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Presentation on theme: "LOSA OVERALL PROCESS ICAO / IATA LOSA TEM Conference"— Presentation transcript:

Captain Chris Nutter Director Flight Safety Alaska Airlines

2 Overall Strategic Process
Union Partnership is Critical Project Definition Objectives, Scope and Magnitude of the Effort Resources Administration & Logistics IT Issues, Hotel Rooms, Expense Reports, Deadheads, etc. Organizational Management is Critical LOSA Plan Development Execution Daily “Command Center” for Operations Post-LOSA Action Plan & Commitment (Do First) Improve the organization, operations and enhance safety Feedback

3 Project Definition Project design requirements
Business decisions Number and type of observations Research decisions How long to accomplish Logistics decisions Post-LOSA process (and commitment) Management decisions (with Union Partnership) Suggest a 3-year plan

4 Resources University of Texas LOSA Collaborative ICAO Industry Data
UT Preparation Checklist ICAO Document 9803 LOSA Industry Data Company Data Published Literature

5 Third Party Audits (LOSA) Aviation Quality Database
Operating VPs Review all audit and performance data To develop corrective actions Aviation Quality Database

6 Administration & Logistics

7 Alaska LOSA 2003 Alaska Flight Safety Bid Packet Announcement Letter
Jan 14, 2002 VP Flight Ops / MEC Chairman Letter to Pilots Mailed Jan 29, 2003 Dec 2002 ALPA ALPA Safety Sense Flight Safety Newsletter Dec 2002 ALPA ALPA Magazine Safe Approach Magazine OBS Training LOSA Steering Committee LOSA Execution Data Validation Program Research and Design Debrief Jan Jul Dec Jan Feb Mar Apr May Sep Nov 2002 2003 Alaska Flight Safety

8 LOSA Project Org Chart Cross Divisional Sanction & Support

9 LOSA Plan Development

10 Overall Plan Development
Preparation – create a Steering Committee Project Definition & Resources Project Management Expertise Detail Planning Daily Execution Post-LOSA Data Validation Results Management Improvement Processes Feedback Process

11 Scope of Observation Plan
OBSERVERS 10-12 Observations 2 Week Period Provide Total Targets Each Self-Scheduled Allow Max Flexibility OBSERVATIONS UT Baseline 3 Focus Areas Max +5% Each Contingencies +5% Sick Observers Canceled Flights UT + 20% Max

12 Defining Observation Schedules

13 Observer Plan Total Observers = 38 Alaska Pilot Core Observers 29
Backup Staff Observers 7 University of Texas Total Observers = 38

14 Observation Plan Total Observations = 399 9% 75 / 20% 39% 200 / 54%
Percent of Fleet # Observations & Percentage B C 9% 75 / 20% B 39% 200 / 54% B 16% B 7% MD80 31% 100 / 27% 70 Boeing 222 107 Total Observations = 399

15 Research Process FOQA - Large quantity of data Data analysis
For 2002, total more than 26,000 flights Data analysis Mathematical Statistics and Numerical Analysis Trends and Regression Techniques Basis for resource allocation for studying FOQA Events research Aircraft-specific research Airport-specific research

16 FOQA Analysis Example4 From Annual Report 2002
Selected 5 high threat indicators in D-A-L Examined these indicators Independently By aircraft type By airport frequency Cross examination of these variables

17 Symptomatic Factors 2000 feet to 1000 feet above touchdown [Event A]
Flight Operations Symptomatic Factors © Alaska Airlines, Inc. - All rights reserved 2000 feet to 1000 feet above touchdown [Event A] 1000 feet to 500 feet above touchdown [Event B] Instrument Stabilized Approach Point 500 feet above touchdown to touchdown [Event C] Flaps < Landing [Event D] Visual Stabilized Approach Point Airspeed is VREF + X [Event E] ILS-NPA-RNAV-RNP Approach

18 Event Rank (of all Events)
9 7 6 4 1 Ranking E (Speed) D (Flaps) C (VSI) B (VSI) A (VSI) EVENT Targeted Observations for Highest Incidence Events

19 737-400 Targeted Airports AIRPORT 9 AIRPORT 8 AIRPORT 4 AIRPORT 3
Top Airports 7 6 4 2 1 Rank (of All Events) E D C B A Event

20 Final Results Multi-Program Integration
FOQA, ASAP, Reporting data Identified Airports, ATC Arrivals of Interest By Model Aircraft and Aircraft-specific Events Operational Management Inputs Fleet Captain, Training and Chief Pilot Union Inputs Targeted a system-wide assessment All nighters, Transcons, Arctic, Mexico, etc. =Identify observer & aircraft assignments

