Captain Don GuntherSenior Director Safety & Regulatory Compliance
““Line Operations Safety Audit Line Operations Safety Audit (LOSA)”(LOSA)”
““Line Operations Safety Audit Line Operations Safety Audit (LOSA)”(LOSA)”
Continental Airlines, Feb 2007Continental Airlines, Feb 2007
Line Operations Safety Audit (LOSA)Line Operations Safety Audit (LOSA)and Threat & Error Management (TEM) and Threat & Error Management (TEM)
are integral parts of a are integral parts of a Safety Management System (SMS)Safety Management System (SMS)
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Aviation Week Article on Healthy Organizations
“Investing the time and money needed to get at the root cause of a problem takes total commitment at the most senior levels of a company or organization. In most organizational settings, communicators learn early in life how bad news can impact their leaders. If the news is valued and the communicator is If the news is valued and the communicator is protected, there is a real chance information can and protected, there is a real chance information can and will routinely flow upward in time for proper action to will routinely flow upward in time for proper action to be takenbe taken.”
Safety Culture
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Corporate Culture
How well does your company accept safety inputs when busy with the Operation?How well does your company accept safety inputs when busy with the Operation?
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Over 95% goes unreported!Over 95% goes unreported!
Human Error
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Data driven Safety Change through Non-Jeopardy Reporting
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The Safety Change Program“Tailored to your Airline”“Tailored to your Airline”
To properly target change you need current operational data, specifically for your airline, which is unique due to its…• History & Culture• Areas of operation (ETOPS, polar routes, etc.)• Philosophy
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By not having data to discover the precursors By not having data to discover the precursors “specific” to an individual airline’s “specific” to an individual airline’s
operations, this is the bottom-line…operations, this is the bottom-line…
Line Observation Safety Audit(LOSA)
Line Observation Safety Audit(LOSA)
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University of Texas
Human Factors
Research ProjectHuman Factors Research ProjectHuman Factors Research Project
www.psy.utexas.edu/HumanFactors
The LOSA CollaborativeThe LOSA Collaborative
www.Losacollaborative.org
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Data for a Safety Culture How do airlines monitor safety?
• Accident investigation• Incident reports – ASRS, ASAP
• Data show events resulting from system and crew failures
• Line checks/Safety audits • Data slanted to crew proficiency and procedural knowledge
Continental Airlines, Feb 2007Continental Airlines, Feb 2007
Data for a Safety Culture How do airlines monitor safety?
• Accident investigation• Incident reports – ASRS, ASAP
• Data show events resulting from system and crew failures
• Line checks • Data slanted to crew proficiency and procedural knowledge
• Observing normal operations – Line Operations Safety Audit (LOSA) • Gives data on why things happen and how they are managed
• Provides a more realistic baseline of safety
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Purpose of LOSA
Data provide a baseline of safety pertaining to:
1. Flight crew performance – strengths and weaknessesa) Proficiency
b) Decision-Making
c) CRM skills
d) Procedural compliance
2. System performance – strengths and weaknessesa) Culture
b) National Airspace System – Airports and Navigational Aids
c) Aircraft design / automation
d) Standards / Training / Safety / Maintenance
e) Crew support – ATC, Cabin, Ground, and Dispatch
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ICAO Perspective on LOSA
- Costa Pereira, ICAO Secretary General in May 8, 2000
“[LOSA] acquires direct, first-hand data on the successful recovery from errors by flight crews during normal line flights. [It] is aimed at collecting data on successful human performance; and this is indeed a first in our industry, since aviation has traditionally collected data on failed human performance, such as an accident or incident investigation.” correspondence to Jane F. Garvey, FAA Administrator
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“Normal” Performance
Normal
FAA CheckAirmen LOSA 1 LOSA 2
• Distance between “Perfect” and “Normal performance varies as a function of culture, training, etc.
• LOSA enables us to get as closer to normal performance than was previously possible.
Perfect
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The Safety Bottom Line What do crews have to do to operate safely?
Error Avoidance1 Avoid committing errors
Manage operational complexity2 Threat Management
Manage their own errors3 Error Management
Undesired State Management
4 Manage deviations
Safety Bottom Line
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The Continental LOSA Process
1st year • LOSA and data analysis followed by course
development
2nd & 3rd years • Training course for all crewmembers, Check Airmen
training and imbedding of TEM into courseware, policy & procedures, etc.
4th year • Preparation for next LOSA and targeting areas to be
measured and new areas to be emphasized.
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Line Operations Safety Audit (LOSA)
LOSA –observations of crew performance during regular scheduled operations• Observers unobtrusive – collecting data not
participating• Team of observers from different backgrounds
• Line personnel / Union representatives• Safety and Training personnel• UT observers
• All data are De-identified and Confidential
Line Observation Safety AuditLine Observation Safety AuditLOSA 1996LOSA 1996
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LOSA
Crew Survey• Measure Safety Culture
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LOSA
Crew Survey• Measure Safety Culture
Crew Interview• Targeted questions
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NewsletterFeedback to the pilots is essential for continued
program success.
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LOSA
Crew Survey• Measure Safety Culture
Crew Interview• Targeted questions
Crew Flight Observations• Data on Threats, Errors & Behaviors
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Threat and Error ManagementThreat and Error Management
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Threat
Event that occurs outside the influence of the flight crew, but which requires crew attention and management if safety margins are to be maintained
Increases the complexity of the operation
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THREATSInfluences that can lead to crew error“Increase complexity of the operation”
Weather
MaintenanceError
Ground CrewError
Cabin CrewError
Passenger eventsATC
Terrain
Similar call sign
Time pressures
Heavy traffic
Unfamiliar airport
Automation event Missed approach
Flight diversion
System malfunction
Distractions
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Threat Management
Strategies/Countermeasures (Industry, Corporate and/or Personal)
• To reduce the number of errors
• To improve the error management process by increasing the awareness of potential errors
• Is managing your future
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Error
Actions or inactions by the flight crew that lead to deviations from intention or expectation
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Error Management
Actions taken to deal with errors committed by either
Detecting and correcting them, or by
Containing and reducing the severity
Is managing your past
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Consequences
Undesired Aircraft State (UAS)
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Threat and Error ManagementThreat and Error Management
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1996 LOSA ACTIONS
Develop training course based on data• Error Management
• Target Check Airmen first
Committees of Subject Matter Experts• Stable Approach • Checklist• Leadership
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Line Observation Safety AuditLOSA 2000
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LOSA 1996 vs. 2000
A 70% reduction in Checklist errors A 60% reduction in unstable
approaches• confirmed by FOQA/FDM data
Overall improvement in crew performance
Still a need for improvement in Leadership skills
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2000 LOSA ACTIONS
Develop training course based on data• Threat & Error Management
• Target Check Airmen• Imbedded throughout entire program
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B-737 Standards MeetingB-737 Standards MeetingFebruary 21February 21stst, 2001, 2001
The Role of the Check Airman inThe Role of the Check Airman inThreat & Error ManagementThreat & Error Management
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Check Airmen Debriefing Guide
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Line Check Safety Audits(LCSA)
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Crew Resource ManagementCrew Resource Management
Effective Crew Resource Management is the bedrock of Threat and Error
Management.
Line Observation Safety AuditLOSA 2004
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To have an effective SMS…
Data is needed to drive effective
Safety Change
&
Safety & Operational Efficiency
need to be combined into a
Corporate “Safety CultureSafety Culture”
Continental Airlines, Feb 2007Continental Airlines, Feb 2007
Threat and Error ManagementThreat and Error Management
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