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to safety management, training and operations. Like FDA programmes, data collected through LOSA can
provide a rich source of information for the proactive identification of systemic safety hazards. A particular
strength of LOSA is that it identifies examples of superior performance that can be reinforced and used as
models for training. (Traditionally, the industry has collected information on failed performance and revised
training programmes accordingly.) With LOSA, training interventions can be based on the most successful
operational performance. For example, based on LOSA data, CRM training can be modified to reflect best
practices for coping with particular types of unsafe conditions and for managing typical errors related to
these conditions.
ICAO’s role
16.4.7 ICAO endorses LOSA as a way to monitor normal flight operations. ICAO supports the
industry’s initiatives with LOSA, serving as an enabling partner in the programme. ICAO’s role includes:
a) promoting the value of LOSA to the international civil aviation community;
b) facilitating research in order to collect necessary data; and
c) acting as a mediator in the culturally sensitive aspects of data collection.
16-16 Safety Management Manual (SMM)
16.4.8 ICAO has published a manual, Line Operations Safety Audit (LOSA) (Doc 9803), to provide
guidance to operators regarding LOSA programmes.
Terminology
Threats
16.4.9 During normal flights, crews routinely face situations created outside the cockpit that they must
manage. Such situations increase the operational complexity of their task and pose some level of safety risk.
These threats may be relatively minor (such as frequency congestion), through to major (such as an enginefire
warning).
16.4.10 Some threats can be anticipated (such as a high workload situation during approach) and the
crew may brief in advance, for example, “In the event of a go-around ...”. Other threats may be unexpected.
Since they occur without warning, no advanced briefing is feasible (for example, a TCAS advisory).
Errors
16.4.11 Errors are a normal part of all human behaviour. Flight crew errors tend to reduce the margin
of safety and increase the probability of accidents. Fortunately, humans are generally quite effective in
balancing the conflicting demands between “getting the job done” and “getting the job done safely”.
16.4.12 Any action or inaction by the flight crew that leads to deviations from expected behaviour is
considered an error. Examples of crew errors might include non-compliance with regulations and SOPs, or
unexpected deviation from company or ATC expectations. Errors may be minor (setting the wrong altitude,
but correcting it quickly) or major (not completing an essential checklist item).
16.4.13 LOSA employs five categories of crew errors. These include:
a) Communication error: Miscommunication, misinterpretation, or failure to communicate pertinent
information among the flight crew or between flight crew and an external agent (for example, ATC or
ground operations personnel);
b) Proficiency error: Lack of knowledge or psychomotor (“stick and rudder”) skills;
c) Operational decision error: Decision-making error that is not standardized by regulation or
operator procedures and that unnecessarily compromises safety (for example, a crew decision to fly
through a known wind shear on approach instead of going around);
d) Procedural error: Deviation in execution of regulatory 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; and
e) Intentional non-compliance error: Wilful deviation from regulations and/or operator procedures
(i.e. violations).
Threat and error management
16.4.14 Since threats and errors are an integral part of daily flight operations, systematic
understanding of them is required for safely dealing with them. LOSA offers an informed perspective on
Chapter 16. Aircraft Operations 16-17
threats and errors from which suitable coping strategies can be developed. Specifically, quantifiable LOSA
data are useful in answering such questions as:
a) What type of threats do flight crews most frequently encounter? When and where do they occur, and
what types are the most difficult to manage?
b) What are the most frequently committed crew errors, and which ones are the most difficult to
manage?
c) What outcomes are associated with mismanaged errors? How many result in the aircraft being in an
“undesired” state (such as fast/slow on final approach)?
d) Are there significant differences between airports, fleets, routes or phases of flight vis-à-vis threats
　
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