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undesired aircraft states
Phase of flight
1 Predepart/Taxi
2 Takeoff/Climb
3 Cruise
4 Des/App/Land
5 Taxi-in
Error Type
1 Intentional
Noncompliance
2 Procedural
3 Communication
4 Proficiency
5 Decision
Error
Code
Use
Code
Book
Who
committed
the error?
Who
detected
the error?
Crew Error
Response
1 Trap
2 Exacerbate
3 Fail to Respond
Error
Outcome
1 Inconsequential
2 Undesired state
3 Additional error
E 1 FO failed to set his airspeed bugs. 1 2 211 2 7 3 3
Error ID
Error Management Undesired Aircraft State
Associated
with a
threat?
(If Yes, enter
Threat ID)
How did the crew manage or mismanage the error? Undesired
Aircraft
State
Code
Who
detected
the state?
Crew Undesired
State Response
1 Mitigate
2 Exacerbate
3 Fail to Respond
Undesired
Aircraft State
Outcome
1 Inconsequential
2 Additional error
E 1 No Error chain to E2
Who Committed /
Detected Codes Undesired Aircraft State Codes
Flightcrew
1 CA
2 FO
3 SO / FE
4 Relief Officer
5 Jumpseat
Rider
6 All crew
members
7 Nobody
Other people
8 ATC
9 Flight
attendant
10 Dispatch
11 Ground
12 MX
Aircraft
20 Aircraft
systems
99 Other
Configuration States
1 Incorrect A/C configuration - flight controls,
brakes, thrust reversers, landing gear
2 Incorrect A/C configuration — systems (fuel,
electrical, hydraulics, pneumatics, airconditioning,
pressurization, instrumentation)
3 Incorrect A/C configuration — automation
4 Incorrect A/C configuration — engines
Ground States
20 Proceeding towards wrong runway
21 Runway incursion
22 Proceeding towards wrong taxiway / ramp
23 Taxiway / ramp incursion
24 Wrong gate
Aircraft Handling States — All Phases
40 Vertical deviation
41 Lateral deviation
42 Unnecessary WX penetration
43 Unauthorized airspace penetration
44 Speed too high
45 Speed too low
46 Abrupt aircraft control (attitude)
47 Excessive banking
48 Operation outside A/C limitations
Approach / Landing States
80 Deviation above G/S or FMS path
81 Deviation below G/S or FMS path
82 Unstable approach
83 Continued landing - unstable approach
84 Firm landing
85 Floated landing
86 Landing off C/L
87 Long landing outside TDZ
99 Other Undesired States
SAMPLE
FOR ILLUSTRATION PURPOSES ONLY
A-12 Line Operations Safety Audit (LOSA)
Copyright 2002 The University of Texas at Austin. All rights reserved.
Error Management Worksheet Error ID
Error Description Error Response / Outcome
Describe the crew error and associated
undesired aircraft states
Phase of flight
1 Predepart/Taxi
2 Takeoff/Climb
3 Cruise
4 Des/App/Land
5 Taxi
Error Type
1 Intentional
Noncompliance
2 Procedural
3 Communication
4 Proficiency
5 Decision
Error
Code
Use
Code
Book
Who
committed
the error?
Who
detected
the error?
Crew Error
Response
1 Trap
2 Exacerbate
3 Fail to Respond
Error
Outcome
1 Inconsequential
2 Undesired state
3 Additional error
E 2 In running the Before Takeoff Checklist, the
FO skipped the takeoff data item. 1 2 200 2 7 3 1
E 3 FO called “flaps up” prior to the flap
retraction speed. 2 2 299 2 1 1 1
Error ID
Error Management Undesired Aircraft State
Associated
with a
threat?
(If Yes, enter
Threat ID)
How did the crew manage or mismanage the error? Undesired
Aircraft
State
Code
Who detected
the
state?
Crew Undesired
State Response
1 Mitigate
2 Exacerbate
3 Fail to Respond
Undesired
Aircraft State
Outcome
1 Inconsequential
2 Additional error
E 2 No
Errors mismanaged — The bug error should have been caught with the
Before Takeoff Checklist, but the FO unintentionally skipped that item.
All checklists during this phase were poorly executed. The FO caught
the error during the takeoff roll.
E 3 No Error managed — CA saw that the aircraft was not at the proper speed
and waited to retract the flaps. Good monitoring in this case.
SAMPLE
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