ICAO / IATA LOSA TEM Conference

LOSA OVERALL PROCESS

Captain Chris NutterDirector Flight SafetyAlaska Airlines

Overall Strategic Process Overall Strategic Process

Union Partnership is CriticalUnion Partnership is Critical Project DefinitionProject Definition

Objectives, Scope and Magnitude of the EffortObjectives, Scope and Magnitude of the Effort ResourcesResources

Administration & LogisticsAdministration & Logistics IT Issues, Hotel Rooms, Expense Reports, Deadheads, etc.IT Issues, Hotel Rooms, Expense Reports, Deadheads, etc. Organizational Management is CriticalOrganizational Management is Critical

LOSA Plan DevelopmentLOSA Plan Development ExecutionExecution

Daily “Command Center” for OperationsDaily “Command Center” for Operations Post-LOSA Action Plan & Commitment (Do First)Post-LOSA Action Plan & Commitment (Do First)

Improve the organization, operations and enhance safetyImprove the organization, operations and enhance safety FeedbackFeedback

Project DefinitionProject Definition

Project design requirementsProject design requirements Business decisionsBusiness decisions

Number and type of observationsNumber and type of observations Research decisionsResearch decisions

How long to accomplishHow long to accomplish Logistics decisionsLogistics decisions

Post-LOSA process (and commitment)Post-LOSA process (and commitment) Management decisions (with Union Partnership)Management decisions (with Union Partnership)

Suggest a 3-year planSuggest a 3-year plan

ResourcesResources

University of Texas LOSA CollaborativeUniversity of Texas LOSA CollaborativeUT Preparation ChecklistUT Preparation Checklist

ICAOICAODocument 9803 LOSADocument 9803 LOSA

Industry DataIndustry DataCompany DataCompany DataPublished LiteraturePublished Literature

B O DS afe ty

C o m m ittee

A d m in is tra tiveA ss is tant

In tern alE va lua tion

R eview B o ard

D irec tor G rou ndS afe ty &

E n viro n m en talA ffa irs

D irec torF lig h t S a fe ty

D irec torS ecu rity

D irec torE m erg en cy

R espo n se P lan n ing

D irec torIn te rn a l Eva lua tion

D irec torQ u a lity Assu ran ce

& F lee t S a fe ty

V ice P res id entS a fe ty

P resid ent&

C E O

AviationQuality

Database

Third PartyAudits

(LOSA)

Operating VPs

Review all audit and performance data

To develop corrective actions

Administration & LogisticsAdministration & Logistics

Alaska Alaska LOSA 2003LOSA 2003

Program Researchand Design

LOSA SteeringCommittee

Dec 2002 ALPAALPA Magazine

Dec 2002 ALPAALPA Safety Sense

VP Flight Ops / MEC ChairmanLetter to Pilots Mailed Jan 29, 2003

Bid Packet Announcement LetterJan 14, 2002

Flight Safety Newsletter

Safe Approach Magazine

Jan Jul Dec Jan Feb Mar Apr May Sep Nov2002 2003

Alaska Flight Safety

OBS Training

Data ValidationDebrief

LOSA Execution

LOSA Project Org ChartLOSA Project Org Chart

LOSA PROJECTOFFICER

FLIGHT CREWSCHEDULING

ALPA CASCLOSA Coordinator

FLIGHT OPS

University of TexasCross DivisionalSanction & Support

LOSA Plan DevelopmentLOSA Plan Development

Overall Plan DevelopmentOverall Plan Development

Preparation – create a Steering CommitteePreparation – create a Steering Committee Project Definition & ResourcesProject Definition & Resources

Project Management ExpertiseProject Management Expertise Detail PlanningDetail Planning Daily ExecutionDaily Execution Post-LOSA Data ValidationPost-LOSA Data Validation Results ManagementResults Management

Improvement ProcessesImprovement Processes Feedback ProcessFeedback Process

Scope of Observation PlanScope of Observation Plan

OBSERVERSOBSERVERS 10-12 Observations10-12 Observations 2 Week Period2 Week Period Provide Total TargetsProvide Total Targets Each Self-ScheduledEach Self-Scheduled Allow Max FlexibilityAllow Max Flexibility

OBSERVATIONSOBSERVATIONS UT BaselineUT Baseline 3 Focus Areas Max3 Focus Areas Max

+5% Each+5% Each

ContingenciesContingencies +5%+5% Sick ObserversSick Observers Canceled FlightsCanceled Flights

