Successful Interventions 8th October 2008

1. Successful Interventions8th October 2008 Presented by John McCollum BAE SYSTEMS Military Air Solutions Head of Aircraft Maintenance & Maintenance Training Royal Aeronautical Society Human Factors Group, Engineering (HFG:E)

2. Contents • BAE Systems MAS Background • Safety Exemplar challenge & where are you? • MAS Error Management Programme • Our System Challenge! • Successful Interventions • Our next steps towards a SMS • Summary

4. Exemplar Challenge • The Leadership of BAE Systems has committed The Company to an “exemplar” position on safety: • This means zero tolerance on unsafe workplace and unsafe working practices to be delivered within each business through target driven performance improvements across both leading and lagging indicators. • Includes the safety obligation with our Partners and Providers. • Safety Culture is defined as an organisations values and behaviours, modelled by its leaders, and internalised by its team members” • This means leading by example!

5. EXEMPLAR / GENERATIVE Safety is how we do business round here ADVANCED / PROACTIVE We work on problems that we still find Increasingly Informed STANDARD / CALCULATIVE We have systems in place to manage all hazards Increased Trust and Accountability FOUNDATION / REACTIVE Safety is important, we do a lot every time we have an accident PATHOLOGICAL Who cares as long as we’re not caught Based upon SHELL model Where are you?

6. Where are you? The Three “ages” of Safety Management Technology • Behaviours • Visible Leadership • Personal Accountability • Shared Attitudes • Safety as a profit centre • Engineering • Equipment design • Design standards • Regulatory compliance Systems Numbers of Incidents • Quality Systems • Human Factors/CRM • Error management systems • Competence • Risk Assessment Culture Time With permission: Why is HSE so Important? A business approach Prof. Patrick Hudson, Leiden University Modified by Baines & McCollum 8

7. 2004 2005 2006 2007 2008 MEDA Training Senior Mgt HF Training HF Programme EMS Training Continuation Training Safety Review Board Safety Action Groups SMS Training The MAS Programme Reactive “Systems” Proactive “Culture” MEMS Report 700 + MEDA Investigations 200 + Initial HF Trained 2600 +

8. Our System Challenge • System within a system • 1000+ Initial HF trained are RAF and Sub-Con personnel • Different cultures & approaches • Different maturity of systems • Unite under flight safety • Sharing & influencing other Organisations approaches • MAOS helping the message • Partnered approach to policy, training & operation • Military forums now forming

9. Successful Interventions

10. Maintenance Model Example (Reactive) (Proactive) Adapted from Air France / Baines & Simmons / ICAO 9859

11. Operational Risk Management in Maintenance Hazard identification, assessment and control, should be an integral part of routine maintenance, rather than limited to project lifecycle phases and implicit personal action. Typical Hazard Considerations for Maintenance Need to consider assessments by aircraft rectification lines and component bays, using personnel from these areas.

12. CAUSED BY RISK RESULTING IN The Basic Bow Tie Concept Events and Circumstances Preventive Controls Recovery Controls Harm Defences or Safety Controls or Secondary Hazards ? Threat HAZARD CONSEQUENCES Threat Top Event Threat Undesirable event with potential for harm or damage Continuing Airworthiness activities Maintenance activities Flight Operations activities With permission: Baines & Simmons Modified by McCollum

13. Summary • Successful Interventions can come from investing in HF learning, but you must be prepared for the journey. • A successful Error Management System needs :- • Energy! • Just Culture led from the Top plus Opinion Leaders • Comprehensive investigations with loads of feedback / publicity • Energy! • Feedback the investigations into your training • Then the toe in the water • Energy! • Then the deluge begins • A Safety Management System can only start once you have a working HF and Error Management System – all about behaviour • The system must integrate within the bigger system!