ICAO 9803-2002 Line Operations Safety Audit (LOSA)《航线运行安全审计(LOSA)第1版》.pdf

1、Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Published in separate English, Arabic, French, Russian and Spanish editions by the International Civil Aviation Organization.

2、All correspondence, except orders and subscriptions, should be addressed to the Secretary General. Orders should be sent to one of the following addresses, together with the appropriate remittance (by bank draft, cheque or money order) in US. dollars or the currency of the country in which the order

3、 is placed. Credit card orders (American Express, MasterCard and Visa) are accepted at ICAO Headquarters. International Civil Aviation Organization. Attention: Document Sales Unit 999 University Street, Montreal, Quebec, Canada H3C 5H7 Telephone: +i (514) 954-8022; Facsimile: +I (514) 954-6769; Sita

4、tex: YULADYA; E-mail: sales-uniticao.int Telephone: +20 (2) 267-4840; Facsimile: +20 (2) 267-4843; Sitatex: CAICAYA Tlphone: +33 (i) 46 41 85 85; Tlcopieur: +33 (i) 46 41 85 00; Sitatex: PAREUYA Telephone: +91 (il) 331-5896; Facsimile: +91 (11) 332-2639 Telephone: +8 i (3) 3503-2686; Facsimile: +8 i

5、 (3) 3503-2689 Telephone: +254 (2) 622-395; Facsimile: +254 (2) 226-706; Sitatex: NBOCAYA Masaryk No. 29-3er. piso, Col. Chapultepec Morales, Mxico, D.F., 11570 Telfono: +52 (55) 52 50 32 11; Facsimile: +52 (55) 52 03 27 57; Sitatex: MEXCAYA Nigeria. Landover Company, P.O. Box 3165, Ikeja, Lagos Tel

6、ephone: +234 (1) 4979780; Facsimile: +234 (i) 4979788; Sitatex: LOSLORK Peru. Director Regional de ia OACI, Oficina Sudamrica, Apartado 4127, Lima 100 Telfono: +51 (1) 302260; Facsimile: +51 (i) 640393; Sitatex: LIMCAYA Russian Federation. Aviaizdat, 48, 1. Franko Street, Moscow 121351 Telephone: +7

7、 (095) 417-0405; Facsimile: +7 (095) 417-0254 Senegal. Directeur rgional de IOACI, Bureau Afrique occidentale et centrale, Bote postale 2356, Dakar Tlphone: +221 8-23-54-52; Tlcopieur: +221 8-23-69-26; Sitatex: DKRCAYA Slovakia. AU Traffic Services of the Slovak Republic, LetovC prevdzkov sluzby Slo

8、venskej Republiky, State Enterprise, Letisko M.R. Stefnika, 823 07 Bratislava 21, Slovak Republic Telephone: +421 (7) 4857 1111; Facsimile: +421 (7) 4857 2105 Telephone: +27 (I 1) 3 15-0003/4; Facsimile: +27 (i 1) 805-3649; E-mail: Planta Tercera, Despacho 3. i i, 28027 Madrid Telfono: +34 (91) 321

9、-3148; Facsimile: +34 (91) 321-3157; Correo-e: sscc.ventasoaciaena.es Telephone: +66 (2) 537-8189; Facsimile: +66 (2) 537-8199; Sitatex: BKKCAYA Telephone: +44 161 499 0023; Facsimile: +44 161 499 0298; E-mail: ; World Wide Web: http:/ Egypt. ICAO Regional Director, Middle East Office, Egyptian Civi

10、l Aviation Complex, Cairo Airport Road, Heliopolis, Cairo 11776 France. Directeur rgional de IOACI, Bureau Europe et Atlantique Nord, 3 bis, villa mile-Bergerat, 92522 Neuilly-sur-Seine (Cedex) India. Oxford Book and Stationery Co., Scindia House, New Delhi 110001 or 17 Park Street, Calcutta 700016

11、Japan. Japan Civil Aviation Promotion Foundation, 15-12, I-chome, Toranomon, Minato-Ku, Tokyo Kenya. ICAO Regional Director, Eastern and Southern African Office, United Nations Accommodation, P.O. Box 46294, Nairobi Mexico. Director Regional de ia OACI, Oficina Norteamrica, Centroamrica y Caribe Sou

12、th Africa. Avex Air Training (Pty) Ltd., Private Bag X102, Halfway House, 1685, Johannesburg, Republic of South Africa Spain. A.E.N.A. - Aeropuertos Espaoles y Navegacin Area, Calle Juan Ignacio Luca de Tena, 14, Thailand. ICAO Regional Director, Asia and Pacific Office, P.O. Box 11, Samyaek Ladprao

