Beyond the Cockpit: The Spread of LOSA and Threat and Error Management

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Beyond 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

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The 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

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Extensions of LOSA in Airlines

• LOSA methodology has been applied (in
  collaboration with Continental Airlines) to
• Dispatch operations (DOSA)
• Ramp operations (ROSA)

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TEM 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

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International 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

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Published 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)

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ASAP Aviation Safety Action ProgramMichelle
Harper, Doctoral Candidate
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ASAP 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

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ASAP 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

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The 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

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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

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Participating Airlines




Northwest airlines not participating in DNAA

AA, UPS and United not using UT ASAP data
collection tools
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NOSS Normal Operations Safety SurveyChris
Henry, Doctoral Candidate
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Normal 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

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NOSS 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

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Accident InvestigationBob Helmreich
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TEM 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

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Current 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

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Extensions 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

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Conclusions

• 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

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• The University of Texas
• Human Factors Research Project
• www.psy.utexas.edu/HumanFactors