Doc9803航线运行安全审计

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6. Trusted, trained and calibrated observers: Primarily,fficeffice" />

pilots conduct LOSAs. Observation teams will

typically include line pilots, instructor pilots, safety

pilots, management pilots, members of Human

Factors groups and representatives of the safety

committee of the pilots organization. Another part of

the team can include external observers who are not

affiliated with the airline. If they have no affiliation

with the airline, external observers are objective and

can serve as an anchor point for the rest of the

observers. Trained, expert external observers add

tremendous value, especially if they have participated

in LOSA projects at other airlines. It is

critical to select observers that are respected and

trusted within the airline to ensure the line’s acceptance

of LOSA. Selecting good observers is the

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lifeline of LOSA. If you have unmotivated orfficeffice" />

untrustworthy observers, LOSA will fail. The size of

the observation team depends on the airline’s size,

the number of flights to be observed and the length

of time needed to conduct the observations. After

observers are selected, everyone is trained and

calibrated in the LOSA methodology, including the

use of the LOSA rating forms and, particularly, the

concepts of threat and error management. Training

of observers in the concepts and methodology of

LOSA will ensure that observations will be conducted

in the most standardized manner. After

completing training, observers spend a period of

time (between one and two months) observing

regularly scheduled line flights. The objective is to

observe the largest number of crews and segments

possible in the time frame, given the flight

schedules, logistics and types of operation sampled.

7. Trusted data collection site: In order to maintain

confidentiality, airlines must have a trusted data

collection site. At the present time, all observations

are sent off-site directly to The University of Texas

at Austin Human Factors Research Project, which

manages the LOSA archives. This ensures that no

individual observations will be misplaced or

improperly disseminated through the airline.

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8. Data verification roundtables: Data-driven programmesfficeffice" />

like LOSA require quality data management

procedures and consistency checks. For

LOSA, these checks are done at data verification

roundtables. A roundtable consists of three or four

department and pilots association representatives

who scan the raw data for inaccuracies. For example,

an observer might log a procedural error for failure

to make an approach callout for which there are

actually no written procedures in the airline’s flight

operations manual. Therefore, it would be the job of

the roundtable to detect and delete this particular

“error” from the database. The end product is a

database that is validated for consistency and

accuracy according to the airline’s standards and

manuals, before any statistical analysis is performed.

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9. Data-derived targets for enhancement: The finalfficeffice" />

product of a LOSA is the data-derived LOSA

targets for enhancement. As the data are collected

and analysed, patterns emerge. Certain errors occur

more frequently than others, certain airports or

events emerge as more problematic than others,

certain SOPs are routinely ignored or modified and

certain manoeuvres pose greater difficulty in adherence

than others. These patterns are identified for

the airline as LOSA targets for enhancement. It is

then up to the airline to develop an action plan based

on these targets, using experts from within the airline

Chapter 2. Implementing LOSA 2-7

to analyse the targets and implement appropriate

change strategies. After two or three years, the

airline can conduct another LOSA to see if their

implementations to the targets show performance

improvements.

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10. Feedback of results to the line pilots: After a LOSAfficeffice" />

is completed, the airline’s management team and

pilots association have an obligation to communicate

LOSA results to the line pilots. Pilots will want to

see not only the results but also management’s plan

for improvement. If results are fed back in an appropriate

fashion, experience has shown that future

LOSA implementations are welcomed by pilots and

thus more successful.

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ffice:smarttags" />2.3.3 Over the years of implementation, the tenfficeffice" />

operating characteristics listed above have come to define

LOSA. Whether an airline uses third party facilitation or

attempts to do a LOSA by itself, it is highly recommended

that all ten characteristics are present in the process. Over

the past five years, the most valuable lesson learned was that

the success of LOSA goes much beyond the data collection

forms. It depends upon how the project is executed and

perceived by the line pilots. If LOSA does not have the trust

from the pilot group, it will probably be a wasted exercise

for the airline.

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Observer assignmentfficeffice" />

ffice:smarttags" />2.3.4 Members of the observation teams are typically

required to observe flights on different aircraft types. This

is an important element of the line audit process for several

reasons. For one, this has the advantage of allowing both line

pilots and instructor pilots of particular fleets to “break out

of the box” (their own fleet) and compare operations of fleets

other than their own. Eventually, this helps the team as a

whole to focus on Human Factors issues and common

systemic problems, rather than on specific, within-fleet

problems. Furthermore, the results are more robust if

observers observe across many fleets instead of observing

only one type.

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Flight crew participationfficeffice" />

ffice:smarttags" />2.3.5 Normally the line audit is announced to crew

members by means of a letter from the highest level of

management within flight operations, with the endorsement

of other relevant personnel such as chief pilots and pilots

association representatives. This letter specifies the purpose

of the audit and the fact that all observations are of a nojeopardy

nature and all data are to be kept strictly

confidential. The letter of announcement should precede the

line audit by at least two weeks, and line observers are given

copies of the letter to show crew members in case questions

should arise. Data are kept anonymous and crews are given

assurance that they are not in disciplinary jeopardy.

Furthermore, crews should have the option to refuse

admission of the observer to perform an observation on their

flight.

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2.4 HOW TO DETERMINE THEfficeffice" />

SCOPE OF A LOSA

ffice:smarttags" />2.4.1 Only smaller airlines with limited numbers of

fleets would find it reasonable to attempt to audit their entire

flight operation, that is, all types of operations and all fleets.

Most airlines will find it cost effective to conduct a LOSA

on only parts of their operation. Evidence from LOSA

suggests that flight crew practices vary naturally by fleet.

The type of operation, such as domestic, international, shorthaul

or long-haul, is also relevant. Usually, auditing any

combination of types of operations is a good way to break

down an entire operation into useful comparison groups.

2.4.2 Ideally, every flight crew should be audited, but

more often than not, this will be impossible or impractical

in material terms. At a major airline and in large fleets,

around 50 randomly selected flight crews will provide

statistically valid data. For smaller fleets, around 30 randomly

selected flight crews will provide statistically valid

data, although the risk of arriving at conclusions that might

not reflect reality increases as the number of flight crews

audited drops. If less than 25 flight crews are audited, the

data collected should be considered as “case studies” rather

than representing the group as a whole.

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ffice:smarttags" />2.4.3 The number of observers needed depends, asfficeffice" />

already discussed, on the intended scope of the audit. For

example, an airline might want to audit 50 flight crews in

each of 2 domestic fleets, for a total of 100 segments. A

conservative rule of thumb to scope this audit would be

2 domestic observations per day per observer. The goal is

thus expressed in terms of flight crews observed, rather than

segments. Should an airline want to audit an international

fleet, the first step is to determine how many international

observations can be made in a day, and this depends on the

length of the segments. For a domestic LOSA, a workable

rule of thumb suggests the need for 50 person/days of work

for the actual audit phase of the LOSA. Using line pilots for

a month of observations, each might be requested to spend

10 days conducting observations, plus 4 days training/

travelling. This requires 14 days per observer. Thus, there

would be a need for 4 observers for this hypothetical audit,

2-8 Line Operations Safety Audit (LOSA)

and this should easily meet the audit’s goals. It is important

to be conservative in the estimates since sometimes it will

be necessary to observe a crew for more than one segment.

This counts as one crew, not two.