Line Operations Safety Audit and Threat and Error Management

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Funded with grants from the Federal Aviation Administration, our project has been involved in the study of crew performance during normal flight operations for over 20 years. The methodology we developed, called the Line Operations Safety Audit (LOSA), utilizes trained observers riding in cockpit jump seats to evaluate several aspects of crew performance. At the core of the LOSA process is Threat and Error Management (TEM), which provides an underlying framework for data collection. In-flight observers record the various threats encountered by aircrew, the types of errors committed, and most importantly, they record how flight crews manage these situations to maintain safety. LOSA observers also collect data on CRM performance and conduct a structured interview that asks pilots for their suggestions to improve safety. These combined LOSA data sources provide airlines with a diagnostic snapshot of safety strengths and weaknesses in normal flight operations. Today, LOSA is recognized as a FAA Voluntary Safety Program and is considered by several other aviation organizations, such as ICAO and IATA, as an industry best practice for normal flight operations monitoring.

LOSA and TEM development and implementation lives on at The LOSA Collaborative, which is an organization founded by UT Human Factors Research Project member, Dr. James Klinect in 2001. For current information on TEM and LOSA, go to www.losacollaborative.org or contact Dr. James Klinect at klinect@losacollaborative.org

Final - FAA LOSA Advisory Circular 120-90 - Final

On April 27, 2006, the FAA approved our draft of the LOSA Advisory Circular. Thanks to the entire aviation industry for their support of LOSA and Threat and Error Management (TEM) over the years.

What is TEM? (Short Paper)

Click on the link below for a basic introduction to TEM concepts supported with results from the LOSA Archive.

Selected Publications

Below are selected publications related to our work in LOSA and TEM. For a full list of all project publications, click here.

Helmreich, R.L. (2002). Crew performance monitoring programme continues to evolve as database grows. International Civil Aviation Organization (ICAO) Journal, 57(4), 6-7.

Intentional Civil Aviation Organization (ICAO). (2002). Line Operations Safety Audit (LOSA). DOC 9803-AN/761. Montreal: International Civil Aviation Organization.

Klinect, J.R. (2002). LOSA searches for operational weaknesses while highlighting systemic strengths. International Civil Aviation Organization (ICAO) Journal, 57(4), 8-9.

Klinect, J.R., Helmreich, R.L., Wilhelm, J.A., Tesmer, B., & Maurino, D. (2002). LOSA: Managing human error. ISASI Forum, 35(3), 12-15.

Klinect, J.R., Murray, P., Merritt, A., & Helmreich, R. (2003). Line Operations Safety Audit (LOSA): Definition and operating characteristics. In Proceedings of the Twelfth International Symposium on Aviation Psychology (pp. 663-668). Dayton, OH: The Ohio State University (click here to download the PDF)

Klinect, J.R. (2005). Line Operations Safety Audit: A Cockpit Observation Methodology for Monitoring Commercial Airline Safety Performance (Doctoral Dissertation) (click here to download the Abstract) (Electronic copies available with an e-mail request to James Klinect - klinect@mail.utexas.edu)

Wilhelm, J.A. (2002). Quality data management requires strategic planning. International Civil Aviation Organization (ICAO) Journal, 57(4), 9, 26-27.

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The ICAO Journal - Special Edition LOSA (2002, Vol 57, No. 4, May) can be downloaded for free at the ICAO Publication website (click here to go to ICAO Publications). Other LOSA articles by Continental and Boeing also appear in this journal. (English, French, and Spanish versions are available)

(Viewing the ICAO Journal requires the DjVu Browser, which is also a free download (click here to go to DjVu Browser download site).

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LOSA Publications Prior to 2001

Helmreich, R.L., Klinect, J.R., & Wilhelm, J.A. (1999). Models of threat, error, and CRM in flight operations. In Proceedings of the Tenth International Symposium on Aviation Psychology (pp. 677-682). Columbus, OH: The Ohio State University.

Helmreich, R.L., Klinect, J.R., & Wilhelm, J.A. (2001). System safety and threat and error management: The line operations safety audit (LOSA). In Proceedings of the Eleventh International Symposium on Aviation Psychology. Columbus, OH: The Ohio State University.

Helmreich, R.L., Wilhelm, J.A., Klinect, J.R., & Merritt, A.C. (2001). Culture, error and Crew Resource Management. In E. Salas, C.A. Bowers, & E. Edens (Eds.), Applying resource management in organizations: A guide for professionals (pp.305-331). Hillsdale, NJ: Erlbaum.

Klinect, J.R., Wilhelm, J.A., & Helmreich, R.L. (1999). Threat and error management: Data from line operations safety audits. In Proceedings of the Tenth International Symposium on Aviation Psychology (pp. 683-688). Columbus, OH: The Ohio State University.

Sexton, J.B., & Klinect, J.R. (2001). The link between safety attitudes and observed performance in flight operations. In Proceedings of the Eleventh International Symposium on Aviation Psychology. Columbus, OH: The Ohio State University.

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