21 Execution

22 Execution Prep Critical Success Factor - Communication
Ensure the Organization knows the LOSA Project Officer (LPO) and their authority Connectivity is crucial – cell, pager Ensure LPO is available 24/7 or a rep Brief FAs, CSAs, Dispatch and SOC/DSO TSA means jumpseat issues

23 Execution University of Texas Management Analysis of Report Data
Primary data and process manager Final Report ID LOSA Targets of Enhancement Management Analysis of Report Data ID Tops Issues, Events, Safety Concerns Update the Post-LOSA Action Plan

24 Post - LOSA

25 Post-LOSA Action Plan Broad Spectrum Data Acquisition & Analysis
Flight Procedures Company Policy Training Programs Qual Standards Content Delivery Administration of Manuals and Content Answers “Why do the FOQA events occur?” MPI Supports Training & 2006 LOSA Planning Communicating the data & results to others

PREVALENCE HIGH TO LOW N/A Colors = Crew Management Effectiveness Communicating the data to others This is an over all “Report Card” of our LOSA. Blue boxes contain those Threats and Errors we are exposed to at a high level, or, encounter at the high end of the range of LOSA Archive averages. Green indicates areas of good Threat and Error management, and good CRM performance. Green doesn’t mitigate a Threat or lessen the concern for an Error. Green just says we do a good job of managing these areas – we don’t let Threats become errors, and we don’t let Errors become more errors or an UAS. Green is good management – the bottom line for flight safety. Yellow indicates areas where we need improvement in error detection and management, and CRM performance. Red indicates areas where we need corrective action, either immediately or short-term. In all of these areas, corrective action is straightforward and relatively simple, involving primarily increased flight discipline.

27 Statistical Risk Ratings Intermediate Threats & Errors Immediate
12 Months Statistical Risk Ratings Systemic Threat & Error Management 6 Months Intermediate Threats & Errors Immediate Checklists Monitor Crosscheck Stable Approach Definition Communicating the data to others

28 LOSA Results Management Line Pilot Focus Group Process
1 Immediate 6 Months 12 Months 2 3 4 7 5 6 8 9 APR 04 MAY 04 JUN 04

29 LOSA Focus Group Action Plan Line Pilot Solutions to Line Problems
8 Focus Groups April-June with 24 Pilots on 9 Major Issues All Fleets – All Seats – All Bases 48 Man-Days of Work

30 * 80 Recommendations

31 Post-LOSA Action Process
LOSA - MPI Flight Safety ID Top Issues Focus Groups ALPA Line Recommendations Management Review STAN Process ALPA This summarizes our basic gameplan for the LOSA after-action work. LOSA and Multi-Program Integration (fusing all our data programs to drive training designs – FOQA, ASAP, etc) have already identified our Top Issues. Safety will form 12 focus groups of 3 pilots each to tackle one major issue – and create recommendations for corrective action. ALPA and Fleet Captains identify these groups of primarily line pilots. Those recommendations will go to Flight Ops, through a Flight Ops process, until a list of accepted corrective actions is finalized. ALPA is part of this process. Flight Ops will then implement these according to a management plan. Flight Ops Implementation

32 What Does Alaska Airlines Do With the Data?
Multi-Program Integration Is A Process For Continuous Improvement

33 AQP / CRM FOQA LOSA ASAP Safety Reporting 2001-2002 V1 Cut Procedure
Memory Item Reduction QRC / QRH Integration LOSA ASAP Safety Reporting

34 Multi Program Integration - MPI
INPUTS AQP FOQA LOSA REPORTING ASAP O-53 SHR CSR CRM OUTPUTS 2005 CQ Recurrent Targeted Training Simulator events Controlled Threats Targeted Education Briefs / Debriefs Training Materials Line Operations Line Checks

35 FEEDBACK Important To All Involved Groups – Pilots Management BOD

36 For 2005 Pilot Training TEM GUIDE

37 TEM Guide for Check Airmen
It is NOT NOT a grading tool NOT identified, logged or filed in any way It IS Jepp sized LOSA Definitions, Targets for Enhancement, Alaska-specific results overview Tool to facilitate familiarization with TEM Discussion generator to raise awareness Feedback for line pilots of our actual LOSA results TEM is 2005 CQ Theme and Line Check Focus



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