qantas flying operations audit september 2005. capt ken ireland gm flying operations audit qantas...
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Qantas Flying Operations Audit
September 2005
2
Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
LOSA was carried out:
May - July 2002
Across 29 Qantas domestic and international
ports
263 sectors
B737, B767, B744
LOSA Overview
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
LOSA Report:
Undesired Aircraft State
Australian law - disclosure
Exec Report to QF Safety Board members
Safety Board gave Chief Pilot three months to
present plan for corrective actions, to be
implemented within six months
LOSA Process
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
All Flight Crew called in for meeting with Chief Pilot
Putting final results directly to pilots meant they
interpreted the poor result as being their fault. Lead to
adverse reaction to LOSA.
Flight Crew thought it was not a practical reflection of
Qantas operations
Flight Crew Response
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
They didn’t just take it out on Flight Ops management…
……….. suddenly posters appeared
Flight Crew Response
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Chief Pilot strengthened Audit department
Audit no longer a ‘monitoring’ department but a
continual LOSA process
Benchmarking other airlines
QF shown to be insular
Permission from University of Texas
Flight Operations Actions re LOSA
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
GM Flying Ops Audit (Captain) full time
Two full time ground staff
25 Auditors (Captains) used as required
Audit Department Structure
Head of Flight Ops and Chief Pilot
GM Flying Ops Audit
Flying Ops Audit Mgr
Flying Ops Audit
Co-ordinator
25 Pilot Auditors
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Qantas mainline
B744, B747, B767, B737, A330. Each fleet every two years
Program
Qantas Group Airlines - audits conducted as requested
Australian Airlines B767
Jetstar B717
JetConnect B737
New procedures
New Approach Procedures, B737 RNP ZQN
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
The following examples show how the University
of Texas’ Threat/Error methodology translates into
tangible outcomes for Flight Crew
Enable Flight Crew to see the practical application
of Threat/Error methodology
Examples
4. Initial departure climb altitude is 3000’ or as directed by ATC
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Perfect flight - optimum flight
Modified to make it less theoretical and more
practical
eg. LAX - busy airport
Differences
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
We only use Captains as Auditors
Acceptance by crew
Decision errors
Auditor opinions and comments
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Decision Errors
Changed rules for recording decision errors
Must be a consequence to the decision
Or;
Decision is changed after external input
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
UAS / NSAPs
Changed title of Undesired Aircraft State to
Non Standard Aircraft Profile (NSAP)
After LOSA, UAS was irrevocably defined as “The
closest an airline gets to having an accident without
actually having one”
NSAP is understood by Flight Crew to mean ‘where the
aircraft is placed in a state of increased risk’
Issues
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Contribution to Crew Effectiveness
In the LOSA report, crews did not understand the
ratings given to them in terms of Contribution to Crew
Effectiveness
Completely different set of ratings
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Well Above Company Standard
Awarded when a crewmember’s “contribution to crew effectiveness” could be filmed and used as a training example to other pilots. It would have been a performance where strict adherence to Standard Operating Procedures, excellent CRM and sound manipulative (PF) or support (PNF) skills were observed. All facets of the performance must equally be to the high “training video” standard otherwise the “Well Above Company Standard” rating cannot be given.
Company Standard
Awarded when a crewmember’s “contribution to crew effectiveness” is highly professional and in line with what is expected by the Chief Pilot. It would not be without error, however, the Captain must demonstrate sound error management skills. Each crewmember must be able to recognise threats to the flight deck operation and the Captain must be able to manage such threats effectively.
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Below Company Standard
Awarded when the Auditor is of the opinion that, given the opportunity to conduct the observed sector once again, the crewmember would have increased their contribution to crew effectiveness in order to achieve a more professional standard of flight deck operation. The performance may have included examples of unintentional deviation from SOPs, threats and/or errors that were not recognised or managed to Company expectations, or manipulative support skills that were below a professional aviator’s ability on the day.
All crewmembers have had “days like these” and this rating does not mean that the crewmember was not trying to give of his/her best. A professional crewmember would have reviewed the sector with the intention of learning from the experience and improving their contribution to the crew effectiveness accordingly.
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Well Below Company Standard
Awarded when a crewmember’s contribution to crew effectiveness falls well short of what the Chief Pilot would reasonably expect of a professional crewmember. There is never any doubt in the mind of the Auditor, when awarding this rating, that the observed performance on the day was unacceptable. Either a complete lack of CRM, poor sector management, intentional violation of SOPs, or manipulative or support skills that did not meet the challenges of the day would have been observed during the crewmember’s performance.
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Audit and narrative writing - 50 sectors B767 $80 000
Wash process (4 weeks, average 3 sectors per day) $50 000
Report writing (2 weeks) $10 000
TOTAL $140 000
Cost of Audit per sector $2 800
Audit meeting (quarterly) $25 000
Costs for Audit Program
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Capt Ken Ireland
GM Flying Operations Audit
Qantas Flying Operations Audit
Where are we now in terms of Threat/Error methodology?
Second B767 Audit - crew response was no
different from the first audit
De-identification
Cabin Auditing