LOSA training group exercise

[figair]

Anyone that could give me some sort of inspiration for a LOSA/AUDIT training group exercise for a group of non aviation related managers.

I have been invited to introduce the aviation LOSA/AUDIT to a group of managers in an industry with no safety culture therefore; I would appreciate if you could suggest ideas for a group exercise in order to bring a component of fun while consolidating the concepts without it being to complicated.

Regards
FA

[alf5071h]

As I understand, LOSA is a process or technique for identifying error through observation. Therefore LOSA/AUDIT training, as a group, associated with ‘no safety culture’ appears to be a most unusual task.

However, a group exercise based on “Combating omission errors through task analysis and good reminders,” J Reason (http://qhc.bmjjournals.com/cgi/content/full/11/1/40) might be suitable training for discussing error and observation of others.
Replace the questionnaire with a team observation task of other people’s activities, e.g Use an old photocopier, suitably set-up (unplugged, out of paper, etc) with an opposing team task (individually) to copy 2-3 pages with some urgency. Discus the observations, error, error origins, and solutions.

An alternative would be to illustrate the connection between errors (identified by LOSA) with the organisation, via a two sided discussion of an event – the person view (sharp end) vs the organisation view (blunt end). Classic James Reason work, but with caution as a dominant ill-informed management might win – presumably you don’t know why the industry has ‘no safety culture.

Organisational Accidents Reason (www.scribd.com/doc/37066515/Organisational-Accidents-Reason)

There may be something here:- Hearts and Minds - Home (www.eimicrosites.org/heartsandminds/)
See The tools and Additional resources.

www.hq.nasa.gov/office/codeq/accident/accident.pdf

How to make unimaginable hazards imaginable? (www.nlr-atsi.com/eCache/ATS/13/416.pdf)

Human Factors (http://info.ogp.org.uk/HF/20Elements.html)

[figair]

Many thanks for your reply. With "No safety culture" I meant "yet" they are trying to change hence this first training and more to come.
FA

[Maurice Chavez]

I don't know how to help you with your question, nor do I know how many airlines are enforcing LOSA audits. My airline has implemented the LOSA audits, although it was not a IOSA requirement during the last IATA/IOSA audit.

Our airline preferably lets a non type rated pilot (rated on another type within our fleet) to conduct the LOSA audit. Even with a non type rated guy sitting on the jumpseat conducting the audit, the flightcrew will fly, or try to fly according to the SOP's. So no abnormally's are noted during this audit, and renders the audit IMHO useless.

LOSA audits are there to identify, if there is a difference between the way crews are trained, and what actually goes on online.

Flightcrews see the LOSA audit as a "checkride" and will try to perform as they would in the sim. I personally do not see the benefit of the audit, but that could just be me.

IATA/IOSA is making it mandatory to capture flightdata from the QADR. IATA even sponsors partial cost of the program. This would be interesting information and by for more realistic then a LOSA audit. The QADR capturing is done randomly and flight crews are not aware that it is their particular flight that has been pulled.

That said, it makes them aware that at anytime the QADR can be downloaded and could be their flight. Therefor it would likely hint them to fly according to published company SOP's/Aircraft Manufactures standards and not their own way of flying the aircraft.

From the data capture of the QADR, your Flight Safety Officer/Flight Data Analyst can determine if crews are actually flying the aircraft the way they are trained.

With all these great rules now in place, we would think the industry is becoming a safe environment. I stand corrected, however I seriously disagree. Pilots are taught to rely on automation, and over complicated procedures.

When automation fails, most of us are lost, mainly due to the lack of flying raw data/hands flying. Raw data and hands flying require a far higher workload from a crew, it exercises (IMHO) the brain far more and allows the crew to be far more confident/vigilant when flying fully automated.

Again, I can not help you with your particular question, on how to make it more fun, especially dealing with managers, I just wanted to point out that a LOSA audit on its own has (IMHO) little value towards the SMS.

[Piltdown Man]

Dial cash into the exercise. If you can their cash. For example, if a transport company, how much do they spends in brakes, fuel etc.? If a manufacturing company, how much do their rejects and re-workings cost? Then the question is: How much would they have saved if their employees had stuck to the company's procedures? These minor deviations from procedures have a cost. They may also compromise safety. The next logical step to to monitor larger deviations from policy which will be by definition, less safe. The next step is to look at serious incidents. I hope you see where I'm going here.

By paying attention to the minor deviations from policy you'll be chipping away at the bottom of the "risk iceberg", thus making the operation both more profitable and at the same time, safer.

PM

[Piltdown Man]

Piltdown Man you demonstrate all that is messed up with the culture in the aviation industry as you want to focus on the lowest risk activities to save money rather than the highest risk activities to protect life.

Yup, too long in the Coffeeshops. Figair wanted, in his/her own words "...inspiration for a LOSA/AUDIT training group exercise for a group of non aviation related managers." So you have not read the starting post, ignored the following posters and decided to play the man and not the ball. Just like a certain football team in a recent World Cup final. In the future, show a little more respect and read the previous posts before spouting off. Your troll-like attitude also clearly demonstrates your total and absolute lack of understanding of safety.

For others who may be reading this thread I'd like to explain why Shell Management is incorrect. My own company (an airline with more than 90,000 movements each years) has data which appears to support the "Safety Triangle" as described by H.W. Heinrich. In this triangle, it is suggested that there are various layers. The top layer or pinnacle is the "smoking hole in the ground". Immediately under is the layer containing a few very serious incidents. Further down there are more the more numerous minor incidents and at the base, tens of thousands of non-events. Not being content to follow a single theory or methodoly, we are testing the data from aircraft and investigating as appropriate. Additionally, we are working are specific areas to improve our operations - the drivers for this are both cash and safety, the two ride together. Here's just one example. We have had a recent "purge" on unstable approaches. Our evidence then goes on to show that we now have fewer unstable approaches. This in turn has shown a reduction in the more serious occurrences of long landings, landing high pitch attitudes and we have had fewer go-arounds. The potential for the more serious over-runs, runway excursions, heavy landings has been reduced. So by chipping away at the bottom of the pyramid, we have been reducing its overall size of the "triangle".

So just to make this clear, by sticking to the SOP's and we have more stable approaches, ended up burning less fuel, have happier customers, meet more schedules and so on. This results in a more profitable and safer operation. And this is just one minor example. In the Western world, safety and profit are on the same sides of the coin - apparently something that those with those with a closed, petty mind and attitude are unable to grasp.

What the thread starter wanted was an intro. That is what I and others tried to give.

PM


"Purge" does not mean punitive or disciplinary action. We have used training, company communications, flight data, line checks etc. to get the message over.

[framer]

Piltdown Man,
Was it a general ¨sticking to SOP's¨ that resulted in the reduction of unstable approaches at your company?
Did you manage to improve personal flight discipline within your pilot group or was there actual SOP changes that helped you achieve your results?
Cheers, Framer