UT + 20% MaxUT + 20% Max

020406080

100120140160180200

MD80 4/7/2009 200

% FleetDepartures# OBS% OBS

Defining Observation SchedulesDefining Observation Schedules

Observer PlanObserver Plan

Total Observers = 38Total Observers = 38

Alaska Pilot Core Observers 29

Backup Staff Observers 7

University of Texas 2

Boeing 737-700

Observation PlanObservation PlanPercentPercent

of Fleetof Fleet

# Observations# Observations

& P& Percentageercentage

B737-200CB737-200C 9%9% 75 / 20% 75 / 20%

B737-400B737-400 39%39%

200 / 54%200 / 54%B737-700B737-700 16%16%B737-900B737-900 7%7%MD80MD80 31%31% 100 / 27% 100 / 27%

Total Observations = 399Total Observations = 399

7070

222222

107107

Research ProcessResearch Process

FOQA - Large quantity of dataFOQA - Large quantity of data For 2002, total more than 26,000 flightsFor 2002, total more than 26,000 flights

Data analysisData analysis MathematicalMathematical

Statistics and Numerical AnalysisStatistics and Numerical Analysis Trends and Regression TechniquesTrends and Regression Techniques

Basis for resource allocation for studyingBasis for resource allocation for studying FOQA Events researchFOQA Events research Aircraft-specific researchAircraft-specific research Airport-specific researchAirport-specific research

FOQA Analysis ExampleFOQA Analysis Example44

From Annual Report 2002From Annual Report 2002Selected 5 high threat Selected 5 high threat indicators in D-A-Lindicators in D-A-L

Examined these indicatorsExamined these indicators IndependentlyIndependentlyBy aircraft typeBy aircraft typeBy airport frequencyBy airport frequency

Cross examination of these variablesCross examination of these variables

© Alaska Airlines, Inc. - All rights reserved

ILS-NPA-RNAV-RNP Approach

Flight Operations

2000 feet to 1000 feet above touchdown [Event A]

1000 feet to 500 feet above touchdown [Event B]

500 feet above touchdown to touchdown [Event C]

Flaps < Landing [Event D]

Airspeed is VREF + X[Event E]

Visual StabilizedApproach Point

Symptomatic Factors

Instrument StabilizedApproach Point

Event Rank (of all Events)Event Rank (of all Events)

737-900737-900

737-700737-700

737-400737-400

9977664411RankingRanking

E E (Speed)(Speed)D (Flaps)D (Flaps)C (VSI)C (VSI)B (VSI)B (VSI)A (VSI)A (VSI)EVENTEVENT

Targeted Observations for Highest Incidence Events

737-400 Targeted Airports737-400 Targeted Airports

AIRPORT 9AIRPORT 9

AIRPORT 8AIRPORT 8AIRPORT 8AIRPORT 8AIRPORT 8AIRPORT 8

AIRPORT 8AIRPORT 8

AIRPORT 9AIRPORT 9AIRPORT 4AIRPORT 4

AIRPORT 3AIRPORT 3

AIRPORT 2AIRPORT 2AIRPORT 2AIRPORT 2

AIRPORT 9AIRPORT 9AIRPORT 2AIRPORT 2AIRPORT 1AIRPORT 1Top AirportsTop Airports

7766442211Rank (of All Events)Rank (of All Events)

EEDDCCBBAAEventEvent

Final ResultsFinal ResultsMulti-Program IntegrationMulti-Program Integration

FOQA, ASAP, Reporting dataFOQA, ASAP, Reporting data Identified Airports, ATC Arrivals of InterestIdentified Airports, ATC Arrivals of InterestBy Model Aircraft and Aircraft-specific EventsBy Model Aircraft and Aircraft-specific Events

Operational Management InputsOperational Management InputsFleet Captain, Training and Chief PilotFleet Captain, Training and Chief Pilot

Union InputsUnion InputsTargeted a system-wide assessmentTargeted a system-wide assessment

All nighters, Transcons, Arctic, Mexico, etc.All nighters, Transcons, Arctic, Mexico, etc.=Identify observer & aircraft assignments=Identify observer & aircraft assignments

ExecutionExecution

Execution PrepExecution Prep

Critical Success Factor - CommunicationCritical Success Factor - CommunicationEnsure the Organization knows the LOSA Ensure the Organization knows the LOSA

Project Officer (LPO) Project Officer (LPO) and their authorityand their authorityConnectivity is crucial – cell, pagerConnectivity is crucial – cell, pagerEnsure LPO is available 24/7 or a repEnsure LPO is available 24/7 or a rep

Brief FAs, CSAs, Dispatch and SOC/DSOBrief FAs, CSAs, Dispatch and SOC/DSOTSA means jumpseat issuesTSA means jumpseat issues

