1. Mount Cook Airline LOSA 2004-2005

2. What Will Be Discussed Demographics Why we did a LOSA How we did a LOSA What we learned from LOSA What we intend doing

3. Little Old New Zealand

4. General Demograhics 12 ATR 72 Turbo-Prop Aircraft 104 Pilots 11 Destinations Max Sector Length: 1.5 hours Utilisation Rate: 8 hours per day

5. Flight Operations Demograhics Pilot Experience Levels Changing Early GA Ops Became Air Transport Ops Reluctance to Look for Best Practises No Regular Simulator Training

6. Flight Operations Demograhics No CRM Training Very Low Incident Reporting Rate Minimalist Manual Suite Non-Standardised Training

7. Why LOSA? – GM Perspective Concerns about training Reputation Risk profile

8. Why LOSA? – GM Perspective Commercial benefits Strategic plan LOSA business case offered solutions

9. Why LOSA? – My Perspective Data for change management project Quantifiable snapshot LOSA shows we are serious about safety Pro-active incident prevention

10. Why LOSA? – My Perspective Want to remeasure in future Want buy-in from pilots Gives reasons for change Saw team-building benefits

11. 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

12. How Did We Do LOSA? Followed LOSA Collaborative guidelines Added a confidentiality agreement LOSA Bulletin to all staff Advice from Air New Zealand

13. 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

14. What Did We Learn? Where our threats are How well we deal with threats How errors manifest themselves What are some of the outcomes

15. What Did We Learn? 4 threats per flight Environment - 71% of all threats Airline - 29% of all threats

16. What Did We Learn? Blue Box Threat Rate – 41% Blue Box Error Rate - 40% Error Detection Rate - 50% Checklist Error Rate – 24%

17. What Did We Learn? Our Safety Reporting System is Not Telling Us How and Why Things Happen!

18. What Did We Learn? We need to improve Procedural Compliance

19. What Did We Learn? We need to improve Monitoring and Cross-Checking Procedures

20. What Did We Learn? We need to improve Workload Management

21. What Did We Learn? We had too many unstable approaches

22. What Did We Learn? Our SOPs need to provide more guidance

23. What Did We Learn? We need to have Standardised Instruction

24. What Did We Learn? There is a significant difference between Training and Line Operations

25. What Did We Learn? Pilots Accept Change More Readily Because of LOSA

26. Action Plan 2005 -2006 Series of Pilot Briefings SOP Committee CRM Training Team TEM Training

27. Action Plan 2005 -2006 Technical Writing Training Rewrite SOPs Incidents & TEM Safety Magazine

28. Action Plan 2005 -2006 TEM Behavioural Marker Database for: –Selection Process –Training –Assessment –Safety Investigations

29. Action Items Blue Box Procedural Compliance TEM Section in Route Guide Incident Reporting Culture

30. Action Plan 2005 -2006 Instructor Training in CRM, HF and TEM TEM Lesson Plans for Sim Error Trapping Gates Monitoring and Cross-Checking

31. Summary Safe Regional Airline Did LOSA During Major Expansion Better Awareness of Flight Operations Data for Preventative Approach to Safety