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LOSA and Threat and Error Management – What is it? The line operations safety audit (LOSA) —which involves the collection of data by trained observers during routine flights to determine how flight crew detect, manage and mismanage threats and errors—has been endorsed by the International Civil Aviation Organization (ICAO) as a tool for monitoring normal flight operations and developing countermeasures against human error. The concept and methodology of LOSA currently are based on threat-and-error management (TEM). ICAO calls TEM the fifth generation of CRM, which, in the context of LOSA, is based on the premise that human error is normal, inevitable and a valuable source of information. Threats increase the operational complexity of the flight and pose a safety risk to the flight at some level. Threats include adverse weather conditions, hazardous terrain, aircraft and aircraft system abnormalities and malfunctions, time pressures and unfamiliar airports. Threats also include errors that are committed by others—including ground-handling personnel, maintenance technicians, dispatchers, flight attendants and air traffic controllers—and that must be managed by the flight crew. Flight crew errors are defined as actions and inactions that lead to deviations from the intentions or expectations of the flight crew or the airline. Errors, in the operational context, tend to reduce the margin of safety and increase the probability of accidents and incidents. The TEM model characterizes flight crew errors as follows: Communications errors include miscommunication, misinterpretation or failure to communicate pertinent information among the flight crew or between the flight crew and external agents such as air traffic controllers or ground-handling personnel. Examples include failing to hear air traffic control instructions, failing to read back ATC instructions and crew miscommunication. Intentional noncompliance errors are willful deviations from regulations and/or operator procedures. Examples include violating the sterile-cockpit rule; omitting required callouts; using nonstandard pilot-controller communication phraseology; conducting checklists from memory; and failing to respond to traffic alert and collision-avoidance system (TCAS) warnings or terrain awareness warning system (TAWS) warnings. Procedural errors are deviations in the execution of regulations and/or operator procedures in which the intention is correct but the execution is flawed. This category includes errors in which flight crew members forget to do something. Examples include failing to conduct checklists, incorrectly setting instruments and failing to cross-check instrument settings. Proficiency-based errors involve lack of knowledge or psychomotor (‘stick-and-rudder’) skills. Examples include inadequate knowledge of aircraft systems and equipment that contribute to hand-flying errors, automation errors or other errors that can influence the direction, speed or configuration of the aircraft. Operational decision errors are decision making errors that are not standardized by regulations or operator procedures and that unnecessarily compromise safety. An operational decision error includes at least one of the following conditions: the flight crew ignores a more conservative option; the crew member who took the decision does not brief other crew members about the decision; or the crew does not use available time to evaluate options. Examples include navigating through known areas of adverse weather and accepting ATC instructions that result in an unstable approach. The TEM model holds that when an error occurs, the flight crew either traps (detects and manages) the error; exacerbates the error with action or inaction that results in additional error, or fails to respond, that is to say, ignores the error. The ‘Management Tools’ of Threat and Error Management include: good situational awareness; a usable model for Aviation Decision Making such as, ‘Perceive, Process, Perform and Evaluate’; sharing information and good ideas through crew interaction, company newsletters, websites and other media of flight crew information exchange. Always keep in mind that the descent, approach and landing phases of a flight contain the most opportunities for threats and errors with serious outcomes.4. Failure to cross-check instrument settings is categorized as （ ） error.
