1. Beyond the Cockpit: The Spread of LOSA and Threat and Error Management
Robert L. Helmreich, PhD, FRAeS
Human Factors Research Project
Department of Psychology
The University of Texas at Austin
4th ICAO-IATA
LOSA and TEM Conference
Toulouse, 16 November

2. The Line Operations Safety Audit
LOSA is application of the methodology of systematic observation to recording flight crew behavior and threats to safety in the operating environment
Historically, the methodology was applied to recording the behavior of Aquanauts living in undersea habitats placed on the ocean floor
Observations of flight crews (precursors to LOSA) began in 1979 with Texas International Airlines and later Pan American Airlines and Delta Airlines

3. Extensions of LOSA in Airlines
LOSA methodology has been applied (in collaboration with Continental Airlines) to
Dispatch operations (DOSA)
Ramp operations (ROSA)

4. TEM & CRM
Research in the LOSA Archive supports the links between TEM and CRM.
Crews that develop contingency management plans, such as proactively discussing strategies for anticipated threats, have fewer mismanaged threats
Crews that exhibit good monitoring and cross-checking make fewer errors
Crews that exhibit strong leadership, inquiry, and workload and automation management have fewer mismanaged errors and undesired aircraft states

5. International Conferences
LOSA Week
2001 Hong Kong
2001 Panama City, Panama
2002 United Arab Emirates, Dubai
2003 Dublin
2006 Toulouse
Threat and Error Management workshop:
2002 San Salvador

6. Published Guidelines
ICAO (2002). Line Operations Safety Audit (LOSA). DOC 9803-AN/761. Montreal: International Civil Aviation Organization (under revision)
FAA (2006) LOSA Advisory Circular Line Operations Safety Audits (Includes Threat and Error Management)

7. ASAP: Aviation Safety Action Program Michelle Harper, Doctoral Candidate

8. ASAP Characteristics
ASAP is an extension of NASA’s Aviation Safety Reporting System (ASRS)
Under ASAP, pilots report threats and errors (excluding intentional non-compliance and drug and alcohol violations) to their company and receive the same limited immunity from punishment provided by ASRS

9. ASAP Benefits
Unlike ASRS, information is immediately available to company management and allows corrective action to be taken
ASAP committee (union, management, regulator) reviews reports and determines corrective action
Actions are reported back to pilot
Don Gunther of Continental can clarify

10. The UT ASAP Data Collection System/ Distributed National ASAP Archive (DNAA)
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

11. System Overview
DNAA 1. 2.
DNAA server
UT developed software that supports the airlines in collecting ASAP data
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

12. Participating Airlines* ** ** **
8 airlines are currently participating in the DNAA
6 airlines are currently using the UT ASAP data collection tools
* Northwest airlines not participating in DNAA
AA, UPS and United not using UT ASAP data collection tools **

13. NOSS: Normal Operations Safety Survey Chris Henry, Doctoral Candidate

14. Normal Operations Safety Survey (NOSS)
NOSS is LOSA adapted to Air Traffic Control
TEM definitions congruent with LOSA
NOSS captures the work context and how controllers discharge their duties within that context
Threats are key elements of task environment
Aggregated Threat and Error Management data capture both system and individual performance
Over-the-shoulder observations
De-identified, non-jeopardy
Identify systemic strengths and vulnerabilities

15. NOSS & TEM: Additional Benefits
Airways NZ is analyzing normal operations and incident data using TEM
Service providers and airlines, using TEM as a common ‘language’ are exchanging more safety information on ATC interface
TEM training is being developed for controllers at service providers

16. Accident Investigation Bob Helmreich

17. TEM as Framework for Accident Investigation
IATA has adopted TEM as framework for classification of causal and contributing factors in global accident and incident database
Robert Sumwalt, new NTSB Vice Chairman
Trained in TEM
Served as LOSA observer

18. Current Investigations
Analysis of factors surrounding crash of LAPA B-737 in Buenos Aires requested by government of Argentina
Analysis of factors surrounding the crash of Flash Airlines B-737 at Sharm El Sheikh, Egypt requested by Boeing
Analysis of crew performance in crash of CRJ200 at Kirksville, MO requested by Bombardier

19. Extensions to Other Professions
Queensland Rail in Australia has adapted both TEM and LOSA to audit their operations
International Association of Fire Chiefs has used TEM in developing US national close call reporting system
RLH is member of committee developing guidelines

20. Conclusions
TEM can be used as the data structure for an organization’s Safety Management System
Allows integration of data from differing sources
Incident reports, incident and accident investigations, and LOSA and its derivatives

21. www.psy.utexas.edu/HumanFactors The University of Texas
Human Factors Research Project