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primary cause, most often “pilot error”, and fail to examine
organizational and system factors that set the stage for the
breakdown. Accident investigations are autopsies of the
system, conducted after the point of no return of the system’s
health has been passed.
1.2.17 There is emerging consensus within the aviation
industry about the need to adopt a positive stance and
anticipate, rather than regret, the negative consequences of
human error in system safety. This is a sensible objective.
The way to achieve it is by pursuing innovative approaches
rather than updating or optimizing methods from the past.
After more than 50 years of investigating failures and
monitoring accident statistics, the relentless prevalence of
human error in aviation safety would seem to indicate a
somewhat misplaced emphasis in regard to safety, human
performance and human error, unless it is believed that the
human condition is beyond hope.
1.3 A CONTEMPORARY APPROACH TO
OPERATIONAL HUMAN PERFORMANCE
AND ERROR
1.3.1 The implementation of normal operations
monitoring requires an adjustment on prevailing views of
human error. In the past, safety analyses in aviation have
viewed human error as an undesirable and wrongful
manifestation of human behaviour. More recently, a considerable
amount of operationally oriented research, based
on cognitive psychology, has provided a very different
perspective on operational errors. This research has proven,
in practical terms, a fundamental concept of cognitive
psychology: error is a normal component of human behaviour.
Regardless of the quantity and quality of regulations the
industry might promulgate, the technology it might design,
or the training people might receive, error will continue to
be a factor in operational environments because it simply is
the downside of human cognition. Error is the inevitable
downside of human intelligence; it is the price human beings
pay for being able to “think on our feet”. Practically speaking,
making errors is a conservation mechanism afforded by
human cognition to allow humans the flexibility to operate
under demanding conditions for prolonged periods without
draining their mental “batteries”.
1.3.2 There is nothing inherently wrong or
troublesome with error itself as a manifestation of human
behaviour. The trouble with error in aviation is the fact that
negative consequences may be generated in operational
contexts. This is a fundamental point in aviation: if the
negative consequences of an error are caught before they
produce damage, then the error is inconsequential. In
operational contexts, errors that are caught in time do not
produce negative consequences and therefore, for practical
purposes, do not exist. Countermeasures to error, including
training interventions, should not be restricted to avoiding
errors, but rather to making them visible and trapping them
before they produce negative consequences. This is the
essence of error management: human error is unavoidable
but manageable.
1.3.3 Error management is at the heart of LOSA and
reflects the previous argument. Under LOSA, flaws in human
performance and the ubiquity of error are taken for granted,
and rather than attempting to improve human performance,
the objective becomes to improve the context within which
humans perform. LOSA ultimately aims — through changes
in design, certification, training, procedures, management
1-8 Line Operations Safety Audit (LOSA)
developing analytic methods to integrate multiple and
diverse data sources. However, most importantly, the real
challenge for the large-scale implementation of LOSA will
be overcoming the obstacles, presented by a blame-oriented
industry, that will demand continued effort over time before
normal operations monitoring is fully accepted by the
operational personnel, whose support is essential.
1.5.2 Despite the challenges and barriers, the aviation
system has more to gain by moving forward to system-wide
implementation of LOSA than by denying progress because
that is not the way business has been done in the past or by
decrying the difficulties involved. The following chapters
present an overview of how to tackle these challenges and
barriers.
2-1
Chapter 2
IMPLEMENTING LOSA
2.1 HISTORY OF LOSA
2.1.1 In 1991, The University of Texas at Austin
Human Factors Research Project, with funding from the
FAA (Human Factors Division, AAR-100), developed
LOSA to monitor normal line operations. In its early form,
LOSA mostly focused on CRM performance. The reason for
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