Mount Cook Airline LOSA

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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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