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was not shared among crew members; or
• The crew must have had time but did not use it
effectively to evaluate the decision.
If any of these conditions were observed, then it is
considered that an operational decision error was made in
the LOSA framework. An example would include the crew’s
decision to fly through known wind shear on an approach
instead of going around.
Definitions of crew error response
2.2.11 LOSA considers three possible responses by
crews to errors:
1. Trap: An active flight crew response in which an
error is detected and managed to an inconsequential
outcome;
2. Exacerbate: A flight crew response in which an error
is detected but the crew action or inaction allows it
to induce an additional error, Undesired Aircraft
State, incident or accident; and
3. Fail to respond: The lack of a flight crew response
to an error because it was either ignored or
undetected.
Definitions of error outcomes
2.2.12 The outcome of the error is dependent upon the
flight crew response. LOSA considers three possible
outcomes of errors depending upon crew response:
1. Inconsequential: An outcome that indicates the
alleviation of risk that was previously caused by an
error;
2. Undesired Aircraft State: An outcome in which the
aircraft is unnecessarily placed in a compromising
situation that poses an increased risk to safety; and
3. Additional Error: An outcome that was the result of
or is closely linked to a previous error.
Undesired Aircraft States
2.2.13 An “Undesired Aircraft State” occurs when the
flight crew places the aircraft in a situation of unnecessary
risk. For instance, an altitude deviation is an Undesired
Aircraft State that presents unnecessary risk. An Undesired
Aircraft State may occur in response to a crew action or
inaction (error). It is important to distinguish between errors
and the Undesired Aircraft State that can result. If an
Undesired Aircraft State is observed, there should always be
a crew error that is responsible for this undesired state. Such
errors may be miscommunications, lack of proficiency, poor
decision making or wilful violation of regulations.
2.2.14 Undesired Aircraft States can also occur as a
result of equipment malfunction or external party errors, for
example, a malfunctioning altimeter or flight management
system (FMS), or an ATC command error. These are not
associated with crew error and would be classified as
external events.
Crew response to Undesired Aircraft States
2.2.15 LOSA considers three possible crew responses
to Undesired Aircraft States:
1. Mitigate: An active flight crew response to an
Undesired Aircraft State that results in the
alleviation of risk by returning from the Undesired
Aircraft State to safe flight;
2. Exacerbate: A flight crew response in which an
Undesired Aircraft State is detected, but the flight
crew action or inaction allows it to induce an
additional error, incident or accident; and
3. Fail to respond: The lack of an active flight crew
response to an Undesired Aircraft State because it
was ignored or undetected.
Definitions of outcomes of Undesired Aircraft States
2.2.16 LOSA considers three possible outcomes to
Undesired Aircraft States:
1. Recovery: An outcome that indicates the alleviation
of risk that was previously caused by an Undesired
Aircraft State;
Chapter 2. Implementing LOSA 2-5
2. End State/Incident/Accident: Any undesired ending
that completes the activity sequence with a negative,
terminal outcome. These outcomes may be of little
consequence, for example, a long landing or a
landing too far to the left or right of the centre line,
or may result in a reportable incident or in an
accident; and
3. Additional error: The flight crew action or inaction
that results in or is closely linked to another cockpit
crew error.
2.3 LOSA OPERATING CHARACTERISTICS
2.3.1 LOSA is a proactive safety data collection
programme. The data generated provide a diagnostic
snapshot of organizational strengths and weaknesses, as well
as an overall assessment of flight crew performance in
normal flight operations. Therefore, the intent of LOSA is
to aid airlines in developing data-driven solutions to improve
overall systemic safety. The classic business principle of
measure, implement change and measure again is pertinent
here, with LOSA providing the metric of implementation
effectiveness. Experience has proven that expert external
oversight, especially on a first LOSA, is essential for
success.
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