Title: Line Operations Safety Audit (LOSA): A Practical Overview
1Line Operations Safety Audit (LOSA) A Practical
Overview
Third ICAO-IATA LOSA TEM Conference Malaysia
Airlines, Kuala Lumpur - September 13-14, 2005
- James Klinect and Patrick Murray
- The University of Texas / The LOSA Collaborative
2Introduction James Klinect
- University of Texas (UT) LOSA research for the
industry - Project Coordinator TEM LOSA
- Director Bob Helmreich
- LOSA Collaborative LOSA implementation for
airlines - Role Founder/President
- De-identified data to University of Texas
- Disclaimer Not an commercial for the LOSA
Collaborative - Sharing of mistakes made and lessons learned
- Provide a enough information to evaluate LOSA and
possibly implement it themselves (ex, Varig, Lan
Chile,.)
3LOSA Airlines 1996-2005
Since 1996, 4500 observations, 25 airlines 11
countries
- AeroMexico
- Asiana Airlines
- Alaska Airlines
- Air New Zealand
- Braathens
- Cathay Pacific
- China Airlines
- COPA
Continental Airlines Continental
Express Continental Micronesia Delta Airlines EVA
Air Frontier Airlines LACSA QANTAS
Malaysia Airlines Mt. Cook Regional
Express Singapore Airlines Silk Air TACA / TACA
Peru UNI Air US Airways
4Presentation Outline
- LOSA Rationale / Deliverables
- Why LOSA and what do you get?
- LOSA Operating Characteristics
- What is the definition of LOSA and how does it
work? - LOSA E-mail Inbox
- What are the most frequently asked LOSA
questions? - Audience Question and Answer
5LOSA Rationale / Deliverables
6Aviation Safety Envelope
Accidents
Incidents
Normal Operations
7Safety Data Coverage
Accidents
Incidents
Normal Operations
8Aviation Safety Envelope
Accidents
Incidents
Normal Operations
LOSA Rationale Proactive snapshot of system /
crew performance strengths and weaknesses in
normal operations (just like a health checkup)
9LOSA Measurement Challenge
- Challenge - What type of observational measure
best captures safety performance data in normal
operations? - Concerns
- Observer overload Cant capture everything
- Data analyst overload Must have a roadmap for
interpretation - Manager overload Data need face value and point
to safety issues - Solution Threat and Error Management (TEM)
10Primary LOSA Measures TEM
- What do flight crews do to safely fly from A to B?
Wheres CRM and human factors? Non-technical
skills are one of many contributors to
effective/ineffective TEM performance
11LOSA Deliverables Diagnostic Findings
- Most frequent and mismanaged threats
- Most frequent and mismanaged errors
- Fleet and operational differences
- Comparison to other airlines on LOSA safety
indices
12Sample LOSA Analysis
13Raw Data Narratives
LOSA Flight 23 Error 1 A340 ARPT 401 to
ARPT 204 (Crew 8) Phase of Flight
Takeoff/Climb Pilot Flying CA Takeoff / Climb
Narrative Almost immediately after takeoff, the
Captain started a turn up the river, and did not
wait until 400 feet, per SOP. About 300 feet,
captain reached over to MCP (called FCU on
Airbus) and selected Flight Path Angle. He did
not tell FO of this selection, which is very
unusual of a setting. In fact, the FO later asked
me if I had ever seen anyone use this selection
and stated that he has never seen it in his 2
years of being on the Airbus. Because the Captain
did not tell the F/O what he was doing, when the
FO noticed this setting, he reselected the more
common mode (Heading). Captain then reached over
and then reselected Flight Path Angle. This led
to a brief discussion of whether of not the
aircraft would capture NAV in this setting. As a
result of all of this, the FO missed ATC handoff
to departure control, a call that was not made
until the aircraft leveled off at 5000 feet. Both
Captain and FO were involved in heads-down stuff
as the aircraft leveled off. If the autopilot
would not have leveled off, then the crew would
have not caught it, because they were doing
extraneous things. (FO, programming MCDU
Captain, looking at weather).
