UK MEMS Group

A Collaborative Approach to Safety

ManagementMick Skinner – CHIRP

IFA Dubai, May 2012

UK MEMS Group membership (29)

Jet AviationCHIRPThomson AirwaysCivil Aviation AuthorityEssex Police (Air Support)Thomas Cook AirwaysKLM UKAirbase InteriorsAltitude Global LtdBritish Airways EngineeringBA Maintenance Glasgow NetjetsQinetiQ Flybe

Virgin AtlanticBMIBostonairMonarchMilitary Aviation AuthorityAir Accident Investigation BranchATC (Lasham) LtdJet2.com DHLCHC HelicoptersMarshalls of CambridgeBristow Helicopters easyjetBritish Business General Aviation

Independent Chairman

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

• 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.

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

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

CAAAN71

UKOTG&

EIMG

CHIRP

• Issue AN71 Maintenance Error Management system recommendations March 2000 (Leaflet B160 updated 2012)

• UK road show on how to establish internal safety reporting programmes

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

• Development of central database and information communications proposed November 2000

Background

Project DevelopmentLondonMeeting

March 2001

MEMS SteeringGroup set up

April 2001

MEMS SteeringGroup closed

April 2003

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

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 pilot study completed

• CHIRP MEMS database developed• CHIRP website distribution set up• Constitution revised for wider membership

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 constitutedApril 2003

Project Methodology

ConfidentialityAgreement

SecureDatabase

Established

Rules of Input

• 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

• 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

• 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• 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 & Manufacturers & Industry SynergiesIndustry Synergies

Next stepsNext steps

Future Financial Security

• 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

CHIRP managed MEMS data input

Group member Owned file

Identified dataGroup member

Owned fileDisidentified data

Data analysis output shared with group

members & Industry

MEDA format data entry via member ID &

Password protection

CAA MORCAA MOR maintenance

error data analysis

CAA SDU monthly report

Current position on data availability

Data input for analysis

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

Voluntary reporting

Mandated reporting

ExamplesExamplesofof

ProjectsProjects• Maintenance error data collectionMaintenance error data collection

• SMS process improvementSMS process improvement

• Human performance improvementHuman 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

0

10

20

30

40

50

60

2005 2006 2007 2008 2009 2010 2011

Installation

Approved data

Servicing

Poor Insp

Misinterp of dataFOD

%

Total errors 2108

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

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

Key ATA 79 – 43

32 – 23

35 - 17 29 – 11

MEL - 32

AMM - 2

IPC - 2

AD/SB – 3

SRM - 1

Incl FOD – 78

Unrecorded work - 14

A/C damage - 10

Total 1890 errors

Summary of key threats and corrective actions

affecting installation (as example)

• 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)

Errors Corrective actionProcess

•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

Reducing risks and cost of

errors

Organisation Investment

Management Involvement

Informal safety system

Formal Safety System

Reporting System

Safety Information System

Error Management

SystemKnowing own

accountability

Maintain professionalis

m

Understand responsibilitie

s

Safety policies & values

Safety standards

above compliance

mins

Safety training/

Understanding role

Ownership of

standards

Risk assessme

ntSafety

leadership at every level

Nucleus of a Safety Nucleus of a Safety Management SystemManagement System

SMSSMS SMS

SMS

MEMS group SMS readiness reviewMEMS group SMS readiness review

MEMS Group SMS Readiness MEMS Group SMS Readiness FeedbackFeedback

Areas ofAreas of strengthstrength andand opportunityopportunity

6

4

2

2

6

4

Average

Above

Below

14 4 1 11 3

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Safe

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easu

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Risk

Ass

essm

ent

Audi

ts

MEMS Group SMS Maturity & CapabilityFeedback

0 1 2 3 4 5

Optimal

Managed

Defined

Repeatable

Initial

Lower Band

Upper band

Lower band1.39

Average3.11

Upper Band4.25

Top 5 behavioural issues forTop 5 behavioural issues for SMS improvement? 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?

• 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 !

24

The General SMS EnvironmentThe General SMS Environment

Theoretical (No Change)

Intention (Continuous

Improvement)

Worst Case (No Action)

Increasing Deviations and Errors

Governance and Regulation

Health and Safety

Improvements with Improvements with changes in attitude changes in attitude

and behaviourand behaviour

Human performance improvementsHuman 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?