CX LOSA CX LOSA © Cathay Pacific Airways 2005

Cathay Pacific Cathay Pacific LOSALOSA

Training for SafetyAiming for Excellence

2001 & 20052001 & 2005

LOSA 2005.LOSA 2005.22CX LOSA CX LOSA © Cathay Pacific Airways 2005

Cathay Pacific AirwaysCathay Pacific Airways

2006 is our 602006 is our 60thth Birthday! Birthday!

from 2 DC3s to a fleet of 95 wide-bodiesfrom 2 DC3s to a fleet of 95 wide-bodies

> 80 pax Aircraft (A340, A330, B777, B747)> 80 pax Aircraft (A340, A330, B777, B747)

14 all-cargo B747 aircraft14 all-cargo B747 aircraft

~ 2000 pilots

~ 16000 total staff

LOSA 2005.LOSA 2005.33CX LOSA CX LOSA © Cathay Pacific Airways 2005

Cathay’s homeCathay’s home Chep Lap Kok, Hong KongChep Lap Kok, Hong Kong

50 Destinations worldwide50 Destinations worldwide

CX aircraft daily in: CX aircraft daily in:

NYC or JNBNYC or JNB

LHR or SYDLHR or SYD

NRT or FRANRT or FRA

DEL or DPSDEL or DPS

CX is truly international…

LOSA 2005.LOSA 2005.44CX LOSA CX LOSA © Cathay Pacific Airways 2005

"Without data you're just another person with an opinion"

"Without data you're just another person with an opinion"

We've got data…We've got data…lots of it!lots of it!

LOSA 2005.LOSA 2005.55CX LOSA CX LOSA © Cathay Pacific Airways 2005

Data Sources…

FOQA/QAR FOQA/QAR – a mature program capturing 90% of flightsa mature program capturing 90% of flights

(part of our change management system)(part of our change management system)

FOQA/QAR FOQA/QAR – a mature program capturing 90% of flightsa mature program capturing 90% of flights

(part of our change management system)(part of our change management system)

Reporting Culture – Air Safety Reports

– Confidential ReportsConfidential Reports

– Training & Check ReportsTraining & Check Reports(8 per pilot per year ~16,000 reports)(8 per pilot per year ~16,000 reports)

Reporting Culture – Air Safety Reports

– Confidential ReportsConfidential Reports

– Training & Check ReportsTraining & Check Reports(8 per pilot per year ~16,000 reports)(8 per pilot per year ~16,000 reports)

LOSA 2005.LOSA 2005.66CX LOSA CX LOSA © Cathay Pacific Airways 2005

How do we make sense of all the data? How do we make sense of all the data?

Is it valid?

Is it relevant?

Does it reveal trends? (or conceal them!)

How can we make the data smarter?

1. In Cathay Pacific, LOSA pointed us to where

we should focus our efforts.

LOSA 2005.LOSA 2005.77CX LOSA CX LOSA © Cathay Pacific Airways 2005

LOSA: - is not Reactive (to an incident / accident)

LOSA: - LOSA: - is not Guessworkis not Guesswork (he who shouts the loudest will be heard)(he who shouts the loudest will be heard)

LOSA: - LOSA: - isis “a day in the life of CPA”“a day in the life of CPA”

LOSA 2005.LOSA 2005.88CX LOSA CX LOSA © Cathay Pacific Airways 2005

Aircraft typeAircraft type Observations Observations

A330/340 A330/340 83 / 117 83 / 117

B777B777 51 / 46 51 / 46

B747-200FB747-200F 0 / 44 0 / 44

B747- 400 (incl. Freighters) B747- 400 (incl. Freighters) 26 (0) / 6726 (0) / 67

Total:Total: 160 / 274 160 / 274

LOSA Flights 2001 / 2005

LOSA 2005.LOSA 2005.99CX LOSA CX LOSA © Cathay Pacific Airways 2005

LOSA 2001 was used to validate and verify data LOSA 2001 was used to validate and verify data from other sources. from other sources.

LOSA 2001, together with the other data, has LOSA 2001, together with the other data, has driven some changes in Cathay Pacific:driven some changes in Cathay Pacific:

– New stabilised approach criteria.New stabilised approach criteria.

– New SOP for Flap and Gear selection.New SOP for Flap and Gear selection.

– New take-off and approach briefings. New take-off and approach briefings.

– New standardised approach and landing callouts.New standardised approach and landing callouts.

LOSA 2005.LOSA 2005.1010CX LOSA CX LOSA © Cathay Pacific Airways 2005

Biggest single shift in Cathay as a result of LOSA 2001

Threat & Error Management programThreat & Error Management program

– Every pilot has completed a TEM course

– Built modules to emphasise TEM into annual recurrent training

– Named "threats" in all departure & arrival briefings

– Got Check & Training pilot buy-in

LOSA 2005.LOSA 2005.1111CX LOSA CX LOSA © Cathay Pacific Airways 2005

We Knew Changes Had Occurred In Our Airline.

2. LOSA helped us to understand these changes.

2. LOSA helped us to understand these changes.

Obvious– Analogue to glass– 3-man to 2-man cockpits– Demographics - multi-cultural crew

Subtle– Experience levels dropping (Hours ≠ Experience)

– Automation complacency (Magenta / green line pilots)

– High threat environment (Weather, ADDs, ATC, etc)

LOSA 2005.LOSA 2005.1212CX LOSA CX LOSA © Cathay Pacific Airways 2005

3. LOSA is underpinned by TEM Principles.

3. LOSA is underpinned by TEM Principles.

Monitor / x-check has become a common phrase among Cathay pilots(LOSA had told us that we were average at monitoring!)

We encourage a culture of “healthy skepticism” on our flightdecks

Error Management can actually be commended (Criticism and blame are not the only responses!)

Threat anticipation is a key ingredient of our briefings

LOSA 2005.LOSA 2005.1313CX LOSA CX LOSA © Cathay Pacific Airways 2005

Moving On…Moving On…In Cathay we took the positives from LOSAIn Cathay we took the positives from LOSAIn Cathay we took the positives from LOSAIn Cathay we took the positives from LOSA

• What have we been doing right?What have we been doing right?

• What are our strengths?What are our strengths?(don’t lose these)

• What are our weaker areas?What are our weaker areas?(let’s focus our attention here)

CX LOSA CX LOSA © Cathay Pacific Airways 2005 LOSA 2005.LOSA 2005.1414

Captain’sLeadership

SOP BriefingsAutomation Management

Where Do We Start?

Everybody likes to hear what we are doing well(Captain’s leadership, Communication environment)

But the safety culture (water level) can only reach the height of the weakest performance mark (lowest stave).

LOSA can point to which stave needs fixing first.

LOSA 2005.LOSA 2005.1515CX LOSA CX LOSA © Cathay Pacific Airways 2005

SUMMARY

• LOSA is underpinned by TEM

• LOSA helped us to understand the changes in our airline

• LOSA pointed us to where we should focus our efforts

LOSA 2005.LOSA 2005.1616CX LOSA CX LOSA © Cathay Pacific Airways 2005

Managing the future…Managing the future…

LOSA is a Safety Management Tool that gives us a health-LOSA is a Safety Management Tool that gives us a health-check of our safety culture. It gives valuable data, enabling check of our safety culture. It gives valuable data, enabling

us to introduce changes to our safety lifestyle. us to introduce changes to our safety lifestyle.

““Life is lived forward but understood backward.”Life is lived forward but understood backward.” Kierkegaard

We all want to be able to see into the future!We all want to be able to see into the future!

LOSA is helping to

“ensure safety comes first”in Cathay Pacific