AIR GEORGIAN LIMITEDLine Operations Safety Audit

Dan Bockner

•Over the summer of 2010 Air Georgian Limited (AGL) conducted a Line Operations Safety Audit (LOSA)

•The LOSA was a very substantial undertaking for a company the size of AGL

•The LOSA was a positive project that has helped us to better understand our operation and improve safety

Introduction

Quality Assurance & Audit IT Systems

Air Georgian Limited

•Air Georgian Limited operates 16 Beech 1900D (15 at the time of the LOSA) providing scheduled Tier III service on behalf of Air Canada

•We have bases in Toronto, Halifax and Calgary (just the first two at the time of the LOSA)

•We also operate five business jets but these crews were not involved in the LOSA

Air Georgian Limited

•Air Georgian Limited operates about 30000 flights per year

•The Company employs 120 pilots with 112 on the Beech 1900D

•Flights are anywhere from 25 minutes to over two hours

Beechcraft 1900D (BE02)

Line Operations Safety Audit•A Line Operations Safety Audit (LOSA)

involves having trained observers fly on a series of flights

•Each observer occupies a suitable seat from where he can make observations on a detailed and tailor-made LOSA form

•The observers must be non-management and are usually pilots

•For our LOSA we used six observers•The observers are plugged in to the intercom

system

Line Operations Safety Audit• The observers do not take part at all in the

operation of the flight and do not communicate with the flight crew (other than an initial briefing)

• Each observer will audit a set number of flights. Once completed the observer enters the results into a database

• Either flight crew member is fully empowered to refuse access to the auditor; participation must be voluntary

• The LOSA is overseen by the LOSA Steering Committee

Line Operations Safety Audit• The LOSA Steering Committee was made up of

myself, the Chief Pilot, the Chief Instructor, the Corporate Safety Officer, the Standards Captain as well as the six observers

• The LOSA Steering Committee planned and oversaw the process from start to finish; outside expert advice was secured in the form of a consultant from TACG who provided a training course at our head office

• The final component of the LOSA is the questionnaire

Line Operations Safety Audit

•Before being entered into the database all data is ‘cleansed’ by the Steering Committee

•A comprehensive report is created using the data collected from the observed flights and the questionnaires

•The report must be distributed widely throughout the organization in order to raise awareness and improve training

Threat and Error Management Model

•TEM is akin to defensive driving•The model posits that threats and errors

are integral parts of daily flight operations and must be managed

•A threat is external and will increase risk•An error is a non-compliance with the

regs, SOPs (or other Company policies), or an unexpected deviation from crew, Company or ATC expectations

Threat and Error Management Model

•An undesired aircraft state (UAS) occurs when the flight crew puts the aircraft into a situation that unnecessarily increases risk (through crew actions or lack thereof)

•Threats, errors and UAS’ are a fact of life every flight. Increased awareness will improve the ability of pilots to deal with them effectively

Union Involvement

•For an effective LOSA pilots must be clear that it involves ‘no jeopardy’

•The union leadership must be involved in the LOSA from the start

•The union leadership must ‘buy-in’ to the concept and actively help to convey the message to the pilot group

LOSA Findings - Threats

•Obvious ones such as:1. weather2. heavy ground and air traffic3. frequency congestion4. ATC errors (especially non-standard

phraseology)5. deferred Mtce items

LOSA Findings - Threats

•Some not so obvious threats such as:1. Two Captains paired together 2. Routine nature of scheduled operations.

This is not necessarily a ‘threat’ as defined in the TEM but it is a real consideration that all should be aware of

LOSA Findings - Errors

•Recurring errors included:1. Sterile cockpit violations2. Excessive taxi speeds3. Failure to properly use the checklist4. Errors in system handling5. Failures to confirm runway data for take

offs and landings

LOSA Findings - Errors

•Some significant specific errors include:1. Knowingly operating with a failed radar

with forecast CBs en-route2. Failure to check NOTAMs; destination

airport closed due to air show3. Failure to enter a defect into the journey

log at the completion of a flight4. Flight crew reading magazines while in

climb with the autopilot engaged5. SOP confusion during a PMA approach

LOSA Findings - UAS

•Some UAS’ observed include:1. Vertical and lateral deviations2. Speed deviations3. Excessive bank4. Unstable approach

LOSA Recommendations

•A total of 15 recommendations were generated by the LOSA and outlined in the final report

•To date 10 of the recommendations have been implemented

Overall Result

•The LOSA made clear that Air Georgian Limited’s operations are safe and professional

•It also made clear that we have much work to do in order to continuously improve

•Being able to prove and quantify our shortcomings to both managers and employees is invaluable

•The LOSA report is a valuable training aid

Lessons for Future LOSAs• Mark overall SOP compliance for each observed

flight• Better confirmation that special equipment needed

is serviceable• Improve scheduling for observers• More training in use of the marking form for the

observers• More notice and communication to Crew

Schedulers and Flight Followers• Increased observation of flight planning at the start

of the flight duty day• More math in the final report