13、, Bangkok 10901 United Kingdom. Airplan Flight Equipment Ltd. (AFE), ia Ringway Trading Estate, Shadowmoss Road, Manchester M22 5LH 1/02 Catalogue of ICAO Publications and Audio-visual Training Aids Issued annually, the Catalogue lists all publications and audio-visual training aids currently availa

14、ble. Monthly supplements announce new publications and audio-visual training aids, amendments, supplements, reprints, etc. Available free from the Document Sales Unit, ICAO Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or net

15、working permitted without license from IHS-,-,-Doc 9803 ANI761 Line Operations Safety Audit (LOSA) Approved by the Secretary General and published under his authority First Edition - 2002 I n t e rn at i o na I Ci v i I Av i at i on O rg a II iza t i o n Copyright International Civil Aviation Organi

16、zation Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-AMENDMENTS No. The issue of amendments is announced regularly in the ICAO Journal and in the monthly Supplement to the Catalogue of ICAO Publications and Audio-visual Trai

17、ning Aids, which holders of this publication should consult. The space below is provided to keep a record of such amendments. Date Date Entered of issue entered by RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS Entered applicable entered I CORRIGENDA (ii) Copyright International Civil Aviation Organ

18、ization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-TABLE OF CONTENTS Page Page Foreword (v) Acronyms and Abbreviations . (vi) Introduction (VU) Chapter 1 . Basic error management concepts 1-1 1.1 Introduction . 1-1 1.2 Ba

19、ckground . 1-2 Reactive strategies 1-2 Combined reactive/proactive strategies . . 1-2 Proactive strategies . 1-4 1.3 A contemporary approach to operational human performance and error . 1-5 1.4 The role of the organizational culture 1-7 1.5 Conclusion 1-7 Chapter 2 . Implementing LOSA . 2-1 2.1 Hist

20、ory of LOSA . 2.2 The Threat and Error Management Model . Threats and errors defined Definitions of crew error response . Definitions of error outcomes . Undesired Aircraft States 2.3 LOSA operating characteristics . Observer assignment Flight crew participation . 2.4 How to determine the scope of a

21、 LOSA . . 2.5 Once the data is collected 2.6 Writing the report 2.7 Success factors for LOSA . 2- 1 2- 1 2- 1 2-4 2-4 2-4 2-5 2-7 2-7 2-7 2-8 2-8 2-8 Chapter 3 . LOSA and the safety change process (SCP) 3-1 3.1 Introduction . 3-1 3.2 A constantly changing scene 3-1 3.3 One operators example of an SC

22、P 3-2 Chapter 4 . How to set up a LOSA . US Airways experience 4-1 4.1 Gathering information . 4-1 4.2 Interdepartmental support 4-1 Safety department 4-1 Flight operations and training departments . 4-2 Pilots union . 4-2 4.4 The key steps of a LOSA 4-2 Goals 4-2 Action plan . 4-2 4.5 The keys to a

23、n effective LOSA . 4-4 Confidentiality and no-jeopardy . 4-4 The role of the observer . 4-5 4.6 Promoting LOSA for flight crews . 4-5 4.3 LOSA steering committee 4-1 Appendix A . Examples of the various forms utilized by LOSA . A-1 Appendix B . Example of an introductory letter by an airline to its

24、flight crews B-1 Appendix C . List of recommended reading and reference material . C-1 (iii) Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Page iv of this document missing

25、and contains no data.Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-FOREWORD The safety of civil aviation is the major objective of the International Civil Aviation Organiza

26、tion (ICAO). Consider- able progress has been made in increasing safety, but additional improvements are needed and can be achieved. It has long been known that the majority of aviation accidents and incidents result from less than optimum human per- formance, indicating that any advance in this fie

27、ld can be expected to have a significant impact on the improvement of aviation safety. This was recognized by the ICAO Assembly, which in 1986 adopted Resolution A26-9 on Flight Safety and Human Factors. As a follow-up to the Assembly Resolution, the Air Navigation Commission formulated the followin

28、g objective for the task: “To improve safety in aviation by making States more aware and responsive to the importance of Human Factors in civil aviation operations through the provision of practical Human Factors materials and measures, developed on the basis of experience in States, and by developi

29、ng and recommending appropriate amendments to existing material in Annexes and other documents with regard to the role of Human Factors in the present and future operational environments. Special emphasis will be directed to the Human Factors issues that may influence the design, transition and in-s

