DEA CRM TRAINING

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Line Operations Safety Audit (LOSA)
Captain Don Gunther Senior Director Safety
Regulatory Compliance
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Line Operations Safety Audit (LOSA)and Threat
Error Management (TEM) are integral parts of a
Safety Management System (SMS)
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Safety Culture

• Aviation 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.

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Corporate Culture
How well does your company accept safety inputs
when busy with the Operation?
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Human Error
Over 95 goes unreported!
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Data driven Safety Change through Non-Jeopardy
Reporting
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The Safety Change ProgramTailored to your
Airline

• To properly target change you need current
  operational data, specifically for your airline,
  which is unique due to its
• History Culture
• Areas of operation (ETOPS, polar routes, etc.)
• Philosophy

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• By not having data to discover the precursors
  specific to an individual airlines operations,
  this is the bottom-line

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Line Observation Safety Audit (LOSA)
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• University of Texas
• Human Factors
• Research Project
• Human Factors Research Project
• www.psy.utexas.edu/HumanFactors
• The LOSA Collaborative
• www.Losacollaborative.org

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Data for a Safety Culture

• How do airlines monitor safety?
• Accident investigation
• Incident reports ASRS, ASAP
• Data show events resulting from system and crew
  failures
• Line checks/Safety audits
• Data slanted to crew proficiency and procedural
  knowledge

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Data for a Safety Culture

• How do airlines monitor safety?
• Accident investigation
• Incident reports ASRS, ASAP
• Data show events resulting from system and crew
  failures
• Line checks
• Data slanted to crew proficiency and procedural
  knowledge
• Observing normal operations Line Operations
  Safety Audit (LOSA)
• Gives data on why things happen and how they are
  managed
• Provides a more realistic baseline of safety

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Purpose of LOSA

• Data provide a baseline of safety pertaining to
• Flight crew performance strengths and
  weaknesses
• Proficiency
• Decision-Making
• CRM skills
• Procedural compliance
• System performance strengths and weaknesses
• Culture
• National Airspace System Airports and
  Navigational Aids
• Aircraft design / automation
• Standards / Training / Safety / Maintenance
• Crew support ATC, Cabin, Ground, and Dispatch

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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

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Normal Performance
FAA
Check Airmen
LOSA 1
LOSA 2
Normal
Perfect

• Distance 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.

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The Safety Bottom Line

• What do crews have to do to operate safely?

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The Continental LOSA Process

• 1st year
• LOSA and data analysis followed by course
  development
• 2nd 3rd years
• Training course for all crewmembers, Check Airmen
  training and imbedding of TEM into courseware,
  policy procedures, etc.
• 4th year
• Preparation for next LOSA and targeting areas to
  be measured and new areas to be emphasized.

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Line Operations Safety Audit (LOSA)

• LOSA observations of crew performance during
  regular scheduled operations
• Observers unobtrusive collecting data not
  participating
• Team of observers from different backgrounds
• Line personnel / Union representatives
• Safety and Training personnel
• UT observers
• All data are De-identified and Confidential

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Line Observation Safety AuditLOSA 1996
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LOSA

• Crew Survey
• Measure Safety Culture

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LOSA

• Crew Survey
• Measure Safety Culture
• Crew Interview
• Targeted questions

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Newsletter

• Feedback to the pilots is essential for continued
  program success.

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LOSA

• Crew Survey
• Measure Safety Culture
• Crew Interview
• Targeted questions
• Crew Flight Observations
• Data on Threats, Errors Behaviors

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Threat and Error Management
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Threat

• Event that occurs outside the influence of the
  flight crew, but which requires crew attention
  and management if safety margins are to be
  maintained
• Increases the complexity of the operation

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THREATS
Influences that can lead to crew error Increase
complexity of the operation
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Threat Management

• Strategies/Countermeasures
• (Industry, Corporate and/or Personal)
• To reduce the number of errors
• To improve the error management process by
  increasing the awareness of potential errors
• Is managing your future

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Error

• Actions or inactions by the flight crew that lead
  to deviations from intention or expectation

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Error Management

• Actions taken to deal with errors committed by
  either
• Detecting and correcting them, or by
• Containing and reducing the severity
• Is managing your past

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Consequences

• Undesired Aircraft State (UAS)

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Threat and Error Management
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1996 LOSA ACTIONS

• Develop training course based on data
• Error Management
• Target Check Airmen first
• Committees of Subject Matter Experts
• Stable Approach
• Checklist
• Leadership

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Line Observation Safety AuditLOSA 2000
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LOSA 1996 vs. 2000

• A 70 reduction in Checklist errors
• A 60 reduction in unstable approaches
• confirmed by FOQA/FDM data
• Overall improvement in crew performance
• Still a need for improvement in Leadership skills

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2000 LOSA ACTIONS

• Develop training course based on data
• Threat Error Management
• Target Check Airmen
• Imbedded throughout entire program

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B-737 Standards MeetingFebruary 21st, 2001

Supervisor
The Role of the Check Airman in Threat Error
Management
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Check Airmen Debriefing Guide
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Line Check Safety Audits(LCSA)
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Crew Resource Management Effective Crew Resource
Management is the bedrock of Threat and
Error Management.
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Line Observation Safety AuditLOSA 2004
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To have an effective SMS
Data is needed to drive effective Safety Change
Safety Operational Efficiency need to be
combined into a Corporate Safety Culture
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Threat and Error Management