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LOSA
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1. The Line Operations Safety Audit: Validating Behavioural Markers in Aviation GIHRE - Zurich
The University of Texas Human Factors Project
Austin, Texas
8 July, 2001
2. LOSA Normal Operations Monitoring Collect data benchmark safety:
Crew performance strengths and weaknesses
Threat and error management
CRM performance
System performance strengths and weaknesses
Culture
Airspace System airports and navigational aids
Aircraft design / automation
Standards / Training / Safety / Maintenance
Crew support ATC, Cabin, Ground, and Dispatch
3. The Evolution of LOSA and Behavioural Markers Initial definition of markers from analysis of accidents and incidents
Validation of specific markers from correlations with expert (global) ratings of crew performance
LOSA focus on process assessment
LOSA shift (1996) to include specification of threats, errors, and their management
Evolution in analysis of LOSA data to include relationships between markers and threat and error and undesired aircraft state management
4. Pending/in progress
Ansett Australia
COPA
Emirates
Frontier
Continental Express
Middle East and European carriers (TBD) Threat and Error Management LOSA
Continental Latin America
Continental Express
Gulfstream Express
Air New Zealand
Air Micronesia
Continental
Delta
US Airways
Cathay Pacific
EVA (Taiwan)
5. Global Consolidation Regional Seminars North America ATA Ops Forum (Marcb 2001)
Asia Hong Kong 15 countries
Latin America Panama Nov. 01 Central & South American
Europe & Middle East Dubai, Jam. 02
6. Threats Defined Environmental Threats
Adverse WX
Terrain
Airport conditions
Heavy traffic / TCAS events
ATC Threats
Command events / errors
Language difficulties
Aircraft Threats
Aircraft malfunctions
Automation events
7. A New Typology of Crew Error (tentative)
1. Task Execution Unintentional physical act that deviates from intended course of action
Wrong altitude setting dialed into the MCP
2. Procedural Unintentional mental (cognitive) slip, lapse, or mistake when trying to follow required course of action
Slip skipping an item on a checklist
Lapse forgetting a required briefing
Mistake choosing the wrong checklist in an abnormal situation
3. Communication Failure to transmit information, failure to understand information, failure to share mental model
ex) Miscommunication with ATC
4. Decision Choice of action unbounded by procedures that unnecessarily increases risk
ex) Unnecessary navigation through adverse weather
5. Intentional Noncompliance violations
ex) Performing a checklist from memory
8. Consequential errors lead to another error or to an UNDESIRED AIRCRAFT STATE
9. Decision Error
Decision that increases risk in a situation with
multiple courses of action possible
time available to evaluate alternatives
no discussion of consequences of alternate
courses of action
no formal procedures to follow
10. Undesired Aircraft State Defined
11. Threat Analysis
12. Threat Management Analysis
Goal Build a threat profile for flight operations
Analytical Questions
What is organizations exposure to threats and how are they managed?
How does organization compare to the LOSA Archive?
What type of threats do flight crews most frequently encounter?
What type of threats are most difficult to manage?
Are there phase of flight effects on threat management?
Are there operations or fleet differences in threat management?
13. Threat Baselines
14. LOSA error frequencies
15. Error Analysis
16. Error Management Analysis Goal Build a crew error profile for organizations flight operations
Analytical Questions
What is organizations baseline of errors and how are they managed?
How does organization compare to the UT LOSA Archive?
What were the most frequently crew errors committed?
What types of crew error are the most difficult to manage?
What were the most frequent undesired aircraft states and how were they managed?
Are there phase of flight effects on error management?
17. Error Baselines
18. LOSA error frequencies
19. The Importance of Violations Airlines cannot allow violations to normalize
Why?
Violations cultivate complacency and a disregard of rules
Crews that commit at least one intentional noncompliance error are twice as likely to:
Commit unintentional errors (Procedural, Communication ..)
