The Focus of this blog is to consider the inter-relationship between Maintenance Error Management Systems (MEMS) – (typically using the Boeing Maintenance Error Decision Aid as a primary tool) and Safety Management through Human Factor Learning within the context of a viable Safety Management System.

What is the Purpose of MEMS?

The rationale behind a MEMS System is to identify any situations which may “promote” the potential for error. In addition to facilitate (using the organisational framework) the risk based decision making process which will lead to stronger defences.

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.

It is not possible to separate the Safety Management System from the need to manage Ramp HF in the most effective way. In fact the more integration the better in terms of understanding and managing the exposure.

All the elements which are considered as part of our Aviation Ramp Safety & Human Factors Exposure may typically be accommodated and addressed as part of the delivery of the SMS system.

If we are able to study and take appropriate action in respect of the human factors issues, we will be able to better prepare to deal with human factors issues and behaviours in our daily routine.

Driven by ICAO obligations European Countries (as well as the rest of the world) are required to demonstrate compliance with the requirements of ICAO Annex 19.

Airports are specifically mentioned within the requirements related to the need for a State Safety Program as well as the need to demonstrate compliance with the SMS obligations.

Introduction

Why people break rules, particularly if the outcome can be negative and even dangerous? What is it that makes a worker break the rules or commit a violation?

A great deal of research has been undertaken during the last 25 years with the focus looking at the view of errors in different way.

Rather than Human error being considered the ultimate cause of system failure, it is important to understand the context in which the error was committed. (For example, was it deliberate or related to Pressure, Fatigue, Stress or any of the other “Dirty Dozen”?)

Violations – Personal or Organizationally Optimizing?

To reduce exposure to violations and errors, a broad range of organisational interventions may be required.

What do we mean by Safety Culture within an Organisation?

Safety Culture is the way safety is perceived, valued and prioritized within an organisation.

Safety Culture reflects the true commitment to safety at all levels in the organisation.

James Reason described it as "how an organisation behaves when no one is watching".

Safety Culture is a combination of a range of drivers including organisational norms, national cultural beliefs and professional attitudes. It reflects people attitude and believe towards the importance of safety.

How important is Safety Culture?

A Positive Safety Culture Matters because it provides a focus on how the organisation approaches incident recording, incident analysis, staff training and the integration of maintenance safety and operational safety priorities.

It is accepted within our aviation community, that the vast majority of aviation accidents (at least 80%) are directly caused by human action or more precisely by human error. However it would be wrong for us to assume that this is simply a manifestation of personal carelessness or even incompetence, rather we should try to consider that the human error itself is actually the final element of a chain of events.

In fact a major element which hitherto was not given sufficient consideration is the role of the organisation in aircraft incidents and accidents. Often the root cause or contributing factors are embedded within the organisations process and procedures. Unfortunately with hindsight we are often able to understand the existence of numerous latent “exposures” (sometimes too late!).

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Aviation Human Factors training has only been mandatory for the last 10 years with the EASA compliant maintenance environment.

Why Aviation Human Factors Training?

Well currently some 80% of aircraft accidents are attributable to human error, shared between pilots, maintenance staff and Air Traffic Control, Ground Operations and a very small percentage to other factors.

In the main it should be understood that this is a situation which is recognized as rectifiable through the process of raising awareness, training including the associated management of competence and implementation of effective process and procedure and effective communication within the workplace.

When we talk about Human Factor (HF) related issues within the Maintenance Planning environment we need to consider also that often visibility of the outcome is moved to another area of the business. For example if due to planning considerations work is loaded onto the check in an uneven way then it is possible to create an environment where we see commercial pressure, which as we know may directly lead to stress and the possibility of an unwanted HF event.

Another issue also relating to visibility may be connected with the iceberg theory of accidents and incidents. We know that for every significant incident or accidents which occur there are maybe 10 externally report able events (to the regulator) and 30 internally report able events, (to the quality or safety system) however there are additionally in region of 300 unreported transgressions which not only go unreported, but may in fact when considered in isolation appear to have minimum direct consequence, nevertheless may in fact become either precursors or contributors to a more serious event.