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UK MEMS Group A Collaborative Approach to Safety Management Mick Skinner – CHIRP IFA Dubai, May 2012. UK MEMS Group membership (29). Independent Chairman. Balanced Portfolio?. Independent Aircraft Maintenance Organisations Fixed Wing Civil Military Rotary Operators

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uk mems group a collaborative approach to safety management mick skinner chirp ifa dubai may 2012

UK MEMS GroupACollaborative Approach to Safety ManagementMick Skinner – CHIRPIFA Dubai, May 2012

uk mems group membership 29
UK MEMS Group membership (29)

Independent Chairman

balanced portfolio
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
    • Engines
slide4

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.
slide5

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.
maintenance error data sharing
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
project development
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

project methodology
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

future development
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

slide10

CHIRP managed MEMSdata 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 MORmaintenance error data analysis

Data analysis output shared with group members & Industry

current position on data availability

Data input for analysis

Voluntary reporting

Mandated reporting

Current position on data availability

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
slide12

Examples

of

Projects

  • Maintenance error data collection
  • SMS process improvement
  • Human performance improvement
the challenge
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
comparison of caa mor and meda maintenance event analysis large aircraft shown as of total

%

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

No. of reports; CAA 1890

MEDA 584

key maintenance error types as of total each year all aircraft categories 2005 2011
Key maintenance error types as % of total each yearAll aircraft categories 2005 - 2011

%

Total errors 2108

mor maintenance error types 2005 2011 large aircraft category
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

summary of key threats and corrective actions affecting installation as example
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)
slide18

Nucleus of a Safety Management System

Safety

training/

Understanding

role

Safety standards above compliance mins

Safety policies & values

Reporting System

Maintain professionalism

Organisation Investment

Reducing risks and cost of errors

Formal Safety System

Safety Information System

Informal safety system

Understand responsibilities

Error Management System

Knowing own accountability

Management Involvement

Ownership of standards

Risk assessment

Safety leadership at every level

SMS

SMS

mems group sms readiness feedback areas of strength and opportunity

MEMS Group SMS Readiness FeedbackAreas ofstrengthandopportunity

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

6

Below

Leadership & Commitment

Mgt of change

Safety Mgt System

Safety Info system

Learning organisation

Safety as bus. issue

mems group sms maturity capability feedback

Optimal

Upper band

Managed

Defined

Repeatable

Lower Band

Initial

5

0

1

2

3

4

Lower band

1.39

Average

Upper Band

4.25

3.11

MEMS Group SMS Maturity & CapabilityFeedback
top 5 behavioural issues for sms improvement
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?
industry sms benchmarking
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 company’s are affected?
  • No common approach to risk management?
  • Benchmarking not established !
the general sms environment
The General SMS Environment

Intention (Continuous Improvement)

Theoretical (No Change)

Health and Safety

Governance and Regulation

Increasing Deviations and Errors

Improvements with changes in attitude and behaviour

Worst Case (No Action)

human performance improvements
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
changing attitudes
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