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Published byIrea Sutton
Modified over 3 years ago
Mount Cook Airline LOSA 2004-2005
What Will Be Discussed Demographics Why we did a LOSA How we did a LOSA What we learned from LOSA What we intend doing
Little Old New Zealand
General Demograhics 12 ATR 72 Turbo-Prop Aircraft 104 Pilots 11 Destinations Max Sector Length: 1.5 hours Utilisation Rate: 8 hours per day
Flight Operations Demograhics Pilot Experience Levels Changing Early GA Ops Became Air Transport Ops Reluctance to Look for Best Practises No Regular Simulator Training
Flight Operations Demograhics No CRM Training Very Low Incident Reporting Rate Minimalist Manual Suite Non-Standardised Training
Why LOSA? – GM Perspective Concerns about training Reputation Risk profile
Why LOSA? – GM Perspective Commercial benefits Strategic plan LOSA business case offered solutions
Why LOSA? – My Perspective Data for change management project Quantifiable snapshot LOSA shows we are serious about safety Pro-active incident prevention
Why LOSA? – My Perspective Want to remeasure in future Want buy-in from pilots Gives reasons for change Saw team-building benefits
Why LOSA? – My Perspective Want to build a credible SMS Want to build Regulator confidence Want a good reputation in NZ aviation Want a proven data collection system
How Did We Do LOSA? Followed LOSA Collaborative guidelines Added a confidentiality agreement LOSA Bulletin to all staff Advice from Air New Zealand
How Did We Do LOSA? Business dynamics that threatened LOSA Saw benefits in dynamics of process LOSA prophets for getting buy-in Short report & MS Access database
What Did We Learn? Where our threats are How well we deal with threats How errors manifest themselves What are some of the outcomes
What Did We Learn? 4 threats per flight Environment - 71% of all threats Airline - 29% of all threats
What Did We Learn? Blue Box Threat Rate – 41% Blue Box Error Rate - 40% Error Detection Rate - 50% Checklist Error Rate – 24%
What Did We Learn? Our Safety Reporting System is Not Telling Us How and Why Things Happen!
What Did We Learn? We need to improve Procedural Compliance
What Did We Learn? We need to improve Monitoring and Cross-Checking Procedures
What Did We Learn? We need to improve Workload Management
What Did We Learn? We had too many unstable approaches
What Did We Learn? Our SOPs need to provide more guidance
What Did We Learn? We need to have Standardised Instruction
What Did We Learn? There is a significant difference between Training and Line Operations
What Did We Learn? Pilots Accept Change More Readily Because of LOSA
Action Plan 2005 -2006 Series of Pilot Briefings SOP Committee CRM Training Team TEM Training
Action Plan 2005 -2006 Technical Writing Training Rewrite SOPs Incidents & TEM Safety Magazine
Action Plan 2005 -2006 TEM Behavioural Marker Database for: –Selection Process –Training –Assessment –Safety Investigations
Action Items Blue Box Procedural Compliance TEM Section in Route Guide Incident Reporting Culture
Action Plan 2005 -2006 Instructor Training in CRM, HF and TEM TEM Lesson Plans for Sim Error Trapping Gates Monitoring and Cross-Checking
Summary Safe Regional Airline Did LOSA During Major Expansion Better Awareness of Flight Operations Data for Preventative Approach to Safety
1 LOSA – A REGULATORS PERSPECTIVE Tim Allen General Manager Airlines Presentation to the LOSA Conference Kuala Lumpur - September 2005.
Human Factors in Flight Operations A CAA Perspective
Integrating the LOSA Relationships 3 rd ICAO-IATA LOSA & TEM Conference Captain Chris KriechbaumCaptain Chris Wright Manager Procedure & Capability DevelopmentLOSA.
Normal Operations Safety Survey (NOSS)
Mount Cook Airline Safety Investigations & Education in an Airline Nathan McGraw 05 June 2010.
Direction générale de lAviation civile sub-directorate for safety and airspace directorate for strategic and technical affairs September 2005 Monitoring.
Robert L. Helmreich, Ph.D. FRAes The University of Texas
1 SAFETY ORGANISATION. 2 Safety Organisation 3 Safety Organisation - Regulator.
Second Global Symposium on TEM and NOSS in Air Traffic Control February 7, 2007 NOSS and the ATS Provider A Perspective from Senior Management Kathy Fox.
