Title: Beyond the Cockpit: The Spread of LOSA and Threat and Error Management
1Beyond the CockpitThe Spread of LOSA and Threat
and Error Management
- Robert L. Helmreich, PhD, FRAeS
- Human Factors Research Project
- Department of Psychology
- The University of Texas at Austin
- 4th ICAO-IATA
- LOSA and TEM Conference
- Toulouse, 16 November
2The Line Operations Safety Audit
- LOSA is application of the methodology of
systematic observation to recording flight crew
behavior and threats to safety in the operating
environment - Historically, the methodology was applied to
recording the behavior of Aquanauts living in
undersea habitats placed on the ocean floor - Observations of flight crews (precursors to LOSA)
began in 1979 with Texas International Airlines
and later Pan American Airlines and Delta
Airlines
3Extensions of LOSA in Airlines
- LOSA methodology has been applied (in
collaboration with Continental Airlines) to - Dispatch operations (DOSA)
- Ramp operations (ROSA)
4TEM CRM
- Research in the LOSA Archive supports the links
between TEM and CRM. - Crews that develop contingency management plans,
such as proactively discussing strategies for
anticipated threats, have fewer mismanaged
threats - Crews that exhibit good monitoring and
cross-checking make fewer errors - Crews that exhibit strong leadership, inquiry,
and workload and automation management have fewer
mismanaged errors and undesired aircraft states
5International Conferences
- LOSA Week
- 2001 Hong Kong
- 2001 Panama City, Panama
- 2002 United Arab Emirates, Dubai
- 2003 Dublin
- 2006 Toulouse
- Threat and Error Management workshop
- 2002 San Salvador
-
6Published Guidelines
- ICAO (2002). Line Operations Safety Audit (LOSA).
DOC 9803-AN/761. Montreal International Civil
Aviation Organization (under revision) - FAA (2006) LOSA Advisory Circular 120-90 Line
Operations Safety Audits (Includes Threat and
Error Management)
7ASAP Aviation Safety Action ProgramMichelle
Harper, Doctoral Candidate
8ASAP Characteristics
- ASAP is an extension of NASAs Aviation Safety
Reporting System (ASRS) - Under ASAP, pilots report threats and errors
(excluding intentional non-compliance and drug
and alcohol violations) to their company and
receive the same limited immunity from punishment
provided by ASRS
9ASAP Benefits
- Unlike ASRS, information is immediately available
to company management and allows corrective
action to be taken - ASAP committee (union, management, regulator)
reviews reports and determines corrective action - Actions are reported back to pilot
- Don Gunther of Continental can clarify
10The UT ASAP Data Collection System/ Distributed
National ASAP Archive (DNAA)
- Project Goals
- Provide airlines with a set of tools that can be
used across the industry to collect and analyze
factors contributing to ASAP events. - Development of web-based tools for supporting
airline ASAP data collection - Establish a data-sharing program based on these
tools to identify industry- and system-level,
high-risk events - Development of the Distributed National ASAP
Archive (DNAA) - Use the UT Threat and Error Management Model as
the common taxonomy for categorizing ASAP events - Development of the DNAA Master List of common
ASAP event descriptors
11 System Overview
DNAA
1.
2.
DNAA server
- UT developed software that supports the airlines
in collecting ASAP data - UT and NASA collaborated to enable airlines to
share de-identified ASAP reports - Each airline shares data through a protected
connection to NASA and UT
12Participating Airlines
Northwest airlines not participating in DNAA
AA, UPS and United not using UT ASAP data
collection tools
13NOSS Normal Operations Safety SurveyChris
Henry, Doctoral Candidate
14Normal Operations Safety Survey (NOSS)
- NOSS is LOSA adapted to Air Traffic Control
- TEM definitions congruent with LOSA
- NOSS captures the work context and how
controllers discharge their duties within that
context - Threats are key elements of task environment
- Aggregated Threat and Error Management data
capture both system and individual performance - Over-the-shoulder observations
- De-identified, non-jeopardy
- Identify systemic strengths and vulnerabilities
15NOSS TEM Additional Benefits
- Airways NZ is analyzing normal operations and
incident data using TEM - Service providers and airlines, using TEM as a
common language are exchanging more safety
information on ATC interface - TEM training is being developed for controllers
at service providers
16Accident InvestigationBob Helmreich
17TEM as Framework for Accident Investigation
- IATA has adopted TEM as framework for
classification of causal and contributing factors
in global accident and incident database - Robert Sumwalt, new NTSB Vice Chairman
- Trained in TEM
- Served as LOSA observer
18Current Investigations
- Analysis of factors surrounding crash of LAPA
B-737 in Buenos Aires requested by government of
Argentina - Analysis of factors surrounding the crash of
Flash Airlines B-737 at Sharm El Sheikh, Egypt
requested by Boeing - Analysis of crew performance in crash of CRJ200
at Kirksville, MO requested by Bombardier
19Extensions to Other Professions
- Queensland Rail in Australia has adapted both TEM
and LOSA to audit their operations - International Association of Fire Chiefs has used
TEM in developing US national close call
reporting system - RLH is member of committee developing guidelines
20Conclusions
- TEM can be used as the data structure for an
organizations Safety Management System - Allows integration of data from differing sources
- Incident reports, incident and accident
investigations, and LOSA and its derivatives
21- The University of Texas
- Human Factors Research Project
- www.psy.utexas.edu/HumanFactors
-