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discovered by the crew, dispatch paperwork errors and
discrepancies in passenger boarding counts by cabin
attendants.
Errors
2.2.6 Cockpit crew error is defined as an action or
inaction by the crew that leads to deviations from
organizational or flight crew intentions or expectations.
Errors in the operational context tend to reduce the margin
of safety and increase the probability of accidents or
incidents. Errors may be defined in terms of non-compliance
with regulations, Standard Operating Procedures (SOPs) and
policies, or unexpected deviation from crew, company or
ATC expectations. Errors observed may be minor (selecting
the wrong altitude into the mode control panel (MCP), but
correcting it quickly) or major (forgetting to do an essential
checklist). Observers should record all cockpit crew errors
that they detect.
2.2.7 Operators set up SOPs and checklists as the
standards for the proper and safe way to conduct flights.
Instructors observing deviations from SOPs or checklists
would define this as an error, and so does LOSA. If a crew
member does not know how to execute a procedure properly
or cannot control the aircraft in the expected manner, an
instructor would also consider this an error, and so does
LOSA. Deviations from expectations of ATC are also
classified as crew errors; these would, for example, include
altitude deviations or significant deviations around thunderstorms
without ATC notification. There are rules in SOPs
and/or operator manuals that, for example, specify how
much deviation crews may make around thunderstorms
before notifying ATC, and observers must be familiar with
and apply these company rules when conducting observations.
Operators also have policies that are less
proscriptive than procedures, where preferred modes of
operation are described. Pilots may violate policies without
violating SOPs or increasing risk, and under LOSA, this is
not defined as an error. However, if the observer feels that
violating a policy unnecessarily increases risk to flight
safety, it would be defined as an error. There are also many
decision points on a normal flight that are not defined by
SOPs or procedures. However, any time the crew makes a
decision that unnecessarily increases risk to flight safety, it
is defined as a crew error.
2.2.8 Crew errors may not have any consequences, but
they still need to be recorded by the observer. For example,
a violation to the sterile cockpit rule may not have any
negative consequence to the flight, but it is a violation of
regulations and thus must be entered as an error. In addition,
errors may be intentional or unintentional. As implied in the
definition, when a crew action is appropriate or prescribed
in SOPs, the lack of action may also be defined as an error.
2.2.9 Is poor crew behaviour that is not a violation of
regulations or SOPs (and did not result in an increased risk
to flight safety) deemed an error? For example, should
observers enter an error if a crew performed the predeparture
briefing in such a way that it was felt to deserve
a “minimal proficiency”? The answer is “No”. If the
minimally proficient or poor pre-departure briefing (or any
other less than optimum behaviour) was not associated with
an error of some kind, then it is not an error in its own right
and should not be entered in the observation form.
2.2.10 LOSA is predicated upon the following five
categories of crew errors:
1. Intentional non-compliance error: Wilful deviation
from regulations and/or operator procedures;
2. Procedural error: Deviation in the execution of
regulations and/or operator procedures. The intention
is correct but the execution is flawed. This
category also includes errors where a crew forgot to
do something;
3. Communication error: Miscommunication, misinterpretation,
or failure to communicate pertinent
information among the flight crew or between the
flight crew and an external agent (for example, ATC
or ground operations personnel);
4. Proficiency error: Lack of knowledge or
psychomotor (“stick and rudder”) skills; and
5. Operational decision error: Decision-making error
that is not standardized by regulations or operator
2-4 Line Operations Safety Audit (LOSA)
procedures and that unnecessarily compromises
safety. In order to be categorized as an operational
decision error, at least one of three conditions must
have existed:
• The crew must have had more conservative
options within operational reason and decided
not to take them;
• The decision was not verbalized and, therefore,
　
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