UK MEMS Group A Collaborative Approach to Safety Management Mick Skinner

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UK MEMS Group A Collaborative Approach to
Safety ManagementMick Skinner CHIRPIFA
Dubai, May 2012
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UK MEMS Group membership (29)
Independent Chairman
Jet Aviation CHIRP Thomson Airways Civil Aviation Authority Essex Police (Air Support) Thomas Cook Airways KLM UK Airbase Interiors Altitude Global Ltd British Airways Engineering BA Maintenance Glasgow Netjets QinetiQ Flybe Virgin Atlantic BMI Bostonair Monarch Military Aviation Authority Air Accident Investigation Branch ATC (Lasham) Ltd Jet2.com DHL CHC Helicopters Marshalls of Cambridge Bristow Helicopters easyjet British Business General Aviation
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Balanced Portfolio?

• Independent Aircraft Maintenance Organisations
• Fixed Wing
• Civil
• Military
• Rotary
• Operators
• Full Service and Low Cost
• Freight
• Regional
• Helicopter
• Private Charter
• Repair and Overhaul Organisations
• Components
• Avionics

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What is the basis for an independent, voluntary,
confidential reporting system in the UK?

• ICAO Annex 13 requires that Member States put in
  place a voluntary, non-punitive incident
  reporting system to complement a mandatory
  incident reporting scheme. (Annex 13 Paras 8.2
  8.3).
• EC Directive 2003/42/EC Article 9 (reflected in
  Article 142 of UK Air Navigation Order)
  establishes the conditions for a voluntary
  reporting system.
• Civil Aviation Publication CAP 784 State Safety
  Programme for the United Kingdom published in
  February 2009 meets the ICAO requirement for
  Contracting States to produce an SSP. Chapter 5
  Para 2.5.3 states that CHIRP fulfils the role of
  a voluntary safety reporting scheme for the UK as
  required by Annex 13.

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MEMS - Maintenance Engineering Management System

• Joint Initiative commenced in 2000 Industry /
  CAA(SRG) / CHIRP
• Objective Share data on engineer human
  performance investigations and promote best
  practice in prevention.
• Role of CHIRP management and analysis of
  company data.
• Current membership 29 engineering related
  organisations.
• Initiative has significantly improved
  understanding of the causal factors in human
  error incidents involving engineers.

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Maintenance Error Data Sharing
Background
CAA AN71

• Issue AN71 Maintenance Error Management system
  recommendations March 2000 (Leaflet B160 updated
  2012)
• UK road show on how to establish internal safety
  reporting programmes

UKOTG EIMG

• UK operators MROs review of data gathering
  methods, propose MEMS initiative November 2000

CHIRP

• Development of central database and information
  communications proposed November 2000

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Project Development

• Review feasibility of sharing MEMS data 21
  attendees
• CAA
• CHIRP
• UKOTG Operators maintenance organisations
• EIMG Independent Maintenance Repair
  Organisations
• Boeing
• Airbus
• GE

London Meeting March 2001

• Pilot study initiated, funding gained from CAA
• MEDA based taxonomy agreed
• CHIRP offered central database
• Constitution agreed with group of 8 UK members

MEMS Steering Group set up April 2001

• MEMS Steering group pilot study completed
• CHIRP MEMS database developed
• CHIRP website distribution set up
• Constitution revised for wider membership

MEMS Steering Group closed April 2003

• UK MEMS group established
• Independent chairman appointed
• 4 members from UKOTG
• 2 members from EIMG
• 1 member from CHIRP
• 1 member from CAA

UK MEMS group constituted April 2003
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Project Methodology

• All group members agreed to keep data
  confidential
• Participants must agree to share information
• Statement read out at each meeting as binding
  agreement on disclosure

Confidentiality Agreement

• Group members sent MEDA reports to CHIRP
• Protected database accepts multi-format
  information
• Database available to all participants via
  password discreet individual file
• CHIRP publishes edited analysis of database to
  group

Secure Database Established

• Generic procedure for MEDA reports
• Website for programme information available to
  all members
• Factual information generated, no opinion or
  hear say given
• Guide to best practice developed

Rules of Input
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Future development

• Progressively expand contributors group
• Each must demonstrate programme capability in
  pre-membership audit
• Further develop analytical capability providing
• a) improvements to safety standards across
  industry
• b) feedback to Manufacturers for improved
  build standards
• c) maintenance improvements to provide more
  effective processes

Next steps
Manufacturers Industry Synergies

• Develop links with Airframe/ Engine
  Manufacturers
• Set up links with Operators/AMOs within EU
• Develop synergies with other MEMS groups

• Safety benefits underpin financial resource
  allocation
• by CAA
• External participation could attract financial
  support
• Future CHIRP strategy requires secure funding
  policy, bi-annual review with CAA

Future Financial Security
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CHIRP managed MEMS data input
MEDA format data entry via member ID Password
protection
Group member Owned file Identified data
Group member Owned file Disidentified data
CAA SDU monthly report
CAA MOR maintenance error data analysis
Data analysis output shared with group members
Industry
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Current position on data availability
Data input for analysis
Voluntary reporting
Mandated reporting
MOR
MEDA