LOSA and Threat and Error Management – What is it? The line operations safety audit (LOSA) —which involves the collection of data by trained observers during routine flights to determine how flight crew detect, manage and mismanage threats and errors—has been endorsed by the International Civil Aviation Organization (ICAO) as a tool for monitoring normal flight operations and developing countermeasures against human error. The concept and methodology of LOSA currently are based on threat-and-error management (TEM). ICAO calls TEM the fifth generation of CRM, which, in the context of LOSA, is based on the premise that human error is normal, inevitable and a valuable source of information. Threats increase the operational complexity of the flight and pose a safety risk to the flight at some level. Threats include adverse weather conditions, hazardous terrain, aircraft and aircraft system abnormalities and malfunctions, time pressures and unfamiliar airports. Threats also include errors that are committed by others—including ground-handling personnel, maintenance technicians, dispatchers, flight attendants and air traffic controllers—and that must be managed by the flight crew. Flight crew errors are defined as actions and inactions that lead to deviations from the intentions or expectations of the flight crew or the airline. Errors, in the operational context, tend to reduce the margin of safety and increase the probability of accidents and incidents. The TEM model characterizes flight crew errors as follows: Communications errors include miscommunication, misinterpretation or failure to communicate pertinent information among the flight crew or between the flight crew and external agents such as air traffic controllers or ground-handling personnel. Examples include failing to hear air traffic control instructions, failing to read back ATC instructions and crew miscommunication. Intentional noncompliance errors are willful deviations from regulations and/or operator procedures. Examples include violating the sterile-cockpit rule; omitting required callouts; using nonstandard pilot-controller communication phraseology; conducting checklists from memory; and failing to respond to traffic alert and collision-avoidance system (TCAS) warnings or terrain awareness warning system (TAWS) warnings. Procedural errors are deviations in the execution of regulations and/or operator procedures in which the intention is correct but the execution is flawed. This category includes errors in which flight crew members forget to do something. Examples include failing to conduct checklists, incorrectly setting instruments and failing to cross-check instrument settings. Proficiency-based errors involve lack of knowledge or psychomotor (‘stick-and-rudder’) skills. Examples include inadequate knowledge of aircraft systems and equipment that contribute to hand-flying errors, automation errors or other errors that can influence the direction, speed or configuration of the aircraft. Operational decision errors are decision making errors that are not standardized by regulations or operator procedures and that unnecessarily compromise safety. An operational decision error includes at least one of the following conditions: the flight crew ignores a more conservative option; the crew member who took the decision does not brief other crew members about the decision; or the crew does not use available time to evaluate options. Examples include navigating through known areas of adverse weather and accepting ATC instructions that result in an unstable approach. The TEM model holds that when an error occurs, the flight crew either traps (detects and manages) the error; exacerbates the error with action or inaction that results in additional error, or fails to respond, that is to say, ignores the error. The ‘Management Tools’ of Threat and Error Management include: good situational awareness; a usable model for Aviation Decision Making such as, ‘Perceive, Process, Perform and Evaluate’; sharing information and good ideas through crew interaction, company newsletters, websites and other media of flight crew information exchange. Always keep in mind that the descent, approach and landing phases of a flight contain the most opportunities for threats and errors with serious outcomes.3. Which of the following is NOT correct?
LOSA and Threat and Error Management – What is it? The line operations safety audit (LOSA) —which involves the collection of data by trained observers during routine flights to determine how flight crew detect, manage and mismanage threats and errors—has been endorsed by the International Civil Aviation Organization (ICAO) as a tool for monitoring normal flight operations and developing countermeasures against human error. The concept and methodology of LOSA currently are based on threat-and-error management (TEM). ICAO calls TEM the fifth generation of CRM, which, in the context of LOSA, is based on the premise that human error is normal, inevitable and a valuable source of information. Threats increase the operational complexity of the flight and pose a safety risk to the flight at some level. Threats include adverse weather conditions, hazardous terrain, aircraft and aircraft system abnormalities and malfunctions, time pressures and unfamiliar airports. Threats also include errors that are committed by others—including ground-handling personnel, maintenance technicians, dispatchers, flight attendants and air traffic controllers—and that must be managed by the flight crew. Flight crew errors are defined as actions and inactions that lead to deviations from the intentions or expectations of the flight crew or the airline. Errors, in the operational context, tend to reduce the margin of safety and increase the probability of accidents and incidents. The TEM model characterizes flight crew errors as follows: Communications errors include miscommunication, misinterpretation or failure to communicate pertinent information among the flight crew or between the flight crew and external agents such as air traffic controllers or ground-handling personnel. Examples include failing to hear air traffic control instructions, failing to read back ATC instructions and crew miscommunication. Intentional noncompliance errors are willful deviations from regulations and/or operator procedures. Examples include violating the sterile-cockpit rule; omitting required callouts; using nonstandard pilot-controller communication phraseology; conducting checklists from memory; and failing to respond to traffic alert and collision-avoidance system (TCAS) warnings or terrain awareness warning system (TAWS) warnings. Procedural errors are deviations in the execution of regulations and/or operator procedures in which the intention is correct but the execution is flawed. This category includes errors in which flight crew members forget to do something. Examples include failing to conduct checklists, incorrectly setting instruments and failing to cross-check instrument settings. Proficiency-based errors involve lack of knowledge or psychomotor (‘stick-and-rudder’) skills. Examples include inadequate knowledge of aircraft systems and equipment that contribute to hand-flying errors, automation errors or other errors that can influence the direction, speed or configuration of the aircraft. Operational decision errors are decision making errors that are not standardized by regulations or operator procedures and that unnecessarily compromise safety. An operational decision error includes at least one of the following conditions: the flight crew ignores a more conservative option; the crew member who took the decision does not brief other crew members about the decision; or the crew does not use available time to evaluate options. Examples include navigating through known areas of adverse weather and accepting ATC instructions that result in an unstable approach. The TEM model holds that when an error occurs, the flight crew either traps (detects and manages) the error; exacerbates the error with action or inaction that results in additional error, or fails to respond, that is to say, ignores the error. The ‘Management Tools’ of Threat and Error Management include: good situational awareness; a usable model for Aviation Decision Making such as, ‘Perceive, Process, Perform and Evaluate’; sharing information and good ideas through crew interaction, company newsletters, websites and other media of flight crew information exchange. Always keep in mind that the descent, approach and landing phases of a flight contain the most opportunities for threats and errors with serious outcomes.2. The tool for monitoring normal flight operations and developing countermeasures against human error is （ ）.
