Presentation is loading. Please wait.

Presentation is loading. Please wait.

Captain Don Gunther Senior Director Safety & Regulatory Compliance Line Operations Safety Audit (LOSA)

Similar presentations


Presentation on theme: "Captain Don Gunther Senior Director Safety & Regulatory Compliance Line Operations Safety Audit (LOSA)"— Presentation transcript:

1 Captain Don Gunther Senior Director Safety & Regulatory Compliance Line Operations Safety Audit (LOSA)

2 Continental Airlines, Feb 2007 Line Operations Safety Audit (LOSA) and Threat & Error Management (TEM) are integral parts of a Safety Management System (SMS)

3 Continental Airlines, Feb 2007 Aviation Week Article on Healthy Organizations If the news is valued and the communicator is protected, there is a real chance information can and will routinely flow upward in time for proper action to be taken Investing the time and money needed to get at the root cause of a problem takes total commitment at the most senior levels of a company or organization. In most organizational settings, communicators learn early in life how bad news can impact their leaders. If the news is valued and the communicator is protected, there is a real chance information can and will routinely flow upward in time for proper action to be taken. Safety Culture

4 Continental Airlines, Feb 2007 Corporate Culture How well does your company accept safety inputs when busy with the Operation?

5 Continental Airlines, Feb 2007 Over 95% goes unreported! Human Error

6 Continental Airlines, Feb 2007 Data driven Safety Change through Non-Jeopardy Reporting

7 Continental Airlines, Feb 2007 Tailored to your Airline The Safety Change Program Tailored to your Airline To properly target change you need current operational data, specifically for your airline, which is unique due to its… History & Culture Areas of operation (ETOPS, polar routes, etc.) Philosophy

8 Continental Airlines, Feb 2007 By not having data to discover the precursors specific to an individual airlines operations, this is the bottom-line…

9 Line Observation Safety Audit (LOSA) Line Observation Safety Audit (LOSA)

10 Continental Airlines, Feb 2007 University of Texas Human Factors Research Project Human Factors Research Project The LOSA Collaborative

11 Continental Airlines, Feb 2007 Data for a Safety Culture How do airlines monitor safety? Accident investigation Incident reports – ASRS, ASAP Data show events resulting from system and crew failures Line checks/Safety audits Data slanted to crew proficiency and procedural knowledge

12 Continental Airlines, Feb 2007 Data for a Safety Culture How do airlines monitor safety? Accident investigation Incident reports – ASRS, ASAP Data show events resulting from system and crew failures Line checks Data slanted to crew proficiency and procedural knowledge Observing normal operations – Line Operations Safety Audit (LOSA) Gives data on why things happen and how they are managed Provides a more realistic baseline of safety

13 Continental Airlines, Feb 2007 Purpose of LOSA Data provide a baseline of safety pertaining to: 1.Flight crew performance – strengths and weaknesses a)Proficiency b)Decision-Making c)CRM skills d)Procedural compliance 2.System performance – strengths and weaknesses a)Culture b)National Airspace System – Airports and Navigational Aids c)Aircraft design / automation d)Standards / Training / Safety / Maintenance e)Crew support – ATC, Cabin, Ground, and Dispatch

14 Continental Airlines, Feb 2007 ICAO Perspective on LOSA - Costa Pereira, ICAO Secretary General in May 8, 2000 [LOSA] acquires direct, first-hand data on the successful recovery from errors by flight crews during normal line flights. [It] is aimed at collecting data on successful human performance; and this is indeed a first in our industry, since aviation has traditionally collected data on failed human performance, such as an accident or incident investigation. correspondence to Jane F. Garvey, FAA Administrator

15 Continental Airlines, Feb 2007 Normal Performance Normal FAA Check Airmen LOSA 1LOSA 2 Distance between Perfect and Normal performance varies as a function of culture, training, etc. LOSA enables us to get as closer to normal performance than was previously possible. Perfect

16 Continental Airlines, Feb 2007 The Safety Bottom Line What do crews have to do to operate safely? Error Avoidance1Avoid committing errorsManage operational complexity2Threat ManagementManage their own errors3Error Management Undesired State Management 4Manage deviations Safety Bottom Line

17 Continental Airlines, Feb 2007 The Continental LOSA Process 1 st year LOSA and data analysis followed by course development 2 nd & 3 rd years Training course for all crewmembers, Check Airmen training and imbedding of TEM into courseware, policy & procedures, etc. 4 th year Preparation for next LOSA and targeting areas to be measured and new areas to be emphasized.

