captain don gunther senior director safety & regulatory compliance line operations safety audit...

Captain Don GuntherSenior Director Safety & Regulatory Compliance

““Line Operations Safety Audit Line Operations Safety Audit (LOSA)”(LOSA)”

““Line Operations Safety Audit Line Operations Safety Audit (LOSA)”(LOSA)”

Continental Airlines, Feb 2007Continental Airlines, Feb 2007

Line Operations Safety Audit (LOSA)Line Operations Safety Audit (LOSA)and Threat & Error Management (TEM) and Threat & Error Management (TEM)

are integral parts of a are integral parts of a Safety Management System (SMS)Safety Management System (SMS)


Aviation Week Article on Healthy Organizations

“Investing the time and money needed to get at the root cause of a problem takes total commitment at the most senior levels of a company or organization. In most organizational settings, communicators learn early in life how bad news can impact their leaders. If the news is valued and the communicator is If the news is valued and the communicator is protected, there is a real chance information can and protected, there is a real chance information can and will routinely flow upward in time for proper action to will routinely flow upward in time for proper action to be takenbe taken.”

Safety Culture


Corporate Culture

How well does your company accept safety inputs when busy with the Operation?How well does your company accept safety inputs when busy with the Operation?


Over 95% goes unreported!Over 95% goes unreported!

Human Error


Data driven Safety Change through Non-Jeopardy Reporting


The Safety Change Program“Tailored to your Airline”“Tailored to your Airline”

To properly target change you need current operational data, specifically for your airline, which is unique due to its…• History & Culture• Areas of operation (ETOPS, polar routes, etc.)• Philosophy


By not having data to discover the precursors By not having data to discover the precursors “specific” to an individual airline’s “specific” to an individual airline’s

operations, this is the bottom-line…operations, this is the bottom-line…

Line Observation Safety Audit(LOSA)

Line Observation Safety Audit(LOSA)


University of Texas

Human Factors

Research ProjectHuman Factors Research ProjectHuman Factors Research Project

www.psy.utexas.edu/HumanFactors

The LOSA CollaborativeThe LOSA Collaborative

www.Losacollaborative.org

http://www.psy.utexas.edu/HumanFactors

http://www.losacollaborative.org/


Data for a Safety Culture How do airlines monitor safety?

• Accident investigation• Incident reports – ASRS, ASAP

• Data show events resulting from system and crew failures

• Line checks/Safety audits • Data slanted to crew proficiency and procedural knowledge


Data for a Safety Culture How do airlines monitor safety?

• Accident investigation• Incident reports – ASRS, ASAP

• Data show events resulting from system and crew failures

• Line checks • Data slanted to crew proficiency and procedural knowledge

• Observing normal operations – Line Operations Safety Audit (LOSA) • Gives data on why things happen and how they are managed

• Provides a more realistic baseline of safety


Purpose of LOSA

Data provide a baseline of safety pertaining to:

1. Flight crew performance – strengths and weaknessesa) Proficiency

b) Decision-Making

c) CRM skills

d) Procedural compliance

2. System performance – strengths and weaknessesa) Culture

b) National Airspace System – Airports and Navigational Aids

c) Aircraft design / automation

d) Standards / Training / Safety / Maintenance

e) Crew support – ATC, Cabin, Ground, and Dispatch


ICAO Perspective on LOSA

- Costa Pereira, ICAO Secretary General in May 8, 2000

“[LOSA] acquires direct, first-hand data on the successful recovery from errors by flight crews during normal line flights. [It] is aimed at collecting data on successful human performance; and this is indeed a first in our industry, since aviation has traditionally collected data on failed human performance, such as an accident or incident investigation.” correspondence to Jane F. Garvey, FAA Administrator


“Normal” Performance

Normal

FAA CheckAirmen LOSA 1 LOSA 2

• Distance between “Perfect” and “Normal performance varies as a function of culture, training, etc.

• LOSA enables us to get as closer to normal performance than was previously possible.

Perfect


The Safety Bottom Line What do crews have to do to operate safely?

Error Avoidance1 Avoid committing errors

Manage operational complexity2 Threat Management

Manage their own errors3 Error Management

Undesired State Management

4 Manage deviations

Safety Bottom Line


The Continental LOSA Process

1st year • LOSA and data analysis followed by course

development

2nd & 3rd years • Training course for all crewmembers, Check Airmen

training and imbedding of TEM into courseware, policy & procedures, etc.

4th year • Preparation for next LOSA and targeting areas to be

measured and new areas to be emphasized.


Line Operations Safety Audit (LOSA)

LOSA –observations of crew performance during regular scheduled operations• Observers unobtrusive – collecting data not

participating• Team of observers from different backgrounds

• Line personnel / Union representatives• Safety and Training personnel• UT observers

• All data are De-identified and Confidential

Line Observation Safety AuditLine Observation Safety AuditLOSA 1996LOSA 1996


LOSA

Crew Survey• Measure Safety Culture


LOSA


Crew Interview• Targeted questions


NewsletterFeedback to the pilots is essential for continued

program success.


LOSA


Crew Interview• Targeted questions

Crew Flight Observations• Data on Threats, Errors & Behaviors


Threat and Error ManagementThreat and Error Management


Threat

Event that occurs outside the influence of the flight crew, but which requires crew attention and management if safety margins are to be maintained

Increases the complexity of the operation


THREATSInfluences that can lead to crew error“Increase complexity of the operation”

Weather

MaintenanceError

Ground CrewError

Cabin CrewError

Passenger eventsATC

Terrain

Similar call sign

Time pressures

Heavy traffic

Unfamiliar airport

Automation event Missed approach

Flight diversion

System malfunction

Distractions


Threat Management

Strategies/Countermeasures (Industry, Corporate and/or Personal)

• To reduce the number of errors

• To improve the error management process by increasing the awareness of potential errors

• Is managing your future


Error

Actions or inactions by the flight crew that lead to deviations from intention or expectation


Error Management

Actions taken to deal with errors committed by either

Detecting and correcting them, or by

Containing and reducing the severity

Is managing your past


Consequences

Undesired Aircraft State (UAS)


1996 LOSA ACTIONS

Develop training course based on data• Error Management

• Target Check Airmen first

Committees of Subject Matter Experts• Stable Approach • Checklist• Leadership


Line Observation Safety AuditLOSA 2000


LOSA 1996 vs. 2000

A 70% reduction in Checklist errors A 60% reduction in unstable

approaches• confirmed by FOQA/FDM data

Overall improvement in crew performance

Still a need for improvement in Leadership skills


2000 LOSA ACTIONS

Develop training course based on data• Threat & Error Management

• Target Check Airmen• Imbedded throughout entire program


B-737 Standards MeetingB-737 Standards MeetingFebruary 21February 21stst, 2001, 2001

The Role of the Check Airman inThe Role of the Check Airman inThreat & Error ManagementThreat & Error Management


Check Airmen Debriefing Guide


Line Check Safety Audits(LCSA)


Crew Resource ManagementCrew Resource Management

Effective Crew Resource Management is the bedrock of Threat and Error

Management.

Line Observation Safety AuditLOSA 2004


To have an effective SMS…

Data is needed to drive effective

Safety Change

&

Safety & Operational Efficiency

need to be combined into a

Corporate “Safety CultureSafety Culture”

captain don gunther senior director safety & regulatory compliance line operations safety audit...

Documents

continental airlines

safety culture slide

continental losa process

deviations safety

safety inputs

purpose of losa data

data driven safety change

perfect slide