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this was that researchers and airlines alike wanted to know
more about the actual practice of CRM rather than just
formulating conclusions about its effectiveness from data
collected within the training environment, as was the
established practice. After LOSA audits were conducted at
more than ten airlines in the early 1990s, it was clear that
the actual practice of CRM was quite different than the one
depicted within the typical training department. Most
important, the unique insights gathered from this methodological
approach of monitoring normal operations not
only advanced the concepts of CRM, but also encouraged
new ways of thinking about crew performance.
2.1.2 After several years of development and
refinement, LOSA has turned into a strategy of systematic
line observations to provide safety data on the way an
airline’s flight operations system is functioning. The data
generated from LOSA observations provide diagnostic
indicators of organizational strengths and weaknesses in
flight operations as well as an overall assessment of crew
performance, both in the technical and human performance
areas. LOSA is a data-driven approach to the development
of countermeasures to operational threats and errors.
2.2 THE THREAT AND ERROR
MANAGEMENT MODEL
2.2.1 LOSA is premised on The University of Texas
Threat and Error Management (UTTEM) Model (see
Figure 2-1). Essentially, the model posits that threats and
errors are integral parts of daily flight operations and must
be managed. Therefore, observing the management or mismanagement
of threats and errors can build the desired
systemic snapshot of performance. Pilots quickly grasp the
concepts of external threats once they are explained, and the
idea of managing the threats has great relevance to them,
more so than error management, which still retains negative
connotations despite attempts to acknowledge its ubiquity
and necessity in human intelligence and information
processing. Crew countermeasures are then seen as the tools
that pilots develop to handle these daily threats and errors.
The UTTEM Model has been successfully incorporated into
training programmes and in some cases has replaced
existing CRM training.*
2.2.2 The UTTEM Model provides a quantifiable
framework to collect and categorize data. Some questions
that can be addressed using this framework include the
following:
• What type of threats do flight crews most frequently
encounter? When and where do they occur, and what
types are the most difficult to manage?
• What are the most frequently committed crew errors,
and which ones are the most difficult to manage?
• What outcomes are associated with mismanaged
errors? How many result in an Undesired Aircraft
State?
• Are there significant differences between airports,
fleets, routes or phases of flight vis-à-vis threats and
errors?
2.2.3 The following paragraphs introduce a brief
overview of the most important building blocks of the
UTTEM Model.
Threats and errors defined
Threats
2.2.4 Threats are external situations that must be
managed by the cockpit crew during normal, everyday
flights. Such events increase the operational complexity of
* Guidance on Threat and Error Management (TEM) training can
be found in the Human Factors Training Manual (Doc 9683).
2-2 Line Operations Safety Audit (LOSA)
Figure 2-1. The Threat and Error Management Model
Threats
Inconsequential Threat management
Crew error
Crew error responses
Undesired
Aircraft State
Crew Undesired
Aircraft State
responses
Chapter 2. Implementing LOSA 2-3
the flight and pose a safety risk to the flight at some level.
Threats may be expected or anticipated and, therefore, the
crew may brief in advance. Threats may also be unexpected.
As they occur suddenly and without any warning, there is
no possibility for the crew to brief in advance. External
threats may be relatively minor or major. Observers should
record all external threats that are on the code sheet or any
others that may be considered significant.
2.2.5 Errors originated by non-cockpit personnel are
considered external threats. For example, if the cockpit crew
detects a fuel loading error made by ground staff, it would
be entered as an external threat, not an error. The crew was
not the source of the error (although they must manage it,
as they would any other external threat). Other examples of
non-cockpit crew errors that would be entered as external
threats are errors in Air Traffic Control (ATC) clearances
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