18 Continental Airlines, Feb 2007 Line Operations Safety Audit (LOSA) LOSA –observations of crew performance during regular scheduled operations Observers unobtrusive – collecting data not participating Team of observers from different backgrounds Line personnel / Union representatives Safety and Training personnel UT observers All data are De-identified and Confidential

19 Line Observation Safety Audit LOSA 1996

20 Continental Airlines, Feb 2007 LOSA Crew Survey Measure Safety Culture

21 Continental Airlines, Feb 2007 LOSA Crew Survey Measure Safety Culture Crew Interview Targeted questions

22 Continental Airlines, Feb 2007 Newsletter Feedback to the pilots is essential for continued program success.

23 Continental Airlines, Feb 2007 LOSA Crew Survey Measure Safety Culture Crew Interview Targeted questions Crew Flight Observations Data on Threats, Errors & Behaviors

24 Continental Airlines, Feb 2007 Threat and Error Management

25 Continental Airlines, Feb 2007 Threat Event that occurs outside the influence of the flight crew, but which requires crew attention and management if safety margins are to be maintained Increases the complexity of the operation

26 Continental Airlines, Feb 2007 THREATS Influences that can lead to crew error Increase complexity of the operation Weather Maintenance Error Ground Crew Error Cabin Crew Error Passenger events ATC Terrain Similar call sign Time pressures Heavy traffic Unfamiliar airport Automation eventMissed approach Flight diversion System malfunction Distractions

27 Continental Airlines, Feb 2007 Threat Management Strategies/Countermeasures (Industry, Corporate and/or Personal) To reduce the number of errors To improve the error management process by increasing the awareness of potential errors Is managing your future

28 Continental Airlines, Feb 2007 Error Actions or inactions by the flight crew that lead to deviations from intention or expectation

29 Continental Airlines, Feb 2007 Error Management Actions taken to deal with errors committed by either Detecting and correcting them, or by Containing and reducing the severity Is managing your past

30 Continental Airlines, Feb 2007 Consequences Undesired Aircraft State (UAS)

31 Continental Airlines, Feb 2007 Threat and Error Management

32 Continental Airlines, Feb LOSA ACTIONS Develop training course based on data Error Management Target Check Airmen first Committees of Subject Matter Experts Stable Approach Checklist Leadership

33 Continental Airlines, Feb 2007 Line Observation Safety Audit LOSA 2000

34 Continental Airlines, Feb 2007 LOSA 1996 vs A 70% reduction in Checklist errors A 60% reduction in unstable approaches confirmed by FOQA/FDM data Overall improvement in crew performance Still a need for improvement in Leadership skills

35 Continental Airlines, Feb LOSA ACTIONS Develop training course based on data Threat & Error Management Target Check Airmen Imbedded throughout entire program

36 Continental Airlines, Feb 2007 B-737 Standards Meeting February 21 st, 2001 The Role of the Check Airman in Threat & Error Management

37 Continental Airlines, Feb 2007 Check Airmen Debriefing Guide

38 Continental Airlines, Feb 2007 Line Check Safety Audits (LCSA)

39 Continental Airlines, Feb 2007 Crew Resource Management Effective Crew Resource Management is the bedrock of Threat and Error Management.

40 Line Observation Safety Audit LOSA 2004

41 Continental Airlines, Feb 2007 To have an effective SMS… Data is needed to drive effective Safety Change & Safety & Operational Efficiency need to be combined into a Safety Culture Corporate Safety Culture

42 Continental Airlines, Feb 2007 Threat and Error Management


Download ppt "Captain Don Gunther Senior Director Safety & Regulatory Compliance Line Operations Safety Audit (LOSA)"

Similar presentations


Ads by Google