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• 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.
6. Trusted, trained and calibrated observers: Primarily,
pilots conduct LOSAs. Observation teams will
typically include line pilots, instructor pilots, safety
pilots, management pilots, members of Human
Factors groups and representatives of the safety
committee of the pilots organization. Another part of
the team can include external observers who are not
affiliated with the airline. If they have no affiliation
with the airline, external observers are objective and
can serve as an anchor point for the rest of the
observers. Trained, expert external observers add
tremendous value, especially if they have participated
in LOSA projects at other airlines. It is
critical to select observers that are respected and
trusted within the airline to ensure the line’s acceptance
of LOSA. Selecting good observers is the
lifeline of LOSA. If you have unmotivated or
untrustworthy observers, LOSA will fail. The size of
the observation team depends on the airline’s size,
the number of flights to be observed and the length
of time needed to conduct the observations. After
observers are selected, everyone is trained and
calibrated in the LOSA methodology, including the
use of the LOSA rating forms and, particularly, the
concepts of threat and error management. Training
of observers in the concepts and methodology of
LOSA will ensure that observations will be conducted
in the most standardized manner. After
completing training, observers spend a period of
time (between one and two months) observing
regularly scheduled line flights. The objective is to
observe the largest number of crews and segments
possible in the time frame, given the flight
schedules, logistics and types of operation sampled.
7. Trusted data collection site: In order to maintain
confidentiality, airlines must have a trusted data
collection site. At the present time, all observations
are sent off-site directly to The University of Texas
at Austin Human Factors Research Project, which
manages the LOSA archives. This ensures that no
individual observations will be misplaced or
improperly disseminated through the airline.
8. Data verification roundtables: Data-driven programmes
like LOSA require quality data management
procedures and consistency checks. For
LOSA, these checks are done at data verification
roundtables. A roundtable consists of three or four
department and pilots association representatives
who scan the raw data for inaccuracies. For example,
an observer might log a procedural error for failure
to make an approach callout for which there are
actually no written procedures in the airline’s flight
operations manual. Therefore, it would be the job of
the roundtable to detect and delete this particular
“error” from the database. The end product is a
database that is validated for consistency and
accuracy according to the airline’s standards and
manuals, before any statistical analysis is performed.
9. Data-derived targets for enhancement: The final
product of a LOSA is the data-derived LOSA
targets for enhancement. As the data are collected
and analysed, patterns emerge. Certain errors occur
more frequently than others, certain airports or
events emerge as more problematic than others,
certain SOPs are routinely ignored or modified and
certain manoeuvres pose greater difficulty in adherence
than others. These patterns are identified for
the airline as LOSA targets for enhancement. It is
then up to the airline to develop an action plan based
on these targets, using experts from within the airline
Chapter 2. Implementing LOSA 2-7
to analyse the targets and implement appropriate
change strategies. After two or three years, the
airline can conduct another LOSA to see if their
implementations to the targets show performance
improvements.
10. Feedback of results to the line pilots: After a LOSA
is completed, the airline’s management team and
pilots association have an obligation to communicate
LOSA results to the line pilots. Pilots will want to
see not only the results but also management’s plan
for improvement. If results are fed back in an appropriate
　
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