LOSA description in PowerPoint presentation.

1. AIR GEORGIAN LIMITED
Line Operations Safety Audit
Dan Bockner

2. Introduction
Quality Assurance & Audit IT Systems
• Over the summer of 2010 Air Georgian Limited
(AGL) conducted a Line Operations Safety Audit
(LOSA)
• The LOSA was a very substantial undertaking for
a company the size of AGL
• The LOSA was a positive project that has helped
us to better understand our operation and
improve safety

3. Air Georgian Limited
• Air Georgian Limited operates 16 Beech 1900D
(15 at the time of the LOSA) providing scheduled
Tier III service on behalf of Air Canada
• We have bases in Toronto, Halifax and Calgary
(just the first two at the time of the LOSA)
• We also operate five business jets but these
crews were not involved in the LOSA

4. Air Georgian Limited
• Air Georgian Limited operates about 30000
flights per year
• The Company employs 120 pilots with 112 on the
Beech 1900D
• Flights are anywhere from 25 minutes to over
two hours

5. Beechcraft 1900D (BE02)

6. Line Operations Safety Audit
• A Line Operations Safety Audit (LOSA) involves
having trained observers fly on a series of flights
• Each observer occupies a suitable seat from
where he can make observations on a detailed
and tailor-made LOSA form
• The observers must be non-management and are
usually pilots
• For our LOSA we used six observers
• The observers are plugged in to the intercom
system

7. Line Operations Safety Audit
• The observers do not take part at all in the operation
of the flight and do not communicate with the flight
crew (other than an initial briefing)
• Each observer will audit a set number of flights.
Once completed the observer enters the results into
a database
• Either flight crew member is fully empowered to
refuse access to the auditor; participation must be
voluntary
• The LOSA is overseen by the LOSA Steering
Committee

8. Line Operations Safety Audit
• The LOSA Steering Committee was made up of
myself, the Chief Pilot, the Chief Instructor, the
Corporate Safety Officer, the Standards Captain as
well as the six observers
• The LOSA Steering Committee planned and oversaw
the process from start to finish; outside expert
advice was secured in the form of a consultant from
TACG who provided a training course at our head
office
• The final component of the LOSA is the
questionnaire

9. Line Operations Safety Audit
• Before being entered into the database all data is
‘cleansed’ by the Steering Committee
• A comprehensive report is created using the data
collected from the observed flights and the
questionnaires
• The report must be distributed widely
throughout the organization in order to raise
awareness and improve training

10. Threat and Error Management Model
• TEM is akin to defensive driving
• The model posits that threats and errors are
integral parts of daily flight operations and must
be managed
• A threat is external and will increase risk
• An error is a non-compliance with the regs,
SOPs (or other Company policies), or an
unexpected deviation from crew, Company or
ATC expectations

11. Threat and Error Management Model
• An undesired aircraft state (UAS) occurs when
the flight crew puts the aircraft into a situation
that unnecessarily increases risk (through crew
actions or lack thereof)
• Threats, errors and UAS’ are a fact of life every
flight. Increased awareness will improve the
ability of pilots to deal with them effectively

12. Union Involvement
• For an effective LOSA pilots must be clear that it
involves ‘no jeopardy’
• The union leadership must be involved in the
LOSA from the start
• The union leadership must ‘buy-in’ to the
concept and actively help to convey the message
to the pilot group

13. LOSA Findings - Threats
• Obvious ones such as:
1. weather
2. heavy ground and air traffic
3. frequency congestion
4. ATC errors (especially non-standard
phraseology)
5. deferred Mtce items

14. LOSA Findings - Threats
• Some not so obvious threats such as:
1. Two Captains paired together
2. Routine nature of scheduled operations. This is
not necessarily a ‘threat’ as defined in the TEM
but it is a real consideration that all should be
aware of

15. LOSA Findings - Errors
• Recurring errors included:
1. Sterile cockpit violations
2. Excessive taxi speeds
3. Failure to properly use the checklist
4. Errors in system handling
5. Failures to confirm runway data for take offs
and landings

16. LOSA Findings - Errors
• Some significant specific errors include:
1. Knowingly operating with a failed radar with
forecast CBs en-route
2. Failure to check NOTAMs; destination airport
closed due to air show
3. Failure to enter a defect into the journey log at
the completion of a flight
4. Flight crew reading magazines while in climb
with the autopilot engaged
5. SOP confusion during a PMA approach

17. LOSA Findings - UAS
• Some UAS’ observed include:
1. Vertical and lateral deviations
2. Speed deviations
3. Excessive bank
4. Unstable approach

18. LOSA Recommendations
• A total of 15 recommendations were generated
by the LOSA and outlined in the final report
• To date 10 of the recommendations have been
implemented

19. Overall Result
• The LOSA made clear that Air Georgian
Limited’s operations are safe and professional
• It also made clear that we have much work to do
in order to continuously improve
• Being able to prove and quantify our
shortcomings to both managers and employees
is invaluable
• The LOSA report is a valuable training aid

20. Lessons for Future LOSAs
• Mark overall SOP compliance for each observed
flight
• Better confirmation that special equipment needed
is serviceable
• Improve scheduling for observers
• More training in use of the marking form for the
observers
• More notice and communication to Crew Schedulers
and Flight Followers
• Increased observation of flight planning at the start
of the flight duty day
• More math in the final report