Monitoring Normal Operations and the Line Operations Safety Audit (LOSA): The Perspective of ICAO...
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Monitoring Normal OperationsMonitoring Normal Operationsand the Line Operations and the Line Operations
Safety Audit (LOSA): Safety Audit (LOSA): The Perspective of ICAO The Perspective of ICAO
Captain Dan MaurinoCaptain Dan MaurinoFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAO
Royal Aeronautical Society Conference onRoyal Aeronautical Society Conference onMitigating Human ErrorMitigating Human Error
London, 15 October 2003London, 15 October 2003
System System designdesign
Baseline performanceBaseline performance
BaselineBaselineperformanceperformance
OperationalOperationalperformanceperformance
““PracticalPracticalDrift”Drift”
OperationalOperationaldeploymentdeployment
When the Book Goes Out of the WindowWhen the Book Goes Out of the Window
Raiding the Lost ArkRaiding the Lost Ark
NaturalNaturalPerformancePerformance
““Angel” Angel” PerformancePerformance
RegulatorRegulator NobodyNobodyLine Line
Checks Checks
LOSA LOSA
A Day at the OfficeA Day at the OfficeTo achieve daily safety and production goals, flight crews mustTo achieve daily safety and production goals, flight crews must
Threat Threat ManagementManagement
Error ManagementError Management
Undesired Aircraft Undesired Aircraft State ManagementState Management3 Manage aircraft deviations
LOSA LOSA IndicesIndices
Manage operational Manage operational complexitycomplexity
1
Manage their own errorsManage their own errors2
Not flight crew errorsNot flight crew errors Not deficiencies in the systemNot deficiencies in the system
Factors external to the flight deck that Factors external to the flight deck that increase complexity of flight operationsincrease complexity of flight operations
Must be managed by the flight crewMust be managed by the flight crew Threats = Red flagsThreats = Red flags
LOSA IndexLOSA Index: Threats: Threats
Threats Threats AreAre the Context the Context
WeatherWeather
MaintenanceMaintenance
GroundGround CrewCrew
CabinCabin CrewCrew
PassengerPassenger eventsevents ATCATC
TerrainTerrain
SimilarSimilar callcall signssigns
TimeTime pressurespressures
HeavyHeavy traffictraffic
UnfamiliarUnfamiliar airportsairports
AutomationAutomation eventsevents MissedMissed approachesapproaches
FlightFlight diversionsdiversions
SystemSystem
malfunctionsmalfunctions
DistractionsDistractions
Threat Types (T otal = 300 LOSA flights )
Threat Prevalence (Perc entage of LOSA flights w ith a threat)
1 0 % 2 0 % 3 0 % ` 4 0 % 5 0 % 6 0 % 7 0 % 8 0 % 9 0 % 1 0 0 %
All T hreats
Adv ers e Weather
AT C
Airline Operational Pres s ure
Airc raft M alfunc tionM EL Item s
97%
58%
57%
31%
22%
Threat Types (T otal = 300 LOSA flights )
Threat M ismanagement (Perc entage of LOSA flights w ith a m is m anaged threat)
1 0 % 2 0 % 3 0 % 4 0 % 5 0 % 6 0 % 7 0 % 8 0 % 9 0 % 1 0 0 %
All T hreats
Adv ers e Weather
AT C
Airline Operational Pres s ure
Airc raft M alfunc tionsM EL Item s
5%
13%
13%
41%
3%
LOSA IndexLOSA Index: [Expert] Errors : [Expert] Errors
Error Types(T otal = 300 LO SA flights )
Error Prevalence (Perc entage of LO SA flights w ith an error)
1 0 % 2 0 % 3 0 % ` 4 0 % 5 0 % 6 0 % 7 0 % 8 0 % 9 0 % 1 0 0 %
All Errors
M anual A irc raft Handling
C hec k lis ts
C allout
81%
34%
19%
10%
Error Types(T otal = 300 LOSA flights )
Error M ismanagement (Perc entage of LOSA flights w ith a m is m anaged error)