LOSA and Threat and Error Management – What is it? The line operations safety audit (LOSA) —which involves the collection of data by trained observers during routine flights to determine how flight crew detect, manage and mismanage threats and errors—has been endorsed by the International Civil Aviation Organization (ICAO) as a tool for monitoring normal flight operations and developing countermeasures against human error. The concept and methodology of LOSA currently are based on threat-and-error management (TEM). ICAO calls TEM the fifth generation of CRM, which, in the context of LOSA, is based on the premise that human error is normal, inevitable and a valuable source of information. Threats increase the operational complexity of the flight and pose a safety risk to the flight at some level. Threats include adverse weather conditions, hazardous terrain, aircraft and aircraft system abnormalities and malfunctions, time pressures and unfamiliar airports. Threats also include errors that are committed by others—including ground-handling personnel, maintenance technicians, dispatchers, flight attendants and air traffic controllers—and that must be managed by the flight crew. Flight crew errors are defined as actions and inactions that lead to deviations from the intentions or expectations of the flight crew or the airline. Errors, in the operational context, tend to reduce the margin of safety and increase the probability of accidents and incidents. The TEM model characterizes flight crew errors as follows: Communications errors include miscommunication, misinterpretation or failure to communicate pertinent information among the flight crew or between the flight crew and external agents such as air traffic controllers or ground-handling personnel. Examples include failing to hear air traffic control instructions, failing to read back ATC instructions and crew miscommunication. Intentional noncompliance errors are willful deviations from regulations and/or operator procedures. Examples include violating the sterile-cockpit rule; omitting required callouts; using nonstandard pilot-controller communication phraseology; conducting checklists from memory; and failing to respond to traffic alert and collision-avoidance system (TCAS) warnings or terrain awareness warning system (TAWS) warnings. Procedural errors are deviations in the execution of regulations and/or operator procedures in which the intention is correct but the execution is flawed. This category includes errors in which flight crew members forget to do something. Examples include failing to conduct checklists, incorrectly setting instruments and failing to cross-check instrument settings. Proficiency-based errors involve lack of knowledge or psychomotor (‘stick-and-rudder’) skills. Examples include inadequate knowledge of aircraft systems and equipment that contribute to hand-flying errors, automation errors or other errors that can influence the direction, speed or configuration of the aircraft. Operational decision errors are decision making errors that are not standardized by regulations or operator procedures and that unnecessarily compromise safety. An operational decision error includes at least one of the following conditions: the flight crew ignores a more conservative option; the crew member who took the decision does not brief other crew members about the decision; or the crew does not use available time to evaluate options. Examples include navigating through known areas of adverse weather and accepting ATC instructions that result in an unstable approach. The TEM model holds that when an error occurs, the flight crew either traps (detects and manages) the error; exacerbates the error with action or inaction that results in additional error, or fails to respond, that is to say, ignores the error. The ‘Management Tools’ of Threat and Error Management include: good situational awareness; a usable model for Aviation Decision Making such as, ‘Perceive, Process, Perform and Evaluate’; sharing information and good ideas through crew interaction, company newsletters, websites and other media of flight crew information exchange. Always keep in mind that the descent, approach and landing phases of a flight contain the most opportunities for threats and errors with serious outcomes.1. Who is to determine how flight crews manage and mismanage threats and errors in LOSA?
