2 Line Operations Safety Audit (LOSA) and Threat & Error Management (TEM) are integral parts of a Safety Management System (SMS)
3 Aviation Week Article on Healthy Organizations Safety CultureAviation 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.”
4 Corporate CultureHow well does your company accept safety inputs when busy with the Operation?
6 Data driven Safety Change through Non-Jeopardy Reporting
7 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 & CultureAreas of operation (ETOPS, polar routes, etc.)Philosophy
8 By not having data to discover the precursors “specific” to an individual airline’s operations, this is the bottom-line…
10 University of Texas Human Factors Research Project The LOSA Collaborative
11 Data for a Safety Culture How do airlines monitor safety?Accident investigationIncident reports – ASRS, ASAPData show events resulting from system and crew failuresLine checks/Safety auditsData slanted to crew proficiency and procedural knowledge
12 Data for a Safety Culture How do airlines monitor safety?Accident investigationIncident reports – ASRS, ASAPData show events resulting from system and crew failuresLine checksData slanted to crew proficiency and procedural knowledgeObserving normal operations – Line Operations Safety Audit (LOSA)Gives data on why things happen and how they are managedProvides a more realistic baseline of safety
13 Purpose of LOSA Data provide a baseline of safety pertaining to: Flight crew performance – strengths and weaknessesProficiencyDecision-MakingCRM skillsProcedural complianceSystem performance – strengths and weaknessesCultureNational Airspace System – Airports and Navigational AidsAircraft design / automationStandards / Training / Safety / MaintenanceCrew support – ATC, Cabin, Ground, and Dispatch
14 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
15 “Normal” Performance FAA LOSA 1 LOSA 2 Perfect Normal CheckAirmenLOSA 1LOSA 2PerfectNormalDistance 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.
16 The Safety Bottom Line What do crews have to do to operate safely? 1Avoid committing errorsError AvoidanceManage operational complexity2Threat ManagementManage their own errors3Error Management4Manage deviationsUndesired State Management
17 The Continental LOSA Process 1st yearLOSA and data analysis followed by course development2nd & 3rd yearsTraining course for all crewmembers, Check Airmen training and imbedding of TEM into courseware, policy & procedures, etc.4th yearPreparation for next LOSA and targeting areas to be measured and new areas to be emphasized.
18 Line Operations Safety Audit (LOSA) LOSA –observations of crew performance during regular scheduled operationsObservers unobtrusive – collecting data not participatingTeam of observers from different backgroundsLine personnel / Union representativesSafety and Training personnelUT observersAll data are De-identified and Confidential
24 Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS
25 ThreatEvent that occurs outside the influence of the flight crew, but which requires crew attention and management if safety margins are to be maintainedIncreases the complexity of the operation
26 THREATS Influences that can lead to crew error “Increase complexity of the operation”WeatherMaintenanceErrorGround CrewCabin CrewPassenger eventsATCTerrainSimilar call signTime pressuresHeavy trafficUnfamiliar airportAutomation eventMissed approachFlight diversionSystem malfunctionDistractionsSlide 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?
27 Strategies/Countermeasures Threat ManagementStrategies/Countermeasures(Industry, Corporate and/or Personal)To reduce the number of errorsTo improve the error management process by increasing the awareness of potential errorsIs managing your future
28 ErrorActions or inactions by the flight crew that lead to deviations from intention or expectation
29 Error Management Actions taken to deal with errors committed by either Detecting and correcting them, or byContaining and reducing the severityIs managing your past
30 Undesired Aircraft State (UAS) ConsequencesUndesired Aircraft State (UAS)
31 Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS
32 1996 LOSA ACTIONS Develop training course based on data Error ManagementTarget Check Airmen firstCommittees of Subject Matter ExpertsStable ApproachChecklistLeadership
33 Line Observation Safety Audit LOSA 2000 Introduce the topic of LOSAThe 2000 LOSA took place between June-September 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.
34 LOSA 1996 vs. 2000 A 70% reduction in Checklist errors A 60% reduction in unstable approachesconfirmed by FOQA/FDM dataOverall improvement in crew performanceStill a need for improvement in Leadership skills
35 2000 LOSA ACTIONS Develop training course based on data Threat & Error ManagementTarget Check AirmenImbedded throughout entire program
36 B-737 Standards Meeting February 21st, 2001 SupervisorThe Role of the Check Airman inThreat & Error Management
39 Crew Resource Management Effective Crew Resource Management is the bedrock of Threat and ErrorManagement.
40 Line Observation Safety Audit LOSA 2004 Introduce the topic of LOSAThe 2000 LOSA took place between June-September 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.
41 To have an effective SMS… Data is needed to drive effectiveSafety Change&Safety & Operational Efficiencyneed to be combined into aCorporate “Safety Culture”
42 Threat and Error Management THREATSStrategiesResistResolveCONSEQUENCEERRORS