Beyond the Cockpit: The Spread of LOSA and Threat and Error Management

1. Beyond the Cockpit:The Spread of LOSA and Threat and Error Management RobertL. Helmreich, PhD, FRAeS Human Factors Research Project Department of Psychology The University of Texas at Austin 4th ICAO-IATA LOSA and TEM Conference Toulouse, 16 November

2. The Line Operations Safety Audit • LOSA is application of the methodology of systematic observation to recording flight crew behavior and threats to safety in the operating environment • Historically, the methodology was applied to recording the behavior of Aquanauts living in undersea habitats placed on the ocean floor • Observations of flight crews (precursors to LOSA) began in 1979 with Texas International Airlines and later Pan American Airlines and Delta Airlines

3. Extensions of LOSA in Airlines • LOSA methodology has been applied (in collaboration with Continental Airlines) to • Dispatch operations (DOSA) • Ramp operations (ROSA)

4. TEM & CRM • Research in the LOSA Archive supports the links between TEM and CRM. • Crews that develop contingency management plans, such as proactively discussing strategies for anticipated threats, have fewer mismanaged threats • Crews that exhibit good monitoring and cross-checking make fewer errors • Crews that exhibit strong leadership, inquiry, and workload and automation management have fewer mismanaged errors and undesired aircraft states

5. International Conferences LOSA Week • 2001 Hong Kong • 2001 Panama City, Panama • 2002 United Arab Emirates, Dubai • 2003 Dublin • 2006 Toulouse Threat and Error Management workshop: • 2002 San Salvador

6. Published Guidelines • ICAO (2002). Line Operations Safety Audit (LOSA). DOC 9803-AN/761. Montreal: International Civil Aviation Organization (under revision) • FAA (2006) LOSA Advisory Circular 120-90 Line Operations Safety Audits (Includes Threat and Error Management)

7. ASAP: Aviation Safety Action ProgramMichelle Harper, Doctoral Candidate

8. ASAP Characteristics • ASAP is an extension of NASA’s Aviation Safety Reporting System (ASRS) • Under ASAP, pilots report threats and errors (excluding intentional non-compliance and drug and alcohol violations) to their company and receive the same limited immunity from punishment provided by ASRS

9. ASAP Benefits • Unlike ASRS, information is immediately available to company management and allows corrective action to be taken • ASAP committee (union, management, regulator) reviews reports and determines corrective action • Actions are reported back to pilot • Don Gunther of Continental can clarify

10. The UT ASAP Data Collection System/ Distributed National ASAP Archive (DNAA) • Project Goals: • Provide airlines with a set of tools that can be used across the industry to collect and analyze factors contributing to ASAP events. • Development of web-based tools for supporting airline ASAP data collection • Establish a data-sharing program based on these tools to identify industry- and system-level, high-risk events • Development of the Distributed National ASAP Archive (DNAA) • Use the UT Threat and Error Management Model as the common taxonomy for categorizing ASAP events • Development of the DNAA Master List of common ASAP event descriptors

11. System Overview DNAA 1. 2. DNAA server • UT developed software that supports the airlines in collecting ASAP data • UT and NASA collaborated to enable airlines to share de-identified ASAP reports • Each airline shares data through a protected connection to NASA and UT

12. Participating Airlines * ** ** ** * Northwest airlines not participating in DNAA ** AA, UPS and United not using UT ASAP data collection tools

13. NOSS: Normal Operations Safety SurveyChris Henry, Doctoral Candidate

14. Normal Operations Safety Survey (NOSS) • NOSS is LOSA adapted to Air Traffic Control • TEM definitions congruent with LOSA • NOSS captures the work context and how controllers discharge their duties within that context • Threats are key elements of task environment • Aggregated Threat and Error Management data capture both system and individual performance • Over-the-shoulder observations • De-identified, non-jeopardy • Identify systemic strengths and vulnerabilities

15. NOSS & TEM: Additional Benefits • Airways NZ is analyzing normal operations and incident data using TEM • Service providers and airlines, using TEM as a common ‘language’ are exchanging more safety information on ATC interface • TEM training is being developed for controllers at service providers

16. Accident InvestigationBob Helmreich

17. TEM as Framework for Accident Investigation • IATA has adopted TEM as framework for classification of causal and contributing factors in global accident and incident database • Robert Sumwalt, new NTSB Vice Chairman • Trained in TEM • Served as LOSA observer

18. Current Investigations • Analysis of factors surrounding crash of LAPA B-737 in Buenos Aires requested by government of Argentina • Analysis of factors surrounding the crash of Flash Airlines B-737 at Sharm El Sheikh, Egypt requested by Boeing • Analysis of crew performance in crash of CRJ200 at Kirksville, MO requested by Bombardier

19. Extensions to Other Professions • Queensland Rail in Australia has adapted both TEM and LOSA to audit their operations • International Association of Fire Chiefs has used TEM in developing US national close call reporting system • RLH is member of committee developing guidelines

20. Conclusions • TEM can be used as the data structure for an organization’s Safety Management System • Allows integration of data from differing sources • Incident reports, incident and accident investigations, and LOSA and its derivatives

21. The University of Texas Human Factors Research Project www.psy.utexas.edu/HumanFactors