30、ervice use of the future ICAO CNS/ATM systems.” One of the methods chosen to implement Assembly Resolution A26-9 is the publication of guidance materials, including manuais and a series of digests, that address various aspects of Human Factors and its impact on aviation safety. These documents are i

31、ntended primarily for use by States to increase the awareness of their personnel of the influence of human performance on safety. The target audience of Human Factors manuais and digests are the managers of both civil aviation administrations and the airline industry, including airline safety, train

32、ing and operational managers. The target audience also includes regulatory bodies, safety and investigation agencies and training establishments, as well as senior and middle non- operational airline management. This manual is an introduction to the latest information available to the international

33、civil aviation community on the control of human error and the development of counter- measures to error in operational environments. Its target audience includes senior safety, training and operational personnel in industry and regulatory bodies. This manual is intended as a living document and wil

34、l be kept up to date by periodic amendments. Subsequent editions will be published as new research results in increased knowledge on Human Factors strategies and more experience is gained regarding the control and management of human error in operational environments. Copyright International Civil A

35、viation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-ADS ATC CFIT CNS/ATM CPDLC CRM DFDR ETOPS FAA FDA FMS FOQA ICA0 LOSA MCP RTO SCP SOPS TEM UTEM QAR ACRONYMS AND ABBREVIATIONS Automatic Dependent Surveillanc

36、e Air Traffic Control Controlled Flight Into Terrain Communications, Navigation and Surveillance/Air Traffic Management Controller-Pilot Data Link Communications Crew Resource Management Digital Flight Data Recorder Extended Range Operations by Twin-engined Aeroplanes Federal Aviation Administration

37、 Flight Data Analysis Flight Management System Flight Operations Quality Assurance International Civil Aviation Organization Line Operations Safety Audit Mode Control Panel Quick Access Recorder Rejected Take-off Safety Change Process Standard Operating Procedures Threat and Error Management Univers

38、ity of Texas Threat and Error Management Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-INTRODUCTION 1. This manual describes a programme for the management of human error i

39、n aviation operations known as Line Operations Safety Audit (LOSA). LOSA is proposed as a critical organizational strategy aimed at developing countermeasures to operational errors. It is an organizational tool used to identify threats to aviation safety, minimize the risks such threats may generate

40、 and implement measures to manage human error in operational contexts. LOSA enables operators to assess their level of resilience to systemic threats, operational risks and front-line personnel errors, thus providing a principled, data-driven approach to prioritize and implement actions to enhance s

41、afety. 2. LOSA uses expert and highly trained observers to collect data about flight crew behaviour and situational factors on “normal” flights. The audits are conducted under strict no-jeopardy conditions; therefore, flight crews are not held accountable for their actions and errors that are observ

42、ed. During flights that are being audited, observers record and code potential threats to safety; how the threats are addressed; the errors such threats generate; how flight crews manage these errors; and specific behaviours that have been known to be associated with accidents and incidents. 3. LOSA

43、 is closely linked with Crew Resource Management (CRM) training. Since CRM is essentially error management training for operational personnel, data from LOSA form the basis for contemporary CRM training refocus andor design known as Threat and Error Man- agement (TEM) training. Data from LOSA also p

44、rovide a real-time picture of system operations that can guide organizational strategies in regard to safety, training and operations. A particular strength of LOSA is that it identifies examples of superior performance that can be reinforced and used as models for training. In this way, training in

45、ter- ventions can be reshaped and reinforced based on successful performance, that is to say, positive feedback. This is indeed a first in aviation, since the industry has traditionally collected information on failed human performance, such as in accidents and incidents. Data collected through LOSA

46、 are proactive and can be immediately used to prevent adverse events. 4. LOSA is a mature concept, yet a young one. LOSA was first operationally deployed following the First LOSA Week, which was hosted by Cathay Pacific Airways in Cathay City, Hong Kong, from 12 to 14 March 2001. Although initially

47、developed for the flight deck sector, there is no reason why the methodology could not be applied to other aviation operational sectors, including air traffic control, maintenance, cabin crew and dispatch. 5. The initial research and project definition was a joint endeavour between The University of

48、 Texas at Austin Human Factors Research Project and Continental Airlines, with funding provided by the Federal Aviation Admin- istration (FAA). In 1999, ICAO endorsed LOSA as the primary tool to develop countermeasures to human error in aviation operations, developed an operational partnership with

49、The University of Texas at Austin and Continental Airlines, and made LOSA the centrai focus of its Flight Safety and Human Factors Programme for the period 2000 to 2004. 6. As of February 2002, the LOSA archives contained observations from over 2 O00 flights. These observations were conducted within the United States and international