Simply put, situation awareness is a case of having the three ‘R’s: knowing the right information at the right time and reacting to it appropriately. If we have all the information we need and we apply the proper procedures, getting safely to and from where we need to go becomes easy. Good situation awareness means that pilots know where they are, the desired route to their destination and any obstacles, hazards or rules to be followed along the way. At aerodromes with control towers, what the controllers intend and what the pilots understand must match exactly. If not, good situation awareness cannot occur either for pilots or for ATC. So if good situation awareness is essential for safe operations, how do we gain and maintain it? Another way of saying this is how and why do pilots loose their situation awareness bearings and make critical mistakes as a result? Research has shown that the following factors often result in diminished situational awareness: incomplete or misunderstood communications; lack of planning; work load peaks; distractions; and loss of visual cues. Let’s examine each to see how they may affect situation awareness.By far the most important cause of poor situation awareness induced mistakes is communication problems. Communication difficulties most often result from one or both of the following: use of non-standard phraseology; lack of language proficiency. These communications shortcomings cause a discrepancy between what ATC intends and what the pilots understand or vice versa. Clear, accurate and timely communications are essential in establishing and updating the shared mental picture necessary for good situation awareness.5. What is the best title of this article?
Simply put, situation awareness is a case of having the three ‘R’s: knowing the right information at the right time and reacting to it appropriately. If we have all the information we need and we apply the proper procedures, getting safely to and from where we need to go becomes easy. Good situation awareness means that pilots know where they are, the desired route to their destination and any obstacles, hazards or rules to be followed along the way. At aerodromes with control towers, what the controllers intend and what the pilots understand must match exactly. If not, good situation awareness cannot occur either for pilots or for ATC. So if good situation awareness is essential for safe operations, how do we gain and maintain it? Another way of saying this is how and why do pilots loose their situation awareness bearings and make critical mistakes as a result? Research has shown that the following factors often result in diminished situational awareness: incomplete or misunderstood communications; lack of planning; work load peaks; distractions; and loss of visual cues. Let’s examine each to see how they may affect situation awareness.By far the most important cause of poor situation awareness induced mistakes is communication problems. Communication difficulties most often result from one or both of the following: use of non-standard phraseology; lack of language proficiency. These communications shortcomings cause a discrepancy between what ATC intends and what the pilots understand or vice versa. Clear, accurate and timely communications are essential in establishing and updating the shared mental picture necessary for good situation awareness.4. For good situation awareness, what is the regarded as good communication?
Simply put, situation awareness is a case of having the three ‘R’s: knowing the right information at the right time and reacting to it appropriately. If we have all the information we need and we apply the proper procedures, getting safely to and from where we need to go becomes easy. Good situation awareness means that pilots know where they are, the desired route to their destination and any obstacles, hazards or rules to be followed along the way. At aerodromes with control towers, what the controllers intend and what the pilots understand must match exactly. If not, good situation awareness cannot occur either for pilots or for ATC. So if good situation awareness is essential for safe operations, how do we gain and maintain it? Another way of saying this is how and why do pilots loose their situation awareness bearings and make critical mistakes as a result? Research has shown that the following factors often result in diminished situational awareness: incomplete or misunderstood communications; lack of planning; work load peaks; distractions; and loss of visual cues. Let’s examine each to see how they may affect situation awareness.By far the most important cause of poor situation awareness induced mistakes is communication problems. Communication difficulties most often result from one or both of the following: use of non-standard phraseology; lack of language proficiency. These communications shortcomings cause a discrepancy between what ATC intends and what the pilots understand or vice versa. Clear, accurate and timely communications are essential in establishing and updating the shared mental picture necessary for good situation awareness.3. What is the most important cause of poor situation awareness?
