“Line Operations Safety Audit (LOSA)” Captain Don Gunther Senior Director Safety & Regulatory Compliance

Line Operations Safety Audit (LOSA) and Threat & Error Management (TEM) are integral parts of a Safety Management System (SMS)

Aviation Week Article on Healthy Organizations Safety Culture 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 protected, there is a real chance information can and will routinely flow upward in time for proper action to be taken.”

Corporate Culture How well does your company accept safety inputs when busy with the Operation?

Human Error Over 95% goes unreported!

Data driven Safety Change through Non-Jeopardy Reporting

The Safety Change Program “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

By not having data to discover the precursors “specific” to an individual airline’s operations, this is the bottom-line…

Line Observation Safety Audit (LOSA)

University of Texas Human Factors Research Project www.psy.utexas.edu/HumanFactors The LOSA Collaborative www.Losacollaborative.org

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

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

Purpose of LOSA Data provide a baseline of safety pertaining to: Flight crew performance – strengths and weaknesses Proficiency Decision-Making CRM skills Procedural compliance System performance – strengths and weaknesses Culture National Airspace System – Airports and Navigational Aids Aircraft design / automation Standards / Training / Safety / Maintenance Crew support – ATC, Cabin, Ground, and Dispatch

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

“Normal” Performance FAA LOSA 1 LOSA 2 Perfect Normal Check Airmen LOSA 1 LOSA 2 Perfect Normal 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.

The Safety Bottom Line What do crews have to do to operate safely? 1 Avoid committing errors Error Avoidance Manage operational complexity 2 Threat Management Manage their own errors 3 Error Management 4 Manage deviations Undesired State Management

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.

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 Audit LOSA 1996

LOSA Crew Survey Measure Safety Culture

LOSA Crew Survey Crew Interview Measure Safety Culture Targeted questions

Feedback to the pilots is essential for continued program success. Newsletter Feedback to the pilots is essential for continued program success.

LOSA Crew Survey Crew Interview Crew Flight Observations Measure Safety Culture Crew Interview Targeted questions Crew Flight Observations Data on Threats, Errors & Behaviors

Threat and Error Management THREATS Strategies Resist Resolve CONSEQUENCE ERRORS

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

THREATS Influences that can lead to crew error “Increase complexity of the operation” Weather Maintenance Error Ground Crew Cabin Crew Passenger events ATC Terrain Similar call sign Time pressures Heavy traffic Unfamiliar airport Automation event Missed approach Flight diversion System malfunction Distractions Slide will appear with the cockpit and title only. ONE MOUSE CLICK will start the animation and automatically show many of the LOSA observer threats. This is a good opportunity to compare the list that the class developed with those that were specifically looked for on the observations. This list is not exhaustive are there any others?

Strategies/Countermeasures 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

Error Actions or inactions by the flight crew that lead to deviations from intention or expectation

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

Undesired Aircraft State (UAS) Consequences Undesired Aircraft State (UAS)

Threat and Error Management THREATS Strategies Resist Resolve CONSEQUENCE ERRORS

1996 LOSA ACTIONS Develop training course based on data Error Management Target Check Airmen first Committees of Subject Matter Experts Stable Approach Checklist Leadership

Line Observation Safety Audit LOSA 2000 Introduce the topic of LOSA The 2000 LOSA took place between June-September 2000. 385 flight were observed and were proportioned according to fleet size. The observations covered all regions of CAL’s operation including is the Pacific data, which was completed in 1999. What the letters stands for.

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

2000 LOSA ACTIONS Develop training course based on data Threat & Error Management Target Check Airmen Imbedded throughout entire program

B-737 Standards Meeting February 21st, 2001 Supervisor The Role of the Check Airman in Threat & Error Management

Check Airmen Debriefing Guide

Line Check Safety Audits (LCSA)

Crew Resource Management Effective Crew Resource Management is the bedrock of Threat and Error Management.

Line Observation Safety Audit LOSA 2004 Introduce the topic of LOSA The 2000 LOSA took place between June-September 2000. 385 flight were observed and were proportioned according to fleet size. The observations covered all regions of CAL’s operation including is the Pacific data, which was completed in 1999. What the letters stands for.

To have an effective SMS… Data is needed to drive effective Safety Change & Safety & Operational Efficiency need to be combined into a Corporate “Safety Culture”

Threat and Error Management THREATS Strategies Resist Resolve CONSEQUENCE ERRORS