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Published byIrea Sutton Modified over 10 years ago
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Mount Cook Airline LOSA 2004-2005
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What Will Be Discussed Demographics Why we did a LOSA How we did a LOSA What we learned from LOSA What we intend doing
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Little Old New Zealand
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General Demograhics 12 ATR 72 Turbo-Prop Aircraft 104 Pilots 11 Destinations Max Sector Length: 1.5 hours Utilisation Rate: 8 hours per day
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Flight Operations Demograhics Pilot Experience Levels Changing Early GA Ops Became Air Transport Ops Reluctance to Look for Best Practises No Regular Simulator Training
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Flight Operations Demograhics No CRM Training Very Low Incident Reporting Rate Minimalist Manual Suite Non-Standardised Training
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Why LOSA? – GM Perspective Concerns about training Reputation Risk profile
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Why LOSA? – GM Perspective Commercial benefits Strategic plan LOSA business case offered solutions
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Why LOSA? – My Perspective Data for change management project Quantifiable snapshot LOSA shows we are serious about safety Pro-active incident prevention
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Why LOSA? – My Perspective Want to remeasure in future Want buy-in from pilots Gives reasons for change Saw team-building benefits
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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
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How Did We Do LOSA? Followed LOSA Collaborative guidelines Added a confidentiality agreement LOSA Bulletin to all staff Advice from Air New Zealand
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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
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What Did We Learn? Where our threats are How well we deal with threats How errors manifest themselves What are some of the outcomes
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What Did We Learn? 4 threats per flight Environment - 71% of all threats Airline - 29% of all threats
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What Did We Learn? Blue Box Threat Rate – 41% Blue Box Error Rate - 40% Error Detection Rate - 50% Checklist Error Rate – 24%
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What Did We Learn? Our Safety Reporting System is Not Telling Us How and Why Things Happen!
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What Did We Learn? We need to improve Procedural Compliance
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What Did We Learn? We need to improve Monitoring and Cross-Checking Procedures
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What Did We Learn? We need to improve Workload Management
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What Did We Learn? We had too many unstable approaches
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What Did We Learn? Our SOPs need to provide more guidance
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What Did We Learn? We need to have Standardised Instruction
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What Did We Learn? There is a significant difference between Training and Line Operations
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What Did We Learn? Pilots Accept Change More Readily Because of LOSA
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Action Plan 2005 -2006 Series of Pilot Briefings SOP Committee CRM Training Team TEM Training
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Action Plan 2005 -2006 Technical Writing Training Rewrite SOPs Incidents & TEM Safety Magazine
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Action Plan 2005 -2006 TEM Behavioural Marker Database for: –Selection Process –Training –Assessment –Safety Investigations
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Action Items Blue Box Procedural Compliance TEM Section in Route Guide Incident Reporting Culture
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Action Plan 2005 -2006 Instructor Training in CRM, HF and TEM TEM Lesson Plans for Sim Error Trapping Gates Monitoring and Cross-Checking
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Summary Safe Regional Airline Did LOSA During Major Expansion Better Awareness of Flight Operations Data for Preventative Approach to Safety
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