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included modification of existing procedures,
implementation of new ones, specific training, and
redefinition of operational philosophies, among others. For
example, checklists were reviewed to ensure relevance of
contents, and clear guidelines for their initiation and
execution were promulgated. Gates and tolerances for
stabilized approaches were defined, as opposed to the
“perfect approach” parameters promulgated by the SOPs
existing at that time. Proper training and checking guidelines
were established, taking into account an error management
approach to crew coordination.
3.3.7 The improved error management performance by
flight crews, successful reduction in checklist performance
errors and reduction in unstabilized approaches discussed
earlier reflect the success of a properly managed SCP, based
upon data collected by observing line operations. They are
also examples of how analysis of LOSA data provides an
opportunity to enhance safety and operational human
performance.
4-1
Chapter 4
HOW TO SET UP A LOSA — US AIRWAYS EXPERIENCE
“Honest and critical self-assessment is one of the most
powerful tools that management can employ to measure
flight safety margins.”
Flight Safety Foundation Icarus Committee
May 1999
4.1 GATHERING INFORMATION
In order to decide if conducting a LOSA would be
beneficial, it is important to understand the LOSA process.
The first contact should be ICAO or The University of Texas
at Austin Human Factors Research Project. Both are able to
provide all the information needed and can discuss benefits
that have been derived from past LOSAs. They will also be
aware of other airlines currently planning or conducting a
LOSA, and it may be possible to attend those airlines’
training classes. It is also a good idea to talk with and/or visit
other airlines that have already completed a LOSA to learn
from their experiences.
4.2 INTERDEPARTMENTAL SUPPORT
4.2.1 When first exploring whether or not to conduct
a LOSA, it is advisable to gather representatives from all
departments that may be potentially involved. This could
include the flight operations, training and safety departments,
as well as representatives from the pilots union. If
LOSA is not supported by all concerned, the effectiveness
of LOSA will be compromised.
4.2.2 As an example, a few years ago a large airline
decided to audit its line flights on a somewhat random basis.
The audit was not a LOSA but did have similarities in that
it used trained observers to ride in the airline’s cockpits. The
airline’s safety department administered the line audit, and
the data that they collected were valid and important.
However, the problem was that the flight operations and
training departments of this airline felt somewhat threatened
by the safety department telling them what “was wrong”
with the airline, and therefore they were not very receptive
to the findings of this particular line audit.
4.2.3 A few years later, this same airline conducted a
very successful LOSA. This time, the airline emphasized
that the audit was not “owned” by the safety department, but
rather, was a product of the flight operations, training and
safety departments, along with the pilots union. Each of
these departments and organizations became members of the
“LOSA steering committee.” This airline’s LOSA was
successful for many reasons, but primarily because right
from the start, all relevant departments were involved with
the development and direction that the LOSA took. In short,
the programme had interdepartmental “buy-in”.
4.3 LOSA STEERING COMMITTEE
4.3.1 This buy-in and support of other departments are
crucial; therefore, consideration should be given to forming
a “LOSA steering committee.” Determining which departments
should be members varies with each organization but,
at a minimum, should include the safety, flight operations
and flight training departments and the pilots union. The role
of each of these is described below.
Safety department
4.3.2 Ideally, the safety department should be the
department to administer the LOSA. There are several
reasons for this. For one, conducting audits is typically a job
function of the safety department. Another important reason
4-2 Line Operations Safety Audit (LOSA)
is that the safety department often holds the trust of the line
pilots regarding confidential information. It is the safety
department that typically administers confidential incident
　
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