Doc 9803. Edition 1
Last modified:1/1/2002
Line Operations sagety Audit (LOSA)
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AMENDMENTSThe issue of amendments is announced regularly in the ICAO Journal and in themonthly Supplement to the Catalogue of ICAO Publications and Audio-visualTraining Aids, which holders of this publication should consult. The space belowis provided to keep a record of such amendments.RECORD OF AMENDMENTS AND CORRIGENDAAMENDMENTSCORRIGENDANo.DateapplicableDateenteredEnteredbyNo.Dateof issueDateenteredEnteredbyii
iiiTABLE OF CONTENTSPagePageForeword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vAcronyms and Abbreviations . . . . . . . . . . . . . . . . .viIntroduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viiChapter 1.Basic error management concepts. .1-11.1Introduction . . . . . . . . . . . . . . . . . . . . . . . . .1-11.2Background . . . . . . . . . . . . . . . . . . . . . . . . .1-2Reactive strategies. . . . . . . . . . . . . . . . . .1-2Combined reactive/proactive strategies. .1-2Proactive strategies . . . . . . . . . . . . . . . . .1-41.3A contemporary approach to operational human performance and error. . . . . . . . . . .1-51.4The role of the organizational culture . . . .1-71.5Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . .1-7Chapter 2.Implementing LOSA . . . . . . . . . . . . .2-12.1History of LOSA. . . . . . . . . . . . . . . . . . . . .2-12.2The Threat and Error Management Model.2-1Threats and errors defined. . . . . . . . . . . .2-1Definitions of crew error response . . . . .2-4Definitions of error outcomes. . . . . . . . .2-4Undesired Aircraft States . . . . . . . . . . . .2-42.3LOSA operating characteristics . . . . . . . . .2-5Observer assignment . . . . . . . . . . . . . . . .2-7Flight crew participation. . . . . . . . . . . . .2-72.4How to determine the scope of a LOSA . .2-72.5Once the data is collected. . . . . . . . . . . . . .2-82.6Writing the report . . . . . . . . . . . . . . . . . . . .2-82.7Success factors for LOSA. . . . . . . . . . . . . .2-8Chapter 3.LOSA and the safety change process SCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-13.1Introduction . . . . . . . . . . . . . . . . . . . . . . . . .3-13.2A constantly changing scene. . . . . . . . . . . .3-13.3One operators example of an SCP . . . . . .3-2Chapter 4.How to set up a LOSA US Airways experience . . . . . . . . . . . . . . . . . . . . . .4-14.1Gathering information. . . . . . . . . . . . . . . . .4-14.2Interdepartmental support . . . . . . . . . . . . . .4-14.3LOSA steering committee. . . . . . . . . . . . . .4-1Safety department . . . . . . . . . . . . . . . . . .4-1Flight operations and trainingdepartments . . . . . . . . . . . . . . . . . . . . . . .4-2Pilots union . . . . . . . . . . . . . . . . . . . . . . .4-24.4The key steps of a LOSA. . . . . . . . . . . . . .4-2Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-2Action plan . . . . . . . . . . . . . . . . . . . . . . .4-24.5The keys to an effective LOSA . . . . . . . . .4-4Confidentiality and no-jeopardy. . . . . . .4-4The role of the observer . . . . . . . . . . . . .4-54.6Promoting LOSA for flight crews . . . . . . .4-5Appendix A Examples of the various forms utilized by LOSA . . . . . . . . . . . . . . . . . . . . . . . . . . .A-1Appendix B Example of an introductory letter by an airline to its flight crews. . . . . . . . . . . . . . . .B-1Appendix C List of recommended reading and reference material. . . . . . . . . . . . . . . . . . . . . . .C-1
