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utilized by LOSA, which is essentially
operational and practical.
• Chapter 3 discusses the safety change process that
should take place following the implementation of
LOSA.
• Chapter 4 introduces the example of one operator’s
experience in starting a LOSA.
• Appendix A provides examples of the various forms
utilized by LOSA.
• Appendix B provides an example of an introductory
letter by an airline to its flight crews.
• Appendix C provides a list of recommended reading
and reference material.
11. This manual is a companion document to the
Human Factors Training Manual (Doc 9683). The
cooperation of the following organizations in the production
of this manual is acknowledged: The University of Texas at
Austin Human Factors Research Project, Continental
Airlines, US Airways and ALPA, International. Special
recognition is given to Professor Robert L. Helmreich,
James Klinect and John Wilhelm of The University of
Texas at Austin Human Factors Research Project; Captains
Bruce Tesmer and Donald Gunther of Continental Airlines;
Captains Ron Thomas and Corkey Romeo of US Airways;
and Captain Robert L. Sumwalt III of US Airways and of
ALPA, International.
1-1
Chapter 1
BASIC ERROR MANAGEMENT CONCEPTS
1.1 INTRODUCTION
1.1.1 Historically, the way the aviation industry has
investigated the impact of human performance on aviation
safety has been through the retrospective analyses of those
actions by operational personnel which led to rare and
drastic failures. The conventional investigative approach is
for investigators to trace back an event under consideration
to a point where they discover particular actions or decisions
by operational personnel that did not produce the intended
results and, at such point, conclude human error as the cause.
The weakness in this approach is that the conclusion is
generally formulated with a focus on the outcome, with
limited consideration of the processes that led up to it. When
analysing accidents and incidents, investigators already
know that the actions or decisions by operational personnel
were “bad” or “inappropriate”, because the “bad” outcomes
are a matter of record. In other words, investigators
examining human performance in safety occurrences enjoy
the benefit of hindsight. This is, however, a benefit that
operational personnel involved in accidents and incidents
did not have when they selected what they thought of as
“good” or “appropriate” actions or decisions that would lead
to “good” outcomes.
1.1.2 It is inherent to traditional approaches to safety
to consider that, in aviation, safety comes first. In line with
this, decision making in aviation operations is considered to
be 100 per cent safety-oriented. While highly desirable, this
is hardly realistic. Human decision making in operational
contexts is a compromise between production and safety
goals (see Figure 1-1). The optimum decisions to achieve the
actual production demands of the operational task at hand
may not always be fully compatible with the optimum
Figure 1-1. Operational Behaviours — Accomplishing the system’s goals
Safety Production
1-2 Line Operations Safety Audit (LOSA)
decisions to achieve theoretical safety demands. All
production systems — and aviation is no exception —
generate a migration of behaviours: due to the need for
economy and efficiency, people are forced to operate at the
limits of the system’s safety space. Human decision making
in operational contexts lies at the intersection of production
and safety and is therefore a compromise. In fact, it might
be argued that the trademark of experts is not years of
experience and exposure to aviation operations, but rather
how effectively they have mastered the necessary skills to
manage the compromise between production and safety.
Operational errors are not inherent in a person, although this
is what conventional safety knowledge would have the
aviation industry believe. Operational errors occur as a result
of mismanaging or incorrectly assessing task and/or situational
factors in a specific context and thus cause a failed
compromise between production and safety goals.
1.1.3 The compromise between production and safety
is a complex and delicate balance. Humans are generally
very effective in applying the right mechanisms to
successfully achieve this balance, hence the extraordinary
safety record of aviation. Humans do, however, occasionally
mismanage or incorrectly assess task and/or situational
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