Auditor En Calidad

Doc 9803 AN/761

Line Operations Safety Audit (LOSA)

Approved by the Secretary General and published under his authority

First Edition — 2002

International Civil Aviation Organization

AMENDMENTS
The issue of amendments is announced regularly in the ICAO Journal and in the monthly Supplement to the Catalogue of ICAO Publications and Audio-visual Training Aids, which holders of thispublication should consult. The space below is provided to keep a record of such amendments.

RECORD OF AMENDMENTS AND CORRIGENDA
AMENDMENTS No. Date applicable Date entered Entered by No. Date of issue CORRIGENDA Date entered Entered by

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TABLE OF CONTENTS

Page Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acronyms and Abbreviations . . . . . . . .. . . . . . . . . (v) (vi) 3.1 3.2 3.3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . A constantly changing scene. . . . . . . . . . . . One operator’s example of an SCP . . . . . . Chapter 3. LOSA and the safety change process (SCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Page

3-1 3-1 3-1 3-2

Introduction . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . (vii) Chapter 1. 1.1 1.2 Basic error management concepts . . 1-1 1-1 1-2 1-2 1-2 1-4 1-5 1-7 1-7

1.3 1.4 1.5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . Reactive strategies . . . . . . . . . . . . . . . . . . Combined reactive/proactive strategies . . Proactive strategies . . . . . . . . . . . .. . . . . A contemporary approach to operational human performance and error . . . . . . . . . . . The role of the organizational culture . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . Implementing LOSA . . . . . . . . . . . . .

Chapter 4. How to set up a LOSA — US Airways experience . . . . . . . . . . . . . . . . . . . . . . 4.1 4.2 4.3 Gathering information . . . . .. . . . . . . . . . . . Interdepartmental support . . . . . . . . . . . . . . LOSA steering committee. . . . . . . . . . . . . . Safety department . . . . . . . . . . . . . . . . . . Flight operations and training departments . . . . . . . . . . . . . . . . . . . . . . . Pilots union . . . . . . . . . . . . . . . . . . . . . . . The key steps of a LOSA . . . . . . . . . . . . . . Goals . . . . . .. . . . . . . . . . . . . . . . . . . . . . Action plan . . . . . . . . . . . . . . . . . . . . . . . The keys to an effective LOSA . . . . . . . . . Confidentiality and no-jeopardy . . . . . . . The role of the observer . . . . . . . . . . . . . Promoting LOSA for flight crews . . . . . . .

4-1 4-1 4-1 4-1 4-1 4-2 4-2 4-2 4-2 4-2 4-4 4-4 4-5 4-5

4.4 Chapter 2. 2.1 2.2 2-1 2-1 2-1 2-1 2-42-4 2-4 2-5 2-7 2-7 2-7 2-8 2-8 2-8 4.5

2.3

2.4 2.5 2.6 2.7

History of LOSA . . . . . . . . . . . . . . . . . . . . . The Threat and Error Management Model. Threats and errors defined. . . . . . . . . . . . Definitions of crew error response . . . . . Definitions of error outcomes . . . . . . . . . Undesired Aircraft States . . . . . . . . . . . . LOSA operating characteristics . . . . . .. . . Observer assignment . . . . . . . . . . . . . . . . Flight crew participation . . . . . . . . . . . . . How to determine the scope of a LOSA . . Once the data is collected . . . . . . . . . . . . . . Writing the report . . . . . . . . . . . . . . . . . . . . Success factors for LOSA . . . . . . . . . . . . . .

4.6

Appendix A — Examples of the various forms utilized by LOSA . . . . . .. . . . . . . . . . . . . . . . . . . . . Appendix B — Example of an introductory letter by an airline to its flight crews . . . . . . . . . . . . . . . . Appendix C — List of recommended reading and reference material . . . . . . . . . . . . . . . . . . . . . . .

A-1

B-1

C-1

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FOREWORD

The safety of civil aviation is the major objective of the International Civil...