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Qantas Flying Operations Audit September 2005. Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 2 LOSA was carried out: May.

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Presentation on theme: "Qantas Flying Operations Audit September 2005. Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 2 LOSA was carried out: May."— Presentation transcript:

1 Qantas Flying Operations Audit September 2005

2 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 2 LOSA was carried out: May - July 2002 Across 29 Qantas domestic and international ports 263 sectors B737, B767, B744 LOSA Overview

3 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 3 LOSA Report: Undesired Aircraft State Australian law - disclosure Exec Report to QF Safety Board members Safety Board gave Chief Pilot three months to present plan for corrective actions, to be implemented within six months LOSA Process

4 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 4 All Flight Crew called in for meeting with Chief Pilot Putting final results directly to pilots meant they interpreted the poor result as being their fault. Lead to adverse reaction to LOSA. Flight Crew thought it was not a practical reflection of Qantas operations Flight Crew Response

5 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 5 They didnt just take it out on Flight Ops management… ……….. suddenly posters appeared Flight Crew Response

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7 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 7 Chief Pilot strengthened Audit department Audit no longer a monitoring department but a continual LOSA process Benchmarking other airlines QF shown to be insular Permission from University of Texas Flight Operations Actions re LOSA

8 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 8 GM Flying Ops Audit (Captain) full time Two full time ground staff 25 Auditors (Captains) used as required Audit Department Structure Head of Flight Ops and Chief Pilot GM Flying Ops Audit Flying Ops Audit Mgr Flying Ops Audit Co-ordinator 25 Pilot Auditors

9 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 9 Qantas mainline B744, B747, B767, B737, A330. Each fleet every two years Program Qantas Group Airlines - audits conducted as requested Australian Airlines B767 Jetstar B717 JetConnect B737 New procedures New Approach Procedures, B737 RNP ZQN

10 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 10 The following examples show how the University of Texas Threat/Error methodology translates into tangible outcomes for Flight Crew Enable Flight Crew to see the practical application of Threat/Error methodology Examples

11 4. Initial departure climb altitude is 3000 or as directed by ATC

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17 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 17 Perfect flight - optimum flight Modified to make it less theoretical and more practical eg. LAX - busy airport Differences

18 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 18 We only use Captains as Auditors Acceptance by crew Decision errors Auditor opinions and comments

19 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 19 Decision Errors Changed rules for recording decision errors Must be a consequence to the decision Or; Decision is changed after external input

20 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 20 UAS / NSAPs Changed title of Undesired Aircraft State to Non Standard Aircraft Profile (NSAP) After LOSA, UAS was irrevocably defined as The closest an airline gets to having an accident without actually having one NSAP is understood by Flight Crew to mean where the aircraft is placed in a state of increased risk

21 Issues

22 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 22

23 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 23

24 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 24 Contribution to Crew Effectiveness In the LOSA report, crews did not understand the ratings given to them in terms of Contribution to Crew Effectiveness Completely different set of ratings

25 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 25 Well Above Company Standard Awarded when a crewmembers contribution to crew effectiveness could be filmed and used as a training example to other pilots. It would have been a performance where strict adherence to Standard Operating Procedures, excellent CRM and sound manipulative (PF) or support (PNF) skills were observed. All facets of the performance must equally be to the high training video standard otherwise the Well Above Company Standard rating cannot be given. Company Standard Awarded when a crewmembers contribution to crew effectiveness is highly professional and in line with what is expected by the Chief Pilot. It would not be without error, however, the Captain must demonstrate sound error management skills. Each crewmember must be able to recognise threats to the flight deck operation and the Captain must be able to manage such threats effectively.

26 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 26 Below Company Standard Awarded when the Auditor is of the opinion that, given the opportunity to conduct the observed sector once again, the crewmember would have increased their contribution to crew effectiveness in order to achieve a more professional standard of flight deck operation. The performance may have included examples of unintentional deviation from SOPs, threats and/or errors that were not recognised or managed to Company expectations, or manipulative support skills that were below a professional aviators ability on the day. All crewmembers have had days like these and this rating does not mean that the crewmember was not trying to give of his/her best. A professional crewmember would have reviewed the sector with the intention of learning from the experience and improving their contribution to the crew effectiveness accordingly.

27 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 27 Well Below Company Standard Awarded when a crewmembers contribution to crew effectiveness falls well short of what the Chief Pilot would reasonably expect of a professional crewmember. There is never any doubt in the mind of the Auditor, when awarding this rating, that the observed performance on the day was unacceptable. Either a complete lack of CRM, poor sector management, intentional violation of SOPs, or manipulative or support skills that did not meet the challenges of the day would have been observed during the crewmembers performance.

28 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 28 Audit and narrative writing - 50 sectors B767 $ Wash process (4 weeks, average 3 sectors per day) $ Report writing (2 weeks) $ TOTAL$ Cost of Audit per sector$2 800 Audit meeting (quarterly) $ Costs for Audit Program

29 Capt Ken Ireland GM Flying Operations Audit Qantas Flying Operations Audit 29 Where are we now in terms of Threat/Error methodology? Second B767 Audit - crew response was no different from the first audit De-identification Cabin Auditing

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