SMS and QMS For Airplane Maintenance

SMS and QMSFor Airplane Maintenance

JULY 28, 2010

Gerardo Hueto

USC

Outline

Concept of Safety SMS QMS Integration or Coordination Example

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Concept of safety (Doc 9859)

Safety is the state in which the risk of harm to persons

or property damage is reduced to, and maintained at

or below, an acceptable level through a continuing

process of hazard identification and risk management.

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Safety Management System Definition

A Safety Management System (SMS) is a set of integrated tools, policies, processes, and procedures used by corporate management to fulfill their responsibility to manage the safety risks associated with their organization’s operations as a part of its overall business.

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ICAO Annex 6 Requirements

“…a safety management system acceptable to the State of the Operator that, as a minimum: identifies safety hazards; ensures that remedial action necessary to maintain an

acceptable level of safety is implemented; and provides for continuous monitoring and regular

assessment of the safety level achieved.”

“An accepted safety management system shall clearly define lines of safety accountability throughout the operator’s organization, including a direct accountability for safety on the part of senior management.”

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The components of SMS (ICAO)

• Safety policy and objectives

• Safety risk management

• Safety assurance

• Safety promotion

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What to include in an SMS?

Flight Operations and Maintenance (ICAO) Other safety activities that could be included

in SMS Personnel safety Environmental safety

It may also include Dispatch, In-flight, Ramp, Fueling

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Maintenance SMS

Acceptable level of Safety? Hard to define, but can use metrics Maintenance metric examples

In-flight shut downs Rejected take-offs (mechanical) Write-ups after heavy checks Number of MEL items (or fleet rate) Flight delays due to maintenance?

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Maintenance Safety Metrics

Should be numerical: Number of events/calendar time or departures

Should have performance targets: % reduction of events in a certain period

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Hazard identification

ICAO hazard identification is Flight Operations oriented

Does not really focus on Maintenance hazards But hazards in maintenance can pose risk to

safety of flight

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Maintenance - related accidents

An airplane failure caused by Maintenance may be:

Primary Cause of an accident.

Contributing Factor to an accident.

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Example: primary cause

Aloha Airlines - 1988

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Investigation findings: Hundreds of cracks undetected prior to

accident Contributing factors:

Lack of resources Fatigue Lack of training

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Alaska Airlines Flight 261 January 31, 2000

13:36:00 13:44:00 13:52:00 14:00:00 14:08:00 14:16:000

5000

10000

15000

20000

25000

30000

P

ressure

Altitude (

ft)

Local Time (PST)

13:36:00 13:44:00 13:52:00 14:00:00 14:08:00 14:16:000

5000

10000

15000

20000

25000

30000

P

ressure

Altitude (

ft)

Local Time (PST)

Stabilizer Movement

Stops

Stabilizer Movement

Stops

AutopilotDisconnect

AutopilotDisconnect

Up to 50 pounds Pulling Force

Up to 50 pounds Pulling Force

Approximately 30 pounds Pulling Force

Approximately 30 pounds Pulling Force

Alaska Airlines Flight 261 Ascent from Puerto VallartaAlaska Airlines Flight 261 Ascent from Puerto Vallarta

16:08:00 16:10:00 16:12:00 16:14:00 16:16:00 16:18:00 16:20:000

5000

10000

15000

20000

25000

30000

P

ressure

Altitude (

ft)

Local Time (PST)

FirstDiveFirstDive

Above Maximum AirspeedAbove Maximum Airspeed

Extremely Loud NoiseExtremely Loud Noise

Alaska Airlines Flight 261 Final 12 Minutes Alaska Airlines Flight 261 Final 12 Minutes

Click on CVRClick on CVRStabilizer moves beyond full nose down Stabilizer moves beyond full nose down

“…kinda stabilized”“…kinda stabilized”Cleared to descend

to 17,000 feetCleared to descend

to 17,000 feet

Slats, Flaps ExtendedSlats, Flaps ExtendedSlats, Flaps RetractedSlats, Flaps Retracted

Sound of faint thumpsSound of faint thumps

Recovered Jackscrew Assembly

Recovered Jackscrew Assembly

• Screw attached to horizontal stabilizer

• Separated from acme nut

• Nut thread remnants on screw

• Screw attached to horizontal stabilizer

• Separated from acme nut

• Nut thread remnants on screw

Summary of FindingsSummary of Findings• Material and structural conditions did not

contribute to the acme nut wear• No grease in working area of the screw• Grease not removed by ocean impact,

exposure, or recovery• Jackscrew grease not contaminated• The wear is caused by sliding contact and is

consistent with an unlubricated condition• Torque tube fractured by low cycle fatigue

• Material and structural conditions did not contribute to the acme nut wear

• No grease in working area of the screw• Grease not removed by ocean impact,

exposure, or recovery• Jackscrew grease not contaminated• The wear is caused by sliding contact and is

consistent with an unlubricated condition• Torque tube fractured by low cycle fatigue

