View
221
Download
0
Category
Preview:
Citation preview
Dr Graham EdkinsGeneral Manager Safety Systems & Education
Corporate Safety Department
Line Operations Safety Audit (LOSA)
“… a program that uses expert and highly trained observers to collect data about flight crew behaviour and situational factors
on normal flights”.
Qantas LOSA Dubai, 14 October 2002
Qantas LOSA Dubai, 14 October 2002
IN BRIEF IN BRIEF
Business rationale for LOSA at Qantas.
How did Qantas implement LOSA?
Lessons learned.
Future plans.
Qantas LOSA Dubai, 14 October 2002
BUSINESS RATIONALEBUSINESS RATIONALE
Crews’ may not always report safety issues.
Crews’ normal behaviour may be different when being
observed during line/route checks.
Current safety information tends to be reliant on
system and crew failure - something bad has to happen!
Lack of data about flight crew strategies for managing
error.
Lack of data about what crew do well.
Qantas LOSA Dubai, 14 October 2002
CONVINCING THE BEANCOUNTERS!
DEVELOPING A BUSINESS CASE
CONVINCING THE BEANCOUNTERS!
DEVELOPING A BUSINESS CASE
Approval signatures
Executive Summary
Purpose and scope of project
Business requirement, benefits and risks
Recommended project approach
Project cost
Project Milestones/Deliverables
Business Case
Line Operations Safety Audit (LOSA) implementationstrategy for Flight Operations
Corporate Safety Department
28 December 2001
Qantas LOSA Dubai, 14 October 2002
STRATEGY FOR LOSA IMPLEMENTATION
STRATEGY FOR LOSA IMPLEMENTATION
Option 1. The utilisation of the University of Texas to provide LOSA planning, data collection, analysis and report writing services.
Option 2. The utilisation of an Australian university to assist in the development of data collection and analysis expertise within Qantas.
Option 3. The development and implementation of LOSA in-house with no external assistance.
Option 4. A combination of options 1-3.
Option 1. The utilisation of the University of Texas to provide LOSA planning, data collection, analysis and report writing services.
Option 2. The utilisation of an Australian university to assist in the development of data collection and analysis expertise within Qantas.
Option 3. The development and implementation of LOSA in-house with no external assistance.
Option 4. A combination of options 1-3.
Qantas LOSA Dubai, 14 October 2002
IPLEMENTATION STRATEGYIPLEMENTATION STRATEGYAdopted a “shotgun” approach.
“Non-blinkered” approach - no pre-analysis of FOQA,
Check or Safety Incident data.
Mimimum of 50 observation per fleet (B737, B767,
B744).
Consideration of sample design issues.
Mix of internal and external observers.
Strive to maintain full integrity of the LOSA process,
eg. minimal QF changes.
Qantas LOSA Dubai, 14 October 2002
WHAT DOES IT COST?WHAT DOES IT COST?
Direct Cost.LOSA Collaborative Fee.
LOSA Collaborative expenses (travel, accommodation, daily
expenses) - AUD $30,000.00 *
Indirect Cost.Unproductive costs of crew (observer) = direct cost X 4 **
* Based on 3 X LOSA Collaborative observers.** Based on 20 X QF Observers conducting a total of 200 observations.
Qantas LOSA Dubai, 14 October 2002
Risks Potential Impact Likelihood Mitigation StrategyNon acceptance ofthe project by linecrew.
Line crew mistrustand scepticism ofLOSA as anotherline check.
Medium Produce regular and clear information to line crewabout the objectives of LOSA. Produce a MOUco-signed by AIPA, GGM Corporate Safety andGGM Flight Operations, clearly outlining howLOSA results will be used.
Non acceptance ofthe project by AIPA.
Delay in thedevelopment ofthe project.
Low Involve AIPA in the selection of LOSA observers.Provide regular updates on LOSAimplementation.
Selection of LOSAobservers that havepoor credibility.
Line crew mistrustand scepticism ofLOSA.
Medium Select LOSA observers using a process agreedto by management and AIPA.
Mis-handling ofsensitive informationcollected throughaudits.
Breach ofconfidentiality ofline crewundergoingLOSA.
Medium Restrict the handling and storage of LOSA data toobservers and UT. Communicate policy to linecrew about observation of non-compliance withSOP’s.
Poor training ofobservers inbehaviouralobservationstrategies.
Lack of valid data. Medium Develop behavioural observation expertise withincore group of LOSA observers. Utilise theUniversity of Texas to conduct observer training.
CONSIDER THE RISKS TO SUCCESSCONSIDER THE RISKS TO SUCCESS
Qantas LOSA Dubai, 14 October 2002
LOSA Observer Quick Reference GuideCaptain Brief (a.k.a., Sales job)
• Ask for permission to ride – show the letters• Stress de-identified and confidential data• Ask if you can to take notes• Schedule the crew interview and time away from the cockpit
The Four Observer Tasks 1. Write a narrative on “what happened and how / why”2. Threats Threat Management Threat Outcome3. Errors Error Management Error Outcome4. Rate CRM performance on how the crew managed threats and errors
Narratives – three questions – keep concise and simple 1. What did the crew do well as risk managers?2. What did the crew do poorly as risk managers?3. How did the crew manage threats, errors, or other significant events?
Threat Management – three questions – follow the model 1. What was the threat?2. How did the crew respond to the threat?3. What was the outcome of the threat?
Error Management – four questions – follow the model 1. What was the error?2. How did the crew respond to the error?3. What was the outcome of the error?4. Did the crew get into any undesired aircraft states?
