Beyond the Cockpit:Beyond the Cockpit:The Spread of LOSA and Threat The Spread of LOSA and Threat

and Error Managementand Error Management

Robert L. Helmreich, PhD, FRAeS

Human Factors Research ProjectDepartment of Psychology

The University of Texas at Austin

44thth ICAO-IATA ICAO-IATALOSA and TEM ConferenceLOSA and TEM Conference

Toulouse, 16 NovemberToulouse, 16 November

The Line Operations Safety AuditThe Line Operations Safety Audit LOSA is application of the methodology of systematic LOSA is application of the methodology of systematic

observation to recording flight crew behavior and observation to recording flight crew behavior and threats to safety in the operating environmentthreats to safety in the operating environment

Historically, the methodology was applied to Historically, the methodology was applied to recording the behavior of Aquanauts living in recording the behavior of Aquanauts living in undersea habitats placed on the ocean floor undersea habitats placed on the ocean floor

Observations of flight crews (precursors to LOSA) Observations of flight crews (precursors to LOSA) began in 1979 with Texas International Airlines and began in 1979 with Texas International Airlines and later Pan American Airlines and Delta Airlineslater Pan American Airlines and Delta Airlines

Extensions of LOSA in AirlinesExtensions of LOSA in Airlines

LOSA methodology has been applied LOSA methodology has been applied (in collaboration with Continental (in collaboration with Continental Airlines) toAirlines) to Dispatch operations (DOSA)Dispatch operations (DOSA) Ramp operations (ROSA)Ramp operations (ROSA)

TEM & CRMTEM & CRM

Research in the LOSA Archive supports the Research in the LOSA Archive supports the links between TEM and CRM. links between TEM and CRM.

Crews that develop contingency management Crews that develop contingency management plans, such as proactively discussing strategies plans, such as proactively discussing strategies for anticipated threats, have fewer mismanaged for anticipated threats, have fewer mismanaged threats threats

Crews that exhibit good monitoring and cross-Crews that exhibit good monitoring and cross-checking make fewer errors checking make fewer errors

Crews that exhibit strong leadership, inquiry, and Crews that exhibit strong leadership, inquiry, and workload and automation management have workload and automation management have fewer mismanaged errors and undesired aircraft fewer mismanaged errors and undesired aircraft states states

International ConferencesInternational ConferencesLOSA WeekLOSA Week

2001 Hong Kong2001 Hong Kong 2001 Panama City, Panama2001 Panama City, Panama 2002 United Arab Emirates, Dubai2002 United Arab Emirates, Dubai 2003 Dublin2003 Dublin 2006 Toulouse2006 Toulouse

Threat and Error Management workshop:Threat and Error Management workshop: 2002 San Salvador2002 San Salvador

Published GuidelinesPublished Guidelines ICAOICAO (2002). Line Operations Safety (2002). Line Operations Safety

Audit (LOSA). DOC 9803-AN/761. Audit (LOSA). DOC 9803-AN/761. Montreal: International Civil Aviation Montreal: International Civil Aviation Organization (under revision)Organization (under revision)

FAA (2006) LOSA Advisory Circular FAA (2006) LOSA Advisory Circular 120-90 Line Operations Safety Audits 120-90 Line Operations Safety Audits (Includes Threat and Error (Includes Threat and Error Management)Management)

ASAP: Aviation Safety ASAP: Aviation Safety Action ProgramAction Program

Michelle Harper, Doctoral CandidateMichelle Harper, Doctoral Candidate

ASAP CharacteristicsASAP Characteristics

ASAP is an extension of NASA’s Aviation ASAP is an extension of NASA’s Aviation Safety Reporting System (ASRS)Safety Reporting System (ASRS)

Under ASAP, pilots report threats and Under ASAP, pilots report threats and errors (excluding intentional non-errors (excluding intentional non-compliance and drug and alcohol compliance and drug and alcohol violations) to their company and receive violations) to their company and receive the same limited immunity from the same limited immunity from punishment provided by ASRSpunishment provided by ASRS

ASAP BenefitsASAP Benefits

Unlike ASRS, information is immediately Unlike ASRS, information is immediately available to company management and available to company management and allows corrective action to be takenallows corrective action to be taken

ASAP committee (union, management, ASAP committee (union, management, regulator) reviews reports and regulator) reviews reports and determines corrective actiondetermines corrective action

Actions are reported back to pilotActions are reported back to pilot Don Gunther of Continental can clarifyDon Gunther of Continental can clarify

