Flight Safety DIGEST FEBRUARY 2005 Line Operations Safety Audit (LOSA) Provides Data On Threats and Errors Flight Safety Digest Flight Safety Foundation For Everyone Concerned With the Safety of Flight Vol. 24 No. 2 February 2005 www.fl ightsafety.org OFFICERS AND STAFF Chairman, Board of Governors Amb. Edward W. Stimpson President and CEO Stuart Matthews In This Issue Executive Vice President Robert H. Vandel Treasurer David J. Barger General Counsel and Secretary Kenneth P. Quinn, Esq. Line Operations Safety Audit (LOSA) Provides Data on Threats and Errors ADMINISTRATIVE Structured observations of routine fl ight operations help reveal Manager, Support Services Linda Crowley Horger an airline’s strengths and weaknesses. The nonpunitive data- FINANCIAL 1 collection program — a planned cornerstone of internationally required safety management systems — is being adapted to Director of Finance other areas, including fl ight dispatch, apron operations and air and Administration Juan G. Gonzalez traffi c control. Accountant Millicent Wheeler MEMBERSHIP Clear Air Turbulence, Downdraft Cited STATS Director, Membership Most Often in U.S. Weather Turbulence and Development Ann Hill Accidents, 1992–2001 Membership Services Coordinator Ahlam Wahdan No fatalities occurred as a result of weather turbulence in air carrier operations during the study period. Eight fatalities PUBLICATIONS occurred in weather turbulence accidents in commuter and 19 Director of Publications Roger Rozelle on-demand operations. Senior Editor Mark Lacagnina Senior Editor Wayne Rosenkrans Simplifying Processes and Tools Senior Editor Linda Werfelman Aids Project Risk Management Associate Editor Rick Darby Web and Print A qualitative methodology, such as posing and answering Production Coordinator Karen K. Ehrlich LIBRARY key questions, is often the best framework for project risk Production Designer Ann L. Mullikin management; nevertheless, say the authors, quantitative Production Specialist Susan D. Reed 24 analysis has its place as well. Librarian, Jerry Lederer Aviation Safety Library Patricia Setze Overfl owing Sink Blamed for 28 TECHNICAL Short Circuit, Fumes in B-717 Director of Technical Programs James M. Burin The accident report said that an electrical odor in the cabin Technical Programs Specialist Joanne Anderson during a domestic fl ight in Australia led to an unscheduled BRIEFS Managing Director of landing. Internal Evaluation Programs Louis A. Sorrentino III Q-Star Program Administrator Robert Feeler Manager, Data Systems and Analysis Robert Dodd, Ph.D. Manager of Aviation Safety Audits Darol V. Holsman Founder Jerome Lederer 1902–2004 Flight Safety Foundation is an international membership organization dedicated to the continuous improvement of aviation safety. Nonprofi t and independent, the Foundation was launched offi cially in 1947 in response to the aviation industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowl- edgeable body that would identify threats to safety, analyze the problems and recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive infl uence on aviation safety. Today, the Foundation provides leadership to more than 900 member organizations in more than 150 countries. Cover photo: © Copyright 2005 Getty images Inc. © Copyright Niels Laan Line Operations Safety Audit (LOSA) Provides Data on Threats and Errors Structured observations of routine flight operations help reveal an airline’s strengths and weaknesses. The nonpunitive data-collection program — a planned cornerstone of internationally required safety management systems — is being adapted to other areas, including flight dispatch, apron operations and air traffic control. —FSF EDITORIAL STAFF he line operations safety audit (LOSA) strengths and weaknesses. LOSA also enables air- — which involves the collection of data lines to compare data among de-identifi ed data by trained observers during routine gathered by other airlines. Tfl ights to determine how fl ight crews detect, manage and mismanage threats and errors “Document 9803 is the bible of LOSA,” said Capt. — has been endorsed by the International Civil Don Gunther, director of human factors and safety Aviation Organization (ICAO) as a tool for moni- for Continental Airlines.2 “The beauty of following toring normal fl ight operations and developing the guidelines in ‘9803’ is that you can compare countermeasures against human error.1 your data with all other airlines that have done LOSAs. You don’t know who the other airlines ICAO in 2002 published Document 9803, Line are, but the de-identifi ed data indicate how you Operations Safety Audit (LOSA), which contains compare to the industry. detailed information on planning and conduct- ing a