The Focus of this blog is to consider the inter-relationship between Maintenance Error Management Systems (MEMS) – (typically using the Boeing Maintenance Error Decision Aid as a primary tool) and Safety Management through Human Factor Learning within the context of a viable Safety Management System.

What is the Purpose of MEMS?

The rationale behind a MEMS System is to identify any situations that may “promote” the potential for error. In addition, it facilitates (using the organisational framework) the risk based decision-making process which will lead to stronger defenses.

Driving Safety Management System (SMS) Value from your Aviation Maintenance Error Management System (MEMS).
Throughout our Industry, we know that Maintenance Errors cost millions of Euros every year through the need for rework, delays, and lost revenue. (To consider also the potential to introduce safety-related exposures.)

What is MEDA?

Boeing developed the MEDA process to assist maintenance organisations in identifying why events occur and how to prevent them in the future.

MEDA provides a process for conducting thorough and consistent investigations, determining the factors that lead to an even,t and making improvements to reduce the likelihood of future incidents.

Sofema Aviation Services (www.sassofia.com) considers the challenges to be found during the implementation & delivery of an effective Maintenance Error Management System (MEMS) within an EASA Part 145 Aircraft Maintenance Organisation (AMO)

Tensions between the desire to ensure safety behaviours and the organisations economic objectives (Production versus Protection) deliver real challenges which have a direct bearing on safety culture.

What is an Aviation Maintenance Safety Culture?

Introduction

It is considered that errors and violations together form the unreliable part of our human performance. Moreover, 70-90 percent of current aviation incidents & accidents are due to in some part to “human factors”.

Errors and violations contribute to accidents both directly and by making the consequences of other problems more serious. An accident typically involves several contributing factors, some usually being quite visible and others possibly latent in nature.

The Role of Maintenance Error Management Systems (MEMS)

The ability of the organisation to investigate Maintenance Error is a valuable tool for understanding causal, contributory, and root elements and developing and providing appropriate mitigation to reduce ongoing exposure.

If we wish to minimize re-occurrence we should address not only the root cause (or causes) of a given outcome but also consider all the contributing causes (and there could be many!) as this will have a significant positive impact on the lowering of the threat level (reduction in exposure).

Introduction

The Key to the successful delivery of “CAMO” Continuing Airworthiness is without a doubt “Core Competency” across the key business elements of Continuing Airworthiness Manager (CAM), Maintenance Planning (MP), Engineering (Eng), Reliability (REL) and Tech Records (T/L).

Remember that the goal of EASA compliance is a step on the journey and not the destination – the focus of any effective Continuing Airworthiness Management Organisation (CAMO) should be to maximize the availability, reliability, and safety of the fleet as well as focus on a reduction in maintenance costs.

EASA Focus is shifting to a Performance Based Approach to Regulation

A “Performance Based Approach” brings to the fore two challenges:

Review the Following

Details of ageing aircraft system requirements with any specified sampling programmes (if applicable).

Details of specific structural maintenance programmes (if applicable), including but not limited to:

a. Damage Tolerance and Supplemental Structural Inspection Programmes (SSID)

SUPPLEMENTAL STRUCTURAL INSPECTION PROGRAMME (SSIP)

Increased utilisation, longer operational lives, and the high safety demands imposed on the current fleet of transport aeroplanes indicate the need for a programme to ensure a high level of structural integrity for all aeroplanes in the transport fleet.

Introduction

The Current Portfolio of SAS “TTT” - training courses currently on offer include Ramp Safety / HF TTT - Maintenance Instructor TTT, Human Factors TTT, Internal Auditor TTT, Safety Management System TTT, Fuel Tank Safety (FTS) & Electrical Wiring Interconnect System (EWIS) TTT and Maintenance Error Decision Aid (MEDA) TTT.

Correct Understanding is Important

Let's have a clear understanding here because it is important to understand that a 3 or 4-day training does not “Deliver” a trainer and we would be “not correct”  if we were to believe this to be so.☺

The reality is that this course as well as other activities is part of a systematic process of building soft skills and competence across a range of topics that support the organization.

It is not possible to separate the Safety Management System from the need to manage Ramp HF most effectively. The more integration the better in terms of understanding and managing the exposure.

All the elements that are considered as part of our Aviation Ramp Safety & Human Factors Exposure may typically be accommodated and addressed as part of the delivery of the SMS system.

If we can study and take appropriate action in respect of human factors issues, we will be able to better prepare to deal with human factors issues and behaviours in our daily routine.

Driven by ICAO obligations European Countries (as well as the rest of the world) are required to demonstrate compliance with the requirements of ICAO Annex 19.

Airports are specifically mentioned within the requirements related to the need for a State Safety Program as well as the need to demonstrate compliance with the SMS obligations.

What are we Trying to Verify?

An Audit will typically generate several findings, and whilst the first step is usually to take an immediate “short-term” action, the important business is ensuring the fundamental cause or “root cause” is addressed – the challenge is that this is far from easy!

Essentially, we are seeking evidence that the cause or “causes” of the problem have either been removed or mitigated acceptably. (It is not always possible to completely fix the issue and sometimes the best outcome we can hope for is a reduction of the causes.)

Essential Evidence for Verification

Steven Bentley MD of Sofema Aviation Services believes it is time to recognise QAS as a component of our organisations' SMS.

Where Should an EASA Compliant Quality Assurance System “Sit” concerning the Organisations SMS?