Project Goals: Provide airlines with a set of tools that can be used across the

industry to collect and analyze factors contributing to ASAP events. Development of web-based tools for supporting airline

ASAP data collection Establish a data-sharing program based on these tools to

identify industry- and system-level, high-risk events Development of the Distributed National ASAP Archive

(DNAA) Use the UT Threat and Error Management Model as the

common taxonomy for categorizing ASAP events Development of the DNAA Master List of common ASAP

event descriptors

The UT ASAP Data Collection System/ Distributed National ASAP Archive

(DNAA)

System Overview

DNAA

server

DNAA DNAA

1. UT developed software that supports the airlines in collecting ASAP data2. UT and NASA collaborated to enable airlines to share de-identified ASAP

reports• Each airline shares data through a protected connection to NASA and

UT

1. 2.

Participating AirlinesParticipating Airlines

* Northwest airlines not participating in DNAA

*

AA, UPS and United not using UT ASAP data collection tools

****

**

**

NOSS: Normal Operations NOSS: Normal Operations Safety SurveySafety Survey

Chris Henry, Doctoral CandidateChris Henry, Doctoral Candidate

Normal Operations Safety Normal Operations Safety Survey (NOSS)Survey (NOSS)

NOSS is LOSA adapted to Air Traffic ControlNOSS is LOSA adapted to Air Traffic Control TEM definitions congruent with LOSATEM definitions congruent with LOSA NOSS captures the work context and how controllers NOSS captures the work context and how controllers

discharge their duties within that contextdischarge their duties within that context Threats are key elements of task environmentThreats are key elements of task environment Aggregated Threat and Error Management data Aggregated Threat and Error Management data

capture both system and individual performancecapture both system and individual performance Over-the-shoulder observationsOver-the-shoulder observations

De-identified, non-jeopardy De-identified, non-jeopardy Identify systemic strengths and vulnerabilitiesIdentify systemic strengths and vulnerabilities

NOSS & TEM: Additional NOSS & TEM: Additional BenefitsBenefits

Airways NZ is analyzing normal operations Airways NZ is analyzing normal operations and incident data using TEMand incident data using TEM

Service providers and airlines, using TEM Service providers and airlines, using TEM as a common ‘language’ are exchanging as a common ‘language’ are exchanging more safety information on ATC interfacemore safety information on ATC interface

TEM training is being developed for TEM training is being developed for controllers at service providerscontrollers at service providers

Accident InvestigationAccident Investigation

Bob HelmreichBob Helmreich

TEM as Framework for TEM as Framework for Accident InvestigationAccident Investigation

IATA has adopted TEM as framework IATA has adopted TEM as framework for classification of causal and for classification of causal and contributing factors in global accident contributing factors in global accident and incident databaseand incident database

Robert Sumwalt, new Robert Sumwalt, new NTSB Vice ChairmanNTSB Vice Chairman Trained in TEMTrained in TEM Served as LOSA observerServed as LOSA observer

Current InvestigationsCurrent Investigations Analysis of factors surrounding crash of Analysis of factors surrounding crash of

LAPA B-737 in Buenos Aires requested by LAPA B-737 in Buenos Aires requested by government of Argentinagovernment of Argentina

Analysis of factors surrounding the crash of Analysis of factors surrounding the crash of Flash Airlines B-737 at Sharm El Sheikh, Flash Airlines B-737 at Sharm El Sheikh, Egypt requested by BoeingEgypt requested by Boeing

Analysis of crew performance in crash of Analysis of crew performance in crash of CRJ200 at Kirksville, MO requested by CRJ200 at Kirksville, MO requested by BombardierBombardier

Extensions to Other Extensions to Other ProfessionsProfessions

Queensland Rail in Australia has Queensland Rail in Australia has adapted both TEM and LOSA to audit adapted both TEM and LOSA to audit their operationstheir operations

International Association of Fire International Association of Fire Chiefs has used TEM in developing US Chiefs has used TEM in developing US national close call reporting systemnational close call reporting system RLH is member of committee developing RLH is member of committee developing

guidelinesguidelines

ConclusionsConclusions

TEM can be used as the data TEM can be used as the data structure for an organization’s Safety structure for an organization’s Safety Management SystemManagement System Allows integration of data from differing Allows integration of data from differing

sourcessources Incident reports, incident and accident Incident reports, incident and accident

investigations, and LOSA and its derivativesinvestigations, and LOSA and its derivatives

The University of Texas The University of Texas Human Factors Research ProjectHuman Factors Research Project

www.psy.utexas.edu/HumanFactors