LOSA. The manual provides guidelines for “If you have an issue, and no one else does, you airlines on using LOSA data to gauge operational can fi nd out what you’re doing wrong. If you have FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 1 LOSA PROVIDES DATA an issue, and everybody else does, psychology at the University of Texas and leader too, you know it’s an industry is- of the UTHF, said that the fi rst fl ight observations sue; and collectively, we might be were conducted in 1994 at the request of Delta able to fi nd a solution.” Air Lines.4 LOSA complements other safety- “This study involved the observation of 480 line data-collection systems such as flights,” Helmreich said. “Delta Air Lines had fl ight-data monitoring (e.g., fl ight developed and implemented an intensive multi- operational quality assurance day CRM training course, which it believed had [FOQA] programs) and voluntary improved crew coordination and enhanced reporting (e.g., aviation safety ac- safety. However, senior airline management felt tion programs [ASAP]). it important to confi rm whether the behaviors being taught were, in fact, practiced during line Capt. Daniel E. Maurino, coordi- operations.” nator of the ICAO Flight Safety and Human Factors Program, Similar fl ight observations were conducted by said that the organization currently is drafting Air New Zealand, American Airlines, Continental standards for safety-management systems that Airlines, Trans World Airlines and US Airways. The will include LOSA, FOQA and ASAP as essential observations showed that the practice of CRM on components.3 the fl ight deck was substantially different than in airline training environments and resulted in the “LOSA has raised the level of safety analysis and development of advanced CRM concepts and provides airlines with earlier warnings of potential “new ways of thinking about crew performance,” problems,” he said. “With FOQA, for example, we ICAO said. know that we have a problem with unstabilized approaches, but we need to experience the unsta- Helmreich said that the early fl ight observations bilized approaches to trigger the data capture. It’s did not provide adequate information about how the same thing with ASAP.” fl ight crews adhere to standard operating proce- dures (SOPs) or about environmental infl uences LOSA conferences are conducted annually by on crew performance. UTHF and Continental ICAO. The fi rst conference was in Hong Kong, Airlines in the late 1990s expanded the concept China, in 2000. Subsequent conferences were con- and methodology to include the recording of ducted in Panama City, Panama; Dubai, United threats (e.g., adverse weather conditions) and er- Arab Emirates; Dublin, Ireland; and Seattle, rors (e.g., human mistakes) and how fl ight crews Washington, U.S. The next conference will be deal with them. conducted Sept. 27–28, 2005, in Kuala Lumpur, Malaysia. “This change greatly enhanced the usefulness of LOSA for airlines, expanding it from a CRM audit to one which places CRM skills into perspective Program Initiated to as operational threat-and-error countermeasures,” Check CRM he said. ith funding from the U.S. Federal Aviation WAdministration (FAA), the University of TEM Model Provides Focus Texas at Austin (Texas, U.S.) Human Factors Research Project (UTHF) in the early 1990s he concept and methodology of LOSA placed trained observers in aircraft jump seats Tcurrently are based on the threat-and- to help airlines gauge the effectiveness of crew error management (TEM) model developed by resource management (CRM) during routine UTHF (Figure 1, page 3). ICAO calls TEM the airline fl ights. “fi fth generation of CRM,” which, in the context of LOSA, is based on the premise that “human The fl ight observations were the precursors of error is ubiquitous, inevitable and a valuable LOSA. Robert L. Helmreich, Ph.D., a professor of source of information.”5 2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 LOSA PROVIDES DATA Figure 1 Threat-and-error Management Model Threats Threat-induced Inconsequential Threat Management Incident or Accident Crew Error Crew Error Responses Undesired Aircraft State Crew Undesired Aircraft Error-induced State Responses Incident or Accident Source: Adapted from James R. Klinect, University of Texas at Austin (Texas, U.S.) Human Factors Research Project “Essentially, the model posits that threats and er- Threats are defi ned as expected or unexpected rors are integral parts of daily fl ight operations external situations that must be managed by the and must be managed,” ICAO said.6 “Therefore, fl ight crew. observing the management or mismanagement of threats and errors can build the desired systemic “[Threats] increase the operational