- What is LOSA?
- Is LOSA just another audit program? We already have similar audit programs running!
- What are threats? What are errors?
- My company has many safety programs. Why do we want LOSA?
- My station's safety performance is great. If it isn't broken, don't fix it. I don't think we need LOSA.
- What is in it for me?
- Do I have to take off work to be a LOSA observer?
- Do I have to participate in LOSA program as an observer?
- Do I have to participate in LOSA program as an observee?
- As a manager/lead/supervisor, do I let my people skip work to conduct LOSA observations?
- Does LOSA ask my employees to report on each other?
- Will LOSA remove all threats?
A Line Operations Safety Assessment (LOSA) is an observational program for collecting safety-related data during normal operations. It is a means for a company to self-assess their safety margins. Monitoring routine operations, the cornerstone of the LOSA process, identifies at-risk behaviors so that they can be proactively managed. The process also reinforces positive behaviors. LOSA, a voluntary, non-threatening, non-punitive, peer-to-peer observational process, has been implemented in airline flight operations since the late 1990s. Due to the success of flight LOSA, the process has been expanded to other areas of the aviation operations, such as air traffic control, dispatch, cabin operations, maintenance, customer service, and ramp operations. On the flight side, LOSA stands for "Line Operations Safety Audit." To better promote voluntary participation and a proactive safety culture, the Airlines for America (A4A) Joint EMMC and Safety Council Human Factors Task Force and other organizations (e.g., International Aviation Transport Association) now use LOSA as an acronym for "Line Operations Safety Assessment."
LOSA is different from audit programs conducted by Quality Assurance Departments, Safety Departments, or external agencies. One essential characteristic of LOSA is "peer-to-peer observations" of normal operations. Maintenance LOSA and Ramp LOSA observations are not carried out by auditors — they are carried out by peers. There are two advantages of having peers conduct the observations. First, it is less intrusive. Let's face it — it is natural for people to "work to the rules" when being watched by an auditor. These altered behaviors do not provide an accurate reading of how work is accomplished during normal operations. On the other hand, frontline employees, while they may alter their behaviors at the start of a LOSA program, soon ease back into their normal behavior when peers conduct the observation. Second, as subject matter experts, who are familiar with local operations and environment, peer observers may be particularly insightful regarding where, when, and what to look for during an observation. LOSA complements other safety programs (e.g., Aviation Safety Action Program, Event Reporting) in a Safety Management System as a predictive hazard identification process.
Threat and Error Management (TEM) provides an underlying framework for LOSA data collection, recognizing that threats and errors are likely to occur in normal operations.
A threat is any condition that increases complexity of the operations and if not managed properly can decrease the safety margin. An error is a mistake that is made when threats are mismanaged. Errors increase the probability of adverse operational events during maintenance or during ground operations. Errors normally occur when threats are mismanaged. However, the threat-error linkage is not necessarily straightforward, and it may not always be possible to observe the threats that lead to an error. Error outcomes can be of three types: inconsequential (i.e., no effect on safety), an undesired operational state (a risky or unsafe condition for the aircraft, equipment, and/or personnel), or additional error(s) linked together across time. Managing an undesired operational state can be considered the last opportunity to avoid an unsafe outcome.
Managing risks associated with hazards has become increasingly important in modern organizations, especially as the aviation industry is moving toward implementation of a Safety Management System. Three methods can be used to find hazards that can be assessed for risk:
- Reactive hazard identification processes are investigations of accidents and incidents to determine the underlying factors (hazards) that lead to the accident/incident.
- Proactive hazard identification processes look for at-risk behaviors (hazards) before they lead to accidents/incidents, such as Quality Assurance audits and Hazard Reporting Systems.
- Predictive hazard identification processes also look for at-risk behaviors (hazards) before they lead to accidents/incidents, but these processes involve much more data collection than proactive processes. This allows the prediction of accidents/incidents. LOSA is a primary process for predictive hazard identification.During a LOSA observation, observers record and code identifiable threats and errors and how those threats and errors are managed. The data from LOSA observations provide indicators of organizational strengths and weaknesses, which facilitate the development of countermeasures to operational threats and errors.
