LOSAs Pave The Way for Safety Best Practices on The Ramp
Service providers often believe that safety data collection is limited to implementing a safety reporting system for employees to report hazardous events and/or accident outcomes to identify the areas of operation that are more prone to hazards. While a functional safety reporting system is an important component of a credible SMS, data collection is not meant to be limited to safety reporting.
Monitoring for engine trends and flight data are other means for safety data collection and analysis that are suitable for organisations specifically involved in aircraft operations. The line operations safety assessment (LOSA) is a safety data collection and analysis program that can be implemented by all sorts of aeronautical service providers, and has been implemented in the domain of aircraft ground handling. Ramp LOSAs (R-LOSAs) are revealing additional pieces of information supporting safety performance management at ground handling companies.
What is LOSA?
Re-elaborating a definition reported in the International Civil Aviation Organisation (ICAO) document 9803, LOSAs use highly trained observers to collect data about line operators’ behaviour and situational factors during “normal” operations. The observations are conducted under strict no-jeopardy conditions; line operators are not held accountable for their actions and errors that are observed. Throughout the duration of operations, observers record and code potential threats to safety, how the threats are addressed, the errors such threats generate, how line operators manage these errors and specific behaviours that are known to be associated with accidents and incidents.
The LOSA concept was developed similarly to flight operations and is closely linked with crew resource management (CRM) training. “Since CRM is essentially error management training for operational personnel, data from LOSA form the basis for contemporary CRM training,” reads the ICAO’s document 9803. “Data from LOSA also provide a real-time picture of system operations that can guide organizational strategies in regard to safety, training and operations. A particular strength of LOSA is that it identifies examples of superior performance that can be reinforced and used as models for training.”
Threat and Error Management
Threat and error management (TEM) models provide theoretical framework for data collection through LOSAs. “The TEM model allows LOSA observers to capture the interaction between people and the operational context by recording how frontline employees manage these situations to maintain safety,” researchers Maggie Ma and William Rankin of Boeing Commercial Airplanes say in a report of the US FAA office of aerospace medicine entitled “Implementation Guideline for Maintenance Line Operations Safety Assessment (M-LOSA) and Ramp LOSA (R-LOSA) Programs.”
Ma and Rankin quote human factors scholar Daniel Maurino in highlighting the three basic components in the TEM framework – threats, errors, and undesired operational states – and in providing their definitions and management tactics:
“Threats are considered routine events that must be managed to ensure safety. A threat is any condition that increases complexity of the operations that demands crew attention and management to maintain safety margins.
“An error is defined as a crew action or inaction that leads to a deviation from organizational intentions or expectations. Errors ultimately reduce the safety margin and increase the probability of adverse operational events on the ground or during flight. Errors normally occur when threats are mismanaged. However, the threat-error linkage is not necessarily straightforward, and it may not always be possible to establish a one-to-one mapping between threats and errors. Errors can be spontaneous without direct linkage to threats (e.g., maintenance technician failing to give a required callout when there is no distraction in the hangar). In the TEM concept, threats and errors must be observable.
“Error outcomes can be of three types. Outcomes of errors can be inconsequential (i.e., no effect on safety), an undesired operational state (a risky or unsafe condition for the aircraft, equipment, and/or personnel), or additional error(s) linked together across time. Managing an undesired operational state can be considered the last opportunity to avoid an incident or accident,” Ma and Rankin say.
As a result, ramp employees must stay vigilant and react quickly to curb all three issues. Ma and Rankin recommend that errors be resolved through a two-step process: resist and resolve. “Resist refers to the variety of safety interventions and work procedures already in place that form defenses in the system such as standard operating procedures (SOPs), checklists, quality control (QC) inspections, and automation. Resolve refers to the maintenance technician or ramp staff realizing that they had made an error and then correcting it,” Ma and Rankin say in their report.
LOSA in ground handling: R-LOSA
On the western side of the Atlantic Ocean, LOSA is particularly popular and has been long used as a safety management program by a variety of North American airlines. “A few years ago the FAA endorsed the creation of an industry working group with the participation of several airlines to develop industry LOSA programs for the maintenance and ramp environments (M-LOSA and R-LOSA). The working group developed an observation form with a list of items to observe during R-LOSAs which was subsequently tested by means of multiple observations with FedEx, UPS and Southwest Airlines. As a result of this testing standard threat and error codes were developed for R-LOSA programs” Kevin Crowley, senior analyst for ground safety programs at JetBlue Airways, says.
Threat and error codes are reference numbers for typical threats and errors encountered in a given operational domain (e.g. aircraft ground handling), and at a given stage of the process under observation (e.g. baggage loading). These are defined at the earliest stages of LOSA implementation, before actual line observations. Coding threats and errors improves the statistical analysis derived from collected data.
Statistical Significance
One thing an organisation needs to know before implementing R-LOSAs is how many observations are needed, both per station and throughout the whole organisation, in order to derive meaningful data. Lisa Crocket, senior manager of quality assurance (LOSA) at United, which has been performing R-LOSAs since 2009, says that United looks for “a minimum of 35 data points before considering any data.”