1 0 % 2 0 % 3 0 % 4 0 % 5 0 % 6 0 % 7 0 % 8 0 % 9 0 % 1 0 0 %
All Errors
M anual A irc raft Handling
C hec k lis ts
C allout5%
27%
9%
42%
LOSA Provides Data LOSA Provides Data OnlyOnly
ProficiencyProficiencyKnowledgeKnowledgeCRM SkillsCRM Skills
Procedural ComplianceProcedural Compliance
Crew Strengths and Crew Strengths and WeaknessesWeaknesses
Corporate CultureCorporate CultureAirports / Navigational AidsAirports / Navigational Aids
Aircraft Design and AutomationAircraft Design and AutomationStandards / Maintenance / Standards / Maintenance /
TrainingTrainingCrew SupportCrew Support
Systemic Strengths and Systemic Strengths and WeaknessesWeaknesses
LOSA Raw DataLOSA Raw Data
LOSA ReportLOSA Report
80%
13%7%
0%
20%
40%
60%
80%
Visual Non-Prec Prec
NCA: Type Of Approach
47%
27%20%
0%
10%
20%
30%
40%
50%
App Chng Rwy Chng Slam Dnk
NCAs Affected By ATC (47%)
93%
7%
0%
50%
100%
Force a Ldg Go - Around
NCA - Crew Response At The Window
47% 53%
0%
20%40%60%80%
100%
Capt FO
NCA: Pilot Flying
Targets for ImprovementTargets for ImprovementStabilized ApproachesStabilized ApproachesChecklistsChecklistsProcedural errorsProcedural errorsAutomation errorsAutomation errorsATC communicationsATC communicationsIntentional non-compliance Intentional non-compliance
SCP: Data Develops Into InformationSCP: Data Develops Into Information
Re-measureRe-measure
ProficiencyProficiencyKnowledgeKnowledgeCRM SkillsCRM Skills
Procedural ComplianceProcedural Compliance
Crew Strengths and WeaknessesCrew Strengths and Weaknesses
Corporate CultureCorporate CultureAirports / Navigational AidsAirports / Navigational Aids
Aircraft Design and AutomationAircraft Design and AutomationStandards / Maintenance / TrainingStandards / Maintenance / Training
Crew SupportCrew Support
Systemic Strengths and WeaknessesSystemic Strengths and Weaknesses
Safety Safety ChangeChangeProcessProcess(SCP)(SCP)
LOSA Raw DataLOSA Raw Data
LOSA ReportLOSA Report
LOSA: Non-Conforming Approaches Percent Improvement Over 1996 (Approaches Outside Required
1000 ft or 500 ft Window)
1996 - ALL 1998 - L.A. 1999 - PACIFIC 2000 - ALL
Reduced
49% Reduced59%
Reduced
59%
LOSA 1996 vs. 2000 Checklist ErrorsLOSA 1996 vs. 2000 Checklist Errors
11% of the flights9% of the flightsLOSA 2000
385 flights
Missed itemsWrong response to a challengeWrong checklist performedUnintentional checklist omission
Performed from memoryNonstandard phraseologySelf initiated
Not called “complete”Intentional checklist omission
Checklist Error
Examples
33% of the flights
Flights with protocol checklist errors
9% of the flights
Flight with unintentional checklist errors
LOSA 1996389 flights
LOSA 2000 indicated a significant drop inLOSA 2000 indicated a significant drop in protocol protocol checklist errorschecklist errors while while unintentional unintentional checklist errors have remained unchangedchecklist errors have remained unchanged
Threat & Error Management Model (Doc 9803)Threat & Error Management Model (Doc 9803)
CrewCrew ErrorError
InconsequentialInconsequential
ErrorError InducedInduced
IncidentIncident oror AccidentAccident
ThreatsThreats
ThreatThreat ManagementManagementThreatThreat InducedInduced
IncidentIncident oror AccidentAccident
UndesiredUndesired AircraftAircraft StateState
CrewCrew UndesiredUndesired
AircraftAircraft StateState
ResponsesResponses
CrewCrew ErrorError ResponsesResponses
TEM Model asTEM Model as Licensing tool (ICAO)Licensing tool (ICAO)Training toolTraining tool (Numerous airlines)(Numerous airlines)Safety management tool (IATA) Safety management tool (IATA) Research tool (Boeing)Research tool (Boeing)