14Raw Data Threats
LOSA Flight 50 Threat 2 B737-700 AUS /
DFW Threat Description Threat runway switch. We
had expected and had briefed 17Left from the ATIS
broadcast. No reason for the switch given by
ATC. Threat Management Description Scramble to
brief new runway plus linked to error of not
finding the proper approach chart and automation
error of not setting up computer for the landing
runway. FO left the approach and arrival route
for 17Left in the FMC instead of the new runway.
Based on this the aircraft reached DIETZ and
started a turn to heading 350 which was still the
active route instead of the 300 heading
assigned. Phase of Flight Des/App/Land Threat
Type ATC Threat Code ATC runway change Threat
Outcome Linked to Flight Crew Error
15Summary - LOSA
- Primary features
- Purely diagnostic no solutions flight
operations health check - Captures system safety and pilot performance
strengths and weaknesses in normal operations
using observations - Analysis
- Aggregated TEM data provides a safety snapshot of
flight operations on a typical day - Organizational change
- Measure the effectiveness safety solutions with a
follow-up LOSA
16LOSA Case Study One
- Two LOSAs (3 years apart)
- 1st LOSA results An example of targets
identified - Undesired number of below standard leadership
ratings - Problems associated with checklist protocol /
usage - High number of unstable approaches
- Low rate of error trapping (errors detected and
managed)
17LOSA Case Study One
- Airline response to data
- Formed committees to address targets for
enhancement - Implemented a leadership training module in
recurrent - Revised checklist philosophy
- Established bottom lines for unstable approaches
- Implemented error management training course for
all pilots - Check airmen were trained in evaluating error
management
18LOSA Case Study One
- 2nd LOSA results
- Captain leadership scores significantly improved
- 40 reduction in checklist errors
- 77 reduction in unstable approaches below 1000
ft. - FOQA (QAR) showed similar trends
- Two fold increase in error trapping rates
- Change in the check culture to evaluate error
management - Increase management buy-in on the safety change
process
19LOSA Case Study Two
- 1st LOSA results - Targets identified
- Improve energy management issues during
descent/approach/land - 18 of flights with a speed deviation undesired
aircraft state - Lower the prevalence of unstable approaches
- 11 of flights with an unstable approach
- Lower prevalence of checklist errors
- 50 of flights with a checklist error
- Improve monitor/cross-checking performance
- 38 of errors went undetected (not responded to
by the flight crew) - Improve ATC threat management
- 22 of ATC threats were mismanaged - linked to
flight crew error
20LOSA Case Study Two
Proactive safety change . Over one year, approx
182,500 flights, 4 rate 7,300 unstable much
better than 11 rate 20,075 unstable
21Convergent Validity LOSA and ASAP
Well, James, very nice information. We see a
lot of the same things in our ASAP database
(voluntary incident reporting)
- Quote from an ASAP
Project manager
- Why would an airline do a LOSA when ASAP
(incident reporting) captures the same things? - ASAP collected when an event occurs
- LOSA collected independent of event
- By focusing on LOSA data implementing effective
solutions, airlines can should be able to lower
their potential for incidents / accidents
22LOSA Operating Characteristics
23Secret to LOSA Success
LOSA is not for all airlines - Its success
depends on pilot trust
Regulator
Check Airman
Nobody
Low pilot trust Low quality data because
there will be no differentiation between LOSA and
proficiency checks by regulators and check airmen
24LOSA How to Gain Pilot Trust
LOSA is defined by 10 operating characteristics
- Jumpseat observations during normal operations
- Anonymous, confidential, and non-punitive data
collection - Voluntary crew participation
- Trusted and trained observers
- Joint management / union sponsorship
- Systematic observation instrument
- Secure data collection repository
- Data verification roundtables
- Data-derived targets for enhancement
- Feedback of results to line pilots
25LOSA Operating Characteristics
- Jumpseat observations during normal operations
- Routine flights only
- No line checks or training flights
- Anonymous, confidential, and non-punitive data
collection - No names, flight numbers, or other identifying
information - Observer identity kept anonymous
- Data only used for safety purposes no
disciplinary action - Voluntary crew participation
- Flight crews have the right to decline a LOSA
observation - Typical denial rate is very low 1 per 100
flights
26LOSA Operating Characteristics
- Trusted and trained observers
- Trust
- Selection process management / union list of
candidates - Mostly regular pilots - Captains and First
Officers - Training
- Five days ground school (2), test observations
(2) recalibration (1) - Curriculum
- LOSA protocol
- How to write quality narratives
- TEM recognition, recording and coding
27LOSA Operating Characteristics
- Joint management / union sponsorship
- Steering committee Flight Ops, Training, Safety
and Union - Symbolized with a signed agreement and sent to
all pilots - Systematic observation instrument TEM based
- Observers only record the TEM events they see
no judgments - Secure data collection repository
- Third party or pilot association gate keeper
- Pilots must believe that observations will not be
misplaced
28LOSA Operating Characteristics
- Data verification roundtables
- TEM data checked for coding accuracy and
consistency with SOP - On completion, data analysis begins
- Data-derived targets for enhancement
- Serve as benchmarks for organizational change
- Measure, change, measure again approach
- Feedback of results to line pilots
- Results and information on how airline management
intends to respond with organizational change
29LOSA Defined
- To ensure standardization, LOSA must have all ten
operating characteristics - If less than ten, the project needs another
acronym - Endorsed by
- ICAO
- FAA (pending advisory circular)
- IATA
- UT
- TLC
- IFALPA
- US ALPA
30Frequently Asked Questions
31LOSA Cost?
