Transcript Maintenance Error Data Sharing

UK MEMS Group
A Collaborative Approach to
Safety Management
Mick Skinner – CHIRP
IFA Dubai, May 2012
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
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
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.
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
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
Review feasibility of sharing MEMS data – 21 attendees
London
Meeting
March 2001
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CAA
CHIRP
UKOTG – Operators maintenance organisations
EIMG – Independent Maintenance Repair Organisations
Boeing
Airbus
GE
Pilot study initiated, funding gained from CAA
MEMS Steering
Group set up
April 2001
• MEDA based taxonomy agreed
• CHIRP offered central database
• Constitution agreed with group of 8 UK members
MEMS Steering group pilot study completed
MEMS Steering
Group closed
April 2003
• CHIRP MEMS database developed
• CHIRP website distribution set up
• Constitution revised for wider membership
UK MEMS group established
UK MEMS group
constituted
April 2003
• Independent chairman appointed
• 4 members from UKOTG
• 2 members from EIMG
• 1 member from CHIRP
• 1 member from CAA
Project Methodology
Confidentiality
Agreement
• 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
Secure
Database
Established
• 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
Rules of Input
• 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
Future development
Next steps
• 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
Manufacturers &
Industry Synergies
• Develop links with Airframe/ Engine Manufacturers
• Set up links with Operators/AMOs within EU
• Develop synergies with other MEMS groups
Future Financial
Security
• 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
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
Current position on data availability
Voluntary
reporting
Data input for
analysis
Mandated
reporting
MOR
MEDA
• Regular monthly report from CAA
• Variable reporting level by industry
• Data needs manual assessment
• Data needs manual assessment
• No root cause analysis (not
always identified)
• Variable standards in identification of
root causes/solutions/risk
• Implemented solutions rarely identified
• No common free text taxonomy
• No common free text taxonomy
Examples
of
Projects
• Maintenance error data collection
• SMS process improvement
• Human performance improvement
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
No. of reports; CAA 1890
MEDA 584
Key maintenance error types as % of total each year
%
All aircraft categories 2005 - 2011
60
Installation
50
Approved data
40
Servicing
30
Poor Insp
20
Misinterp of
data
10
FOD
0
2005 2006 2007 2008 2009 2010 2011
Total errors 2108
MOR Maintenance error types 2005-2011
Large Aircraft Category
AMM - 181
Key ATA 79 – 43
Procs - 131
32 – 23
Incl
FOD
MEL
- 119
35 - 17
SRM
- 49
29 – 11
AD/SB - 27
– 78
AMP
-9
IPC
-6
WDM
-6
Unrecorded work - 14
A/C damage - 10
Instruction non-adherence – 325
Poor inspection
MEL - 32
AMM - 2
IPC
-2
AD/SB – 3
SRM
-1
Total 1890 errors
- 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
Summary of key threats and corrective actions
affecting installation (as example)
Errors
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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)
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
Nucleus of a Safety Management
System
Safety
training/
Understanding
role
Safety
policies &
values
Maintain
professionalism
Understand
responsibilities
Informal safety
system
Safety
standards
above
compliance
mins
Reporting
System
Organisation
Investment
Reducing risks
and cost of errors
Knowing own
accountability
Error
Management
System
Management
Involvement
Ownership
of
standards
Risk
assessment
Safety
leadership at
every level
Formal Safety
System
Safety
Information
System
MEMS group SMS readiness review
MEMS Group SMS Readiness Feedback
Areas of strength and opportunity
Above
6
4
2
Average
1
2
4
Below
6
4
4
1
1
1
3
MEMS Group SMS Maturity & Capability
Feedback
Optimal
Upper band
Managed
Defined
Repeatable
Lower Band
Initial
0
1
2
Lower band
1.39
3
Average
3.11
4
Upper Band
4.25
5
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?
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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
Improvements with
changes in attitude and
behaviour
24
Governance and Regulation
Health and Safety
Theoretical (No Change)
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
• 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
Any Questions?