Lubrication:The ProcedureLubrication:The Procedure

• Gain access to

the tail

• Remove access

panels

• Gain access to

the tail

• Remove access

panels


• Apply grease to

acme nut fitting with

grease gun until

grease exits out top

of acme nut

• Apply grease to

acme nut fitting with

grease gun until

grease exits out top

of acme nut

FAIRING

ACCESS PANELS

GREASE GUN


• Brush application of “light

coat of grease” onto

jackscrew threads

• Operate jackscrew “through

full range of travel”

• Brush application of “light

coat of grease” onto

jackscrew threads

• Operate jackscrew “through

full range of travel”

BRUSHBRUSH

Jackscrew Lubrication:Alaska Airlines Interval ExtensionJackscrew Lubrication:Alaska Airlines Interval Extension

0 1000 2000 3000 4000FLIGHT HOURS

1996

1994

1991

1988

1987

YE

AR

0 1000 2000 3000 4000FLIGHT HOURS

1996

1994

1991

1988

1987

YE

AR

Manufacturer's Recommended IntervalAlaska Airlines Interval

End Play Check:Alaska Airlines Interval ExtensionEnd Play Check:Alaska Airlines Interval Extension

0 2000 4000 6000 8000 10000FLIGHT HOURS

1996

1988

1985

YE

AR

0 2000 4000 6000 8000 10000FLIGHT HOURS

1996

1988

1985

YE

AR

Manufacturer's Recommended Interval

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Loss of pitch control due to the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads caused by excessive wear due to insufficient lubrication.

Contributing factors Airline extended lubrication interval and FAA approval

of that interval. Airline extended end-play check interval and FAA’s

approval of the interval. Acme nut zerk fitting was clogged with hardened

grease residue.

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SMS and QMS

Quality is the degree to which a system consistently meets specified requirements, satisfies stated needs, or produces desired outcomes

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SMS and QMS

ICAO Document 9859, Section 7.6

SMS focuses on the safety, human and organizational aspects of an organization (i.e. safety satisfaction); while QMS focuses on the products and services of an organization (i.e. customer satisfaction)

..”ICAO safety management SARPs included in Annexes 1, 6, 8, 11 and 14…are limited to SMS. There are no ICAO requirements…with regard to QMS, with the sole exception of a requirement for approved maintenance organizations (AMO) in Annex 6, Part I, Chapter 8”

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SMS and QMS

Quality Control Rejection Review

Quality Assurance Findings Review

Quality Review Process Quality Review Board Reliability Review Board

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SMS and QMS

Acceptable level of Quality? Metrics

Nature of rejections/findings Operational Both should be numerical and have performance targets

AloQ alignment with AloS? Coordinated Metrics, Risk Matrix Shared Objectives

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SMS and QMS

Options Integrate or Coordinate Pros / Cons

In a Large Carrier QMS reviewed by CASS (Continued Analysis and

Surveillance System) SMS can be integrated or coordinated with CASS

30

PROBABILITY

A B C DSEVERITY

I

II

III

IV

CATASTROPHIC

CRITICAL

MARGINAL

NEGLIGIBLE

2 3

4

2 3 4 5

3 4 5 5

SEVERE

NEGLIGIBLE

LOW

RISK MATRIX

E

HIGH

MEDIUM

LOW

SEVERE

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SMS Presentation.ppt35

RISK ASSESSMENT MATRIX

Potential Consequence of the Incident Increasing Probability

Env'ment

0

2

3

4

5

Seriousinjury

Multiplefatality

Singlefatality

Minorinjury

reported> 3 X / yr.in location

Minordamage <US$ 50K

Localdamage <US$ 250K

Majordamage <US$ 1M

Extensivedamage >US$ 1M

MassiveEffect

Zerodamage

Localised Effect

MajorEffect

Minor Effect

1

Assets

Slightinjury

Slightdamage <US$ 10K

SlightEffect

ZeroEffect

B C D EA

Noinjury

Knownin aviation industry

reported> 3x / yr. in Comp.

No Impact

InternationalI m p a c t

IndustryI m p a c t

N a t i o n a lI m p a c t

Slight Impact

1

2

3

Unknown but possible in the aviationindustry

happenedbefore inCompany

L i m i t e dI m p a c t

ReputationPeopleRating

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Analysis:

Correlation between findings, safety reports, and operational events

* Rate per 1000 Revenue Departures

02040

High1.2.2 Major Repairs and Alterations RecordsX

Medium1.2.1 Airworthiness Release or Log Book Entry XLow1.2.3 Maintenance Log / Recording RequirementsXRiskDistributionQty

Example: SMS and QMS Coordination

Action Items: Who: Due: Status:

42Self Disclosure

Rolling 20XXJul 20XXCorrective Actions

Rolling 20XXJul 20XXRisk Level

41716Closed3In-Progress

12Low 33High

22Average

Rolling 20XXJul 20XXSource

1MSR

113ASAP

241 / 967 / 5Findings / Audits

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SMS and QMS: Education and Training

Prior to Implementation During Deployment Phase Ongoing after SMS is in Place Dealing with Interfaces

Vendors Other Operational Areas

Providing Feedback To Individuals To Other Departments

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SMS and QMS

Questions?

SMS and QMS For Airplane Maintenance

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