Evolution Cabin Crew Training & Assessment for the Future.
Airservices Australia The NOSS Experience Airservices Australia The NOSS Experience Marcus Knauer – NOSS Project Manager.
NOSS Trial May / June 2005 Experience. Format Brief History of Airways NZ Safety Culture Why we ran the trial Preparation for the Trial Conduct of the.
Slide 1Lesson 14: Fundamentals of the CAP Flying Safety Program Fundamentals of the CAP Flying Safety Program.
Module N° 8 – SSP implementation plan. SSP – A structured approach Module 2 Basic safety management concepts Module 2 Basic safety management concepts.
Australian Warbirds Assocation Limted (AWAL). Stephen Crocker CEO AWAL Welcome.
Implementing SMS in Civil Aviation: the Canadian Perspective.
SMS/ATM introduction An identified weakness is the way that different States have applied safety standards ICAO mandate for the use of SMS to standardize.
“Line Operations Safety Audit (LOSA)”
AVIATION SAFETY QUALITY ASSURANCE PROGRAMME
A Glimpse at Archie: The LOSA Archive
Rob Kella - Chief Risk Officer
Normal Operations Safety Survey Airservices Australia Marcus Knauer Normal Operations Safety Survey Airservices Australia Marcus Knauer.
Intro to Threat & Error Management
Human Factors & Safety Management Systems Mike O’Leary Eddie Rogan.
Gretchen Haskins Chief Exec. Safety Through Collaboration What is HeliOffshore? An alliance of global Helicopter Operators & their stakeholders. Committed.
Downloaded from 9/14/2015 Aeronautical Decision Making - The Theory Behind the Practice 1 AERONAUTICAL DECISION MAKING The Theory Behind The.
Greg Down 2 nd ICAO Global TEM & NOSS Symposium FAA – Washington, DC Normal Operations Safety Surveys The NAV CANADA Experience.
SMS Implications for Education Jim Dow Chief, Flight Training & Examinations Transport Canada Presentation to National Training Aircraft Symposium
CX LOSA © Cathay Pacific Airways 2005 Cathay Pacific LOSA Training for Safety Aiming for Excellence 2001 & 2005.
Instructor Seminar October 11th 2011
for Cabin Safety Inspectors
ICAO Harmonized Safety Management Requirements – The Safety Concern ICAO Harmonized Safety Management Requirements – The Safety Concern Captain Daniel.
The Credibility of NOSS Data Chris Henry The University of Texas Human Factors Research Project The University of Texas at Austin 2 nd ICAO TEM & NOSS.
1 Safety Management Systems A Transport Canada Civil Aviation Program Update.
SMS for a Modern Flight Training Organization
Bringing an SMS Manual to Life Simon Roberts SMS Programme Lead UK CAA.
1 SWISS Safety, 30 March 2006 SVFB Welcome! Operational Safety – Technical Safety.
Implementing HF & NTS Training and Assessment in RPT Operations: A Regulator’s Perspective CASA Ian Banks Section Head, Human Factors.
1 Report of the Controller and Auditor-General Civil Aviation Authority: Certification and Surveillance Functions CAA Progress Report To Select Committee.
NOTECHS. Objectives By the end of this workshop you will: Understand facilitation techniques, and be able to apply them to manage a constructive debrief.
Session No. 3 ICAO Safety Management Standards. The Big Picture Two audience groups Two audience groups States States Service providers Service providers.
ICAO European Regional Runway Safety Seminar Amsterdam, The Netherlands 8 March 2012 ir. Job Brüggen, LVNL safety manager The global voice of ATM.
Safety and Security in Air Traffic Management Rod Graff Agenda Item 2.
Qantas Flying Operations Audit
THOMAS COOK CRM STANDARDS ASSESSMENT Captain Karen Varney CRM Manager Thomas Cook Airlines UK.
Patient Safety in Primary Care The Linneaus Collaboration www. linneaus-pc.eu Aneez Esmail Professor of General Practice University of Manchester (UK)
SSP implementation plan
Flight Operations Research Centre of Excellence Dr. Hazel Courteney Head of Research & Strategic Analysis.
Flight Department 1 A Research and a Result Barcelona October 2003 Capt. Cor Blokzijl, Aero Lloyd 10 th Airbus Flight Safety Conference.
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