Key safety of flight issues in aviation maintenance
1 / 25

Key Safety of Flight Issues in Aviation Maintenance - PowerPoint PPT Presentation

  • Uploaded on

Key Safety of Flight Issues in Aviation Maintenance. Joseph Barclay Vice Chairman - MAC Flight Safety Foundation. The Maintenance Advisory Committee. MAC established as a global think tank to identify key issues in aviation maintenance that have a negative effect on safety of flight

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Key Safety of Flight Issues in Aviation Maintenance' - saxton

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Key safety of flight issues in aviation maintenance

Key Safety of Flight Issues in Aviation Maintenance

Joseph Barclay

Vice Chairman - MAC

Flight Safety Foundation

The maintenance advisory committee
The Maintenance Advisory Committee

  • MAC established as a global think tank to identify key issues in aviation maintenance that have a negative effect on safety of flight


    “Increased commitment to the advancement of safety culture in the aviation maintenance community.”

The impact to flight safety
The Impact to Flight Safety

  • The Maintenance Role in Safety of Flight

  • The Need for Comprehensive Review of Maintenance Issues Affecting Flight Safety

Flight safety foundation in maintenance
Flight Safety Foundation in Maintenance

  • FSF has long history in Maintenance and Engineering

  • Aviation Mechanics Bulletins became a standard in shops and hangars all over the world

  • Bulletins were incorporated into AeroSafetyWorld in 2006

Flight safety foundation in maintenance1
Flight Safety Foundation in Maintenance

  • The “Mechanic’s Creed” was originally written by Jerome Lederer in 1941

  • The creed appeared on the back cover of the first issues of Flight Safety Foundation's Aviation Mechanics Bulletin in 1953 and proved to be extremely popular

  • Mechanics around the world, "from Tokyo to Frankfurt, from Canada to Puerto Rico," wrote to request copies to hang in their offices and shops

Then and now
Then and Now

  • “Secondary causes were a generally low standard of maintenance due to lack of tools, spares, adequate lighting, hurried workmanship, and inexperience in lower staff grades.”

    • 1948, Pakistan Airways C-47A

  • “The [maintenance provider] quality assurance inspector’s failure to detect the incorrect rigging of the elevator system…”

    • 2003, Air Midwest, B-1900

  • "The progressive failure of both engines, due to the lack of compliance with proper maintenance standards.“

    • 1953, Miami Airlines, DC-3

  • “The uncontrollable pitch up was caused by sudden uncommanded downward movement of the Trimmable Horizontal Stabilizer leading edge. This was due to partial detachment of its 'actuator forward bearing support' fitting due non installation of required hi-lok fasteners. Poor aircraft maintenance practices at [MRO] contributed to the accident."

    • 1998, Alliance Air, Dornier 228

What are the maintenance issues
What Are The Maintenance Issues?

  • MAC reviewed maintenance accident history

  • 4 “High Level” issues identified

  • Review of existing work on these key issues

Failure to follow procedures
Failure to Follow Procedures

  • Work targeted at understanding WHY procedures are not followed

  • Review of previous work and guidance:

    • Has guidance been effective?

    • Why?

    • What can be done about it?

Professionalism in aviation maintenance
Professionalism in Aviation Maintenance

  • Professionalism – Marks of our Profession

    • Conduct

    • Methods

    • Character

    • Ethical Responsibilities

    • Standards


Oversight and quality
Oversight and Quality

  • Quality systems must be assessed against operational context

  • Contract maintenance is the norm

  • Have systems been adjusted adequately?

    • Regulatory oversight

    • SMS interface

    • Quality interface

    • Quality and SMS interface

    • Predictive systems integration

Leadership and safety culture
Leadership and Safety Culture

  • Leadership can shape professionals


  • Safety Culture is a product of many things


The way forward
The Way Forward

  • The MAC is continuing to analyze issues and develop mitigation strategies

    • Working groups being developed

  • International perspective is important

  • Solutions must be feasible to be effective

    • Business minded approach

    • Return on investment

    • Realistic

    • Front line impact

  • Quality approach

    • Measurable results

Leadership and safety culture1

Leadership and Safety Culture

Ed MacAskill - MAC Member

Brad Brugger – MAC Member

Changing a culture to focus on safety
Changing a Culture to Focus on Safety

"We are at the very beginning of time for the human race. It is not unreasonable that we grapple with problems. But there are tens of thousands of years in the future. Our responsibility is to do what we can, learn what we can, improve the solutions, and pass them on."

-- Richard Feynman

Techniques for enhancing a safety culture
Techniques for Enhancing a Safety Culture

  • Encouraging Voluntary Employee Reporting of Errors and Safety Concerns

  • Ensuring a Just Culture foundation

  • Establishing a Safety Management System

  • Setting Clear Expectations and Focus on Shared Values

Voluntary employee reporting
Voluntary Employee Reporting

  • Ensure employees are provided an avenue for confidential reporting of errors, violations or safety concerns without fear of reprisal

  • Aviation Safety Action Program (ASAP) is an example of an effective reporting program whose primary objective is to learn and improve safety

  • The FAA guidance on ASAP promises no certificate enforcement action for accepted reports in exchange for information the organization may not have known otherwise

Understanding our safety culture





Understanding our Safety Culture

What type of Safety Culture do we have?

Understanding our safety culture1
Understanding our Safety Culture

What is a “Just” Culture?

System of accountability that best supports a safety culture


Blame-Free Culture

Punitive Culture

Facets of a just culture
Facets of a Just Culture

  • Managing System Design

  • Anticipating and Managing Human Errors

  • Anticipating and Managing Organizational Drift (At Risk Behavior)

  • Setting Clear Expectations and Managing the Occasional Reckless Act

Organizational Values

Just culture foundation within asap
Just Culture foundation Within ASAP

Just Culture training and tools (algorithm) in ASAP provide:

  • A common methodology

  • A common focus

  • Alignment of the ASAP committee

  • Defined rejection criteria

Just culture foundation within the organization
Just Culture Foundation Within the Organization

Just Culture training and tools embedded into the organization (policy):

  • Maintain and enhance a positive safety culture

  • Recognize that all humans are fallible and susceptible to drift

  • Requires an organizational commitment

The benefits of a “Just Policy”:

  • Increased workforce trust

  • Improved quality data collected

  • Enhanced organizational risk picture

  • Ability to share valuable lessons learned

Setting clear values based expectations
Setting Clear (Values-Based) Expectations

  • The most effective way to drive a culture change that is reflected in individual attitudes and behaviors is to focus your efforts on the foundation – organizational values and expectations.

  • Think of a “School-Zone” in which the shared value is the preservation of life and the expectations are clear.

  • In a school zone, the system is designed to support desired behaviors and discourage unacceptable behaviors.

  • An organization will know when it has effectively changed its culture, when its individual members are holding themselves, and each other, accountable.


*St. Louis University, Parks College – Safety Culture Pyramid