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refocus and/or design known as Threat and Error Management
(TEM) training. Data from LOSA also provide a
real-time picture of system operations that can guide
organizational strategies in regard to safety, training and
operations. A particular strength of LOSA is that it identifies
examples of superior performance that can be reinforced and
used as models for training. In this way, training interventions
can be reshaped and reinforced based on successful
performance, that is to say, positive feedback. This is indeed
a first in aviation, since the industry has traditionally
collected information on failed human performance, such as
in accidents and incidents. Data collected through LOSA are
proactive and can be immediately used to prevent adverse
events.
4. LOSA is a mature concept, yet a young one. LOSA
was first operationally deployed following the First LOSA
Week, which was hosted by Cathay Pacific Airways in
Cathay City, Hong Kong, from 12 to 14 March 2001.
Although initially developed for the flight deck sector, there
is no reason why the methodology could not be applied to
other aviation operational sectors, including air traffic
control, maintenance, cabin crew and dispatch.
5. The initial research and project definition was a joint
endeavour between The University of Texas at Austin
Human Factors Research Project and Continental Airlines,
with funding provided by the Federal Aviation Administration
(FAA). In 1999, ICAO endorsed LOSA as the
primary tool to develop countermeasures to human error in
aviation operations, developed an operational partnership
with The University of Texas at Austin and Continental
Airlines, and made LOSA the central focus of its Flight
Safety and Human Factors Programme for the period 2000
to 2004.
6. As of February 2002, the LOSA archives contained
observations from over 2 000 flights. These observations
were conducted within the United States and internationally
and involved four United States and four non-United States
operators. The number of operators joining LOSA has
constantly increased since March 2001 and includes major
international operators from different parts of the world and
diverse cultures.
7. ICAO acts as an enabling partner in the LOSA
programme. ICAO’s role includes promoting the importance
of LOSA to the international civil aviation community;
facilitating research in order to collect necessary data; acting
as a cultural mediator in the unavoidably sensitive aspects
of data collection; and contributing multicultural observations
to the LOSA archives. In line with these objectives,
the publication of this manual is a first step at providing
information and, therefore, at increasing awareness within
the international civil aviation community about LOSA.
8. This manual is an introduction to the concept,
methodology and tools of LOSA and to the potential
remedial actions to be undertaken based on the data
collected under LOSA. A very important caveat must be
introduced at this point: this manual is not intended to
convert readers into instant expert observers and/or LOSA
auditors. In fact, it is strongly recommended that LOSA not
be attempted without a formal introduction to it for the
(viii) Line Operations Safety Audit (LOSA)
following reasons. First, the forms presented in Appendix A
are for illustration purposes exclusively, since they are
periodically amended on the basis of experience gained and
feedback obtained from continuing audits. Second, formal
training in the methodology, in the use of LOSA tools and,
most important, in the handling of the highly sensitive data
collected by the audits is absolutely essential. Third, the
proper structuring of the data obtained from the audits is of
paramount importance.
9. Therefore, until extensive airline experience is
accumulated, it is highly desirable that LOSA training be
coordinated through ICAO or the founding partners of the
LOSA project. As the methodology evolves and reaches full
maturity and broader industry partnerships are developed,
LOSA will be available without restrictions to the
international civil aviation community.
10. This manual is designed as follows:
• Chapter 1 includes an overview on safety, and
human error and its management in aviation
operations. It provides the necessary background
information to understand the rationale for LOSA.
• Chapter 2 discusses the LOSA methodology and
provides a guide to the implementation of LOSA
within an airline. It also introduces a model of crew
error management and proposes the error classification
　
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