Monitoring Normal Operations and the Line Operations Safety Audit (LOSA): The Perspective of ICAO

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Monitoring Normal Operationsand the Line
Operations Safety Audit (LOSA) The Perspective
of ICAO

• Captain Dan Maurino
• Flight Safety and Human Factors ICAO
• Royal Aeronautical Society Conference on
• Mitigating Human Error
• London, 15 October 2003

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When the Book Goes Out of the Window
Baseline performance
Practical Drift
Baseline performance
System design
Operational performance
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Raiding the Lost Ark
Regulator
Line Checks
Nobody
Natural Performance
Angel Performance
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A Day at the Office

• To achieve daily safety and production goals,
  flight crews must

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LOSA Index Threats

• Not flight crew errors
• Not deficiencies in the system
• Factors external to the flight deck that increase
  complexity of flight operations
• Must be managed by the flight crew
• Threats Red flags

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Threats Are the Context
Distractions
Passenger events
ATC
Cabin Crew
Terrain
Weather
Similar call signs
Maintenance
Time pressures
Ground Crew
Flight diversions
Heavy traffic
System malfunctions
Unfamiliar airports
Automation events
Missed approaches
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LOSA Index Expert Errors
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LOSA Provides Data Only
LOSA Raw Data
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Targets for Improvement

• Stabilized Approaches
• Checklists
• Procedural errors
• Automation errors
• ATC communications
• Intentional non-compliance

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SCP Data Develops Into Information
Re-measure
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Reduced 49
Reduced 59
Reduced 59
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LOSA 1996 vs. 2000 Checklist Errors
Flights with protocol
Flight with unintentional
checklist errors
checklist errors
LOSA 1996
33 of the flights
9 of the flights
389 flights
LOSA 2000
11 of the flights
9 of the flights
385 flights
Missed items
Performed from memory
Wrong response to a challenge
Nonstandard phraseology
Checklist
Error
Wrong checklist performed
Self initiated
Examples
Unintentional checklist omission
Not called complete
Intentional checklist omission
LOSA 2000 indicated a significant drop in
protocol checklist errors while unintentional
checklist errors have remained unchanged
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Threat Error Management Model (Doc 9803)
Threats

  Inconsequential
Threat Induced Incident or Accident
Threat Management
Crew Error
Crew Error Responses
Undesired Aircraft State
Error Induced Incident or Accident
Crew Undesired Aircraft State Responses
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The Expanding Role of the TEM Model

• TEM Model as
• Licensing tool (ICAO)
• Training tool (Numerous airlines)
• Safety management tool (IATA)
• Research tool (Boeing)

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TEM - Licensing Tool (ICAO FCLT/P)
Performance criteria
SKAs
Competencies
Threat Management
CRM skills TEM principles
Error Management
Undesired Aircraft State Management
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Managing the Red Flags
System resources

• SOPs
• Checklists
• Briefings
• Training

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Managing the Red Flags (cont.)
The human contribution
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Real World Human Performance
Effective warning
Checklist works

• Flaps
• omitted

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Descent, Approach Landing
Highest risk phase of flight
?
Configuration
FAF

• Most errors (LOSA)
• Most consequential errors (LOSA)
• Most accidents worldwide (ALAR)

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Briefing the Approach

• Crews who brief before TOD commit 1.6 times less
  errors during descent, approach and land than
  crews who brief after TOD
• Landing runway changes occurred 8 percent of the
  time
• Training point brief approach prior TOD

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TEM Model - Training Tool

• CRM, circa 2003
• Beyond behavioural stereotypes
• Operational performance
• Develop and support threat and error management
  competencies

• The bottom line is safe and efficient
• operational performance, not CRM

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SMS Data Triangle
FDA
Voluntary Reporting
Normal Operations
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A Casque Bleu Perspective
LOSA, CRM and NOTECHS

• LOSA a tool to capture systemic data
• NOTECHS a CRM evaluation template
• LOSA context and cognition
• NOTECHS/CRM behaviours
• CRM just one piece of the infinitely broader
  information picture developed from LOSA

• A situation, generated by misperceptions and
  misinformation, that must be put behind