Steve Bentley MD of SAS (www.sassofia.com) discusses the various areas where the Maintenance Planning Process was able to become a precursor contributing to potential maintenance.

EASA commissioned a “Study on the need for a common worksheet/workcard system” to evaluate the impact of maintenance documentation on the Human Factor concern.

(Specifications N°: EASA/2006/OP/25 On demand of the European Aviation Safety Agency (EASA), BUREAU VERITAS conducted a “Study on the need for a common worksheet/work card system” from January to November 2007. The present document presents the results of this study.)

The study aimed to provide further insights into the use of documentation, and the common practices in place between operators and maintenance organisations and to assess whether current rules and practices may still contribute to incidents/accidents.

Among other results, the study produced a list of incidents/accidents related to the use of maintenance documentation.

Introduction

Whilst currently (October 2018) EASA does not mandate the obligation to ensure CAMO & Maintenance Planning Staff receive HF training, the reality is that the potential for Human Factor Error knows no bounds and it is just as likely that a Human Factor (HF) error could originate from exposure within the Maintenance Planning Environment as anywhere else within the “Aviation System”.

Currently, some 80% of aircraft accidents are attributable to human error however, this is a situation where it is possible to manage and or address by managing the exposure.

Human Error is recognised as rectifiable through the process of raising awareness, implementation of effective processes and procedures, and effective communication within the workplace.

Introduction

Whilst Aircraft fuel-tank entry is essential for both inspection and modification it poses several hazards to maintenance personnel performing the work.

Fuel tank work can be accomplished as required without placing personnel at risk through effective preparation and training.

The Maintenance Organisation should strive to ensure a safe, healthy work environment for fuel-tank personnel by identifying potential hazards, developing control measures, and instructing personnel on the specific procedures to be followed during all Aircraft fuel-tank maintenance activities.

Considering the role of a Fuel Tank Entry Team

An essential requirement to minimize exposure to the risk of injury during fuel-tank work is a properly trained and equipped team.

Personnel with authorization to enter the fuel tank and perform work must be able to recognize potential hazards and initiate evacuation if there are any concern issues.

The following elements are critical to safe working conditions:

a) Communication
b) Respiratory protection
c) Ventilation and air monitoring
d) Electrically powered tooling & equipment
e) Airplane damage considerations

Primary Hazards Related to Fuel Tank Working

There are several potential hazards that fuel-tank maintenance personnel may experience whilst engaged in Fuel Tank Work however the 2 primary hazards are:

a) Chemical
b) Physical

Considering Chemical Hazards and their Consequences - Fuel

Of course the most commonly recognized hazard is the jet fuel itself which is a flammable liquid and will ignite if the temperature of the fuel is such that vapour is created. (The temperature at which the vapours of a flammable liquid can ignite is known as the "flash point".)

Preparation for Entry Into the Fuel Tank

It is most important to ensure that all persons who are engaged in the process of Fuel Tank Entry are fully trained on all aspects of the following information to ensure that all precautions are taken and all risks minimised.

Steps that must be taken include the following:

a) Ensure the aircraft is electrically grounded

b) Ensure that Fire Extinguishers are available (typically CO2 would be used for a Fuel Fire

c) Deactivate all Electrical Systems on the Aircraft and suitable placard

d) Defuel the aircraft using the Aircraft Maintenance Manual Procedures

e) Deliver a safe atmosphere for maintenance personnel by ensuring the following:

Introduction

A large percentage of the work involved in performing inspection and modification of aircraft fuel tanks and their systems is typically carried out with the fuel tank itself. Such tasks require maintenance personnel to physically enter the tank, where significant environmental hazards exist.

Fuel Tank-related work is one of the most difficult challenges an aircraft maintenance worker may face. Not only the challenge of physical entry and moving around within the tank, the additional challenge of multiple hazards including health and safety hazards, most notably oxygen deficiency, flammability, explosion, and the toxic effects of fuel vapours.

