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International Civil Aviation Organization Approved by the Secretary General and published under his authority Line Operations Safety Audit (LOSA) First Edition — 2002 Doc 9803 AN/761 AMENDMENTS 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 Training Aids, which holders of this publication should consult. The space below is provided to keep a record of such amendments. RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS CORRIGENDA No. Date applicable Date entered Entered by No. Date of issue Date entered Entered by (ii) (iii) TABLE OF CONTENTS Page Page Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (v) Acronyms and Abbreviations . . . . . . . . . . . . . . . . . (vi) Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (vii) Chapter 1. Basic error management concepts . . 1-1 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 1-1 1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . 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 History of LOSA . . . . . . . . . . . . . . . . . . . . . 2-1 2.2 The Threat and Error Management Model. 2-1 Threats and errors defined. . . . . . . . . . . . 2-1 Definitions of crew error response . . . . . 2-4 Definitions of error outcomes . . . . . . . . . 2-4 Undesired Aircraft States . . . . . . . . . . . . 2-4 2.3 LOSA operating characteristics . . . . . . . . . 2-5 Observer assignment . . . . . . . . . . . . . . . . 2-7 Flight crew participation . . . . . . . . . . . . . 2-7 2.4 How to determine the scope of a LOSA . . 2-7 2.5 Once the data is collected . . . . . . . . . . . . . . 2-8 2.6 Writing the report . . . . . . . . . . . . . . . . . . . . 2-8 2.7 Success factors for LOSA. . . . . . . . . . . . . . 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 operator’s example of an SCP . . . . . . 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 4.3 LOSA steering committee. . . . . . . . . . . . . . 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 an 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 Appendix A — Examples of the various forms utilized by LOSA . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1 Appendix B — Example of an introductory letter by an airline to its flight crews. . . . . . . . . . . . . . . . B-1 Appendix C — List of recommended reading and reference material . . . . . . . . . . . . . . . . . . . . . . . C-1 (v) FOREWORD The safety of civil aviation is the major objective of the International Civil Aviation Organization (ICAO). Considerable 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 performance, indicating that any advance in this field 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 www.aero.cn 航空翻譯 www.aviation.cn 本文鏈接地址：Doc9803航線運行安全審計