Commit consequential errors that lead to additional errors or undesired aircraft states
20. Error Responses and Outcomes
21. Undesired State Analysis
22. Undesired Aircraft States
23. Error Management by Phase of Flight
24. The Blue Box
25. The Blue Box
26. Behavioural Marker Validation
27. An Expanded Definition of CRM
28. Threat and Error Countermeasures CRM skills are best defined as threat and error countermeasures. The following have been validated as critical in LOSA
Different skills play different roles in threat, error management, and undesired state management
Team Climate critical in all areas of crew performance
Leadership, communication environment, and flight attendant briefing
Planning critical in threat management
SOP briefings, plans stated, workload assignment, and contingency mgmt
Execution critical in error management
Monitor / cross check, workload mgmt, vigilance, and automation mgmt
Review and Modify critical in undesired aircraft state management
Evaluation of plans, inquiry, and assertiveness
29. LOSA Data Lead to a Model of Threat and Error Management (UT-TEMM)
30. Why Develop Such a Model? Accurately describe and investigate threat and error and their management
Determine latent factors that lead to system failures
Go beyond root cause analysis to determine how complex situations are managed effectively
Data to teach from good examples as well as system failures
Used for analysis of accidents and incidents
31. Latent systemic threats Latent systemic threats
Culture (National, Professional, and Organizational)
Airports and navigational aides
Aircraft design, automation, and maintenance
Regulations, policies, and procedures
Training curriculum and implementation
Flight crew support (ATC, MX, Ground, Dispatch, & Cabin)
Latent threat often detected only after an incident or accident
Normal operations data identify latent systemic threats before they become consequential
33. Predicting Line Performancefrom Safety Culture
34. Forming a Safety Culture Scale Pilots observed in LOSA also completed a survey with items from the UT Flight Management Attitudes Questionnaire
Items related to organizational culture regarding safety were summed to form a Safety Culture Scale
35. Safety Culture Scale Items Read the itemsRead the items
36. Classifying the Pilot Population Low Safety Culture Crews had captains and
first officers in the bottom 33% of distribution
Average Safety Culture Crews had captains and first officers in the middle 33% of distribution
High Safety Culture Crews had captains and first officers in the top 33% of distribution
Safety indices for each group were contrasted
38. Safety Indices Violators make more errors link to BobViolators make more errors link to Bob
39. Applying lessons from aviation to medicine
40. Major issues in the OR Threat and error are common
The OR is a complex environment (more than aviation)
multiple teams
part of a larger organization
Unclear lines of authority
who is in charge?
Communication across disciplines
Multi-cultural environment
Professional culture
Denial of vulnerability
41. Observable Medical Error
1. Task Execution Unintentional physical act that deviates from intended course of action
Nicking of artery during surgery
2. Procedural Countermeasure Unintentional failure to follow mandated procedures
Failure to follow required treatment protocols
3. Communication Failure to transmit information, failure to understand information, failure to share mental model
Failure to communicate critical patient information during shift change
4. Decision Choice of action unbounded by procedures that unnecessarily increases risk
Failure to use temperature probe during surgery
5. Intentional Noncompliance violation of formal procedures or regulations
Surgeon elects not to sign surgical site
42. Procedures as Countermeasure and Problem Standard Operating Procedures (SOP) were aviations first countermeasures against threat and error
Aviation is arguably over-proceduralized
Tombstone regulation
Medicine is under-proceduralized
Example: checklists are a critical error countermeasure
43. Adapting the Threat and Error Management Model to Medicine
46. Where are we going?
47. Priority Items for Medicine Behavioural markers have been refined and limited in aviation
We now know that markers are differentially related to situations (i.e., threat, error avoidance, undesired state)
It is likely that the potent markers from aviation will apply in specific medical situations
Operating theatre
ER
Obstetrics
(simulation)
Markers need to be defined and validated in simulation as well as the OR
TEMM has been adopted by Kaiser-Permanente as a teaching tool and a means of analyzing adverse and sentinel events (10,000 doctors)
The University of Texas has also committed to a comprehensive patient safety programme (6 medical schools)