Introduction

Historically (and growing up in the workplace through the 1970’s I can attest to the fact) there was no formal Quality Assurance within European Aviation Operations.

Of course, we had Quality Control and the Role of Flight Operations Director and within Maintenance the Role of “Chief Inspector”.

As the Joint Airworthiness Authority’s influence grew the concept of an independent assessment of conformity became the acceptable way of demonstrating compliance.

To deliver effective EASA compliance audits it is necessary to pay attention to several key areas which are identified below for discussion purposes.

a) Maintaining Objectivity
b) Sample Size
c) Value of Finding Raised
d) Operator’s Authority on Area of Audit

Maintaining Objectivity

Objectivity requires both perspective and balance on the part of the auditor. We should also pay attention to the fundamental reason we are carrying out the audit.

An essential element of any system is to be able to measure the effectiveness of the various processes which are involved in delivering the overall product.

The Quality System consists of 2 distinct parts:

a) The Quality Control Processes – Embedded in all production areas
b) The Quality Audit Processes – An independent way of assessing point a) above

By measuring the effectiveness of both parts of the company’s quality system (QA & QC) we will be able to provide a detailed status of the strength of the Quality Management System (QMS) as well as to provide a detailed understanding that will facilitate management planning and development.

Step 1 - Organisation & Regulatory Review

All EASA Approvals typically provide an independent Quality Assurance Function (EASA Part 21J requires a design assurance system)

The next comment is to consider the EASA “take” on QA & QC (A Quality System Contains Both). QC is embedded in every aspect and element of the Production Process.

The primary objective of EASA Compliant Quality Auditing is to ensure both external and internal compliance with regulatory and organisational procedures.

We have many secondary objectives which are typically organisationally driven rather than EASA-driven. (Nevertheless, such elements provide an indication of the intent and effectiveness of the organisation.)

An example of a secondary objective would be a demonstration of continuous improvement – which would mean a reduction in findings over time for a consistent level of auditing activity.

So let’s take a look at how we could perform an Audit of the Internal Reporting System within an operator's Management System.

Consider First the Background Regulatory Obligations and note that we need in this case to comply with both 965/2012 and 376/2014 (Proposed Audit Items are identified as AI-N)

AMC1 ORO.GEN.200(a)(2) Management system
COMPLEX OPERATORS - SAFETY POLICY

(a) The safety policy should:

(4) Include safety reporting principles. AI-1

(b) The safety policy should include a commitment:

(5) Not to blame someone for reporting something which would not have been otherwise detected. AI-2

Introduction

The essential purpose of an EASA compliance audit is to support the maintenance of the regulatory approval.

Quality Assurance Compliance Audits are a systematic and independent comparison of the way the system process or objective is met. Using the observations made during this audit, as “objective evidence” a comparison is thus made against the standard, generating non-conformities or corrective actions in the event of any discrepancy.

The audits should be documented with a checklist that shows the details of the audit standard or audit criteria which is being applied to the audit.

Note 1 Quality Assurance Audits are Prescriptive in as much as they are always referenced against a standard – means compliant.

A discussion paper by Steve Bentley MD of SAS (www.sassofia.com)

So what is the Fundamental Mistake?

Essentially it is to "believe" that there is a similarity between ISO & EASA – there is not! Sure, Quality is Quality but make no mistake – EASA is all about compliance.

Even the Quality Assurance Manager has received a name change "makeover" He or She, is now called the Compliance Manager (CM).

What Does EASA Expect?

There are two expectations:

Time Constraints

This is a circular tour where people are time challenged which presents them with fixing the problem which will provide them with additional free time!

Many companies are caught in this catch-22 situation where whilst there are multiple disconnects, Often the organisation does not have enough “trained” people to perform the root cause analysis.

The Fire Brigade

People are often too busy fixing today's problems to address ongoing disconnects. Short-term fixes are usually aimed at contributing factors without doing a root cause analysis. (Even if we add more people, intending to solve the situation the effort will usually not succeed since without training, additional resources are used ineffectively due to poor planning and scheduling.)

Reality Check

Whilst typically front-line staff may recognize a given problem, senior management often does not appreciate the dynamics of the same issue.

Often when senior management does understand the problem, they are pressured to deliver a quick fix to the situation.

Introduction

Why do people break rules, particularly if the outcome can be negative and even dangerous? What is it that makes a worker break the rules or commit a violation?

A great deal of research has been undertaken during the last 25 years with the focus looking at the view of errors in different way.

Rather than Human error being considered the ultimate cause of system failure, it is important to understand the context in which the error was committed. (For example, was it deliberate or related to Pressure, Fatigue, Stress, or any of the other “Dirty Dozen”?)

Violations – Personal or Organizationally Optimizing?

To reduce exposure to violations and errors, a broad range of organisational interventions may be required.

Steven Bentley MD of SAS www.sassofia.com considers the potential for HF Error with an EASA/GCAA compliant CAMO

Introduction

The Primary Roles of the CAMO are Maintenance Planning, Technical Records, Reliability & Engineering. Each “Role” brings the challenges of how we can ensure enough attention to both personal and organisational responsibility when we consider the potential for HF error.

HF Example – Stress Caused by Pressure from “Poor Planning”

We are not considering here that it could be the Maintenance Planning Worker who is stressed - however this is of course a possibility, and we should always make sure that our team members have the appropriate level of “Competence” for the role.