LOSA Manual

LOSA MANUAL
Petroleum Air Services

EGYPT
LOSA Document
(Doc No. CSD-D03 – LOSA)
Revision 0.0
1 March , 2017
Safety Department
LOSA DOCUMENT Chapter: 1
Section : 1
LOSA MANUAL
CSD-D03
DOCUMENT APPROVAL
Cosultant
Safety Consultant Chairman
Title Written By Chairman
Manager for Operations
for FW Ops
Capt.
Capt. Marco Capt. Hesham
Name Mohamed Capt. Akram Fawzy
Arcesi El-Hamahmy
Deifullah
Date 01.03.2017 01.03.2017 01.03.2017 01.03.2017
Signature
Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 1 | 14

IMPORTANT: Controlled page. If this page is copied or reproduced for use outside this
document, it becomes an uncontrolled document and for reference only. www.pas.com.eg
Safety Department
Section : 1
Distribution List
Serial Title / Authority
No.
1 Assistant Chairman Operations 1
2 FW Operations GM 2
3 FW Tech Support GM 3
4 Chief Pilot 4
5 Safety Manager 5
Note:
• Original Hard Copy and accepted manual will be in the Corporate Safety
Department.
• Electronic Copies of this manual that are distributed are
UNCONTROLLED. And have been emailed to all PAS Employees.
• This latest revision and update of the LOSA Document will be found on the
Company’s Digital Document Library. Any revisions will be distributed by
the Corporate Safety Department.

Safety Department
Section : 1
Contents
LOSA MANUAL ........................................................................................................................................ 1
1. INTRODUCTION .................................................................................................................................. 4
2. WHAT IS LOSA? ................................................................................................................................... 4
3. BENEFITS OF LOSA. ........................................................................................................................... 6
4. LOSA PROGRAM- STEPS FOR IMPLEMENTATION .................................................................... 10

Safety Department
Section : 1
LOSA –LINE ORIENTED SAFETY ASSESSMENT
1. INTRODUCTION
This document describes the project for the implementation within PAS of a
program for the management of human error in aviation operations known as
Line Operations Safety Assessment (LOSA).
The program is focused on the PAS Fixed Wing Flight Deck Operations
but, as it can be equally appreciated, it would be extremely valuable if
extended and implemented in other PAS Departments, such as Technical
Support (for both Fixed and rotary Wings), Helicopter Flight Deck
Operations, Ramp Operations, and Flight Dispatchers.
2. WHAT IS LOSA?
Line Operations Safety Assessment (LOSA) is proposed as a critical
organizational strategy aimed at developing countermeasures to operational
errors.
It is an organizational tool used to identify threats to aviation safety,
minimize the risks such threats may generate and implement measures to
manage human error in operational contexts.
It involves a structured program of observation of front line activities built

around the Threat and Error Management (TEM) concept.
LOSA provides a way to assess the level of organizational flexibility to
systemic threats in accordance with the principles of a data-driven approach.
LOSA uses trained observers to collect data about pilot behavior and its
situational context on “normal” flights from jump seats on the flight deck.
Such monitoring allows the capture of data that can characterize pilot
strategies for managing "threats, errors and undesirable states".

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The observations are conducted under strict confidential and no-jeopardy

conditions; therefore, flight crews will not be held accountable for their
actions and errors that are observed.
During flights that are being audited, observers record and code:
▪ potential threats to safety;
▪ how the threats are addressed;
▪ the errors such threats generate;
▪ how flight crews manage these errors;
▪ specific behaviors that have been known to be associated with accidents
and incidents.
LOSA is distinct from - but complementary to - other proactive safety

programs such as electronic data acquisition systems (e.g., FDM), and
voluntary reporting systems (e.g., ASR). However, these programs have two
major conceptual differences.
First, FDM and ASR rely on outcomes to generate data. For FDM, it is flight
parameter exceedances; for ASR, it is adverse events that crews report. By
contrast, LOSA samples all activities in normal operations.
LOSA provides a unique opportunity to study the flight management process,
both successful and unsuccessful, by noting the problems crews encounter on
the line and how they manage them.
The second major difference is the perspective taken by each program. With
its focus on electronic data acquisition downloaded directly from the aircraft,
FDM can be said to have the “airplane perspective.” ASR provides the “pilot
perspective” by using pilots’ voluntary disclosure and self-reporting of events.
By contrast, LOSA provides a “neutral, third-party perspective” in that LOSA
observers record contextual and flight crew data on every phase of flight,
regardless of the outcome.
All three perspectives provide useful data to an airline’s safety management
system.
Despite these differences, data from one program can be cross-referenced and
used to guide data collection in another. For example, ASR or FDM reports
may highlight a problem with departures at a particular airport. This

