Line Oriented Safety Audit LOSA

Line Operations Safety Audit (LOSA)
Robert L. Helmreich, PhD, FRAeS James Klinect, PhD Cand.

North American Aviation Safety Conference Atlanta, February 2003 Human Factors Research Project The University of Texas at Austin
Data to Identify Safety Issues
Accident investigation
Limited, non-representative sample Data slanted to events resulting from system and flight crew failures UT HF developing data category system with AA & CO
Incident reports (ASRS and ASAP)

Formal checkrides (Line and Proficiency)
Data show crew capability and procedural knowledge

Data show what happened in terms of flight parameters
Flight Data Recorders FOQA
Non-jeopardy observation of normal flights
Give data on why things happen and how they are managed Provides realistic baseline of safety data Is proactive
LOSA
Jump seat observations of flight crew performance during regular scheduled flights
Observers unobtrusive collecting data not participating in flight
Team of observers from different backgrounds

Line pilots / Union representatives Check airmen Safety and Training pilots UT observers
All data are DE-IDENTIFIED and CONFIDENTIAL
Scientific Background

LOSA uses systematic observation of behavior Systematic observation is a validated methodology using observers trained and calibrated to high reliability Systematic observation has been employed in scientific studies of crew performance in demanding environments
For example, Aquanauts in undersea habitats during Project SEALAB and Project Tektite
Purpose of LOSA
Collect valid empirical data on: 1. Crew performance strengths and

weaknesses

Proficiency Decision-Making CRM skills Procedural compliance Threat and error management
2.
weaknesses
System performance strengths and

Culture Airspace System airports and navigational Aids Aircraft design / automation Standards / Training / Safety / Maintenance Crew support ATC, Cabin, Ground, and Dispatch
History of LOSA
Formal LOSA developed at request of Delta Airlines to validate operational impact of Human Factors (CRM) training The focus of initial LOSA was systematic assessment of CRM-related crew behaviors In 1997, collaborating with Continental Airlines, LOSA was expanded to record threats and errors and their management during flight operations
CRM LOSA 1992 - 1996
Delta domestic Delta international TWA American Continental USAirways
Threat and Error Management LOSA (1997-2002)
Continental Latin America Continental Express Gulfstream Express Air New Zealand Air Micronesia Continental Delta
USAirways Cathay Pacific EVA Air Uni Air (Taiwan) Frontier QANTAS Braathens Singapore (forthcoming)
1900+ flight segments. All foreign carriers are U.S. codeshares
LOSA Components

Part Part Part Part
1. 2. 3. 4.
Flight crew survey Flight crew interview Descent and approach CRM Countermeasures
Behavioral markers
Part 5. Threat and error mgt
LOSA Data: Flight Crew

For each flight segment, observers collect data on:
General Flight Crew Information

Flight Crew Performance

Demographics
Attitudes / perceptions / safety culture (FMAQ) Safety interview comments Observer narrative Overt threats
Behavioral markers Crew errors and violations Undesired aircraft states
Flight Description

Technical data for approaches
Type and stability
Operational complexity
Threat management Error management Undesired state management
Threat
Threat Management
Threats - Originate outside the flight crews influence but require active management to prevent them from becoming consequential to safety
Adverse weather Terrain Traffic Airport conditions A/C malfunctions Automation events Communication events
Operational time pressures Non-normal operations ATC command events / errors Cabin events / errors MX events / errors Dispatch events / errors Ground crew events / errors
Representative Threat Findings
90% of flight segments had one or more threats Organizational range 84% to 97% Most frequent threats
Adverse
weather 19% ATC clearances/late changes 16%
Error
Error Avoidance
Complete error avoidance is impossible errors are inevitable 63% of flights observed had one or more errors
Must look for sources of error to strengthen system defenses
Human Limitations Lead to Error

Limited memory capacity Limited processing capacity
multi-tasking capability tunnel vision
Limits imposed by stressors
Limits imposed by fatigue and other physiological factors Poor group dynamics Cultural influences
Flight Crew Error Types

Intentional Noncompliance violations
ex) Performing a checklist from memory
Procedural Followed procedures but wrong

execution
ex) Wrong altitude setting dialed into the MCP
Communication Missing information or

misinterpretation within cockpit
ex) Miscommunication by crew with ATC
Decision Discretionary decision that unnecessarily

increases risk
ex) Unnecessary navigation through adverse weather
Decision Error
Choice increasing risk in a situation with
multiple courses of action possible time available to evaluate alternatives no discussion of consequences of alternate courses of action no formal procedures to follow
Error Response

45% Undetected 29% Detected and action taken 5% Detected and ignored
Error Outcomes
Inconsequential 71% Consequential 29%
Additional
Errors 8% (Error Chains) Undesired Aircraft States 21%
Undesired Aircraft State

