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underlying this continuous change process include, among
others, regulatory changes (airworthiness directives, advisory
circulars, etc.); changes in national or international
airspace systems (automatic dependent surveillance (ADS),
data link/controller-pilot data link communications
(CPDLC), reduced vertical separation, extended range
operations by twin-engined aeroplanes (ETOPS), etc.);
changes to improve operational efficiencies (reduction of
costs, improvement of on-time performance, etc.); operational
events (diversions, rejected take-offs, etc.); and
progress (route expansion, fleet modernization, new
technologies, etc.)
3.2.2 Virtually everyone in an airline is somehow
involved in these changes. For example, Chief Executive
Officers and their staff decide to buy new equipment;
marketing opens up new routes; engineering must install
new components; flight operations faces new staffing
requirements and adjustments to line procedures; flight
standards must define new policies and procedures; and
flight training faces acquisition of new simulators.
3.2.3 These changes are achieved and monitored both
through established formal and informal mechanisms
underlying change processes. Formal mechanisms include
meetings (daily, weekly, monthly and quarterly), reports and
reviews at all levels of the organization. Informal
3-2 Line Operations Safety Audit (LOSA)
mechanisms include crosstalk, spontaneous information
transfer, and sharing in general by everyone in the
organization. Both mechanisms work toward actively
maintaining focus on the changes affecting safety.
3.2.4 Therefore, when in spite of these formal and
informal mechanisms an airline experiences an accident or
an incident, the immediate question arises: What is
happening “out there”? The fact is that system changes and
organizational responses to these changes generate active
and latent threats to daily line operations. Active and latent
threats themselves constantly change in a manner proportional
to system changes. Active and latent threats
become the breeding grounds of crew errors. Many organizations
are not aware of these active and latent threats for
a number of reasons, including the following:
• The “big picture” of flight operations is constantly
changing because of the constantly changing scene;
• Crews may not report threats, fearing punishment;
• Crews may not report threats because they do not
receive any feedback on their reports;
• Crews operate unsupervised most of the time;
• Line Checks (supervised performance) are poor
indicators of normal operations; and
• Management may have difficulty screening out valid
reported crew concerns from over-reported crew
complaints.
3.2.5 Active and latent threats are the precursors to
accidents and incidents. Threats cannot be identified through
the investigation of accidents and incidents until it is too late.
Most threats, however, can be proactively identified through
LOSA (and other safety data collection programmes such as
flight data analysis) and considered as targets for enhancement.
For example, following a LOSA, an airline might
identify the following targets for enhancement:
• Stabilized approaches
• Checklists
• Procedural errors
• Automation errors
• ATC communications
• International flight operations guide
• Captain leadership (intentional non-compliance
errors)
3.2.6 To sustain safety in a constantly changing
environment, data must be collected and analysed on a
routine basis to identify the targets for enhancement and then
a formal safety change process (SCP) must occur in order
to bring about improvement. The basic steps of the SCP
include the following and are also shown in Figure 3-1.
• Measurement (with LOSA) to obtain the targets
• Detailed analysis of targeted issues
• Listing of potential changes for improvement
• Risk analysis and prioritization of changes
• Selection and funding of changes
• Implementation of changes
• Time allocation for changes to stabilize
• Re-measurement
3.2.7 Airlines need a defined SCP to keep the
organization working together to achieve the same safety
objectives. A well-defined SCP keeps the organization from
getting into “turf” issues, by clearly specifying who and
what impacts flight operations. An SCP also contributes to
improving the safety culture by maximizing the capabilities
of current and future safety programmes. Last, but not least,
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