- Depends on a number of factors indirect and
direct costs - Number of observations to be collected
- Number of external and internal observers
- Depth of data analysis
- Insurance discounts?
- External provider fee LOSA Collaborative and
others - Some examples of misleading efforts to lower
costs - Observations only no roundtables or data
analysis - Operating crew as their own observers / self
report - Video in the cockpit / analyzed by one retired
pilot in the airline - These projects MIGHT have value but they are not
LOSA
32Length and Size of LOSA?
- Project Length
- Average 8 months from planning to a final report
- Airline 75 of time spent on planning
- LOSA Collaborative
- 30 of time spent on planning, observer training,
data collection - 70 spent on data verification, analysis and
final report - Project Size Want to extrapolate to everyday
operations - Weighted sample to match daily departure rates
per fleet - Minimum number of observations per fleet 40
observations - Cap observers to no more than 15 observations to
prevent observer fatigue
33Continuous or Snapshot LOSA?
- Recommended Snapshot approach with a sample of
observations - Continuous LOSA more cost, questionable value
over snapshot LOSA - A snapshot approach is more manageable
- There is a start and end for data collection that
marks a point in time to derive targets and get
to the real work of making changes - Snapshots can complement other continuous safety
efforts such as QAR or incident reporting
34How Realistic is LOSA Data?
- Doesnt observers change the way flight crews
behave? - If they do, then LOSA results are
underestimates of what actually occurs in
normal operations - If pilots fake good in front an observer,
explain. - Average three errors per flight 25 are
mismanaged - Average 32 of flights have an undesired aircraft
state - Common to observe substandard CRM or procedural
violations - Pilots calling girlfriends during taxi-out
- Offering cigarettes to LOSA observers in the
cockpit
35What about observer bias?
- Major sources of observer bias
- Sensitivity Observers are more sensitive to
certain areas of flight operations (ex, human
factor experts that only see human factor
problems) - Proficiency - Lack of TEM knowledge to correctly
collect data - Fatigue Observer burnout less data collected
less precise - Some data quality controls
- Use many different observers (Captains, First
Officers, instructors, external) - Cap the number of observations per observer
- Focus observers on gathering just the facts
no judgment of causes - Test for TEM knowledge during training backed up
with data verification
36Biggest Threats to LOSA Success?
- LOSA mutations and people calling or thinking its
LOSA - Senior management not briefed and/or prepared for
the possibility of undesirable results - Results not communicated to pilots affects
pilot acceptance for the second LOSA - Unmotivated observers
- No safety change process in place to act on LOSA
findings
37More Information about LOSA?
- ICAO LOSA Handbook Document 9803
- ICAO Journal LOSA Special Edition (vol. 57,
no.4, 2002) - UT website (www.psy.utexas.edu/HumanFactors)
- FAA LOSA Advisory Circular (Draft) Pending 2006
- Klinect Ph.D. dissertation - Academic
demonstration of LOSA (available on request by
e-mail) - Research papers on TEM and LOSA
38Audience Question and Answer