曝光台 注意防骗
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max gross wt. T/O, rejected T/O
Cabin Threats
40 Cabin event / distraction / interruption
41 Flight attendant error
ATC Threats
50 ATC command — challenging clearances,
late changes
51 ATC error
52 ATC language difficulty
53 ATC non-standard phraseology
54 ATC radio congestion
55 Similar call signs
Crew Support Threats
80 MX event
81 MX error
82 Ground handling event
83 Ground crew error
84 Dispatch/ paperwork event
85 Dispatch / paperwork error
86 Crew scheduling event
87 Manuals / charts incomplete /
incorrect
99 Other Threats
Who Committed / Detected Codes Undesired Aircraft State Codes
Flightcrew
1 CA
2 FO
3 SO / FE
4 Relief Officer
5 Jumpseat
Rider
6 All crew
members
7 Nobody
Other people
8 ATC
9 Flight attendant
10 Dispatch
11 Ground
12 MX
Aircraft
20 Aircraft systems
99 Other
Configuration States
1 Incorrect A/C configuration — flight controls,
brakes, thrust reversers, landing gear
2 Incorrect A/C configuration — systems (fuel,
electrical, hydraulics, pneumatics, airconditioning,
pressurization, instrumentation)
3 Incorrect A/C configuration — automation
4 Incorrect A/C configuration — engines
Ground States
20 Proceeding towards wrong runway
21 Runway incursion
22 Proceeding towards wrong taxiway / ramp
23 Taxiway / ramp incursion
24 Wrong gate
Aircraft Handling States — All Phases
40 Vertical deviation
41 Lateral deviation
42 Unnecessary WX penetration
43 Unauthorized airspace penetration
44 Speed too high
45 Speed too low
46 Abrupt aircraft control (attitude)
47 Excessive banking
48 Operation outside A/C limitations
Approach / Landing States
80 Deviation above G/S or FMS path
81 Deviation below G/S or FMS path
82 Unstable approach
83 Continued landing - unstable approach
84 Firm landing
85 Floated landing
86 Landing off C/L
87 Long landing outside TDZ
99 Other Undesired States
SAMPLE
FOR ILLUSTRATION PURPOSES ONLY
A-20 Line Operations Safety Audit (LOSA)
Copyright 2002 The University of Texas at Austin. All rights reserved.
LOSA Crew Interview
1. Training
a) Is there a difference in how you were trained, and how things really go in line operations?
b) If so, why?
2. Standardization
a) How standardized are other crews that you fly with?
b) If there is a lack of standardization, what do you think is the reason(s) for procedural non-compliance?
3. Automation
a) What are the biggest automation “gotchas” for this airplane?
4. Overall safety improvements – concerns and suggestions for improvement
a) Flight Ops
b) Dispatch
c) Airports and ATC
d) SOPs
SAMPLE
FOR ILLUSTRATION PURPOSES ONLY
B-1
Appendix B
EXAMPLE OF AN INTRODUCTORY LETTER
BY AN AIRLINE TO ITS FLIGHT CREWS
To: All US Airways Pilots
From: Captain Ed Bular
Senior Director, Flight Operations
Captain Ron Schilling
Director, Flight Training and Standards
Captain Pete Eichenlaub
Director, US Airways Flight Safety and Quality Assurance
Captain Terry McVenes
Chairman, ALPA Central Air Safety Committee
Subject: Line Operations Safety Audit (LOSA)
Date: October 1, 2000
Beginning mid-October and continuing for approximately five weeks, US Airways will conduct a Line
Operations Safety Audit (LOSA). For this audit, we will use US Airways pilots to conduct cockpit jumpseat
observations, along with three observers from the University of Texas Human Factors Research Project (a.k.a.
“NASA/UT Aerospace Crew Research Project.”
LOSA observations are no-jeopardy events, and all data are confidential and de-identified. LOSA data go
directly to the UT Human Factors Research Program for data entry and analysis. Be assured that these
observations are not checkrides. Although some LOSA observers may be US Airways check airmen, they
are not there to critique your performance — their mission is to be an unobtrusive observer and to fill out
data collection forms after the flight is completed.
Early on, it was decided that the ultimate customer of the audit should be the US Airways line pilot. By
that, the audit should help us identify problem areas so that we can correct them and make your job easier.
Did you ever see a procedure that could be done better, but didn’t feel like you had a way to feed that idea
into the system for possible change? Are some procedures better than others as far as helping avoid, trap
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