mount cook airline losa 2004-2005. what will be discussed demographics why we did a losa how we did...
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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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