ICAO / IATA LOSA TEM Conference

LOSA OVERALL PROCESS

Captain Chris Nutter Director Flight Safety Alaska Airlines

Overall Strategic Process

Union Partnership is Critical Project Definition

Objectives, Scope and Magnitude of the Effort Resources

Administration & Logistics

IT Issues, Hotel Rooms, Expense Reports, Deadheads, etc. Organizational Management is Critical

LOSA Plan Development Execution

Daily Command Center for Operations Improve the organization, operations and enhance safety

Post-LOSA Action Plan & Commitment (Do First) Feedback

Project Definition

Project design requirements

Business decisions
Research decisions Logistics decisions

Number and type of observations

How long to accomplish

Post-LOSA process (and commitment)

Management decisions (with Union Partnership)

Suggest a 3-year plan

Resources

University of Texas LOSA Collaborative

UT Preparation Checklist
Document 9803 LOSA

ICAO

Industry Data Company Data Published Literature

Third Party Audits (LOSA)

BOD Safety Committee President & CEO Vice President Safety

Operating VPs Review all audit and performance data To develop corrective actions

Administrative Assistant

Internal Evaluation Review Board

Director Ground Safety & Environmental Affairs Director Security

Director Flight Safety

Director Emergency Response Planning

Director Internal Evaluation

Director Quality Assurance & Fleet Safety

Aviation Quality Database

Administration & Logistics

Alaska LOSA 2003

Bid Packet Announcement Letter Jan 14, 2002 Dec 2002 ALPA ALPA Safety Sense VP Flight Ops / MEC Chairman Letter to Pilots Mailed Jan 29, 2003 Flight Safety Newsletter

Dec 2002 ALPA ALPA Magazine

LOSA Steering Committee

Safe Approach Magazine OBS Training

LOSA Execution
Data Validation Debrief Jan Feb Mar Apr May 2003 Sep Nov

Program Research and Design

Jan 2002 Jul Dec

Alaska Flight Safety

LOSA Project Org Chart

LOSA PROJECT OFFICER

University of Texas

Cross Divisional Sanction & Support

FLIGHT CREW SCHEDULING

ALPA CASC LOSA Coordinator

FLIGHT OPS

LOSA Plan Development

Overall Plan Development

Preparation create a Steering Committee

Project Definition & Resources

Project Management Expertise Detail Planning Daily Execution Post-LOSA Data Validation Results Management

Improvement Processes

Feedback Process

Scope of Observation Plan

OBSERVERS 10-12 Observations 2 Week Period Provide Total Targets Each Self-Scheduled Allow Max Flexibility

OBSERVATIONS UT Baseline 3 Focus Areas Max

+5% Each +5% Sick Observers Canceled Flights

Contingencies

UT + 20% Max

Defining Observation Schedules

200 180 160 140 120 100 80 60 40 20 0 MD80 4/7/2009 200

% Fleet Departures # OBS % OBS

Observer Plan
Alaska Pilot Core Observers
Backup Staff Observers

29
7

University of Texas

Total Observers = 38

Observation Plan
Percent of Fleet # Observations & Percentage

B737-200C B737-400

9% 39% 16% 7% 31%

75 / 20% 70 200 / 54% 222

Boeing 737-700

B737-700
B737-900 MD80

100 / 27% 107

Total Observations = 399

Research Process

FOQA - Large quantity of data

For 2002, total more than 26,000 flights

Mathematical

Data analysis

Statistics and Numerical Analysis

Trends and Regression Techniques FOQA Events research Aircraft-specific research Airport-specific research

Basis for resource allocation for studying

FOQA Analysis Example4

From Annual Report 2002

Selected 5 high threat indicators in D-A-L

Examined these indicators

Independently By aircraft type By airport frequency

Cross examination of these variables

Flight Operations

Symptomatic Factors
2000 feet to 1000 feet above touchdown [Event A]

Alaska Airlines, Inc. - All rights reserved

1000 feet to 500 feet above touchdown [Event B]

Instrument Stabilized Approach Point

500 feet above touchdown to touchdown [Event C]

Flaps < Landing [Event D]