Comments by Steve Bentley MD Sofema Aviation Services www.sassofia.com

Introduction

As a precursor to the introduction of Regulation 376/2014, EASA identified shortcomings related to Aviation Occurrence Reporting and proposed in 2010 a new regulation which in compliance with ICAO objectives moved the focus from a ‘reactive’ system to a pro-active, risk and evidence-based system.  It also acknowledges that safety occurrence data is vital to allow for the timely identification and management of potential safety hazards and acts upon this before these hazards turn into actual accidents. 

EASA introduced EU Regulation 376/2014, (repealing EU directive 2003/42/EC), which came into force on 15th Nov 2015. The regulation provides additional safeguards to address the lack of protection of the reporters, the lack of harmonisation in the occurrence of data collection and integration (leading to low-quality reports and incomplete information), as well as insufficient requirements regarding safety analysis and the resulting recommendations.

Introduction

Effective safety reporting of hazards by operational personnel is an important cornerstone of the management of safety. Therefore, an operational environment in which operational personnel have been trained and are constantly encouraged to report hazards is the prerequisite for effective safety reporting.

The ICAO requirements require that aviation service providers develop and maintain, within the scope of their SMS, a formal process for collecting, recording, acting on, and generating feedback about hazards in operations. The process shall be based on a combination of reactive, proactive, and predictive methods of safety data collection. 

Best Practice Considerations

Consider the following as best practice objectives regarding the delivery of an optimized and effective Safety Management System.

Sofema Aviation Services www.sassofia.com looks at the ICAO Data Reporting System

ADREP Introduction

The Accident/Incident Data Reporting (ADREP) is operated and maintained by ICAO.

The ADREP system receives, stores, and provides States with occurrence data that will assist them in validating safety.

In this context, the term ‘occurrence’ includes both accidents and incidents.

The system was established in 1976 but has evolved to meet changes in information technology and the aviation industry. The version of the ADREP system in current use is ADREP 2000.

Annex 13 to the Chicago Convention — Aircraft Accident Investigation - contains Standards that require Contracting States to report to the International Civil Aviation Organisation (ICAO) information on all aircraft accidents that involve aircraft of a maximum certificated take-off mass of over 2 250 kg.

The Organisation also gathers information on aircraft incidents considered important for safety and accident prevention.

Risk Assessment

Driven by ICAO Annex 19 Identifying, Assessing, and Mitigating Risk is at the epicenter of an effective Aviation Safety Management System (SMS).

The challenge is to ensure that the Safety Risk Assessment is performed genuinely with tangible benefits as a measurable outcome. The consequence of a risk can usually be expressed in several ways and these will affect the assessment of severity and likelihood, requiring care competence, and diligence on the part of the analysts. 

Delivering Effective Risk Assessment Requires?

When considering Risk the challenge will always be related to the subjectivity of the perceived exposure. Therefore a broad range of contributors to the Risk Assessment Process is highly beneficial including.

Considering ICAO's Definition of Safety

ICAO Annex 19 defines safety as ‘the state in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level’ and safety performance as a service provider’s safety achievement as defined by its safety performance targets and safety performance indicators’.

Challenges to Establish Confidence in Safety Performance?

Whilst it is usual for safety metrics to focus on serious incidents and accidents it is also possible to gain a false impression regarding the overall level of safety due in part to a system with a low number of high-consequence negative outcomes, which means the low frequency of such outcomes may give the wrong impression that your system is safe.

Sofema Aviation Service www.sassofia.com looks at SMS reporting from the EASA perspective

What do we mean by Safety Occurrence Reporting?

We use the term Safety Occurrence to identify as a collective term that is used to embrace all events that have, or could have significance in the context of aviation safety.

Events identified may range from minor events which are deemed to have a potential for an impact on safety to incidents or events that should be reported to more serious events including serious incidents and accidents.

Building a Reporting Culture

The willingness to report, safety-related exposures is a significant measure when we are considering the effectiveness of a Safety Management System.