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information can be fed to the LOSA steering committee, which can then target
more observations out of that airport to understand the magnitude and
specifics of the problem. As another example, a LOSA may identify a high
incidence of unstable approaches, leading to a review of procedures and the
specification of new approach parameters.
3. BENEFITS OF LOSA.
A LOSA provides unique data about an airline’s defenses and vulnerabilities.
As explained before, a LOSA does not replace other safety-data sources such
as FDM or ASR. Instead, it complements these programs and extends the
reach of an airline’s safety management system.
The data collected during a LOSA can impact almost every department in an
air operator, as they can help to:
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a. Identify Threats in the Airline’s Operating Environment. Observers

note events in the operational environment (e.g., adverse weather,
airport conditions, air traffic control (ATC) clearances, terrain, and
traffic congestion, and how they are managed by flightcrews.
b. Identify Threats from within the Operations. Observers note events
arising from within the operations and how they are managed (e.g.,
operational time pressure, dispatch errors, aircraft malfunction/minimum
equipment list (MEL) items, and problems with ground, ramp,
maintenance, and cabin personnel). A high number of threats arising
from dispatch or cabin might signal that these departments require
attention, or that intergroup cooperation with pilots needs to be
improved, or that procedures are inconsistent across departments. As
above, prevalence and management rates provide cues for prioritizing
action.
c. Assess the Degree of Transference of Training to the Line. Data
provided by Line Operation Evaluations (Proficiency Checks), and Line-
Operational Flight Training (LOFT) can provide insight on whether
training concepts are learned, but not whether they are actually practiced
on the line. A LOSA provides that operational information, which can
be reviewed from a training perspective to understand which areas of
training, if any, are not transferring successfully to the line.
d. Check the Quality and Usability of Procedures. A LOSA provides
insights about potential problems with procedures. For example, if 5
percent of observed crews make a callout error during
descent/approach/land, there may be a problem with those crews.
However, if 50 percent of observed crews make the same error, then the
evidence suggests a problem with the callout procedure. Procedures can
be ill-timed, over-long, confusing, and/or compete for the pilots’
attention with other more important activities. A LOSA will locate
problematic procedures and policies via poor adherence rates. A LOSA
can also identify the extent of procedural deviations across fleets.
e. Identify Design Problems in the Human/Machine Interface. A LOSA
captures aircraft handling and automation errors on different fleets that
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can highlight systemic flaws in design, interface, or adaptation. The rate

at which certain errors go undetected and become consequential can also
indicate potential design vulnerabilities. An airline can feed these LOSA
findings back to the aircraft manufacturers, as well as writing standard
operating procedures (SOP) to circumvent the flaws.
f. Understand Pilots’ Shortcuts and Workarounds. With experience
comes expertise; pilots learn ways to save time and be more efficient.
These techniques are rarely seen in a line check, when performance is
usually done “by the book.” A LOSA provides a principled manner by
which an airline can capture collective expertise from within the pilot
group. Also, a false expertise — the adoption of a shortcut or
workaround that is flawed in its safety assumptions — can also be
identified and remedied.
g. Assess Safety Margins. Threats and errors that are mismanaged can
result in undesired aircraft states, if sufficiently serious. Vertical and
lateral deviations and unstable approaches are examples of undesired
aircraft states, also known as accident and incident precursors. A LOSA
provides data about the prevalence and management of these incident
and accident precursors. Thus, it is possible to acquire data about how
close operations are to the edge of the safety envelope, without crossing
the boundary into an incident or accident.
h. Provide a Baseline for Organizational Change. LOSA results provide
baseline and outcome measurement data against which organizational
interventions can be measured. Using the medical metaphor, this would
be akin to the patient deciding to cut out fried foods upon learning of a
high cholesterol count. The next checkup reveals, in quantifiable form,
whether this strategy has been effective in reducing cholesterol or
whether other actions are necessary. Similarly, a LOSA provides a new
set of results that will show whether the organizational changes were
effective in reducing certain threats, errors, and/or undesired states.
i. 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 interventions.

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j. Reduce Insurance Costs. LOSA is viewed very favorably by insurance

companies and most offer reductions in insurance premiums for
organizations that have a LOSA program in place.
k. IATA Recommended. LOSA is highly recommended by IATA for
airlines that intend to be listed in the IOSA Registry.(the IATA
Operational Safety Audit (IOSA) is the benchmark for global safety
management in airlines).
It would be highly beneficial to consider PAS Line Pilots a main

“customers” of this LOSA program, meaning that whatever problems would
be identified, the necessary actions will be taken to correct them and to make
the system safer and more efficient for our Pilots.

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4. LOSA PROGRAM- STEPS FOR IMPLEMENTATION

Following are depicted the key steps to be performed for the implementation
and for the success of the LOSA program.
STEP • Form LOSA Steering Commitee and appoint

1 a LOSA Coordinaltor
• Identify who will provide the LOSA

STEP training.
2
STEP • Select observers and schedule observers training

3
•Publicize LOSA within the FW organization (letter to Pilot)

STEP 4
STEP • Determine the focus of LOSA observation.

5
• Conduct observer training and development of data
STEP collection form & repositary database
6
STEP • Schedule observation dates.

