UK MEMS Group A Collaborative Approach to Safety Management Mick Skinner – CHIRP IFA Dubai, May 2012

1. UK MEMS GroupACollaborative Approach to Safety ManagementMick Skinner – CHIRPIFA Dubai, May 2012

2. UK MEMS Group membership (29) Independent Chairman

3. 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

4. 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.

5. 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.

6. 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

7. Project Development • Review feasibility of sharing MEMS data – 21 attendees • CAA • CHIRP • UKOTG – Operators maintenance organisations • EIMG – Independent Maintenance Repair Organisations • Boeing • Airbus • GE London Meeting March 2001 • 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 set up April 2001 • MEMS Steering group pilot study completed • CHIRP MEMS database developed • CHIRP website distribution set up • Constitution revised for wider membership MEMS Steering Group closed April 2003 • 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 constituted April 2003

8. Project Methodology • 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 Confidentiality Agreement • 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 Secure Database Established • 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 Rules of Input

9. 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 Next steps Manufacturers & Industry Synergies • 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 Future Financial Security

10. CHIRP managed MEMSdata 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 MORmaintenance error data analysis Data analysis output shared with group members & Industry

11. Data input for analysis Voluntary reporting Mandated reporting Current position on data availability 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

12. Examples of Projects • Maintenance error data collection • SMS process improvement • Human performance improvement

13. 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

14. % Comparison of CAA MOR and MEDA maintenance event analysisLarge Aircraft – shown as % of total No. of reports; CAA 1890 MEDA 584

15. Key maintenance error types as % of total each yearAll aircraft categories 2005 - 2011 % Total errors 2108

16. 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 Key ATA 79 – 43 32 – 23 35 - 17 29 – 11 Incl FOD – 78 Unrecorded work - 14 A/C damage - 10 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 MEL - 32 AMM - 2 IPC - 2 AD/SB – 3 SRM - 1 Total 1890 errors

17. Summary of key threats and corrective actions affecting installation (as example) • 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 Errors • 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)

18. Nucleus of a Safety Management System Safety training/ Understanding role Safety standards above compliance mins Safety policies & values Reporting System Maintain professionalism Organisation Investment Reducing risks and cost of errors Formal Safety System Safety Information System Informal safety system Understand responsibilities Error Management System Knowing own accountability Management Involvement Ownership of standards Risk assessment Safety leadership at every level SMS SMS

19. MEMS group SMS readiness review

20. MEMS Group SMS Readiness FeedbackAreas ofstrengthandopportunity Above 6 4 2 Training Average 1 4 4 1 1 1 3 Audits Risk Assessment 2 Safety measures LM safety role Communication 4 Trust by employees Employee safety views Employee involvement 6 Below Leadership & Commitment Mgt of change Safety Mgt System Safety Info system Learning organisation Safety as bus. issue

21. Optimal Upper band Managed Defined Repeatable Lower Band Initial 5 0 1 2 3 4 Lower band 1.39 Average Upper Band 4.25 3.11 MEMS Group SMS Maturity & CapabilityFeedback

22. 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?

23. 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 Environment Intention (Continuous Improvement) Theoretical (No Change) Health and Safety Governance and Regulation Increasing Deviations and Errors Improvements with changes in attitude and behaviour Worst Case (No Action)

25. 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

26. 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

27. Any Questions?