The Expanding Role of the TEM ModelThe Expanding Role of the TEM Model
TEM - Licensing Tool (ICAO FCLT/P)TEM - Licensing Tool (ICAO FCLT/P) PerformancePerformance criteriacriteriaCompetenciesCompetencies SKA’sSKA’s
ErrorError ManagementManagement
Threat ManagementThreat Management
UndesiredUndesired AircraftAircraft StateState ManagementManagement
•FollowFollow SOPsSOPs•PerformPerform BriefingBriefing•StateState plansplans•AssignAssign workloadworkload•ContingencyContingency planningplanning•MonitorMonitor//CrossCross-check-check•ManageManage automationautomation•……•……•……
CRMCRM skillsskills
TEMTEM principlesprinciples
Managing the Red FlagsManaging the Red Flags
System resourcesSystem resources GPWSGPWSAutomationAutomationATCATCDispatchDispatch
SOP’s SOP’s ChecklistsChecklistsBriefingsBriefingsTrainingTraining……
Managing the Red Flags (cont.)Managing the Red Flags (cont.)
The human contributionThe human contribution
ProficiencyProficiency VigilanceVigilanceAssertivenessAssertivenessMonitoringMonitoring
DecisionDecision makingmakingExperienceExperienceLeadershipLeadershipDiscipline Discipline ……
Real World Human PerformanceReal World Human Performance
FlapsFlapsomittedomitted
EffectiveEffectivewarningwarning
NormalNormaloperationoperation
ChecklistChecklist worksworks
Descent, Approach & LandingDescent, Approach & Landing
TOTOD
1000010000 ft.
ConfigurationConfiguration
FAFFAF
Flare
LandingLanding
BottomBottom LinesLines
Most errors (LOSA)Most errors (LOSA)Most consequential errors (LOSA)Most consequential errors (LOSA)Most accidents worldwide (ALAR)Most accidents worldwide (ALAR)
Highest riskHighest riskphase of flightphase of flight
Briefing the ApproachBriefing the Approach
Crews who brief Crews who brief before before TOD commit TOD commit 1.6 times less 1.6 times less errorserrors during descent, approach and land than during descent, approach and land than crews who brief crews who brief afterafter TOD TOD
Landing runway changes occurred Landing runway changes occurred 8 percent8 percent of the of the timetimeTraining point: brief approach prior TODTraining point: brief approach prior TOD
TEM Model - Training ToolTEM Model - Training Tool
CRM, CRM, circacirca 2003 2003 Beyond behavioural stereotypesBeyond behavioural stereotypesOperational performanceOperational performanceDevelop and support threat and error management Develop and support threat and error management
competenciescompetencies
The bottom line is safe and efficient The bottom line is safe and efficient operational performance, operational performance, notnot CRMCRM
SMS Data TriangleSMS Data Triangle
Normal Normal Operations Operations
FDAFDA Voluntary Voluntary ReportingReporting
A A Casque BleuCasque Bleu Perspective Perspective
LOSA: a LOSA: a tooltool to capture systemic data to capture systemic data NOTECHS: a CRM evaluation templateNOTECHS: a CRM evaluation template LOSA: context and cognitionLOSA: context and cognition NOTECHS/CRM: behavioursNOTECHS/CRM: behaviours CRM: just one piece of the infinitely broader CRM: just one piece of the infinitely broader
information picture developed from LOSAinformation picture developed from LOSA A situation, generated by misperceptions and A situation, generated by misperceptions and misinformation, that must be put behindmisinformation, that must be put behind
LOSA, CRM and NOTECHSLOSA, CRM and NOTECHS