A compromised situation placing the flight at increased risk
Lateral deviation
Vertical deviation Speed too high Speed too low Incorrect aircraft configuration Flight controls Systems Fuel Automation
Unstable approach
Abrupt aircraft control Long landing no go around
Firm landing Forced landing Runway incursion Wrong taxiway, ramp, runway, country
Phase of Flight Effects

Phase of Flight
Pre-Departure / Taxi
Takeoff / Climb Cruise Descent / Approach / Land Taxi / Park
Threats by Phase
Errors by Phase
42%
14% 8%
26%
23% 4%
32%
4%
42%
5%
Descent / approach / land phase contains the most variability in crew performance and consequential errors
Organizational Differences
Airline A Mean Threats Mean Errors Mean Und. State 2.25 0.93 0.19 Airline B 4.64 1.97 0.42 Airline C 3.27 4.32 0.95
Threat and Error

Relationship between number of threats and errors is relatively weak, although statistically significant (r=.19)
A model of Threat and Error Management derived from LOSA data

The model is being used as framework for the analysis of ASAP reports, incidents, and accidents
Threat and Error Management Model

Threats: Latent and Overt
Threat M anagement
Errors
Inconsequential
Error M anagement
Incident / Accident
Undesired Aircraft State
Undesired Aircraft State M anagement
LOSA and CRM
Interpreting LOSA Data for CRM

Procedural errors - may indicate poor workload management and/or poor procedures Communications errors - may reflect inadequate CRM (monitoring and challenging) or complacency Proficiency errors - suggest pressures to train and/or need for higher standards and better monitoring by check airmen Decision errors - may indicate need for more CRM training on expert decision making and risk assessment Violations - suggest poor procedures, weak captain leadership and/or a culture of non-compliance
Support for LOSA

[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. - Costa Pereira, ICAO Secretary General in May 8, 2000 correspondence
to Jane F. Garvey, FAA Administrator
It is recommended that, IATA and Operators together further promote the use of Flight Operations Quality Assurance, the Line Operations Safety Audit (LOSA)
-IATA Safety Report (Jet) 2000 Executive Summary, p. vi
Endorsed as safety priority by ALPA and IFALPA
Recognition and Extension of LOSA

Flight Safety Foundation/Aviation Week and Space Technology Laurels, 2001 The UT Threat and Error Management Model adopted as framework for analysis of accidents by IATA Dispatch LOSA (with Continental) underway
The University of Texas Human Factors Research Project www.psy.utexas.edu/HumanFactors

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What data collection methods are discussed for identifying safety issues?

What data collection methods are discussed for identifying safety issues?

What is LOSA and what does it observe?

What is LOSA and what does it observe?

Line Operations Safety Audit (LOSA)

Robert L. Helmreich, PhD, FRAeS James Klinect, PhD Cand.

Data to Identify Safety Issues

Incident reports (ASRS and ASAP)

Formal checkrides (Line and Proficiency)

Data show crew capability and procedural knowledge

Flight Data Recorders FOQA

Non-jeopardy observation of normal flights

Observers unobtrusive collecting data not participating in flight

Team of observers from different backgrounds

All data are DE-IDENTIFIED and CONFIDENTIAL

Collect valid empirical data on: 1. Crew performance strengths and

System performance strengths and

CRM LOSA 1992 - 1996

Delta domestic Delta international TWA American Continental USAirways

Threat and Error Management LOSA (1997-2002)

1900+ flight segments. All foreign carriers are U.S. codeshares

Part Part Part Part

Part 5. Threat and error mgt

LOSA Data: Flight Crew

Flight Crew Performance

Behavioral markers Crew errors and violations Undesired aircraft states

Technical data for approaches

Type and stability

Threat management Error management Undesired state management

Representative Threat Findings

weather 19% ATC clearances/late changes 16%

Must look for sources of error to strengthen system defenses

Human Limitations Lead to Error

Limited memory capacity Limited processing capacity

multi-tasking capability tunnel vision

Limits imposed by stressors

Flight Crew Error Types

Procedural Followed procedures but wrong

Communication Missing information or

Decision Discretionary decision that unnecessarily

Errors 8% (Error Chains) Undesired Aircraft States 21%

Undesired Aircraft State

Phase of Flight Effects

Threat and Error

A model of Threat and Error Management derived from LOSA data

Threat and Error Management Model

Undesired Aircraft State

Undesired Aircraft State M anagement

LOSA and CRM

Interpreting LOSA Data for CRM

Support for LOSA

Endorsed as safety priority by ALPA and IFALPA

Recognition and Extension of LOSA

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

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