• Regular monthly report from CAA
• Data needs manual assessment
• No root cause analysis (not always
  identified)
• Implemented solutions rarely identified
• No common free text taxonomy

• Variable reporting level by industry
• Data needs manual assessment
• Variable standards in identification of
  root causes/solutions/risk
• No common free text taxonomy

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Examples of Projects

• Maintenance error data collection
• SMS process improvement
• Human performance improvement

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The Challenge

• Improve current error management across industry
• Threats identified and HF training provided but
  so what, can changes be identified!?
• Similar errors reoccur for much the same reason
• Reduce the risk of events reoccurring and reduce
  the costs of maintenance

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Comparison of CAA MOR and MEDA maintenance event
analysisLarge Aircraft shown as of total

No. of reports CAA 1890
MEDA 584
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Key maintenance error types as of total each
yearAll aircraft categories 2005 - 2011

Total errors 2108
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MOR Maintenance error types 2005-2011Large
Aircraft Category
AMM - 181 Procs - 131 MEL - 119 SRM -
49 AD/SB - 27 AMP - 9 IPC - 6 WDM
- 6
Key ATA 79 43 32 23
35 - 17 29 11

Incl FOD 78 Unrecorded work -
14 A/C damage - 10
Instruction non-adherence 325 Poor inspection
- 158 Wrong part fitted
- 96 Part not fitted
- 73 Wrong orientation -
54 Cross connection - 35 Poor
insp (IND) - 33 Poor
insp/test - 32 Panel
detached in flt - 13 Wrong location
-10
MEL - 32 AMM - 2 IPC - 2 AD/SB 3 SRM
- 1
Total 1890 errors
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Summary of key threats and corrective actions
affecting installation (as example)

• Corrective action
• Process
• Simplify task instructions
• Align task card with AMM
• Instruct staff to follow approved data
• Amend AMM for correct orientation
• Improve tool control inc safety pins
• Provide panel chart
• Improve progressive task certification
• People
• Provide feedback/communications
• Improve supervisory level/standards
• Provide documentation/procedures training
• Improve hand-overs
• Experienced staff assigned to task
• Manpower plan reflecting ALL trades

Errors

• Information not used
• Procedures not followed
• Repetitive / monotonous task
• Not familiar with new task
• Inadequate task knowledge
• Lack of supervision
• Time constraints/ distraction
• Communications between staff/shifts
• Poor environment high noise/lighting/cold
• Tools/equipment unavailable
• Easy to install incorrectly (design)

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Nucleus of a Safety Management System
Safety training/ Understanding role
Safety standards above compliance mins
Safety policies values
Reporting System
Organisation Investment
Maintain professionalism
Reducing risks and cost of errors
Formal Safety System
Safety Information System
Informal safety system
Understand responsibilities
Error Management System
Management Involvement
Knowing own accountability
Ownership of standards
Risk assessment
Safety leadership at every level
SMS
SMS
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MEMS group SMS readiness review
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MEMS Group SMS Readiness Feedback Areas of
strength and opportunity
Above
6
4
2
Training
Average
1
4
4
1
1
1
3
Audits
Risk Assessment
2
Safety measures
LM safety role
Communication
4
Trust by employees
Employee safety views
Employee involvement
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Below
Leadership Commitment
Mgt of change
Safety Mgt System
Safety Info system
Learning organisation
Safety as bus. issue
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MEMS Group SMS Maturity CapabilityFeedback
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Top 5 behavioural issues for SMS improvement?

• Accountable Manager unsure of their SMS role?
• Lack of trust in just/fair culture within the
  organisation?
• Not putting into practice what is preached?
• Lack of resilience to make change happen?
• Lack of staff involvement in safety improvements?

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Industry SMS benchmarking?

• No common error taxonomy?
• No common set of basic SMS measures?
• No clear evidence of why events reoccur?
• Over sensitivity to discussing error, all
  companys are affected?
• No common approach to risk management?
• Benchmarking not established !

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The General SMS Environment
Intention (Continuous Improvement)
Theoretical (No Change)
Governance and Regulation
Health and Safety
Increasing Deviations and Errors
Improvements with changes in attitude and
behaviour
Worst Case (No Action)
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Human performance improvements

• Error traps identified
• Time pressure, Distractions, Lack of
  knowledge,
• Complacency, Poor communication, etc.
• Behavioural tools and techniques
• Pre-job briefing, Questioning attitude, Use
  of procedures, Peer checking, Self checking,
  etc.
• Develop learning environment through observation
  and feedback

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Changing attitudes

• Maintenance Operation Safety Survey (MOSS)
• - Trial carried out with Cranfield University
  in conjunction with UK MEMS group member
  (Thomas Cook).
• - Developed using FAA LOSA principles, focused
  on maintenance requirements, process improvements
  on existing Maintenance LOSA
• - Implemented with full sponsorship of
  management and trade unions
• - Focused on process error causes and peer
  learning opportunity
• - Data derived targets for improvements

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Any Questions?