Sofema Online considers the challenge of Managing Errors.

Introduction

To Errоr is to be Human, this is true in aviation as in any other activity, however, aviation is maybe less forgiving and we should understand the outcomes can be catastrophic.

Background

Introduction

Aviation Maintenance Error is not only insidious but it also has the potential to lead to incidents and accidents.

Senior Management including the Executive Leadership Team as well as Line Managers should understand the key principles of error management. To ensure a positive learning culture together with the ability to drive change which will minimise exposure and prevent reoccurrence.

Considering the role of Maintenance Error Decision Aid (MEDA) within the context of an effective Maintenance Error Management System Process.

An Effective MEMS system not only provides a mechanism for conducting thorough and consistent investigations, the outcome of which identifies both the root cause and the contributing causes, related to a specific maintenance event.

Over the last decades we have come to understand that a significant number of very serious flight safety events have been caused by Maintenance Error.

Driving Safety Management System (SMS) Value from your Aviation Maintenance Error Management System (MEMS).
Throughout our Industry we know that Maintenance Errors cost millions of Euros every year through the need for rework, delays and lost revenue. (To consider also the potential to introduce safety related exposures.)

What is MEDA?

Boeing developed the MEDA process to assist maintenance organisations identify why events occur and how to prevent them in the future.

MEDA provides a process for conducting thorough and consistent investigations, determining the factors that lead to an event and making improvements to reduce the likelihood of future incidents.

Introduction

It is considered that errors and violations together form the unreliable part of our human performance. Moreover, that 70-90 percent of current aviation incidents & accidents are due to in some part to “human factors”.

Errors and violations contribute to accidents both directly and by making the consequences of other problems more serious. An accident typically involves several contributing factors, some usually being quite visible and others possibly latent in nature.

Steven Bentley MD of SAS www.sassofia.com considers the potential for HF Error with an EASA/GCAA compliant CAMO

Introduction

The Primary Roles of the CAMO are Maintenance Planning, Technical Records, Reliability & Engineering. Each “Role” brings the challenges of how we can ensure enough attention to both personal and organisational responsibility, when we consider the potential for HF error.

HF Example – Stress Caused by Pressure from “Poor Planning”

We are not considering here that it could be the Maintenance Planning Worker who is stressed - however this is of course a possibility, and we should always make sure that our team members have the appropriate level of “Competence” for the role.

To be effective our Maintenance Error Management System should be composed of multiple elements working together to deliver an effective system.

Consider:

a) Training
b) Competence
c) Procedures