7
STEP • Perform the observations Recalibrate the

8 Observers
STEP • Verify observations data
9
•Analyze observation data

STEP 10
• Provide LOSA report (to include list of targets for

STEP improvement )
11
•Provide LOSA report feedback to system and carry out
STEP 12 improvements to system
• Monitor safety change process

STEP 13

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STEP ACTION WHO WHAT

1 Form LOSA Safety LOSA steering committee is formed
Steering Manager with representatives from both
Committee and Safety and FW Ops Depts and is
appoint a LOSA responsible for planning,
Coordinator scheduling, observer support and,
later, data verification.
2 Identify who will Safety Outsourced organization expert on
provide the Manager LOSA training will be contracted to
LOSA training. provide Observers training.
3 Select observers Steering Observers shall be selected tohave
and schedule Committee representatives from flight
observers training operations, training and safety.  
4 Publicize LOSA FW Ops A first task is advance publicity via

within the FW Manager company publications to build line
organization pilot awareness and acceptance of
(letter to Pilot) the upcoming LOSA. The FW OPS
manager organizes and distributes a
letter to all pilots explaining the
purpose of the LOSA.
5 Determine the Steering The LOSA will aimed to sample
focus of LOSA Committee broadly across the entire FW flight
observation. operations, with focus on specific
problems identified by other data
sources (i.e. FDM)
6 Conduct observer Outsourced Observers shall be trained about the
training and provider LOSA purposes and rationale,
development of processes and observations. From
data collection contracted outsourced provider.
form & Training will be focused on the
repository TEM model.
database External provider will also make
available LOSA observation form
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software and repository database.
7 Schedule LOSA Plan no more than two observations

observation Coordinator per observer per day to allow
dates. sufficient time to complete the
observation form and write a rich
narrative. Schedule observers across
fleets regardless of their type rating
to encourage a more general, cross-
fleet perspective of flight crew
performance. Complete all the
observation (target is 120
observations) within 3 months
period.
8 Perform the LOSA In accordance with the LOSA
observations Observers coordinator schedule, perform the
observations.
9 Verify Steering tThe ask is to review and verify the
observations data Committee observations against current
manuals, policies, and procedures.
10 Analyze Outsourced LOSA data reveal strengths and
observations data provider vulnerabilities in an airline’s
operations. The data analyst should
investigate the prevalence and
management of different events and
errors, to identify targets for
improvements
11 Provision of Outsourced Outsourced LOSA expert provider
LOSA report provider woll present a written report that
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illustrates the overall findings of

the assessment. Along with the
results, the report should provide an
initial list of targets for
enhancement. Targets need to be
action-focused and data-driven
12 Provide LOSA Safety The LOSA report will be presented
report feedback Manager to management in operations,
to system and training, safety, and possibly other
carry out departments depending on the
improvements to results.
system Feedback will identify the findings
for operational areas.
Line Pilots will also be informed of
the significant results in the LOSA
report to sustain the pilots’ interest
in the LOSA project.
Pilots will want to know what
changes will be undertaken because
of the LOSA.
13 Monitor safety Safety A LOSA provides specific and
changes process Manager quantified results. To take full
advantage of this specificity, the
targets for enhancement that arise
from the data analysis should go
through a formal safety change
process to produce improvement.
The basic steps pf this process are:
 Measurement (with LOSA) to
obtain the targets;
 Detailed analysis of targeted
issues; 
 List of potential changes for
improvement; 
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 Risk analysis and prioritization

of changes;
 Selection and funding of
changes;
 Implementation of changes; 
 Time for changes to stabilize; 
 Re-measurement


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LOSA MANUAL

Petroleum Air Services

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 1 | 14

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 2 | 14

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 3 | 14

LOSA –LINE ORIENTED SAFETY ASSESSMENT

It involves a structured program of observation of front line activities built

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 4 | 14

The observations are conducted under strict confidential and no-jeopardy

LOSA is distinct from - but complementary to - other proactive safety

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 5 | 14

a. Identify Threats in the Airline’s Operating Environment. Observers

can highlight systemic flaws in design, interface, or adaptation. The rate

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 8 | 14

j. Reduce Insurance Costs. LOSA is viewed very favorably by insurance

It would be highly beneficial to consider PAS Line Pilots a main

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 9 | 14

4. LOSA PROGRAM- STEPS FOR IMPLEMENTATION

STEP • Form LOSA Steering Commitee and appoint

• Identify who will provide the LOSA

STEP • Select observers and schedule observers training

•Publicize LOSA within the FW organization (letter to Pilot)

STEP • Determine the focus of LOSA observation.

STEP • Schedule observation dates.

STEP • Perform the observations Recalibrate the

•Analyze observation data

• Provide LOSA report (to include list of targets for

• Monitor safety change process

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 10 | 14

STEP ACTION WHO WHAT

4 Publicize LOSA FW Ops A first task is advance publicity via

software and repository database.

7 Schedule LOSA Plan no more than two observations

illustrates the overall findings of

 Risk analysis and prioritization

Issue: 00 Rev: 0.0 Date: 01.02.2017 Page 14 | 14

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