My station's safety performance is great. If it isn't broken, don't fix it. I don't think we need LOSA.
Current great safety performance does not mean there are no safety risks or hazards lurking about. Maybe you have just been lucky. The US Federal Aviation Administration (FAA) will soon require through regulation that 121 operators implement a Safety Management System (SMS). The SMS will require that you have reactive, proactive, and predictive hazard identification processes in place. LOSA will meet the predictive hazard identification process requirement.
A LOSA program offers many benefits, for example, identifying strengths and weaknesses of normal operations, reducing undesirable events and consequently operating costs, and improving efficiency. A LOSA program is very relevant to the frontline employees like you; here are some reasonswhy:
- Assess the Degree of Transfer of Training. A LOSA provides a consistent measure of the adequacy and focus of training programs that allow an operator to manage those programs effectively.
- Check the Quality and Usability of Procedures. A LOSA provides insights about potential problems with procedures. A LOSA will locate problematic procedures and policies via poor adherence rates. A LOSA can also identify the extent of procedural deviations across tasks or fleets.
- Identify Design Problems in the Human/Machine Interface. A LOSA captures aircraft design, tooling design, and ground service equipment design issues for which technicians and ground servicing personnel have developed "work arounds." Some of these interface issues may be able to be fixed so that no work arounds are required.
- Understand Frontline Employees' Shortcuts and Workarounds. With experience comes expertise; frontline employees learn ways to save time and be more efficient. These techniques are rarely seen in a traditional audit, when performance is usually done "by the book." A LOSA provides an opportunity for the organization to capture collective expertise from within the frontline employee group, and then share that information with all its employees through formal organization communication channels. Using LOSA, false expertise — the adoption of a shortcut or work around that is flawed in its safety assumptions — can also be identified and remedied.
- Provide a Rationale for Allocation of Resources. Because LOSA results highlight both the strengths and weaknesses in an organization, the results provide a data-driven rationale for prioritizing and allocating scarce organizational resources toward continuous improvement.
No. Your training and observations will be scheduled during your normal work shift.
No. LOSA is a volunteer based program. Volunteering to assist your organization in reducing threats and errors in a non-punitive manner is a benefit to you and your fellow employees. LOSA relies upon trust and open communication on the peer-to-peer level. A volunteer has the personal drive and motivation toward the success of the program versus someone who is told they must engage.
LOSA is a voluntary program in which people agree to participate. If a LOSA observer is going to observe you carrying out a turn on the ramp or observe you carrying out a maintenance task, you have a right to refuse to be observed. However, after having the program purpose and methodology explained to you, the hope is that you will be happy to be observed. Each individual carrier or ground operator is fully responsible for interpreting and defining voluntary participation to its frontline employees in order to reach a mutual understanding.
Staff do not "skip work" when they carry out a LOSA observation. Management supports the program, and the staff volunteer to be LOSA observers as part of their job. The real issue is how many observations can be carried out and still make sure all of the work of the organization gets done. Ideally, with senior management's support, there will be enough manpower to allow LOSA observations to be conducted. The number of LOSA observations that can be carried out during a given time period will be dependent on workload and staffing. The frequency can be one observation per shift, one observation per day, or two to three observations each week — whatever can be accommodated. Based on previous successes, LOSA can be used for even small operations where the trained observers are part of the working crew.
No. Employee names are never recorded on the LOSA observation forms. LOSA observers report on the behaviors of employees and their systemic processes, not the employees themselves. The program collects data and trends of these behaviors and processes without punitive consequences. The foundation of LOSA is that it is peer-to-peer and non-punitive. Since peers are observing peers, with a non-punitive understanding, your employees will have a more conducive environment for an observation of realistic behavior and processes. This increases the opportunity for the observer to observe the associated risks.
No. LOSA is not a "Silver Bullet," but it does provide your organization the benefit of data collection and trending. This data will help identify the tacit and unknown threats to your system and processes. LOSA should not be viewed as a standalone process, but a complement to other Safety Management System processes already in place.