ExecutionExecution

University of TexasUniversity of TexasPrimary data and process managerPrimary data and process managerFinal ReportFinal Report ID LOSA Targets of EnhancementID LOSA Targets of Enhancement

Management Analysis of Report DataManagement Analysis of Report Data ID Tops Issues, Events, Safety ConcernsID Tops Issues, Events, Safety ConcernsUpdate the Post-LOSA Action PlanUpdate the Post-LOSA Action Plan

Post - LOSAPost - LOSA

Post-LOSA Action PlanPost-LOSA Action Plan

Broad Spectrum Data Acquisition & AnalysisBroad Spectrum Data Acquisition & Analysis Flight ProceduresFlight Procedures Company PolicyCompany Policy Training ProgramsTraining Programs

Qual StandardsQual Standards ContentContent DeliveryDelivery

Administration of Manuals and ContentAdministration of Manuals and Content Answers “Why do the FOQA events occur?”Answers “Why do the FOQA events occur?” MPI Supports Training & 2006 LOSA PlanningMPI Supports Training & 2006 LOSA Planning Communicating the data & results to othersCommunicating the data & results to others

THREAT / MGMTTHREAT / MGMT ERROR / MGMTERROR / MGMT CRM / MGMTCRM / MGMT

THREATTHREAT ERRORERROR CRM FACTORSCRM FACTORS

PREVALENCEPREVALENCE PREVALENCEPREVALENCE PREVALENCEPREVALENCE

HIGHHIGH

TOTO

LOWLOW

N/AN/A

Colors = Crew Management EffectivenessColors = Crew Management Effectiveness

Communicating the Communicating the data to othersdata to others

Checklists

Stable Approach DefinitionMonitor Crosscheck

IntermediateThreats & Errors

SystemicThreat & Error

Management

Communicating the data to others

LOSA Results ManagementLOSA Results ManagementLine Pilot Focus Group ProcessLine Pilot Focus Group Process

Immediate

6 Months

12 Months

1

APR 04 MAY 04 JUN 04

2

3

4

5

6

9

8

7

LOSA Focus Group Action PlanLine Pilot Solutions to Line Problems

8 Focus Groups April-June with 24 Pilots on 9 Major IssuesAll Fleets – All Seats – All Bases

48 Man-Days of Work

LOSA Focus Group Recommendations*

Great Simple19%

6-12 Months31%

1-2 Years37%

Not Ever13%

* 80 Recommendations

Post-LOSA Action ProcessPost-LOSA Action Process

Focus GroupsALPA Line

Focus GroupsALPA Line

RecommendationsRecommendations

ManagementReview

ManagementReview STAN Process

ALPASTAN Process

ALPA

ID Top IssuesID Top Issues

ImplementationImplementation

What Does Alaska AirlinesWhat Does Alaska AirlinesDo With the Data?Do With the Data?

Multi-Program IntegrationMulti-Program Integration

Is A ProcessIs A Process

For Continuous ImprovementFor Continuous Improvement

2001-2002V1 Cut ProcedureMemory Item ReductionQRC / QRH Integration

Multi Program Integration - MPIMulti Program Integration - MPI

INPUTSINPUTS AQPAQP FOQAFOQA LOSALOSA REPORTINGREPORTING

ASAPASAPO-53O-53SHRSHRCSRCSR

CRMCRM

OUTPUTSOUTPUTS 2005 CQ Recurrent2005 CQ Recurrent TargetedTargeted Training Training

Simulator eventsSimulator events Controlled ThreatsControlled Threats

TargetedTargeted Education Education Briefs / DebriefsBriefs / Debriefs Training MaterialsTraining Materials Line OperationsLine Operations Line ChecksLine Checks

FEEDBACKImportantTo AllInvolvedGroups –• Pilots• Management• BOD

TEM GUIDE

For 2005 Pilot TrainingFor 2005 Pilot Training

TEM Guide for Check AirmenTEM Guide for Check Airmen

It is NOTIt is NOT NOT a grading toolNOT a grading tool NOT identified, logged or filed in any wayNOT identified, logged or filed in any way

It ISIt IS Jepp sized LOSA Definitions, Targets for Jepp sized LOSA Definitions, Targets for

Enhancement, Alaska-specific results overviewEnhancement, Alaska-specific results overview Tool to facilitate familiarization with TEMTool to facilitate familiarization with TEM Discussion generator to raise awarenessDiscussion generator to raise awareness Feedback for line pilots of our actual LOSA resultsFeedback for line pilots of our actual LOSA results

TEM is 2005 CQ Theme and Line Check FocusTEM is 2005 CQ Theme and Line Check Focus