Visual Stabilized Approach Point Airspeed is VREF + X [Event E]

ILS-NPA-RNAV-RNP Approach

Event Rank (of all Events)

EVENT
Ranking 737-400 737-700 737-900

A (VSI)
1

B (VSI)
4

C (VSI)
6

D (Flaps) E (Speed)
7 9

Targeted Observations for Highest Incidence Events

737-400 Targeted Airports

Event
Rank (of All Events)

A
1 AIRPORT 1 AIRPORT 2 AIRPORT 3 AIRPORT 4

B
2 AIRPORT 2

C
4 AIRPORT 2

D
6 AIRPORT 9

E
7

Top Airports

AIRPORT 9

AIRPORT 8 AIRPORT 8 AIRPORT 8 AIRPORT 8 AIRPORT 9

Final Results Multi-Program Integration

FOQA, ASAP, Reporting data

Identified Airports, ATC Arrivals of Interest By Model Aircraft and Aircraft-specific Events

Operational Management Inputs

Fleet

Captain, Training and Chief Pilot

Union Inputs Targeted a system-wide assessment

All nighters, Transcons, Arctic, Mexico, etc.

=Identify observer & aircraft assignments

Execution

Execution Prep

Critical Success Factor - Communication

Ensure the Organization knows the LOSA Project Officer (LPO) and their authority Connectivity is crucial cell, pager Ensure LPO is available 24/7 or a rep

Brief FAs, CSAs, Dispatch and SOC/DSO TSA means jumpseat issues

Execution

University of Texas
Primary data and process manager Final Report ID LOSA Targets of Enhancement

Management Analysis of Report Data ID Tops Issues, Events, Safety Concerns Update the Post-LOSA Action Plan

Post - LOSA

Post-LOSA Action Plan

Broad Spectrum Data Acquisition & Analysis

Flight Procedures Company Policy Training Programs

Qual Standards Content Delivery

Administration of Manuals and Content

Answers Why do the FOQA events occur? MPI Supports Training & 2006 LOSA Planning Communicating the data & results to others

THREAT / MGMT ERROR / MGMT

THREAT PREVALENCE ERROR PREVALENCE

CRM / MGMT
CRM FACTORS PREVALENCE

HIGH
TO

LOW
N/A
Colors = Crew Management Effectiveness Communicating the data to others

Systemic Threat & Error Management

Intermediate Threats & Errors

Checklists Monitor Crosscheck Stable Approach Definition

Communicating the data to others

LOSA Results Management Line Pilot Focus Group Process

Immediate 1 2 3 6 Months 4 5 6 8 12 Months APR 04 MAY 04 9 JUN 04 7

LOSA Focus Group Action Plan Line Pilot Solutions to Line Problems

8 Focus Groups April-June with 24 Pilots on 9 Major Issues All Fleets All Seats All Bases 48 Man-Days of Work

LOSA Focus Group Recommendations*

Not Ever 13%

Great Simple 19%

1-2 Years 37%

6-12 Months 31%

* 80 Recommendations

Post-LOSA Action Process

ID Top Issues

Focus Groups ALPA Line

Recommendations

Management Review

STAN Process ALPA Implementation

What Does Alaska Airlines Do With the Data?

Multi-Program Integration Is A Process For Continuous Improvement

2001-2002 V1 Cut Procedure Memory Item Reduction QRC / QRH Integration

Multi Program Integration - MPI

INPUTS

OUTPUTS

AQP FOQA LOSA REPORTING ASAP O-53 SHR CSR CRM

2005 CQ Recurrent Targeted Training

Simulator events Controlled Threats Briefs / Debriefs Training Materials Line Operations Line Checks

Targeted Education

FEEDBACK Important To All Involved Groups Pilots Management BOD

For 2005 Pilot Training

TEM GUIDE

TEM Guide for Check Airmen

It is NOT

NOT a grading tool NOT identified, logged or filed in any way

Jepp sized LOSA Definitions, Targets for Enhancement, Alaska-specific results overview Tool to facilitate familiarization with TEM Discussion generator to raise awareness Feedback for line pilots of our actual LOSA results

It IS

TEM is 2005 CQ Theme and Line Check Focus