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and errors?
Systemic countermeasures
16.4.15 Accepting that error is inevitable, the most effective countermeasures go beyond trying to
simply prevent errors. They need to highlight unsafe conditions early enough to permit flight crews to take
corrective action before adverse consequences result from the error. In other words, they “trap” the error.
16.4.16 The most effective countermeasures seek to improve the everyday work situation in which
flight crews face the inevitable threats to safe performance, measures which give crews a “second chance”
to recover from their errors. Such systemic countermeasures include changes in aircraft design, crew
training, company operating procedures, management decisions, etc.
Defining characteristics of LOSA
16.4.17 The following characteristics of LOSA ensure the integrity of the methodology and its data:
a) Jump seat observations during normal flight operations: LOSA observations are limited to
routine flights (as opposed to line checks, or other training flights). Check pilots add to an already
high stress level, thus providing an unrealistic picture of performance. The best observers learn to
be unobtrusive and non-threatening, recording minimum detail in the cockpit.
b) Joint management/pilot sponsorship: In order for LOSA to succeed as a viable safety
programme, both management and pilots support the project. Joint sponsorship provides “checks
and balances” for the project to ensure that any necessary change will be made as a result of LOSA
data. As with the implementation of a successful FDA programme, a LOSA audit does not proceed
without the endorsement of the pilots via a signed agreement with management. A LOSA steering
committee with pilot and management representatives shares responsibility for the planning,
scheduling, supporting observers and verifying the data.
c) Voluntary crew participation: Maintaining the integrity of LOSA within the airline is extremely
important for long-term success. One way to accomplish this goal is to collect all observations with
voluntary crew participation. Before conducting LOSA observations, an observer obtains the flight
crew’s permission. If an airline conducting LOSA has an unreasonably high number of refusals by
pilots to be observed, this may indicate that there are critical “trust” issues to be dealt with first.
16-18 Safety Management Manual (SMM)
d) Collection of only de-identified, confidential safety data: LOSA observers do not record names,
flight numbers, dates or any other data that can identify a crew. This allows for a high level of
protection against disciplinary action. Airlines should not squander an opportunity to gain insight into
their operations by having pilots fearful that a LOSA observation could be used against them in
disciplinary proceedings. In other words, LOSA must not only be seen to be non-punitive, it must be
non-punitive.
e) Targeted observations: All data are collected on a specifically designed LOSA Observation Form.
(Examples of the forms are included in Doc 9803.) Typically, the following types of information are
collected by the LOSA observer:
1) flight and crew demographics such as city pairs, aircraft type, flight time, years of experience in
that position and with that airline, and crew familiarity;
2) written narratives describing what the crew did well and what they did poorly and how they
managed threats or errors for each phase of the flight;
3) CRM performance ratings using validated behavioural markers;
4) technical worksheet for the descent/approach/landing phases that highlight the type of approach
flown, the landing runway and whether the crew met the parameters of a stabilized approach;
5) threat management worksheet that details each threat and how it was handled;
6) error management worksheet that lists each error observed, how each error was handled and
the final outcome; and
7) crew interview conducted during low workload periods of the flight, such as cruise, that asks
pilots for their suggestions to improve safety, training, and flight operations.
f) Trusted, trained and standardized observers: Observers are primarily pilots drawn from the line,
training department, safety department, management, etc. Experienced LOSA observers from a
non-affiliated airline may be more objective and serve to provide an anchor point for company
observers, especially for companies initiating a new LOSA programme. Regardless of the source, it
is critical that the observers are respected and trusted to ensure acceptance of LOSA by the line
pilots. The observers must be trained in concepts of threat and error management and in the use of
the LOSA rating forms. Standardized rating is vital to the validity of the programme.
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Safety Management Manual (SMM) 安全管理手册(118)
