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FOR ILLUSTRATION PURPOSES ONLY
Appendix A. Examples of the various forms utilized by LOSA A-13
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 4 CA and FO failed to verify multiple altitude
changes. 2 1 140 1 6 3 1
E 5
FO, who was new to the aircraft, let it slip
a little to the left during the final approach.
Resulted in landing left of the centerline.
4 4 402 2 6 1 2
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 4 No No error management — intentional error
E 5 No
Error mismanaged — FO tried to correct but still landed left of the
centerline. Approach was stable and they made the first high-speed
taxiway. The CA did not verbalize the deviation during the approach.
86 6 1 1
SAMPLE
FOR ILLUSTRATION PURPOSES ONLY
A-14 Line Operations Safety Audit (LOSA)
Copyright 2002 The University of Texas at Austin. All rights reserved.
Intentional Noncompliance Error Codes
Sterile Cockpit Errors
100 Sterile cockpit violation
Callout Errors
104 Omitted takeoff callouts (i.e., V-speeds)
105 Omitted climb or descent callouts
106 Omitted approach callouts
Crew to ATC Errors
109 Altitude deviation without ATC clearance
110 Course or heading deviation without ATC clearance
(deviation more than 20 degrees)
111 Use of nonstandard ATC phraseology
112 Omitted position report to ATC
113 Omitted non-radar environment report to ATC
114 Omitted call signs to ATC
Checklist Errors
120 Checklist performed from memory
121 Completed checklist not called "complete"
122 Checklist not performed to completion
123 Use of nonstandard checklist protocol (i.e., use of
nonstandard responses)
124 Omitted checklist
125 Self-performed checklist — no challenge or response
126 Omitted abnormal checklist
127 Self initiated checklist — not called for by PF
128 Self initiated checklist — not called for by CA
129 Checklist performed late or at wrong time
Cross-Verification Errors
140 Failure to cross-verify MCP / altitude alerter changes
141 Failure to cross-verify FMC/CDU changes before
execution
142 Failure to cross-verify altimeter settings
Hard Warning Errors
160 Failure to respond to GPWS warnings
161 Failure to respond to TCAS warnings
162 Failure to respond to overspeed warning
Briefing Errors
170 Omitted takeoff briefing
171 Omitted approach briefing
172 Omitted flight attendant briefing (only for the first flight
of a trip or crew change)
173 Omitted engine-out briefing
179 Intentional failure to arm spoilers
Approach Errors
180 Failure to execute a go-around after passing procedural
bottom lines of an unstable approach
181 Speed deviation without ATC clearance
183 Intentionally flying below the G/S
184 PF makes own flight control settings
Automation and Instrument Setting Errors
185 PF makes own MCP changes
186 PF makes own FMC changes
187 Failure to set altitude alerter
189 Setting altimeters before the transition altitude
190 Using equipment placarded inoperative
Other Noncompliance Errors
195 Taxi-in or out without a wing walker
196 A/C operation with unresolved MEL item
199 Other noncompliance errors not listed in the code
book
SAMPLE
FOR ILLUSTRATION PURPOSES ONLY
Appendix A. Examples of the various forms utilized by LOSA A-15
Copyright 2002 The University of Texas at Austin. All rights reserved.
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