International Civil Aviation Organization
Approved by the Secretary General
and published under his authority
Line Operations
Safety Audit (LOSA)
First Edition — 2002
Doc 9803
AN/761
AMENDMENTS
The issue of amendments is announced regularly in the ICAO Journal and in the
monthly Supplement to the Catalogue of ICAO Publications and Audio-visual
Training Aids, which holders of this publication should consult. The space below
is provided to keep a record of such amendments.
RECORD OF AMENDMENTS AND CORRIGENDA
AMENDMENTS CORRIGENDA
No.
Date
applicable
Date
entered
Entered
by No.
Date
of issue
Date
entered
Entered
by
(ii)
(iii)
TABLE OF CONTENTS
Page Page
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (v)
Acronyms and Abbreviations . . . . . . . . . . . . . . . . . (vi)
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (vii)
Chapter 1. Basic error management concepts . . 1-1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
Reactive strategies . . . . . . . . . . . . . . . . . . 1-2
Combined reactive/proactive strategies . . 1-2
Proactive strategies . . . . . . . . . . . . . . . . . 1-4
1.3 A contemporary approach to operational
human performance and error . . . . . . . . . . . 1-5
1.4 The role of the organizational culture . . . . 1-7
1.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 1-7
Chapter 2. Implementing LOSA . . . . . . . . . . . . . 2-1
2.1 History of LOSA . . . . . . . . . . . . . . . . . . . . . 2-1
2.2 The Threat and Error Management Model. 2-1
Threats and errors defined. . . . . . . . . . . . 2-1
Definitions of crew error response . . . . . 2-4
Definitions of error outcomes . . . . . . . . . 2-4
Undesired Aircraft States . . . . . . . . . . . . 2-4
2.3 LOSA operating characteristics . . . . . . . . . 2-5
Observer assignment . . . . . . . . . . . . . . . . 2-7
Flight crew participation . . . . . . . . . . . . . 2-7
2.4 How to determine the scope of a LOSA . . 2-7
2.5 Once the data is collected . . . . . . . . . . . . . . 2-8
2.6 Writing the report . . . . . . . . . . . . . . . . . . . . 2-8
2.7 Success factors for LOSA. . . . . . . . . . . . . . 2-8
Chapter 3. LOSA and the safety change
process (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
3.2 A constantly changing scene. . . . . . . . . . . . 3-1
3.3 One operator’s example of an SCP . . . . . . 3-2
Chapter 4. How to set up a LOSA —
US Airways experience . . . . . . . . . . . . . . . . . . . . . . 4-1
4.1 Gathering information . . . . . . . . . . . . . . . . . 4-1
4.2 Interdepartmental support . . . . . . . . . . . . . . 4-1
4.3 LOSA steering committee. . . . . . . . . . . . . . 4-1
Safety department . . . . . . . . . . . . . . . . . . 4-1
Flight operations and training
departments . . . . . . . . . . . . . . . . . . . . . . . 4-2
Pilots union . . . . . . . . . . . . . . . . . . . . . . . 4-2
4.4 The key steps of a LOSA . . . . . . . . . . . . . . 4-2
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2
Action plan . . . . . . . . . . . . . . . . . . . . . . . 4-2
4.5 The keys to an effective LOSA . . . . . . . . . 4-4
Confidentiality and no-jeopardy . . . . . . . 4-4
The role of the observer . . . . . . . . . . . . . 4-5
4.6 Promoting LOSA for flight crews . . . . . . . 4-5
Appendix A — Examples of the various forms
utilized by LOSA . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
Appendix B — Example of an introductory letter
by an airline to its flight crews. . . . . . . . . . . . . . . . B-1
Appendix C — List of recommended reading
and reference material . . . . . . . . . . . . . . . . . . . . . . . C-1
(v)
FOREWORD
The safety of civil aviation is the major objective of the
International Civil Aviation Organization (ICAO). Considerable
progress has been made in increasing safety, but
additional improvements are needed and can be achieved. It
has long been known that the majority of aviation accidents
and incidents result from less than optimum human performance,
indicating that any advance in this field can be
expected to have a significant impact on the improvement
of aviation safety.
This was recognized by the ICAO Assembly, which in 1986
adopted Resolution A26-9 on Flight Safety and Human
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