide safety data on the way an

airline’s flight operations system is functioning. The data

generated from LOSA observations provide diagnostic

indicators of organizational strengths and weaknesses in

flight operations as well as an overall assessment of crew

performance, both in the technical and human performance

areas. LOSA is a data-driven approach to the development

of countermeasures to operational threats and errors.

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2.2 THE THREAT AND ERRORfficeffice" />

MANAGEMENT MODEL

ffice:smarttags" />2.2.1 LOSA is premised on The University of Texas

Threat and Error Management (UTTEM) Model (see

Figure 2-1). Essentially, the model posits that threats and

errors are integral parts of daily flight operations and must

be managed. Therefore, observing the management or mismanagement

of threats and errors can build the desired

systemic snapshot of performance. Pilots quickly grasp the

concepts of external threats once they are explained, and the

idea of managing the threats has great relevance to them,

more so than error management, which still retains negative

connotations despite attempts to acknowledge its ubiquity

and necessity in human intelligence and information

processing. Crew countermeasures are then seen as the tools

that pilots develop to handle these daily threats and errors.

The UTTEM Model has been successfully incorporated into

training programmes and in some cases has replaced

existing CRM training.*

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ffice:smarttags" />2.2.2 The UTTEM Model provides a quantifiablefficeffice" />

framework to collect and categorize data. Some questions

that can be addressed using this framework include the

following:

• What type of threats do flight crews most frequently

encounter? When and where do they occur, and what

types are the most difficult to manage?

• What are the most frequently committed crew errors,

and which ones are the most difficult to manage?

• What outcomes are associated with mismanaged

errors? How many result in an Undesired Aircraft

State?

• Are there significant differences between airports,

fleets, routes or phases of flight vis-à-vis threats and

errors?

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ffice:smarttags" />2.2.3 The following paragraphs introduce a brieffficeffice" />

overview of the most important building blocks of the

UTTEM Model.

Threats and errors defined

Threats

2.2.4 Threats are external situations that must be

managed by the cockpit crew during normal, everyday

flights. Such events increase the operational complexity of

* Guidance on Threat and Error Management (TEM) training can

be found in the Human Factors Training Manual (Doc 9683).

2-2 Line Operations Safety Audit (LOSA)

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Figure 2-1. The Threat and Error Management Modelfficeffice" />

Threats

Inconsequential Threat management

Crew error

Crew error responses

Undesired

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

Crew Undesired

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

responses

Chapter 2. Implementing LOSA 2-3

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the flight and pose a safety risk to the flight at some level.fficeffice" />

Threats may be expected or anticipated and, therefore, the

crew may brief in advance. Threats may also be unexpected.

As they occur suddenly and without any warning, there is

no possibility for the crew to brief in advance. External

threats may be relatively minor or major. Observers should

record all external threats that are on the code sheet or any

others that may be considered significant.

ffice:smarttags" />2.2.5 Errors originated by non-cockpit personnel are

considered external threats. For example, if the cockpit crew

detects a fuel loading error made by ground staff, it would

be entered as an external threat, not an error. The crew was

not the source of the error (although they must manage it,

as they would any other external threat). Other examples of

non-cockpit crew errors that would be entered as external

threats are errors in Air Traffic Control (ATC) clearances

discovered by the crew, dispatch paperwork errors and

discrepancies in passenger boarding counts by cabin

attendants.