One of the biggest barriers to an effective Safety Management System (SMS) depends on the willingness of the employees to engage with the organisational system and for the managers to support such a program in a positive and tolerant way.

Without the willingness to engage with the Safety Management System (SMS) the level of data capture will lead to the creation of barriers.

Full engagement by the Management Team is an essential first step on the journey and without doubt. If we are going to maintain a healthy safety management system (SMS) we require an open process of hazard reporting which allows us to understand the exposure and to reduce the operational risk.

How we impact the various organisational barriers is in turn impacted by cultural and other behaviours which are often routed in mistrust.

Safety is defined as “The condition to which risks are managed to acceptable levels.”

Whenever Humans and Machines are involved there will always be potential for accidents and incidents. Safety management is based on the premise that hazards, risks, and threats will always exist.

With a Safety Management System (SMS) we focus on the real possibility of reducing the organisations exposure across a range of business areas – we do this by delivering a systematic approach to risk management.

It is possible to promote transparent processes that establish clear lines of accountability and aid decision-making and to use this as a tool to drive positive change.

Sofema Aviation Services www.sassofia.com  & www.sofemaonline.com looks at the bigger picture driven by the recent changes to the EASA Basic Regulation 1139/2018.

Introduction

On 11th September this year entered in force the new EASA Basic Regulation No 1139/2018 which repeals existing Regulation (EU) 216/2008.

The European Aviation Safety Agency (EASA) welcomes the adoption by the Council of the European Union of updated aviation safety rules for Europe which include a new mandate for EASA.

The so-called new Basic Regulation formalises EASA’s role in the domain of drones and urban air mobility, enabling the Agency to prepare rules for all sizes of civil drones and harmonize standards for the commercial market across Europe.

Within the workplace the consequences of human failure can be significant, unfortunately, we are all capable of error regardless of our training or motivation.

A human error is an action or decision that was not intended, however, it is important to consider that human failure is not random. There are two main types of human failure: errors and violations.

Errors often occur in highly trained procedures where the person carrying them out does not need to concentrate on what they are doing (Improved design can reduce their likelihood and provide a more error-tolerant system).

Violations are rarely malicious (sabotage) and usually result from an intention to get the job done as efficiently as possible. Getting to the root cause of any violation is the key to understanding and hence preventing the violation.

Organisation Obligations

The potential for Human Error should be managed proactively and should be addressed as part of a wider risk assessment process.

There are several ways we can assess the integrity of a Vendor/Supplier to improve the supplier performance.

Understanding the purpose of Receipt Discrepancy Processes and Component Reliability Assessment including warranty issues.

Why would we carry out a Vendor Survey?

Essentially it is a process that sits alongside the Supplier Evaluation Procedures and enables an ongoing assessment of the effectiveness of the supply chain arrangement with a given vendor.

What do we want to know concerning our vendors?

We want to know how effective is the product that is received from a particular supplier, and we measure this in several ways:

Certain Parts will require special attention due to their size for example Aircraft Landing Gears and Engines. To ensure adequate inspection techniques are followed the following should be included.

a) Written procedures?

b) Internal quality audit procedures?

c) Signature procedures?

d) Procedures for checking for physical damage and defects?

e) Preservation procedures?

f) Procedures for quantities received controls?

g) Verification procedures for part/model/serial numbers?

h) Documentation matches part(s)/material(s) received?

Sofema Aviation Services www.sassofia.com looks at the basic requirements related to an effective EASA Compliant Aviation Stores

Regulatory Drivers

Storage, Tagging, and Release of Aircraft Components and Materials to Aircraft Maintenance

[Part 145.A.25 (d), AMC 145.A.25 (d) 1, 2, 3 - Part 145.A.40 (a) - AMC 145.A.42 (b) - Part 145.A.70 (a) 12] 

Concerning Storage

Stores shall provide the necessary capacity to stock aircraft components, consumables, and raw materials in the manner recommended by the manufacturer’s instructions and following the relevant regulations and safety precautions.