Malaysia Airlines, Kuala Lumpur - September 13-14, 2005 ... LOSA is not for all airlines - Its success depends on pilot trust ...
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The University of Texas
Human Factors Research Project
Third ICAO-IATA LOSA & TEM Conference
Malaysia Airlines, Kuala Lumpur - September 13-14, 2005
Line Operations Safety Audit (LOSA): A Practical Overview
James Klinect and Patrick Murray
The University of Texas / The LOSA Collaborative
Air New Zealand
Since 1996, 4500+ observations, 25 airlines & 11 countries
TACA / TACA Peru
Voluntary Incident Reports
Mandatory Incident Reports
Proactive snapshot of system / crew performance strengthsand weaknesses
in normal operations (just like a health checkup)
Manage operational complexity
Manage their own errors
Manage aircraft deviations
Undesired Aircraft State Management
What do flight crews do to safely fly from A to B?
Where’s CRM and human factors? Non-technical skills are one of many contributors to effective/ineffective TEM performance
Most frequent and mismanaged threats
Most frequent and mismanaged errors
Fleet and operational differences
Comparison to other airlines on LOSA safety indices
LOSA Raw Data
LOSA Flight #23Error #1A340 ARPT 401 to ARPT 204(Crew #8)
Phase of Flight: Takeoff/ClimbPilot Flying: CA
Takeoff / Climb Narrative – Almost immediately after takeoff, the Captain started a turn up the river, and did not wait until 400 feet, per SOP. About 300 feet, captain reached over to MCP (called FCU on Airbus) and selected Flight Path Angle. He did not tell FO of this selection, which is very unusual of a setting. In fact, the FO later asked me if I had ever seen anyone use this selection and stated that he has never seen it in his 2 years of being on the Airbus. Because the Captain did not tell the F/O what he was doing, when the FO noticed this setting, he reselected the more common mode (Heading). Captain then reached over and then reselected Flight Path Angle. This led to a brief discussion of whether of not the aircraft would capture NAV in this setting. As a result of all of this, the FO missed ATC handoff to departure control, a call that was not made until the aircraft leveled off at 5000 feet. Both Captain and FO were involved in heads-down stuff as the aircraft leveled off. If the autopilot would not have leveled off, then the crew would have not caught it, because they were doing extraneous things. (FO, programming MCDU; Captain, looking at weather).
LOSA Flight #:50Threat #2B737-700AUS / DFW
Threat: runway switch. We had expected and had briefed 17Left from the ATIS broadcast. No reason for the switch given by ATC.
Threat Management Description
Scramble to brief new runway plus linked to error of not finding the proper approach chart and automation error of not setting up computer for the landing runway. FO left the approach and arrival route for 17Left in the FMC instead of the new runway. Based on this the aircraft reached DIETZ and started a turn to heading 350 which was still the active route instead of the 300 heading assigned.
Phase of FlightDes/App/Land
Threat CodeATC runway change
Threat Outcome:Linked to Flight Crew Error
Proactive safety change …….
Over one year, approx 182,500 flights, 4% rate = 7,300 unstable – much better than 11% rate = 20,075 unstable
“Well, James, very nice information. We see a lot of the same things in our ASAP database (voluntary incident reporting)”
- Quote from an ASAP Project manager
LOSA data quality
LOSA is not for all airlines - Its success depends on pilot trust
Low pilot trust = Low quality data because there will be no differentiation between LOSA and proficiency checks by regulators and check airmen
Jumpseat observations during normal operations
Anonymous, confidential, and non-punitive data collection
Voluntary crew participation
Trusted and trained observers
Joint management / union sponsorship
Systematic observation instrument
Secure data collection repository
Data verification roundtables
Data-derived targets for enhancement
Feedback of results to line pilots
LOSA is defined by 10 operating characteristics
To ensure standardization, LOSA must have all ten operating characteristics
If less than ten, the project needs another acronym
FAA (pending advisory circular)