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Beyond the Cockpit: The Spread of LOSA and Threat and Error Management Robert L. Beyond the Cockpit: The Spread of LOSA and Threat and Error Management Robert L. Helmreich, Ph. D, FRAe. S Human Factors Research Project Department of Psychology The University of Texas at Austin 4 th ICAO-IATA LOSA and TEM Conference Toulouse, 16 November

The Line Operations Safety Audit § § § LOSA is application of the methodology 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

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

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

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

Published Guidelines § § ICAO (2002). Line Operations Safety Audit (LOSA). DOC 9803 -AN/761. 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)

ASAP: Aviation Safety Action Program Michelle Harper, Doctoral Candidate ASAP: Aviation Safety Action Program Michelle Harper, Doctoral Candidate

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

ASAP Benefits § § § Unlike ASRS, information is immediately available to company management 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 n Don Gunther of Continental can clarify

The UT ASAP Data Collection System/ Distributed National ASAP Archive (DNAA) Project Goals: n The UT ASAP Data Collection System/ Distributed National ASAP Archive (DNAA) Project Goals: n n § Provide airlines with a set of tools that can be used across the industry to collect and analyze factors contributing to ASAP events. ü 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 ü Development of the Distributed National ASAP Archive (DNAA) Use the UT Threat and Error Management Model as the common taxonomy for categorizing ASAP events ü Development of the DNAA Master List of common ASAP event descriptors

System Overview 1. 2. DNAA server 1. UT developed software that supports the airlines System Overview 1. 2. DNAA server 1. UT developed software that supports the airlines in collecting ASAP data 2. 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

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

NOSS: Normal Operations Safety Survey Chris Henry, Doctoral Candidate NOSS: Normal Operations Safety Survey Chris Henry, Doctoral Candidate

Normal Operations Safety Survey (NOSS) § § NOSS is LOSA adapted to Air Traffic 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 n Threats are key elements of task environment n Aggregated Threat and Error Management data capture both system and individual performance Over-the-shoulder observations n De-identified, non-jeopardy n Identify systemic strengths and vulnerabilities

NOSS & TEM: Additional Benefits § § § Airways NZ is analyzing normal operations 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

Accident Investigation Bob Helmreich Accident Investigation Bob Helmreich

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

Current Investigations Analysis of factors surrounding crash of LAPA B -737 in Buenos Aires Current Investigations Analysis of factors surrounding crash of LAPA B -737 in Buenos Aires requested by government of Argentina n Analysis of factors surrounding the crash of Flash Airlines B-737 at Sharm El Sheikh, Egypt requested by Boeing n Analysis of crew performance in crash of CRJ 200 at Kirksville, MO requested by Bombardier n

Extensions to Other Professions § § Queensland Rail in Australia has adapted both TEM 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 n RLH is member of committee developing guidelines

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

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