ICAO / IATA LOSA TEM Conference
LOSA OVERALL PROCESS
Captain Chris Nutter
Director Flight Safety
Alaska Airlines
Overall Strategic Process
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Union Partnership is Critical
Project Definition
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Administration & Logistics
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Daily “Command Center” for Operations
Post-LOSA Action Plan & Commitment (Do First)
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IT Issues, Hotel Rooms, Expense Reports, Deadheads, etc.
Organizational Management is Critical
LOSA Plan Development
Execution
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Objectives, Scope and Magnitude of the Effort
Resources
Improve the organization, operations and enhance safety
Feedback
Project Definition
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Project design requirements
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Number and type of observations
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Logistics decisions
Post-LOSA process (and commitment)
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Research decisions
How long to accomplish
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Business decisions
Management decisions (with Union Partnership)
Suggest a 3-year plan
Resources
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University of Texas LOSA Collaborative
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UT Preparation Checklist
ICAO
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Document 9803 LOSA
Industry Data
 Company Data
 Published Literature
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Third Party
Audits
(LOSA)
BOD
Safety
Committee
Operating VPs
President
&
CEO
Review all audit and
performance data
Vice President
Safety
To develop corrective
actions
Administrative
Assistant
Internal
Evaluation
Review Board
Director Ground
Safety &
Environmental
Affairs
Director
Flight Safety
Director
Security
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
Program Research
and Design
Jan
2002
Jul
Dec
Jan Feb Mar Apr May
2003
Alaska Flight Safety
Sep
Nov
LOSA Project Org Chart
LOSA PROJECT
OFFICER
University of Texas
FLIGHT CREW
SCHEDULING
ALPA CASC
LOSA Coordinator
Cross Divisional
Sanction & Support
FLIGHT OPS
LOSA Plan Development
Overall Plan Development
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Preparation – create a Steering Committee
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Project Management Expertise
Detail Planning
Daily Execution
Post-LOSA Data Validation
Results Management
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Project Definition & Resources
Improvement Processes
Feedback Process
Scope of Observation Plan
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OBSERVERS
10-12 Observations
2 Week Period
Provide Total Targets
Each Self-Scheduled
Allow Max Flexibility
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OBSERVATIONS
UT Baseline
3 Focus Areas Max
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Contingencies
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+5% Each
+5%
Sick Observers
Canceled Flights
UT + 20% Max
Defining Observation Schedules
200
180
160
140
120
100
80
60
40
20
0
% Fleet
Departures
# OBS
% OBS
MD80 4/7/2009
200
Observer Plan
Alaska Pilot Core Observers
29
Backup Staff Observers
7
University of Texas
2
Total Observers = 38
Observation Plan
Percent
of Fleet
B737-200C
B737-400
B737-700
B737-900
MD80
9%
39%
16%
7%
31%
# Observations
& Percentage
75 / 20% 70
200 / 54% 222
Boeing 737-700
100 / 27% 107
Total Observations = 399
Research Process
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FOQA - Large quantity of data
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For 2002, total more than 26,000 flights
Data analysis
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Mathematical
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Statistics and Numerical Analysis
Trends and Regression Techniques
Basis for resource allocation for studying
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FOQA Events research
Aircraft-specific research
Airport-specific research
FOQA Analysis Example4
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From Annual Report 2002
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Selected 5 high threat indicators in D-A-L
Examined these indicators
Independently
 By aircraft type
 By airport frequency
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Cross examination of these variables
Flight Operations
© Alaska Airlines, Inc. - All rights reserved
Symptomatic Factors
2000 feet to 1000 feet above touchdown [Event A]
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
A (VSI)
B (VSI)
C (VSI)
D (Flaps) E (Speed)
Ranking
1
4
6
7
9
737-400
737-700
737-900
Targeted Observations for Highest Incidence Events
737-400 Targeted Airports
Event
A
B
C
D
E
Rank (of All
Events)
1
2
4
6
7
Top Airports
AIRPORT 1
AIRPORT 2
AIRPORT 2
AIRPORT 9
AIRPORT 2
AIRPORT 3
AIRPORT 4
AIRPORT 9
AIRPORT 8
AIRPORT 8
AIRPORT 8
AIRPORT 8
AIRPORT 9
Final Results
Multi-Program Integration
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FOQA, ASAP, Reporting data
Identified Airports, ATC Arrivals of Interest
 By Model Aircraft and Aircraft-specific Events
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Operational Management Inputs
 Fleet
Captain, Training and Chief Pilot
Union Inputs
 Targeted a system-wide assessment
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All nighters, Transcons, Arctic, Mexico, etc.
=Identify observer & aircraft assignments
Execution
Execution Prep
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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
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Brief FAs, CSAs, Dispatch and SOC/DSO
 TSA means jumpseat issues
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Execution
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University of Texas
Primary data and process manager
 Final Report
 ID LOSA Targets of Enhancement
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Management Analysis of Report Data
 ID Tops Issues, Events, Safety Concerns
 Update the Post-LOSA Action Plan
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Post - LOSA
Post-LOSA Action Plan
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Broad Spectrum Data Acquisition & Analysis
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Flight Procedures
Company Policy
Training Programs
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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
CRM / MGMT
THREAT
ERROR
CRM FACTORS
PREVALENCE
PREVALENCE
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
4
6 Months
7
5
6
8
12 Months
9
APR 04
MAY 04
JUN 04
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%
1-2 Years
37%
* 80 Recommendations
Great Simple
19%
6-12 Months
31%
Post-LOSA Action Process
ID Top Issues
Management
Review
Focus Groups
ALPA Line
Recommendations
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
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INPUTS
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AQP
FOQA
LOSA
REPORTING
 ASAP
 O-53
 SHR
 CSR
CRM
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OUTPUTS
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2005 CQ Recurrent
Targeted Training
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Simulator events
Controlled Threats
Targeted Education
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Briefs / Debriefs
Training Materials
Line Operations
Line Checks
FEEDBACK
Important
To All
Involved
Groups –
• Pilots
• Management
• BOD
For 2005 Pilot Training
TEM
GUIDE
TEM Guide for Check Airmen
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It is NOT
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It IS
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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
TEM is 2005 CQ Theme and Line Check Focus