“Regarding data collection we ask locations to consider conducting LOSAs at a rate of 3% of their departures, provided they have the resources to do so,” Crocket says. “However, we stress more for consistency than actual numbers.”
While some LOSA programs at United are periodic (flight operations, dispatch, load planning), R-LOSAs are among the programs performed on an on-going basis, together with maintenance and customer service, says Crocket.
At JetBlue, R-LOSAs are conducted periodically, not daily, at the carrier’s seven hub cities where more 100 flights are handled every day. R-LOSAs are performed every 3-4 months, for a period of approximately two weeks, during which a total number of around 200 single observations are accomplished, say Crowley.
Implementing R-LOSAs
United has been implementing R-LOSAs as part of a wider LOSA program focussing on all safety sensitive operational domains. “We have well over a million individual observations in our database,” Crocket says. “We trained over 500 observers worldwide. Beginning in 2015, we re-qualified observers, and are in the process of recalibration. We expect to grow LOSA activity in 2015. The growth includes our Network Operations group who reached out to us requesting LOSAs in the areas of Crew Scheduling, Central Load Planning, and Ramp Tower operations for example, in addition to Dispatch Operations. Completion of these periodic LOSAs and others will take us from 4 LOSA programs to 9 in 2015.” says Crocket.
A frequent challenge in LOSA implementation is that line operators may not be very enthusiastic about being observed. “There was initial resistance and hesitation however over time there was a natural progression to normal behaviors and resistance disappeared,” Crocket says.
According to Zachary Steglin, network performance manager at Global Load Control (GLC) of South Africa, R-LOSA is an intriguing tool that should holistically address the surveillance and implementation needs of an organisation operating in a safety environment in the aviation sector.
Steglin points out that, ideally, all aviation services companies have a similar culture towards improvement. Yet the sad reality is that many are hampered by access to a certain caliber of staff who can implement that culture; infrastructural or cost limitations and bottlenecked projects take priority in achieving certification for operational reasons, even more so in Africa.
“At GLC, although the model is not R-LOSA, the safety management activities all function towards the same logic of continuous improvement and self-reporting practices,” Steglin says. “Where we are still developing is the ability to monitor and analyse the various operational activities, in relation to which - due to internal and external causes - we depart from the process to address a non-conformance or reportable incident.”
Checklists and Codes
Ground service providers contemplating R-LOSAs need to think about the observation checklists and the coding system for threats and errors to be used during line observations for data collection purposes.
The FAA has made some pre-determined lists of codes and errors and R-LOSA observation forms which any ground service provider can directly access on its website. Individual organisations may opt to customise documentation to their needs; this has been the case at United.
“While the initial checklist included close to 100 questions we reduced the checklist to 55 questions in June 2015 in order to focus data collection of higher risk items,” Crocket says. “In order to trim the checklist we removed vendor and non-ramp related questions. Historical data and risk ranking combined were also used to condense the checklist. We acknowledge that vendor and non-ramp data is important to collect and expect to either add questions back or perhaps replace current questions as compliance reaches an expected level with vendor or non-ramp questions.”
What do R-LOSAs reveal?
R-LOSAs allow the identification of areas for improvement in the ground handling system on a factual basis and with statistical confidence. “Early data revealed lower compliance in personal protection such as seat belt usage and hearing protection, and belt-loader safety handrail usage as well as some receipt and dispatch procedures” says Crocket.
The main findings of R-LOSAs at JetBlue are of a similar nature: violations in the use of personal protective equipment, issues regarding the thoroughness of the aircraft walk-around and loading errors are the most populated fields of errors based on the results of the observation, according to Crowley.
Managing change
In the same way the identification of safety issues in the ground handling environment can be performed on a factual, easier to justify, way through R-LOSAs, so too can the request for budget to implement the changes needed for safety improvement.
“Systemic data is reviewed at the corporate level on a monthly basis,” Crocket says. “Systemic changes to receipt and dispatch of aircraft and procedural changes/improvements occurred as a result of data. Additionally, stations are expected to review their data regularly and have been provided easy-to-use tools to accomplish this, including leading-edge data visualization tools that identify compliance and threats by location on the airport property.”
Crocket also stresses that audit results should be communicated to front-line employees and not only to leadership. “It makes them mindful of the conditions and compliance beyond their individual performance and heightens awareness of threats in their performance,” says Crocket.
Looking Forward
R-LOSA has recently been the focus of attention from representatives of Japan’s aviation industry. “At JetBlue we have recently hosted a delegation from All Nippon Airways, Japan Airlines and the Japanese civil aviation authority in New York to illustrate them the use of LOSA for ground handling safety and they were very positively impressed,” says Crowley.
R-LOSA is a good way to gather safety intelligence, a practice that is being affirmed as best industry practice. “We are convinced that Maintenance and Ramp Line Operations Safety Assessment (LOSA) is certain means to provide critical predictive data for a Safety Management System,” Bill Johnson, chief scientific and technical advisor for maintenance human factors at the FAA, says.
