Qantas Flying Operations Audit

September 2005

2

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

LOSA was carried out:

May - July 2002

Across 29 Qantas domestic and international

ports

263 sectors

B737, B767, B744

LOSA Overview

3

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

LOSA Report:

Undesired Aircraft State

Australian law - disclosure

Exec Report to QF Safety Board members

Safety Board gave Chief Pilot three months to

present plan for corrective actions, to be

implemented within six months

LOSA Process

4

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

All Flight Crew called in for meeting with Chief Pilot

Putting final results directly to pilots meant they

interpreted the poor result as being their fault. Lead to

adverse reaction to LOSA.

Flight Crew thought it was not a practical reflection of

Qantas operations

Flight Crew Response

5

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

They didn’t just take it out on Flight Ops management…

……….. suddenly posters appeared

Flight Crew Response

7

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Chief Pilot strengthened Audit department

Audit no longer a ‘monitoring’ department but a

continual LOSA process

Benchmarking other airlines

QF shown to be insular

Permission from University of Texas

Flight Operations Actions re LOSA

8

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

GM Flying Ops Audit (Captain) full time

Two full time ground staff

25 Auditors (Captains) used as required

Audit Department Structure

Head of Flight Ops and Chief Pilot

GM Flying Ops Audit

Flying Ops Audit Mgr

Flying Ops Audit

Co-ordinator

25 Pilot Auditors

9

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Qantas mainline

B744, B747, B767, B737, A330. Each fleet every two years

Program

Qantas Group Airlines - audits conducted as requested

Australian Airlines B767

Jetstar B717

JetConnect B737

New procedures

New Approach Procedures, B737 RNP ZQN

10

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

The following examples show how the University

of Texas’ Threat/Error methodology translates into

tangible outcomes for Flight Crew

Enable Flight Crew to see the practical application

of Threat/Error methodology

Examples

4. Initial departure climb altitude is 3000’ or as directed by ATC

17

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Perfect flight - optimum flight

Modified to make it less theoretical and more

practical

eg. LAX - busy airport

Differences

18

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

We only use Captains as Auditors

Acceptance by crew

Decision errors

Auditor opinions and comments

19

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Decision Errors

Changed rules for recording decision errors

Must be a consequence to the decision

Or;

Decision is changed after external input

20

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

UAS / NSAPs

Changed title of Undesired Aircraft State to

Non Standard Aircraft Profile (NSAP)

After LOSA, UAS was irrevocably defined as “The

closest an airline gets to having an accident without

actually having one”

NSAP is understood by Flight Crew to mean ‘where the

aircraft is placed in a state of increased risk’

Issues

22

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

23

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

24

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Contribution to Crew Effectiveness

In the LOSA report, crews did not understand the

ratings given to them in terms of Contribution to Crew

Effectiveness

Completely different set of ratings

25

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Well Above Company Standard

Awarded when a crewmember’s “contribution to crew effectiveness” could be filmed and used as a training example to other pilots. It would have been a performance where strict adherence to Standard Operating Procedures, excellent CRM and sound manipulative (PF) or support (PNF) skills were observed. All facets of the performance must equally be to the high “training video” standard otherwise the “Well Above Company Standard” rating cannot be given.

Company Standard

Awarded when a crewmember’s “contribution to crew effectiveness” is highly professional and in line with what is expected by the Chief Pilot. It would not be without error, however, the Captain must demonstrate sound error management skills. Each crewmember must be able to recognise threats to the flight deck operation and the Captain must be able to manage such threats effectively.

26

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Below Company Standard

Awarded when the Auditor is of the opinion that, given the opportunity to conduct the observed sector once again, the crewmember would have increased their contribution to crew effectiveness in order to achieve a more professional standard of flight deck operation. The performance may have included examples of unintentional deviation from SOPs, threats and/or errors that were not recognised or managed to Company expectations, or manipulative support skills that were below a professional aviator’s ability on the day.

All crewmembers have had “days like these” and this rating does not mean that the crewmember was not trying to give of his/her best. A professional crewmember would have reviewed the sector with the intention of learning from the experience and improving their contribution to the crew effectiveness accordingly.

27

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Well Below Company Standard

Awarded when a crewmember’s contribution to crew effectiveness falls well short of what the Chief Pilot would reasonably expect of a professional crewmember. There is never any doubt in the mind of the Auditor, when awarding this rating, that the observed performance on the day was unacceptable. Either a complete lack of CRM, poor sector management, intentional violation of SOPs, or manipulative or support skills that did not meet the challenges of the day would have been observed during the crewmember’s performance.

28

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Audit and narrative writing - 50 sectors B767 $80 000

Wash process (4 weeks, average 3 sectors per day) $50 000

Report writing (2 weeks) $10 000

TOTAL $140 000

Cost of Audit per sector $2 800

Audit meeting (quarterly) $25 000

Costs for Audit Program

29

Capt Ken Ireland

GM Flying Operations Audit

Qantas Flying Operations Audit

Where are we now in terms of Threat/Error methodology?

Second B767 Audit - crew response was no

different from the first audit

De-identification

Cabin Auditing