Simply put, situation awareness is a case of having the three ‘R’s: knowing the right information at the right time and reacting to it appropriately. If we have all the information we need and we apply the proper procedures, getting safely to and from where we need to go becomes easy. Good situation awareness means that pilots know where they are, the desired route to their destination and any obstacles, hazards or rules to be followed along the way. At aerodromes with control towers, what the controllers intend and what the pilots understand must match exactly. If not, good situation awareness cannot occur either for pilots or for ATC. So if good situation awareness is essential for safe operations, how do we gain and maintain it? Another way of saying this is how and why do pilots loose their situation awareness bearings and make critical mistakes as a result? Research has shown that the following factors often result in diminished situational awareness: incomplete or misunderstood communications; lack of planning; work load peaks; distractions; and loss of visual cues. Let’s examine each to see how they may affect situation awareness.By far the most important cause of poor situation awareness induced mistakes is communication problems. Communication difficulties most often result from one or both of the following: use of non-standard phraseology; lack of language proficiency. These communications shortcomings cause a discrepancy between what ATC intends and what the pilots understand or vice versa. Clear, accurate and timely communications are essential in establishing and updating the shared mental picture necessary for good situation awareness.2. Which is not a factor that helps maintain good situation awareness according to the author?
Simply put, situation awareness is a case of having the three ‘R’s: knowing the right information at the right time and reacting to it appropriately. If we have all the information we need and we apply the proper procedures, getting safely to and from where we need to go becomes easy. Good situation awareness means that pilots know where they are, the desired route to their destination and any obstacles, hazards or rules to be followed along the way. At aerodromes with control towers, what the controllers intend and what the pilots understand must match exactly. If not, good situation awareness cannot occur either for pilots or for ATC. So if good situation awareness is essential for safe operations, how do we gain and maintain it? Another way of saying this is how and why do pilots loose their situation awareness bearings and make critical mistakes as a result? Research has shown that the following factors often result in diminished situational awareness: incomplete or misunderstood communications; lack of planning; work load peaks; distractions; and loss of visual cues. Let’s examine each to see how they may affect situation awareness.By far the most important cause of poor situation awareness induced mistakes is communication problems. Communication difficulties most often result from one or both of the following: use of non-standard phraseology; lack of language proficiency. These communications shortcomings cause a discrepancy between what ATC intends and what the pilots understand or vice versa. Clear, accurate and timely communications are essential in establishing and updating the shared mental picture necessary for good situation awareness.1. Which of the following is not a key of situation awareness?
Nowhere else is the communication process more important than in the cockpit of an aircraft. As history has repeatedly shown, a breakdown in the communication process often leads to less than desirable events that can be illustrated as follows: ● In 1977, at Tenerife in the Canary Islands, heavy accents and improper terminology among a Dutch KLM crew, an American Pan Am crew and a Spanish air traffic controller led to the worst aviation disaster in history, in which 583 passengers perished. ● In 1980, another Spanish air traffic controller at Tenerife gave a holding pattern clearance to a Dan Air flight by saying turn to the left when he should have said turns to the left - resulting in the aircraft making a single left turn rather than making circles using left turns. The jet hit a mountain killing 146 people. ● In 1990, Colombian Avianca pilots in a holding pattern over Kennedy Airport told controllers that their 707 was low on fuel. The crew should have stated they had a fuel emergency, which would have given them immediate clearance to land. Instead, the crew declared a minimum fuel condition and the plane ran out of fuel, crashing and killing 72 people. ● In 1993, Chinese pilots flying a U.S.-made MD-80 were attempting to land in northwest China. The pilots were baffled by an audio alarm from the plane＇s ground proximity warning system. A cockpit recorder picked up the pilot＇s last words: What does ＇pull up＇ mean? ● In 1995, an American Airlines jet crashed into a mountain in Colombia after the captain instructed the autopilot to steer towards the wrong beacon. A controller later stated that he suspected from the pilot＇s communications that the jet was in trouble, but that the controller＇s English was not sufficient for him to understand and articulate the problem. ● On November 13, 1996, a Saudi Arabian airliner and a Kazakhstan plane collided in mid-air near New Delhi, India. While an investigation is still pending, early indications are that the Kazak pilot may not have been sufficiently fluent in English and was consequently unable to understand an Indian controller giving instructions in English. (Aviation Today: Special Reports, 2004) All of the above examples are the result of language barriers. But, barriers to effective communication can come in other forms as well, including noise, vibration, radio clutter, distractions, and even cultural differences between crew members. This list is not all-inclusive, but does depict some of the more common problems in today＇s cockpits.5. Which of the following is not a communication barrier according to the author?