vFOREWORDThe safety of civil aviation is the major objective of theInternational Civil Aviation Organization ICAO. Consider-able progress has been made in increasing safety, butadditional improvements are needed and can be achieved. Ithas long been known that the majority of aviation accidentsand incidents result from less than optimum human per-formance, indicating that any advance in this field can beexpected to have a significant impact on the improvementof aviation safety.This was recognized by the ICAO Assembly, which in 1986adopted Resolution A26-9 on Flight Safety and HumanFactors. As a follow-up to the Assembly Resolution, the AirNavigation Commission formulated the following objectivefor the taskTo improve safety in aviation by making States more awareand responsive to the importance of Human Factors in civilaviation operations through the provision of practicalHuman Factors materials and measures, developed on thebasis of experience in States, and by developing andrecommending appropriate amendments to existing materialin Annexes and other documents with regard to the role ofHuman Factors in the present and future operationalenvironments. Special emphasis will be directed to theHuman Factors issues that may influence the design,transition and in-service use of the future ICAO CNS/ATMsystems.One of the methods chosen to implement AssemblyResolution A26-9 is the publication of guidance materials,including manuals and a series of digests, that addressvarious aspects of Human Factors and its impact on aviationsafety. These documents are intended primarily for use byStates to increase the awareness of their personnel of theinfluence of human performance on safety.The target audience of Human Factors manuals and digestsare the managers of both civil aviation administrations andthe airline industry, including airline safety, training andoperational managers. The target audience also includesregulatory bodies, safety and investigation agencies andtraining establishments, as well as senior and middle non-operational airline management.This manual is an introduction to the latest informationavailable to the international civil aviation community on thecontrol of human error and the development of counter-measures to error in operational environments. Its targetaudience includes senior safety, training and operationalpersonnel in industry and regulatory bodies.This manual is intended as a living document and will bekept up to date by periodic amendments. Subsequenteditions will be published as new research results inincreased knowledge on Human Factors strategies and moreexperience is gained regarding the control and managementof human error in operational environments.
viACRONYMS AND ABBREVIATIONSADSAutomatic Dependent SurveillanceATCAir Traffic ControlCFITControlled Flight Into TerrainCNS/ATMCommunications, Navigation and Surveillance/Air Traffic ManagementCPDLCController-Pilot Data Link CommunicationsCRMCrew Resource ManagementDFDRDigital Flight Data RecorderETOPSExtended Range Operations by Twin-engined AeroplanesFAAFederal Aviation AdministrationFDAFlight Data AnalysisFMSFlight Management SystemFOQAFlight Operations Quality AssuranceICAOInternational Civil Aviation OrganizationLOSALine Operations Safety AuditMCPMode Control PanelQARQuick Access RecorderRTORejected Take-OffSCPSafety Change ProcessSOPsStandard Operating ProceduresTEMThreat and Error ManagementUTTEMUniversity of Texas Threat and Error Management
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Doc 9683. Edition 1. Human Factors Training ManualCircular 247. Edition 1. Human Factors Digest No. 10 - Human Factors, Management and OrganizationDoc 9868. Edition 2. TrainingDoc 9868. Edition 3. Procedures For Air Navigation Services. TrainingDoc 9814. Annual Report of the Council - 2002 umentation for the Session of the Assembly in 2004Doc 9842. Programme Budget of the Organization 2005-2006-2007Doc 9868. Edition 1. Procedures for Air Navigation Services TrainingDoc 10002. Edition 1. Cabin Crew Safety Training ManualDoc 10002. Edition 2. Cabin Crew Safety Training ManualCircular 302. Edition 1. Human Factors Digest No. 16 - Cross-Cultural Factors in Aviation SafetyCircular 314. Edition 1. Threat and Error Management (TEM) in Air Traffic ControlCircular 323. Edition 1. Guidelines for Aviation English Training ProgrammesВСЕ ДОКУМЕНТЫALL DOCUMENTSDoc 9803
Table Of Contents
COVER PAGE
AMENDMENTS
TABLE OF CONTENTS
FOREWORD
ACRONYMS AND ABBREVIATIONS
INTRODUCTION
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Appendix A
Appendix B
Appendix C