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an SCP provides a principled approach to target limited
resources.
3.2.8 In the past, SCPs were based on accident and
incident investigations, experience and intuition. Today,
SCPs must be based on the “data wave”, the “data
warehouse” and the “drill-down” analysis. Measurement is
fundamental, because until an organization measures, it can
only guess. In the past, SCPs dealt with accidents. Today,
SCPs must deal with the precursors of accidents.
3.3 ONE OPERATOR’S EXAMPLE
OF AN SCP
3.3.1 This section briefly presents some of the very
positive results obtained by one airline that pioneered LOSA
in international civil aviation. The examples represent a
two-year period, between 1996 and 1998, and include
Chapter 3. LOSA and the safety change process (SCP) 3-3
aggregate data collected during 100 flight segments. During
this two-year period, 85 per cent of the crews observed made
at least one error during one or more segments, and 15 per
cent of the crews observed made between two and five
errors. Errors were recorded in 74 per cent of the segments
observed, with an average of two errors per segment (see
Chapter 2 for a description of the error categories in LOSA).
These data, asserted as typical of airline operations,
substantiated the pervasiveness of human error in aviation
operations, while challenged beyond question the illusion of
error-free operational human performance.
3.3.2 LOSA observations indicated that 85 per cent of
errors committed were inconsequential, which led to two
conclusions. First, the aviation system possesses very strong
and effective defences, and LOSA data allow a principled
and data-driven judgement of which defences work and
which do not, and how well defences fulfil their role.
Second, it became obvious that pilots intuitively develop ad
hoc error management skills, and it is therefore essential to
discover what pilots do well so as to promote safety through
organizational interventions, such as improved training,
procedures or design, based on this “positive” data.
Figure 3-1. Basic steps of the safety change process
Re-measurement
Measurement
Risk analysis and
prioritization of changes
Listing of
potential changes
Analysis of
targets
Time allocation
for changes
Implementation
of changes
Selection and
funding of changes
LOSA
3-4 Line Operations Safety Audit (LOSA)
3.3.3 When the airline started conducting base-line
observations in 1996, the crew error-trapping rate was 15 per
cent; that is, flight crews detected and trapped only 15 per
cent of the errors they committed. After two years, following
implementation of organizational strategies aimed at error
management based on LOSA data, the crew error-trapping
rate increased to 55 per cent (see Figure 3-2).
3.3.4 Base-line observations in 1996 suggested
problems in the area checklist performance. Following
remedial interventions — including review of standard
operating procedures, checklist design and training —
checklist performance errors decreased from 25 per cent to
15 per cent, which is a 40 per cent reduction in checklist
errors (see Figure 3-3).
Figure 3-2. Crew error-trapping rate
Figure 3-3. Checklist errors
15%
55%
0%
10%
20%
40%
50%
60%
1996 1998
30%
25%
15%
0%
5%
10%
15%
20%
25%
1996 1998
40%
Reduction
Chapter 3. LOSA and the safety change process (SCP) 3-5
3.3.5 Lastly, base-line observations in 1996 suggested
that 34.2 per cent of approaches did not meet all requirements
of the audit’s stabilized approach criteria, as specified
in the operator’s SOPs. Unstabilized approaches (using more
stringent criteria than during the 1996 audit) decreased to
13.1 per cent (a 62 per cent reduction) in 1998, following
remedial action through organizational interventions. The
data accessed through the operator’s flight operations quality
assurance (FOQA) programme is consistent with LOSA data
and shows a similar decline for 1998.
3.3.6 How does such change take place? By adopting
a defined SCP. Following data acquisition and analysis, the
airline decided to form specific committees including a
checklist committee and an unstabilized approaches committee.
Each committee considered the problems identified
by the analysis of the LOSA data and then proposed
organizational interventions to address them. Such interventions
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