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International Civil Aviation Organizationfficeffice" />

Approved by the Secretary General

and published under his authority

Line Operations

Safety Audit (LOSA)

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First Edition — 2002fficeffice" />

Doc 9803

AN/761

AMENDMENTS

The issue of amendments is announced regularly in the ICAO Journal and in the

monthly Supplement to the Catalogue of ICAO Publications and Audio-visual

Training Aids, which holders of this publication should consult. The space below

is provided to keep a record of such amendments.

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RECORD OF AMENDMENTS AND CORRIGENDAfficeffice" />

AMENDMENTS CORRIGENDA

No.

Date

applicable

Date

entered

Entered

by No.

Date

of issue

Date

entered

Entered

by

(ii)

(iii)

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TABLE OF CONTENTSfficeffice" />

Page Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (v)

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . (vi)

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (vii)

Chapter 1. Basic error management concepts . . 1-1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . 1-2

Reactive strategies . . . . . . . . . . . . . . . . . . 1-2

Combined reactive/proactive strategies . . 1-2

Proactive strategies . . . . . . . . . . . . . . . . . 1-4

ffice:smarttags" />1.3 A contemporary approach to operational

human performance and error . . . . . . . . . . . 1-5

1.4 The role of the organizational culture . . . . 1-7

1.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 1-7

Chapter 2. Implementing LOSA . . . . . . . . . . . . . 2-1

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2.1 History of LOSA . . . . . . . . . . . . . . . . . . . . . 2-1fficeffice" />

2.2 The Threat and Error Management Model. 2-1

Threats and errors defined. . . . . . . . . . . . 2-1

Definitions of crew error response . . . . . 2-4

Definitions of error outcomes . . . . . . . . . 2-4

Undesired Aircraft States . . . . . . . . . . . . 2-4

2.3 LOSA operating characteristics . . . . . . . . . 2-5

Observer assignment . . . . . . . . . . . . . . . . 2-7

Flight crew participation . . . . . . . . . . . . . 2-7

2.4 How to determine the scope of a LOSA . . 2-7

2.5 Once the data is collected . . . . . . . . . . . . . . 2-8

2.6 Writing the report . . . . . . . . . . . . . . . . . . . . 2-8

2.7 Success factors for LOSA. . . . . . . . . . . . . . 2-8

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Chapter 3. LOSA and the safety changefficeffice" />

process (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

ffice:smarttags" />3.2 A constantly changing scene. . . . . . . . . . . . 3-1

3.3 One operator’s example of an SCP . . . . . . 3-2

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Chapter 4. How to set up a LOSA —fficeffice" />

US Airways experience . . . . . . . . . . . . . . . . . . . . . . 4-1

4.1 Gathering information . . . . . . . . . . . . . . . . . 4-1

4.2 Interdepartmental support . . . . . . . . . . . . . . 4-1

4.3 LOSA steering committee. . . . . . . . . . . . . . 4-1

Safety department . . . . . . . . . . . . . . . . . . 4-1

Flight operations and training

departments . . . . . . . . . . . . . . . . . . . . . . . 4-2

Pilots union . . . . . . . . . . . . . . . . . . . . . . . 4-2

4.4 The key steps of a LOSA . . . . . . . . . . . . . . 4-2

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2

Action plan . . . . . . . . . . . . . . . . . . . . . . . 4-2

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4.5 The keys to an effective LOSA . . . . . . . . . 4-4fficeffice" />

Confidentiality and no-jeopardy . . . . . . . 4-4

The role of the observer . . . . . . . . . . . . . 4-5

4.6 Promoting LOSA for flight crews . . . . . . . 4-5

Appendix A — Examples of the various forms

utilized by LOSA . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Appendix B — Example of an introductory letter

by an airline to its flight crews. . . . . . . . . . . . . . . . B-1

Appendix C — List of recommended reading

and reference material . . . . . . . . . . . . . . . . . . . . . . . C-1

(v)

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FOREWORDfficeffice" />

The safety of civil aviation is the major objective of the

International Civil Aviation Organization (ICAO). Considerable

progress has been made in increasing safety, but

additional improvements are needed and can be achieved. It

has long been known that the majority of aviation accidents

and incidents result from less than optimum human performance,

indicating that any advance in this field can be

expected to have a significant impact on the improvement

of aviation safety.