• 한국항공운항학회지
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• 제29권4호
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• pp.124-133
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• 2021

The airline industry has been growing steadily since 2016 with more than 100 million air passengers, renewing the largest number of air passengers every year. Increasing air demand leads to an increase in air traffic in limited airspace, increasing the likelihood of accidents between aircraft. Due to the massive human and material damage caused by a single mistake, aviation safety is being heavily focused around the world to efficiently use limited airspace. Studies related to various human factors are underway as most of the aviation accidents are found to be caused by human factors, but research on human factors by controllers is insufficient while they are active in terms of control and operation. Given that 82% of air accidents caused by controllers are caused by human error, the importance of management of human error and changes in perception are urgently needed. This study aims to understand the seriousness of the controller's human error by analyzing the accident cases caused by the controller's human error using TEM to identify threats and errors and derive common human factors.

• 한국항공운항학회지
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• 제18권2호
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• pp.60-66
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• 2010

Normal Operations Safety Survey (NOSS), a methodology for capturing safety data during normal Air Traffic Control (ATC) operations. The NOSS methodology is based on the Threat and Error Management (TEM) framework, and is a safety management tool to monitor safety during normal aviation operations. Monitoring safety in normal operations is an essential activity within the safety management systems of Air Traffic Services (ATS) providing organizations, and NOSS is proposed as a suitable way to do this. This study, operating in the latter half of the year of 2010 in South Korea on NOSS was the understanding and to apply.

• 한국항행학회논문지
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• 제18권4호
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• pp.319-324
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• 2014

LOSA(line operation safety audit)는 정상적인 운항 상태에서 운항 승무원이 발생할 수 있는 사고를 수집하기 위한 선제적 데이터 수집 방식으로 비행 중 발생하는 TEM(threat error management)과 CRM(crew resource management) 등을 수집하는 안전관리프로그램이다. 기존의 LOSA 기록 방식은 워크시트(worksheet) 에 관찰자가 직접 작성하여 자료를 보관하고 관리를 수행하였으나, 자료 보관의 어려움과 비밀 보장이 어려운 문제점이 있다. 기존의 LOSA 수집방식 대신 웹(web) 형태로 한국형 LOSA(K-LOSA)를 구현과 TEM 분류 코드를 변경하므로 효과적인 자료 관리 및 비밀 보장성을 확보하였다. 본 논문에서는 LOSA에 대하여 살펴보고 K-LOSA 프로그램의 구성을 소개한다.

• 한국항공운항학회지
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• 제18권2호
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• pp.54-59
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• 2010

The flight deck crew must manage complexity during daily flight operations. The Airline may obtain data regarding threats and errors through LOSA(Line Operations Safety Audits) on normal flights as predictive safety tool in Safety Management System of the Airline to actively improve the systems such as SOP(Standard Operation Procedure), training, evaluation and the TEM(Threat and Error Management) for the flight deck crew. The flight deck crew make errors when they fail managing threats. The crew mismanage around ten percent of threats and commit errors. The major mismanaged threats are aircraft malfunction, ATC(Air Traffic Communication), and wether threats. The effective countermeasures of TEM for manageing threats are leadership, workload management, monitor & cross check, Vigilance, communication environment and cooperation of the crew. It is important that organizations must monitor for the hazards of threats and improve system for the safer TEM environments.

• 한국항공운항학회:학술대회논문집
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• 한국항공운항학회 2006년도 추계학술대회 논문집
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• pp.61-65
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• 2006

The flight deck crew are under the operational time pressure in the cockpit. The crew tend to make errors when they face the threats of operational time pressure because they are in a rush. The flight deck crew can reduce threats and errors which existing within the airlines by using threat and error management when the crew know these threats and errors. The airlines can implement meaningful safety management system by analyzing into the useful information for to identify the hazard and manage the risk to reduce these threats and errors since aircrafts accidents can be fatal.With the threats and errors that were found regard to operational time pressures, company may implements safety change process to improve the safety systematically and the crew can manage the threats and errors more effectively.

• 한국항공운항학회:학술대회논문집
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• 한국항공운항학회 2007년 춘계학술대회 논문집
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• pp.44-47
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• 2007

• 한국항공운항학회지
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• 제16권2호
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• pp.43-50
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• 2008

ICAO(International Civil Aviation Organization) Doc 9803의 국제규정에 의거하여 SMS(Safety Management System-안전관리시스템)의 대표적인 비행안전 모니터링 프로그램으로 인정된 신개념의 운항감사제도인 LOSA(Line Operations Safety Audit-항공운항 안전감사)를 항공사에서 실시하여 정상 운항시의 운항승무원을 관찰하여 실제의 안전취약 및 위협요소, Error를 포착하여 텍사스대학 인적요인 연구소에서 작성한 최종보고서의 분석을 통해 제도와 방안을 개선한다. 본 논문에서는 LOSA실행을 통한 승무원들의 위협 및 error의 유형과 발생율, 관리율 및 관리여부를 분석하여 설명하고 항공사내 개선인 SCP(Safety Change Process)를 소개하는데 있다.

• 한국항공운항학회지
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• 제17권2호
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• pp.62-67
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• 2009

LOSA is a flight safety program that analyses human errors in normal operations. Trained pilot observers monitor the normal flights at the observer seat. LOSA is a proactive non jeopardy data collection tool using threat and error management(TEM) as a framework. With the analysis of crew behaviors through LOSA with The LOSA collaborative(TLC), the airlines can identify the behaviors of the crew during normal operations. The major objective of LOSA is to measure how the crew manage threats, errors and undesired aircraft deviations in the cockpit on day to day operations. The airlines are able to set up effective TEM training with practical six generation Crew recourse management(CRM) with data of error from LOSA instead of theoretical CRM courses. The Airlines can use TEM as an integral part of a Safety Management System(SMS) and uses monitoring and cross-checking skills in the flight operations to manage threats and errors effectively when we know the errors we make in the cockpit on daily operation. The result of LOSA indicates that the error detection rate should be enhanced since around the half of the errors went undetected. The areas which should be focused for enhancing the error detection are monitor, cross-check, the management of workload, automation and taxiway/ runway to manage errors effectively.

• 항공우주시스템공학회지
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• 제2권3호
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• pp.7-11
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• 2008

This is a study to research the effective way to enhance the performance of safety management by gathering and analyzing the information of undesirable occurrences that may result in accident or serious incident. This includes the way to identify the potential hazards related with the proactive activities. As detailed improvements, this paper introduces the mandatory and voluntary reporting system, normal operation safety survey, ATC quality assurance and the encouragement of just culture.

• 한국항공운항학회지
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• 제22권3호
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• pp.15-23
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• 2014

There have been CFIT(Controlled Flight Into Terrain) accidents that can be prevented if the crew executed go-around. This study is to analyse the common factors of three typical CFIT accidents of Korea in TEM(threat and error management) frame, and the examples of go-around gate and the countermeasures of eight airlines through the survey facilitating go-around to prevent CFIT. The common factors found in three typical CFIT accidents occurred in Korea or by Korean carriers turned out to be in mountainous terrain, in bad weather while in non-precision approach or circling approach by captain as PF(Pilot Flying) when crew make monitoring errors and communication errors. It also turned out that the crew in all three typical tragic CFIT accidents did not execute go-around in unstabilized approaches. The captains did not respond immediately when first officers advised them to go-around until it is too late. Seven out of eight Airlines answered that they use stabilized approach height as 1,000 feet to be stabilized earlier to have more safety margin by enhancing go-around gate regardless of the weather to prevent CFIT in the survey.