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1-4 Line Operations Safety Audit (LOSA)
provide an inexpensive mechanism to obtain significant
information regarding many aspects of the organization,
including the perceptions and opinions of operational
personnel; the relevance of training to line operations; the
level of teamwork and cooperation among various employee
groups; problem areas or bottlenecks in daily operations;
and eventual areas of dissatisfaction. Surveys can also probe
the safety culture; for example, do personnel know the
proper channels for reporting safety concerns and are they
confident that the organization will act on expressed
concerns? Finally, surveys can identify areas of dissent or
confusion, for example, diversity in beliefs among particular
groups from the same organization regarding the appropriate
use of procedures or tools. On the minus side, surveys
largely reflect perceptions. Surveys can be likened to
incident reporting and are therefore subject to the
shortcomings inherent to reporting systems in terms of
understanding operational human performance and error.
Flight data recording
1.2.12 Digital Flight Data Recorder (DFDR) and
Quick Access Recorder (QAR) information from normal
flights is also a valuable diagnostic tool. There are, however,
some limitations about the data acquired through these
systems. DFDR/QAR readouts provide information on the
frequency of exceedences and the locations where they
occur, but the readouts do not provide information on the
human behaviours that were precursors of the events. While
DFDR/QAR data track potential systemic problems, pilot
reports are still necessary to provide the context within
which the problems can be fully diagnosed.
1.2.13 Nevertheless, DFDR/QAR data hold high
cost/efficiency ratio potential. Although probably underutilized
because of cost considerations as well as cultural
and legal reasons, DFDR/QAR data can assist in identifying
operational contexts within which migration of behaviours
towards the limits of the system takes place.
Proactive strategies
Normal line operations monitoring
1.2.14 The approach proposed in this manual to
identify the successful human performance mechanisms that
contribute to aviation safety and, therefore, to the design of
countermeasures against human error focuses on the
monitoring of normal line operations.
Figure 1-2. Training Behaviours — Accomplishing training goals
Safety
Production
Chapter 1. Basic error management concepts 1-5
1.2.15 Any typical routine flight — a normal process
— involves inevitable, yet mostly inconsequential errors
(selecting wrong frequencies, dialling wrong altitudes,
acknowledging incorrect read-backs, mishandling switches
and levers, etc.) Some errors are due to flaws in human
performance while others are fostered by systemic shortcomings;
most are a combination of both. The majority of
these errors have no negative consequences because operational
personnel employ successful coping strategies and
system defences act as a containment net. In order to design
remedial strategies, the aviation industry must learn about
these successful strategies and defences, rather than continue
to focus on failures, as it has historically done.
1.2.16 A medical analogy may be helpful in
illustrating the rationale behind LOSA. Human error could
be compared to a fever: an indication of an illness but not
its cause. It marks the beginning rather than the end of the
diagnostic process. Periodic monitoring of routine flights is
therefore like an annual physical: proactively checking
health status in an attempt to avoid getting sick. Periodic
monitoring of routine flights indirectly involves measurement
of all aspects of the system, allowing identification of
areas of strength and areas of potential risk. On the other
hand, incident investigation is like going to the doctor to fix
symptoms of problems; possibly serious, possibly not. For
example, a broken bone sends a person to the doctor; the
doctor sets the bone but may not consider the root cause(s)
— weak bones, poor diet, high-risk lifestyle, etc. Therefore,
setting the bone is no guarantee that the person will not turn
up again the following month with another symptom of the
same root cause. Lastly, accident investigation is like a postmortem:
the examination made after death to determine its
cause. The autopsy reveals the nature of a particular
pathology but does not provide an indication of the
prevalence of the precipitating circumstances. Unfortunately,
many accident investigations also look for a
　
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