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Undesired Aircraft Statesfficeffice" />

ffice:smarttags" />2.2.13 An “laceName w:st="on">UndesiredlaceName> laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>” occurs when the

flight crew places the aircraft in a situation of unnecessary

risk. For instance, an altitude deviation is an Undesired

laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType> that presents unnecessary risk. An Undesired

Aircraft State may occur in response to a crew action or

inaction (error). It is important to distinguish between errors

and the Undesired Aircraft State that can result. If an

Undesired Aircraft State is observed, there should always be

a crew error that is responsible for this undesired state. Such

errors may be miscommunications, lack of proficiency, poor

decision making or wilful violation of regulations.

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ffice:smarttags" />2.2.14 Undesired Aircraft States can also occur as afficeffice" />

result of equipment malfunction or external party errors, for

example, a malfunctioning altimeter or flight management

system (FMS), or an ATC command error. These are not

associated with crew error and would be classified as

external events.

Crew response to Undesired Aircraft States

2.2.15 LOSA considers three possible crew responses

to Undesired Aircraft States:

1. Mitigate: An active flight crew response to an

Undesired laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType> that results in the

alleviation of risk by returning from the Undesired

laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType> to safe flight;

2. Exacerbate: A flight crew response in which an

Undesired laceName w:st="on">AircraftlaceName> State is detected, but the flight

crew action or inaction allows it to induce an

additional error, incident or accident; and

3. Fail to respond: The lack of an active flight crew

response to an Undesired Aircraft State because it

was ignored or undetected.

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Definitions of outcomes of Undesired Aircraft Statesfficeffice" />

ffice:smarttags" />2.2.16 LOSA considers three possible outcomes to

Undesired Aircraft States:

1. Recovery: An outcome that indicates the alleviation

of risk that was previously caused by an Undesired

laceName w:st="on">AircraftlaceName> laceType w:st="on">StatelaceType>;

Chapter 2. Implementing LOSA 2-5

2. End State/Incident/Accident: Any undesired ending

that completes the activity sequence with a negative,

terminal outcome. These outcomes may be of little

consequence, for example, a long landing or a

landing too far to the left or right of the centre line,

or may result in a reportable incident or in an

accident; and

3. Additional error: The flight crew action or inaction

that results in or is closely linked to another cockpit

crew error.

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2.3 LOSA OPERATING CHARACTERISTICSfficeffice" />

ffice:smarttags" />2.3.1 LOSA is a proactive safety data collection

programme. The data generated provide a diagnostic

snapshot of organizational strengths and weaknesses, as well

as an overall assessment of flight crew performance in

normal flight operations. Therefore, the intent of LOSA is

to aid airlines in developing data-driven solutions to improve

overall systemic safety. The classic business principle of

measure, implement change and measure again is pertinent

here, with LOSA providing the metric of implementation

effectiveness. Experience has proven that expert external

oversight, especially on a first LOSA, is essential for

success.

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ffice:smarttags" />2.3.2 LOSA is defined by the following ten operatingfficeffice" />

characteristics that act to ensure the integrity of the LOSA

methodology and its data. Without these characteristics, it is

not a LOSA. These characteristics are:

1. Jump-seat observations during normal flight

operations: LOSA observations are limited to

regularly scheduled flights. Line checks, initial line

indoctrination or other training flights are off-limits

due to the extra level of stress put upon the pilots

during these types of situations. Having another

observer on board only adds to an already high stress

level, thus providing an unrealistic picture of performance.

In order for the data to be representative

of normal operations, LOSA observations must be

collected on regular and routine flights.

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2. Joint management / pilot sponsorship: In order forfficeffice" />

LOSA to succeed as a viable safety programme, it

is essential that both management and pilots

(through their professional association, if it exists)

support the project. The joint sponsorship provides

a “check and balance” for the project to ensure that

change, as necessary, will be made as a result of

LOSA data. When considering whether to conduct

a LOSA audit, the first question to be asked by

airline management is whether the pilots endorse the

project. If the answer is “No”, the project should not

be initiated until endorsement is obtained. This issue

is so critical in alleviating pilot suspicion that the

existing LOSA philosophy is to deny airline

assistance if a signed agreement is not in place

before commencing a LOSA. A LOSA steering

committee is formed with representatives from both

groups and is responsible for planning, scheduling,

observer support and, later, data verification (see

Point 8).

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3. Voluntary crew participation: Maintaining thefficeffice" />

integrity of LOSA within an airline and the industry

as a whole is extremely important for long-term

success. One way to accomplish this goal is to

collect all observations with voluntary crew

participation. Before conducting LOSA observations,

an observer must first obtain the flight

crew’s permission to be observed. The crew has the

option to decline, with no questions asked. The

observer simply approaches another flight crew on

another flight and asks for their permission to be

observed. If an airline conducts a LOSA and has an

unreasonably high number of refusals by crews to be

observed, then it should serve as an indicator to the

airline that there are critical “trust” issues to be dealt

with first.

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4. De-identified, confidential and safety-minded datafficeffice" />

collection: LOSA observers are asked not to record

names, flight numbers, dates or any other

information that can identify a crew. This allows for

a level of protection against disciplinary actions. The

purpose of LOSA is to collect safety data, not to

punish pilots. Airlines cannot allow themselves to

squander a unique opportunity to gain insight into

their operations by having pilots fearful that a LOSA

observation could be used against them for

disciplinary reasons. If a LOSA observation is ever

used for disciplinary reasons, the acceptance of

LOSA within the airline will most probably be lost

forever. Over 6 000 LOSA observations have been

conducted by The University of Texas at ffice:smarttags" />Austin

Human Factors Research Project and not one has

ever been used to discipline a pilot.

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5. Targeted observation instrument: The current datafficeffice" />

collection tool to conduct a LOSA is the LOSA

Observation Form. It is not critical that an airline use

this form, but whatever data collection instrument is

used needs to target issues that affect flight crew

performance in normal operations. An example of

2-6 Line Operations Safety Audit (LOSA)

the LOSA Observation Form is shown in

Appendix A. The form is based upon the UTTEM

Model and generates data for a variety of topics,

including the following:

• Flight and crew demographics such as city pairs,

aircraft type, flight time, years of experience

within the airline, years of experience within

position, and crew familiarity;

• Written narratives describing what the crew did

well, what they did poorly and how they

managed threats or errors for each phase of the

flight;

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• CRM performance ratings using researchdevelopedfficeffice" />

behavioural markers;

• Technical worksheet for the descent/approach/

land phases that highlights the type of approach

flown, landing runway and whether the crew met

airline stabilized approach parameters;

• Threat management worksheet that details each

threat and how it was handled;

• Error management worksheet that lists each

error observed, how each error was handled and

the final outcome; and

• Crew interview conducted during low workload

periods of the flight, such as cruise, that asks

pilots for their suggestions to improve safety,

training, and flight operations.