CRM Performance • Don’t have to rate everything – rate markers with confidence• Justify behavioral markers with ratings 1,2, or 4
Crew Interview • Ask questions first and demographics last
Blue Box Information • Was the approach briefed before the TOD?• Did the crew begin the descent before or at the TOD?• Did the aircraft get significantly above / below FMS path?• Approach flown?
o Visual, Precision, Non-precision, or precision to visualo Hand-flown or automation flown?
• Weather (VMC or IMC)
• Stabilized approach parameters (1500, 1000, and 500 HAT)o Airspeed – CAC to Vref +20o ROD <1000o Engines spooled appropriate to conditionso +1/-1 dot on G/S and localizero Proper landing configuration before 500’
• Landing runway and did the crew brief the landing runway?
SEND OBSERVATIONS: observations@losacollaborative.org
SAVE FILE AS:1 .ObserverID.ObservationNumber.doc2. ObserverID.ObservationNumber.ExtraThreats.doc3. ObserverID.ObservationNumber.ExtraErrors.doc
Examples) 3059.#1.doc or 99997.#5.ExtraThreats.doc
James Klinect contact: klinect@losacollaborative.org
Pat Murray contact: psmurray@bigpond.net.au Home: 0755 029 748Cell Phone: 0402 019 747Mail: PO Box 241, Sanctuary Cove, QLD 4212
Ian Topfer Numbers:Mobile: 0417 265 313 Home: 9983 9994 Work: 9691 1881
Qantas LOSA Dubai, 14 October 2002
26 April 2002
Re: Letter of Introduction for LOSA Observers
Dear Qantas Captain,
This letter introduces a Line Operations Safety Audit (LOSA) observer, who is conductingsafety observation flights during May and June 2002 across Qantas B737, B767 and B747operations.
LOSA is a new safety audit program being introduced by Flight Operations in conjunctionwith the Corporate Safety Department and the University of Texas. Trained observers collectinformation on normal flights about how crew identify potential threats to safety and howthese threats are managed.
By gaining an understanding of these issues, Qantas will be better able to identify safety risks,training needs, and high threat operations. This information will complement our wellestablished programs such as FOQA and safety reporting.
The trained observers are not check and training oriented. They are there to observe andrecord data that will be de-identified and sent directly to the University of Texas. No names,flight numbers or dates are collected.
If any Captains have concerns about LOSA they should contact Captain Ian Topfer on (02)9691 1881 or 0417 265 313.
The LOSA program has the full support of both Flight Operations Management and AIPA.
Yours sincerely,
Captain Ian Lucas Captain Chris ManningGGM Flight Operations & Chief Pilot President, AIPA
Qantas LOSA Dubai, 14 October 2002
TARGETED AND CONDUCTED OBSERVATIONS
TARGETED AND CONDUCTED OBSERVATIONS
Fleet Minimum ObservationsTargeted
Actual Observations
B 737 70 77
B 747-400 50 69
B 767 80 116
TOTALS 200 262
* Observers conducted observation on at least 2 of 3 fleets
Qantas LOSA Dubai, 14 October 2002
OBSERVER DEMOGRAPHICSOBSERVER DEMOGRAPHICS
ObserverPosition
Number ofObservers
Number ofObservations
Captain 10 107
First Officer 6 77
Other QantasPilots/Personnel
4 49
LOSA Collaborative 3 29
TOTALS 23 262
Qantas LOSA Dubai, 14 October 2002
TIME (2002) TASKJan-April Education/communication activities, sample
design issues, finalise selection of LOSAobservers
April 30 Observer training course
May-June Conduct of 200 + observations
June Data entry of observation forms (UT)
August Data cleaning (UT)
September Briefing by UT to Qantas on results
October Develop strategy for action on LOSA results
November Briefing to QF Board Safety Committee
IMPLEMENTING LOSAIMPLEMENTING LOSA
Qantas LOSA Dubai, 14 October 2002
LESSONS LEARNEDLESSONS LEARNED
Lack of B737 observers.
Inform CSM’s about LOSA program earlier.
Warn Captains about LOSA flight.
Be better prepared for the use of external observers.
Should have conducted observations on B747 “classic”.
Lack of B737 observers.
Inform CSM’s about LOSA program earlier.
Warn Captains about LOSA flight.
Be better prepared for the use of external observers.
Should have conducted observations on B747 “classic”.
Qantas LOSA Dubai, 14 October 2002
FUTURE PLANSFUTURE PLANS
Have appointed Lead Project Manager to develop action strategy for LOSA findings.
Qantas Link LOSA implementation 2003.
The monitoring of safe behaviour in airport ramp operations:
CASA funded Phd Scholarship - Michael Piotrowitz - University of Newcastle.
Cabin Crew LOSA.
Have appointed Lead Project Manager to develop action strategy for LOSA findings.
Qantas Link LOSA implementation 2003.
The monitoring of safe behaviour in airport ramp operations:
CASA funded Phd Scholarship - Michael Piotrowitz - University of Newcastle.
Cabin Crew LOSA.
Qantas LOSA Dubai, 14 October 2002
APPLICATION ISSUESThere are a number of logistical problems in
conducting a cabin crew type LOSA:
APPLICATION ISSUESThere are a number of logistical problems in
conducting a cabin crew type LOSA:
) Cabin environment is not as contained as a cockpit.
) Double deck aircraft.) All information goes through CSM. ) Observers are more obtrusive in cabin.) Errors tend to be less consequential in
the cabin. ) Impact on customers & service. ) Multiple crew to observe.) Less external threats to inflight safety
in the cabin.
) Cabin environment is not as contained as a cockpit.
) Double deck aircraft.) All information goes through CSM. ) Observers are more obtrusive in cabin.) Errors tend to be less consequential in
the cabin. ) Impact on customers & service. ) Multiple crew to observe.) Less external threats to inflight safety
in the cabin.
Recommended