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Factors. As a follow-up to the Assembly Resolution, the Air
Navigation Commission formulated the following objective
for the task:
“To improve safety in aviation by making States more aware
and responsive to the importance of Human Factors in civil
aviation operations through the provision of practical
Human Factors materials and measures, developed on the
basis of experience in States, and by developing and
recommending appropriate amendments to existing material
in Annexes and other documents with regard to the role of
Human Factors in the present and future operational
environments. Special emphasis will be directed to the
Human Factors issues that may influence the design,
transition and in-service use of the future ICAO CNS/ATM
systems.”
One of the methods chosen to implement Assembly
Resolution A26-9 is the publication of guidance materials,
including manuals and a series of digests, that address
various aspects of Human Factors and its impact on aviation
safety. These documents are intended primarily for use by
States to increase the awareness of their personnel of the
influence of human performance on safety.
The target audience of Human Factors manuals and digests
are the managers of both civil aviation administrations and
the airline industry, including airline safety, training and
operational managers. The target audience also includes
regulatory bodies, safety and investigation agencies and
training establishments, as well as senior and middle nonoperational
airline management.
This manual is an introduction to the latest information
available to the international civil aviation community on the
control of human error and the development of countermeasures
to error in operational environments. Its target
audience includes senior safety, training and operational
personnel in industry and regulatory bodies.
This manual is intended as a living document and will be
kept up to date by periodic amendments. Subsequent
editions will be published as new research results in
increased knowledge on Human Factors strategies and more
experience is gained regarding the control and management
of human error in operational environments.
(vi)
ACRONYMS AND ABBREVIATIONS
ADS Automatic Dependent Surveillance
ATC Air Traffic Control
CFIT Controlled Flight Into Terrain
CNS/ATM Communications, Navigation and Surveillance/Air Traffic Management
CPDLC Controller-Pilot Data Link Communications
CRM Crew Resource Management
DFDR Digital Flight Data Recorder
ETOPS Extended Range Operations by Twin-engined Aeroplanes
FAA Federal Aviation Administration
FDA Flight Data Analysis
FMS Flight Management System
FOQA Flight Operations Quality Assurance
ICAO International Civil Aviation Organization
LOSA Line Operations Safety Audit
MCP Mode Control Panel
QAR Quick Access Recorder
RTO Rejected Take-Off
SCP Safety Change Process
SOPs Standard Operating Procedures
TEM Threat and Error Management
UTTEM University of Texas Threat and Error Management
(vii)
INTRODUCTION
1. This manual describes a programme for the
management of human error in aviation operations known
as Line Operations Safety Audit (LOSA). LOSA is proposed
as a critical organizational strategy aimed at developing
countermeasures to operational errors. It is an organizational
tool used to identify threats to aviation safety, minimize the
risks such threats may generate and implement measures to
manage human error in operational contexts. LOSA enables
operators to assess their level of resilience to systemic
threats, operational risks and front-line personnel errors,
thus providing a principled, data-driven approach to
prioritize and implement actions to enhance safety.
2. LOSA uses expert and highly trained observers to
collect data about flight crew behaviour and situational
factors on “normal” flights. The audits are conducted under
strict no-jeopardy conditions; therefore, flight crews are not
held accountable for their actions and errors that are
observed. During flights that are being audited, observers
record and code potential threats to safety; how the threats
are addressed; the errors such threats generate; how flight
crews manage these errors; and specific behaviours that have
been known to be associated with accidents and incidents.
3. LOSA is closely linked with Crew Resource
Management (CRM) training. Since CRM is essentially
error management training for operational personnel, data
from LOSA form the basis for contemporary CRM training
　
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