Doc9803航线运行安全审计

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Errorsfficeffice" />

ffice:smarttags" />2.2.6 Cockpit crew error is defined as an action or

inaction by the crew that leads to deviations from

organizational or flight crew intentions or expectations.

Errors in the operational context tend to reduce the margin

of safety and increase the probability of accidents or

incidents. Errors may be defined in terms of non-compliance

with regulations, Standard Operating Procedures (SOPs) and

policies, or unexpected deviation from crew, company or

ATC expectations. Errors observed may be minor (selecting

the wrong altitude into the mode control panel (MCP), but

correcting it quickly) or major (forgetting to do an essential

checklist). Observers should record all cockpit crew errors

that they detect.

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ffice:smarttags" />2.2.7 Operators set up SOPs and checklists as thefficeffice" />

standards for the proper and safe way to conduct flights.

Instructors observing deviations from SOPs or checklists

would define this as an error, and so does LOSA. If a crew

member does not know how to execute a procedure properly

or cannot control the aircraft in the expected manner, an

instructor would also consider this an error, and so does

LOSA. Deviations from expectations of ATC are also

classified as crew errors; these would, for example, include

altitude deviations or significant deviations around thunderstorms

without ATC notification. There are rules in SOPs

and/or operator manuals that, for example, specify how

much deviation crews may make around thunderstorms

before notifying ATC, and observers must be familiar with

and apply these company rules when conducting observations.

Operators also have policies that are less

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proscriptive than procedures, where preferred modes offficeffice" />

operation are described. Pilots may violate policies without

violating SOPs or increasing risk, and under LOSA, this is

not defined as an error. However, if the observer feels that

violating a policy unnecessarily increases risk to flight

safety, it would be defined as an error. There are also many

decision points on a normal flight that are not defined by

SOPs or procedures. However, any time the crew makes a

decision that unnecessarily increases risk to flight safety, it

is defined as a crew error.

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ffice:smarttags" />2.2.8 Crew errors may not have any consequences, butfficeffice" />

they still need to be recorded by the observer. For example,

a violation to the sterile cockpit rule may not have any

negative consequence to the flight, but it is a violation of

regulations and thus must be entered as an error. In addition,

errors may be intentional or unintentional. As implied in the

definition, when a crew action is appropriate or prescribed

in SOPs, the lack of action may also be defined as an error.

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ffice:smarttags" />2.2.9 Is poor crew behaviour that is not a violation offficeffice" />

regulations or SOPs (and did not result in an increased risk

to flight safety) deemed an error? For example, should

observers enter an error if a crew performed the predeparture

briefing in such a way that it was felt to deserve

a “minimal proficiency”? The answer is “No”. If the

minimally proficient or poor pre-departure briefing (or any

other less than optimum behaviour) was not associated with

an error of some kind, then it is not an error in its own right

and should not be entered in the observation form.

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ffice:smarttags" />2.2.10 LOSA is predicated upon the following fivefficeffice" />

categories of crew errors:

1. Intentional non-compliance error: Wilful deviation

from regulations and/or operator procedures;

2. Procedural error: Deviation in the execution of

regulations and/or operator procedures. The intention

is correct but the execution is flawed. This

category also includes errors where a crew forgot to

do something;

3. Communication error: Miscommunication, misinterpretation,

or failure to communicate pertinent

information among the flight crew or between the

flight crew and an external agent (for example, ATC

or ground operations personnel);

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4. Proficiency error: Lack of knowledge orfficeffice" />

psychomotor (“stick and rudder”) skills; and

5. Operational decision error: Decision-making error

that is not standardized by regulations or operator

2-4 Line Operations Safety Audit (LOSA)

procedures and that unnecessarily compromises

safety. In order to be categorized as an operational

decision error, at least one of three conditions must

have existed:

• The crew must have had more conservative

options within operational reason and decided

not to take them;

• The decision was not verbalized and, therefore,

was not shared among crew members; or

• The crew must have had time but did not use it

effectively to evaluate the decision.

If any of these conditions were observed, then it is

considered that an operational decision error was made in

the LOSA framework. An example would include the crew’s

decision to fly through known wind shear on an approach

instead of going around.

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Definitions of crew error responsefficeffice" />

ffice:smarttags" />2.2.11 LOSA considers three possible responses by

crews to errors:

1. Trap: An active flight crew response in which an

error is detected and managed to an inconsequential

outcome;

2. Exacerbate: A flight crew response in which an error

is detected but the crew action or inaction allows it

to induce an additional error, Undesired Aircraft

State, incident or accident; and

3. Fail to respond: The lack of a flight crew response

to an error because it was either ignored or

undetected.

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Definitions of error outcomesfficeffice" />

ffice:smarttags" />2.2.12 The outcome of the error is dependent upon the

flight crew response. LOSA considers three possible

outcomes of errors depending upon crew response:

1. Inconsequential: An outcome that indicates the

alleviation of risk that was previously caused by an

error;

2. laceName w:st="on">UndesiredlaceName> laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>: An outcome in which the

aircraft is unnecessarily placed in a compromising

situation that poses an increased risk to safety; and

3. Additional Error: An outcome that was the result of

or is closely linked to a previous error.