Mount Cook Airline LOSA

2004-2005

What Will Be Discussed

• Demographics

• Why we did a LOSA

• How we did a LOSA

• What we learned from LOSA

• What we intend doing

Little Old New Zealand

General Demograhics

• 12 ATR 72 Turbo-Prop Aircraft

• 104 Pilots

• 11 Destinations

• Max Sector Length: 1.5 hours

• Utilisation Rate: 8 hours per day

Flight Operations Demograhics

• Pilot Experience Levels Changing

• Early GA Ops Became Air Transport Ops

• Reluctance to Look for Best Practises

• No Regular Simulator Training

Flight Operations Demograhics

• No CRM Training

• Very Low Incident Reporting Rate

• Minimalist Manual Suite

• Non-Standardised Training

Why LOSA? – GM Perspective

• Concerns about training

• Reputation

• Risk profile

Why LOSA? – GM Perspective

• Commercial benefits

• Strategic plan

• LOSA business case offered solutions

Why LOSA? – My Perspective

• Data for change management project

• Quantifiable snapshot

• LOSA shows we are serious about safety

• Pro-active incident prevention

Why LOSA? – My Perspective

• Want to remeasure in future

• Want ‘buy-in’ from pilots

• Gives reasons for change

• Saw team-building benefits

Why LOSA? – My Perspective

• Want to build a credible SMS

• Want to build Regulator confidence

• Want a good reputation in NZ aviation

• Want a proven data collection ‘system’

How Did We Do LOSA?

• Followed LOSA Collaborative guidelines

• Added a confidentiality agreement

• LOSA Bulletin to all staff

• Advice from Air New Zealand

How Did We Do LOSA?

• Business dynamics that threatened LOSA

• Saw benefits in dynamics of process

• LOSA ‘prophets’ for getting ‘buy-in’

• Short report & MS Access database

What Did We Learn?

Where our threats are

How well we deal with threats

How errors manifest themselves

What are some of the outcomes

What Did We Learn?

• 4 threats per flight

• Environment - 71% of all threats

• Airline - 29% of all threats

What Did We Learn?

• Blue Box Threat Rate – 41%

• Blue Box Error Rate - 40%

• Error Detection Rate - 50%

• Checklist Error Rate – 24%

What Did We Learn?

Our Safety Reporting

System is Not Telling Us

How and Why Things Happen!

What Did We Learn?

We need to improve

Procedural Compliance

What Did We Learn?

We need to improve

Monitoring and

Cross-Checking Procedures

What Did We Learn?

We need to improve

Workload Management

What Did We Learn?

We had too many

unstable approaches

What Did We Learn?

Our SOPs need to provide

more guidance

What Did We Learn?

We need to have

Standardised Instruction

What Did We Learn?

There is a significant difference

between Training and

Line Operations

What Did We Learn?

Pilots Accept Change

More Readily

Because of LOSA

Action Plan 2005 -2006

• Series of Pilot Briefings

• SOP Committee

• CRM Training Team

• TEM Training

Action Plan 2005 -2006

• Technical Writing Training

• Rewrite SOPs

• Incidents & TEM Safety Magazine

Action Plan 2005 -2006

• TEM Behavioural Marker Database for:

– Selection Process

– Training

– Assessment

– Safety Investigations

Action Items

• ‘Blue Box’

• Procedural Compliance

• TEM Section in Route Guide

• Incident Reporting Culture

Action Plan 2005 -2006

• Instructor Training in CRM, HF and TEM

• TEM Lesson Plans for Sim

• Error Trapping ‘Gates’

• Monitoring and Cross-Checking

Summary

• Safe Regional Airline

• Did LOSA During Major Expansion

• Better Awareness of Flight Operations

• Data for Preventative Approach to Safety