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?