Line Operations Safety Audit Proactively Identifies Threats to Avoid Mishaps

By MR. BRIAN RISLEY, HQ AMC Flight Safety

Managing risk has become increasingly important regardless of the area concerned, especially when it comes to aviation. The Air Force Aviation Safety Programs (ASP) are three data-driven, proactive programs used to identify risks, analyze collected data, and prevent future mishaps. Military Flight Operations Quality Assurance (MFOQA) data show when flight parameters are exceeded. The Airman Safety Action Program (ASAP) is an identity-protected, self-reporting system designed to encourage the voluntary reporting of issues that increase risk to flight operations.

The Line Operations Safety Audit (LOSA) is distinct from, but complements, MFOQA and ASAP. LOSA could be compared with a patient’s annual physical examination. The patient has a battery of tests done, blood pressure checked, cholesterol, and so forth, all in hopes of identifying early signs of an upcoming health problem. If those signs are addressed early and effectively, the exam could save the patient’s life. LOSA collects information on the health of a system by identifying threats to the aircrew that may ultimately lead to a mishap. In 2010, Air Mobility Command (AMC) adopted the LOSA program from the airlines after witnessing its proven success.

To objectively collect data and provide a diagnostic snapshot of strengths and weaknesses in a community as it conducts its daily business requires extreme trust between the operator and the observer. The crew members must be assured that they are not to be penalized for mistakes or actions and that they are not on an evaluation checkride of any sort. LOSA is nonpunitive, anonymous, and completely voluntary for those being observed. Even the aircraft commander has the right to deny the observer access for any reason. As stated in a memorandum published by Gen Maryanne Miller, Commander of Air Mobility Command, on March 11, 2019, “A Just Culture should be continuously promoted and reinforced through leadership actions throughout organizations by encouraging members to address hazards and mitigate risk without fear of adverse actions.”

The majority of AMC aircraft are on a four-year LOSA schedule. To kick off a LOSA cycle, a Threat and Error Matrix workshop is conducted by our LOSA contractor. In the workshop, subject matter experts (SMEs) with specific aircraft experience formulate a specific list of criteria that will be used by a team of observers in the following phase. These SMEs are typically a collection of experienced instructor or evaluator aircrew members.

LOSA observers are then recruited through solicitations from AMC Safety to all wings and sister commands. The LOSA observers are Mission Design Series experts and are trained to observe. Many tend to be volunteers from the Air National Guard or Air Force Reserves. Over a period of several months, these observers watch different crews on a variety of missions, noting all the threats encountered, how crew members respond to the threats, and if they (or any support agencies) make any errors and why. The observers also record whether the threat is mitigated properly. If the threat is not mitigated properly, it likely will lead to what is referred to as an undesired aircraft state. All this information can then be analyzed with the objective of preventing a future occurrence. LOSA observations are done across the globe, proportional to the number and type of missions conducted by the fleet.

Following the observation period, all the data are analyzed by a contractor and input into a database. Later, a working group of SMEs, known as “The Roundtable,” reviews and validates the data. The C-5 LOSA Roundtable was held at Scott Air Force Base, IL, in April of this year. One observation revealed that scheduled sorties frequently did not match the circadian rhythm of the aircrew, which led to excessive fatigue. Several observations detailed increased cargo load times on the ground due to a combination of cargo configuration changes and degraded loading equipment aboard the aircraft. Those circumstances could drive crews to compromise safety and rush to make a scheduled takeoff time.

Once the data are thoroughly vetted, a safety investigation board (SIB) convenes to review all the findings and make recommendations to the AMC Commander on how to mitigate the risks found and prevent potential mishaps. A SIB is typically assembled following a mishap to investigate the incident, report its findings, and make recommendations to prevent a similar mishap in the future. A LOSA SIB convenes before a mishap occurs, but it receives the same focus and treatment. The LOSA SIB consists of an O-6 Board President, investigating officer, pilots, other aircrew members (dependent on the aircraft type), a recorder, and other SMEs as needed. The recommendations of the LOSA SIB are briefed directly to the AMC Commander. Once approved by the command, each recommendation becomes an actionable item to be addressed in a timely manner with due attention from leadership.

LOSA is a robust program that has proven successful. LOSAs have identified threats such as an inadequate weather radar on the C-21. The upgrade was approved, funded, and accelerated thanks to the LOSA effort. Almost the entire C-21 fleet is now equipped with a new, fully capable weather radar system and controller. Other successful outcomes following a LOSA SIB include procedural changes, checklist rewrites, systems replacement, and even changes affecting the current culture.

AMC Flight Safety is currently finalizing a C-5 LOSA and is overseeing LOSAs for the C-40, C-21, and C-17 aircraft. AMC is looking to expand LOSA into fields beyond aircraft operation, such as maintenance and Aeromedical Evacuation (AE). Working with an AMC AE team, AMC Flight Safety is making groundbreaking efforts to conduct the first-ever AE LOSA.

Combined with MFOQA and ASAP, LOSA gives AMC a powerful tool to help prevent mishaps. Using the analyses from these programs, commanders are able to assess risks and adjust policy and training to mitigate those risks, identify material requirements, or accept the risk as necessary for mission accomplishment.