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g) Trusted data collection site: In order to maintain confidentiality, airlines must have a trusted data
collection site. No observations can be misplaced or improperly disseminated within the airline,
without compromising LOSA integrity. Some airlines use a “third party” to provide a neutral party for
objective analysis of results.
h) Data verification round-tables: Data-driven programmes like LOSA require data quality
management procedures and consistency checks. For LOSA, round table discussions with
representatives of management and the pilots’ association scan raw data for inconsistencies. The
database must be validated for consistency and accuracy before a statistical analysis can proceed.
i) Data-derived targets for enhancement: As the data are collected and analysed, patterns emerge.
Certain errors occur frequently, certain airports or activities are problematic, certain SOPs are
ignored or modified, and certain manoeuvres pose particular difficulties. These patterns become
Chapter 16. Aircraft Operations 16-19
targets for enhancement. The airline then develops an action plan and implements appropriate
change strategies based on the input of expertise available to the airline. Through subsequent
LOSA audits, the effectiveness of the changes can be measured.
j) Feedback of results to the line pilots: After a LOSA is completed; the airline’s management team
and the pilots’ association have an obligation to communicate the findings to the line pilots. Pilots
are interested not only in the results but also management’s plan for improvement.
Safety change process
16.4.18 Like other tools for risk management, a closed-loop process is required to effect a safety
change. Problems are identified and analysed, strategies developed, priorities established, remedial
measures implemented, and effectiveness monitored to identify any residual problems.
16.4.19 LOSA directs organizational attention to the most important safety issues in daily operations.
However, LOSA does not provide the solutions; they must come from organizational strategies. The
organization must evaluate the data obtained through LOSA, identify those hazards posing the greatest risks
to the organization and then take the necessary actions to address them. LOSA can only reach its full
potential if the organizational willingness and commitment exist to act upon the lessons of LOSA. Without
meaningful safety action, LOSA data will join the tremendous banks of unused safety data already available
within the international civil aviation community.
16.4.20 Following are some typical safety change strategies for airlines following a LOSA audit:
a) redefining operational philosophies and guidelines;
b) modifying existing procedures or implementing new ones;
c) arranging specific training in threat and error management and crew countermeasures;
d) reviewing checklists to ensure relevance of the content and then issuing clear guidance for their
initiation and execution; and
e) defining tolerances for stabilized approaches, as opposed to the “perfect approach” parameters
promoted by existing SOPs.
16.4.21 Early successes with LOSA have been most noticeable with respect to:
a) improvement in error management by flight crew;
b) reduction in checklist performance errors; and
c) reduction in unstabilized approaches.
Implementing LOSA
16.4.22 Undertaking a LOSA audit is a major safety initiative. It cannot be undertaken lightly. While
LOSA is very suitable for application in larger airlines with mature SMS, it is increasingly being adopted by
medium and smaller sized operations. Like successful FDA and CRM training programmes, the knowledge
and experience of specialists are required for the design and conduct of an effective LOSA.
16-20 Safety Management Manual (SMM)
16.4.23 Organizations wishing to implement a LOSA programme should consult the Line Operations
Safety Audit (LOSA) (Doc 9803) manual and an airline experienced in operating LOSA. In particular, formal
training in the methodology and the use of the specialized LOSA tools and in the handling of the highly
sensitive data collected is essential.
16.4.24 Since the support of all parties is required for a successful LOSA programme, representatives
from flight operations, training and safety departments, as well as representatives from the pilots’ union
should meet at the outset and agree on such issues as:
a) operational requirement for a LOSA and the likelihood of conducting a successful audit;
b) programme goals;
c) resources available to guide the conduct of the audit;
d) creation of a LOSA Steering Committee to assist in planning and obtaining buy-in to the programme
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