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communications to discuss the purpose and
logistics of a LOSA audit with management, pilots
and any pilots associations. Experience shows that
airlines often underestimate the amount of communication
required so they must be persistent in
their efforts;
• Stressing that observations cannot be used for
discipline purposes: This is the key issue and must
be stated as such in the letter of endorsement;
• Informing the regulatory authority of the proposed
activity: It is as much a courtesy as it is a way of
communicating the presence of LOSA;
• Choosing a credible observer team: A line crew
always has the prerogative to deny cockpit access to
an observer; hence the observer team is most
effective when composed of credible and wellaccepted
pilots from a mix of fleets and departments
(for example, training and safety). This was achieved
at one airline by asking for a list of potential
observers from the management and the pilots
association; those pilots whose names appeared on
both lists were then selected as acceptable to
everyone;
• Using “a fly on the wall” approach: The best
observers learn to be unobtrusive and nonthreatening;
they use a pocket notebook while in the
cockpit, recording minimal detail to elaborate upon
later. At the same time, they know when it is
appropriate to speak up if they have a concern,
without sounding authoritarian;
• Communicating the results: Do not wait too long
before announcing the results to the line or else
pilots will believe nothing is being done. A summary
of the audit, excerpts from the report and relevant
statistics will all be of interest to the line; and
• Using the data: The LOSA audit generates targets
for enhancement, but it is the airline that creates an
action plan. One airline did this by creating a
committee for each of the central concerns, and they
were then responsible for reviewing procedures,
checklists, etc., and implementing change, where
appropriate.
3-1
Chapter 3
LOSA AND THE SAFETY CHANGE PROCESS (SCP)
3.1 INTRODUCTION
3.1.1 When an airline commits to LOSA, it must also
commit to acting upon the results of the audit. LOSA is but
a data collection tool. LOSA data, when analysed, are used
to support changes aimed at improving safety. These may be
changes to procedures, policies or operational philosophy.
The changes may affect multiple sectors of the organization
that support flight operations. It is essential that the organization
has a defined process to effectively use the analysed
data and to manage the changes the data suggest.
3.1.2 LOSA data should be presented to management
in at least the areas of operations, training, standards and
safety, with a clear analysis describing the problems related
to each, as captured by LOSA. The LOSA report should
clearly describe the problems the analysed data suggest but
should not attempt to provide solutions. These will be better
provided through the expertise in each of the areas in
question.
3.1.3 LOSA directs organizational attention to the
most important safety issues in daily operations and it
suggests what questions should be asked; however, LOSA
does not provide the solutions. The solutions lie in
organizational strategies. The organization must evaluate the
data obtained through LOSA, extract the appropriate
information and then carry out the necessary interventions
to address the problems thus identified. LOSA will only
realize its full potential if the organizational willingness and
commitment exist to act upon the data collected and the
information such data support. Without this necessary step,
LOSA data will join the vast amounts of untapped data
already existing throughout the international civil aviation
community.
3.1.4 The following would be some of the typical
expected actions, in no particular order, by an airline
following a LOSA:
• Modifying existing procedures or implementing new
ones;
• Redefining operational philosophies and guidelines;
• Arranging specific training in error management and
crew countermeasures;
• Reviewing checklists to ensure relevance of the
content and then issuing clear guidelines for their
initiation and execution; and
• Defining tolerances for stabilized approaches, as
opposed to the “perfect approach” parameters
promoted by existing SOPs.
3.2 A CONSTANTLY CHANGING SCENE
3.2.1 Airlines are continually involved in changes that,
at some point or other, have an effect upon safety. Factors
　
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