Key Safety of Flight Issues in Aviation Maintenance

1. Key Safety of Flight Issues in Aviation Maintenance Joseph Barclay Vice Chairman - MAC Flight Safety Foundation

2. The Maintenance Advisory Committee • MAC established as a global think tank to identify key issues in aviation maintenance that have a negative effect on safety of flight Mission: “Increased commitment to the advancement of safety culture in the aviation maintenance community.”

3. The Impact to Flight Safety • The Maintenance Role in Safety of Flight • The Need for Comprehensive Review of Maintenance Issues Affecting Flight Safety

4. Flight Safety Foundation in Maintenance • FSF has long history in Maintenance and Engineering • Aviation Mechanics Bulletins became a standard in shops and hangars all over the world • Bulletins were incorporated into AeroSafetyWorld in 2006

5. Flight Safety Foundation in Maintenance • The “Mechanic’s Creed” was originally written by Jerome Lederer in 1941 • The creed appeared on the back cover of the first issues of Flight Safety Foundation's Aviation Mechanics Bulletin in 1953 and proved to be extremely popular • Mechanics around the world, "from Tokyo to Frankfurt, from Canada to Puerto Rico," wrote to request copies to hang in their offices and shops

6. Then and Now • “Secondary causes were a generally low standard of maintenance due to lack of tools, spares, adequate lighting, hurried workmanship, and inexperience in lower staff grades.” • 1948, Pakistan Airways C-47A • “The [maintenance provider] quality assurance inspector’s failure to detect the incorrect rigging of the elevator system…” • 2003, Air Midwest, B-1900 • "The progressive failure of both engines, due to the lack of compliance with proper maintenance standards.“ • 1953, Miami Airlines, DC-3 • “The uncontrollable pitch up was caused by sudden uncommanded downward movement of the Trimmable Horizontal Stabilizer leading edge. This was due to partial detachment of its 'actuator forward bearing support' fitting due non installation of required hi-lok fasteners. Poor aircraft maintenance practices at [MRO] contributed to the accident." • 1998, Alliance Air, Dornier 228

7. What Are The Maintenance Issues? • MAC reviewed maintenance accident history • 4 “High Level” issues identified • Review of existing work on these key issues

8. Failure to Follow Procedures • Work targeted at understanding WHY procedures are not followed • Review of previous work and guidance: • Has guidance been effective? • Why? • What can be done about it?

9. Professionalism in Aviation Maintenance • Professionalism – Marks of our Profession • Conduct • Methods • Character • Ethical Responsibilities • Standards -PAMA

10. Oversight and Quality • Quality systems must be assessed against operational context • Contract maintenance is the norm • Have systems been adjusted adequately? • Regulatory oversight • SMS interface • Quality interface • Quality and SMS interface • Predictive systems integration

11. Leadership and Safety Culture • Leadership can shape professionals • BUT HOW DO WE SHAPE LEADERSHIP? • Safety Culture is a product of many things • WHICH ONES CAN WE MANAGE?

12. The Way Forward • The MAC is continuing to analyze issues and develop mitigation strategies • Working groups being developed • International perspective is important • Solutions must be feasible to be effective • Business minded approach • Return on investment • Realistic • Front line impact • Quality approach • Measurable results

13. Leadership and Safety Culture Ed MacAskill - MAC Member Brad Brugger – MAC Member

14. Changing a Culture to Focus on Safety "We are at the very beginning of time for the human race. It is not unreasonable that we grapple with problems. But there are tens of thousands of years in the future. Our responsibility is to do what we can, learn what we can, improve the solutions, and pass them on." -- Richard Feynman

15. Techniques for Enhancing a Safety Culture • Encouraging Voluntary Employee Reporting of Errors and Safety Concerns • Ensuring a Just Culture foundation • Establishing a Safety Management System • Setting Clear Expectations and Focus on Shared Values

16. Voluntary Employee Reporting • Ensure employees are provided an avenue for confidential reporting of errors, violations or safety concerns without fear of reprisal • Aviation Safety Action Program (ASAP) is an example of an effective reporting program whose primary objective is to learn and improve safety • The FAA guidance on ASAP promises no certificate enforcement action for accepted reports in exchange for information the organization may not have known otherwise

17. Secretive Blame Reporting Just Understanding our Safety Culture What type of Safety Culture do we have?

18. Understanding our Safety Culture What is a “Just” Culture? System of accountability that best supports a safety culture Reporting Blame-Free Culture Punitive Culture

19. Facets of a Just Culture • Managing System Design • Anticipating and Managing Human Errors • Anticipating and Managing Organizational Drift (At Risk Behavior) • Setting Clear Expectations and Managing the Occasional Reckless Act Organizational Values

20. Just Culture foundation Within ASAP Just Culture training and tools (algorithm) in ASAP provide: • A common methodology • A common focus • Alignment of the ASAP committee • Defined rejection criteria

21. Just Culture Foundation Within the Organization Just Culture training and tools embedded into the organization (policy): • Maintain and enhance a positive safety culture • Recognize that all humans are fallible and susceptible to drift • Requires an organizational commitment The benefits of a “Just Policy”: • Increased workforce trust • Improved quality data collected • Enhanced organizational risk picture • Ability to share valuable lessons learned

22. Safety Management System

23. Setting Clear (Values-Based) Expectations • The most effective way to drive a culture change that is reflected in individual attitudes and behaviors is to focus your efforts on the foundation – organizational values and expectations. • Think of a “School-Zone” in which the shared value is the preservation of life and the expectations are clear. • In a school zone, the system is designed to support desired behaviors and discourage unacceptable behaviors. • An organization will know when it has effectively changed its culture, when its individual members are holding themselves, and each other, accountable.

24. Conclusion *St. Louis University, Parks College – Safety Culture Pyramid

25. THANK YOU!