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An essential element of any system is to be able measure the effectiveness of the various processes which are involved in delivering the overall product.

The Quality System consists of 2 distinct parts:

a) The Quality Control Processes – Embedded in all production areas
b) The Quality Audit Processes – An independent way of assessing point a) above

By measuring the effectiveness of both parts of the company’s quality system (QA & QC) we will be able to provide a detailed status of the strength of the Quality Management System (QMS) as well as to provide a detailed understanding which will facilitate management planning and development.

Step 1 - Organisation & Regulatory Review

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All EASA Approvals typically provide an independent Quality Assurance Function (EASA Part 21J requires a design assurance system)

The next comment is to consider the EASA “take” on QA & QC (A Quality System Contains Both). QC is embedded in every aspect and element of the Production Process.

The primary objective of an EASA Compliant Quality Auditing is to ensure both external and internal compliance with regulatory and organisational procedures.

We have a number of secondary objectives which are typically organisationally driven rather than EASA driven. (Never the less such elements provide for an indication of the intent and effectiveness of the organisation.)

An example of a secondary objective would be a demonstration of continuous improvement – which would mean a reduction in findings over time for a consistent level of auditing activity.

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So let’s take a look at how we could perform an Audit of the Internal Reporting System within an Operators Management System.

Consider First the Background Regulatory Obligations and to note that we need in this case to comply with both 965/2012 and 376/2014 (Proposed Audit Items are identified as AI-N)

AMC1 ORO.GEN.200(a)(2) Management system
COMPLEX OPERATORS - SAFETY POLICY

(a) The safety policy should:

(4) Include safety reporting principles. AI-1

(b) The safety policy should include a commitment:

(5) Not to blame someone for reporting something which would not have been otherwise detected. AI-2

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Introduction

The essential purpose of an EASA compliance audit is to support the maintenance of the regulatory approval.

Quality Assurance Compliance Audits are a systematic and independent comparison of the way the system process or objective is met. Using the observations made during this audit, as “objective evidence” a comparison is thus made against the standard, generating non-conformities or corrective actions in the event of any discrepancy.

The audits should be documented with a checklist which shows the details of the audit standard or audit criteria which is being applied to the audit.

Note 1 Quality Assurance Audits are Prescriptive in as much as they are always referenced against a standard – means compliant.

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A discussion paper by Steve Bentley MD of SAS (www.sassofia.com)

So what is the Fundamental Mistake?

Essentially it is to "believe" that there is a similarity between ISO & EASA – there is not! Sure, Quality is Quality but make no mistake – EASA is all about compliance.

Even the Quality Assurance Manager has received a name change "makeover" He or She, is now called the Compliance Manager (CM).

What Does EASA Expect?

There are actually two expectations:

Tagged in: CM EASA ISO QA QAM
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Time Constraints

This is a circular tour where people are time challenged which presents them from fixing the problem which will provide them with additional free time!

Many companies are caught in this catch-22 situation where whilst there are multiple disconnects, Often the organisation does not have enough “trained” people to perform the root cause analysis.

The Fire Brigade

People are often too busy fixing todays problems to address ongoing disconnects. Short term fixes are usually aimed at contributing factors without doing a root cause analysis. (Even if we add more people, with the intention to solve the situation the effort will usually not succeed since without training, additional resources are used ineffectively due to poor planning and scheduling.)

Reality Check

Whilst typically front-line staff may recognize a given problem, senior management often do not appreciate the dynamics of the same issue.

Often when senior management do understand the problem, they are pressured to deliver a quick fix to the situation.

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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.

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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.

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Steve Bentley MD of SAS (www.sassofia.com) discusses the various areas where the Maintenance Planning Process was able to become a precursor contributing to potential maintenance.

EASA commissioned a “Study on the need of a common worksheet/work card system” to evaluate the impact of maintenance documentation on the Human Factor concern.

(Specifications N°: EASA/2006/OP/25 On demand of the European Aviation Safety Agency (EASA), BUREAU VERITAS conducted a “Study on the need of a common worksheet/work card system” from January to November 2007. The present document presents the results of this study.)

The study aimed at providing further insights on the use of documentation, the common practices in place between operators and maintenance organisations and to assess whether current rules and practices may still contribute to incidents/accidents.

Among other results, the study produced a list of incidents/accidents related to the use of maintenance documentation.

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Introduction

Whilst currently (October 2018) EASA does not mandate the obligation to ensure CAMO & Maintenance Planning Staff receive HF training, the reality is that the potential for Human Factor Error knows no bounds and it is just as likely that a Human Factor (HF) error could originate from an exposure within the Maintenance Planning Environment as anywhere else within the “Aviation System”.

Currently some 80% of aircraft accidents are attributable to human error, however this is a situation where it is possible to manage and or address by managing the exposure.

Human Error is recognised as rectifiable through the process of raising awareness, implementation of effective process and procedure and effective communication within the workplace.

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Introduction

Whilst Aircraft fuel-tank entry is essential for both inspection and modification it poses a number of hazards to maintenance personnel performing the work.

Fuel-tank work can be accomplished as required without placing personnel at risk through effective preparation and training.

The Maintenance Organisation should strive to ensure a safe, healthy work environment for fuel-tank personnel by identifying potential hazards, developing control measures, and instructing personnel in the specific procedures to be followed during all Aircraft fuel-tank maintenance activities.

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Considering the role of a Fuel Tank Entry Team

An essential requirement to minimize exposure to the risk of injury during fuel-tank work is a properly trained and equipped team.

Personnel with authorization to enter the fuel tank and perform work must be able to recognize potential hazards and initiate evacuation if there are any concern issues.

The following elements are critical to safe working conditions:

a) Communication
b) Respiratory protection
c) Ventilation and air monitoring
d) Electrically powered tooling & equipment
e) Airplane damage considerations

Tagged in: Aviation Entry Fuel Tank
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Primary Hazards related to Fuel Tank Working

There are a number of potential hazards which fuel-tank maintenance personnel may experience whilst engaged in Fuel Tank Work however the 2 primary hazards are:

a) Chemical
b) Physical

Considering Chemical Hazards and their Consequences - Fuel

Off course the most commonly recognized hazard is the jet fuel itself which is a flammable liquid and will ignite if the temperature of the fuel is such that vapour is created. (The temperature at which the vapours of a flammable liquid can ignite is known as the "flash point".)

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Preparation for Entry Into the Fuel Tank

It is most important to ensure that all persons who are engaged in the process of Fuel Tank Entry are fully trained on all aspects of the following information to ensure that all precautions are taken and all risks minimised.

Steps which must be taken include the following:

a) Ensure the aircraft is electrically grounded

b) Ensure that Fire Extinguishers are available (typically CO2 would be used for a Fuel Fire

c) Deactivate all Electrical Systems on the Aircraft and suitable placard

d) Defuel the aircraft using the Aircraft Maintenance Manual Procedures

e) Deliver a safe atmosphere for maintenance personnel by ensuring the following:

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Introduction

A large percentage of the work involved in performing inspection and modification of aircraft fuel tanks and their systems is typically carried out with the fuel tank itself. Such tasks require maintenance personnel to physically enter the tank, where significant environmental hazards exist.

Fuel Tank related work is one of the most difficult challenges an aircraft maintenance worker may face. Not only the challenge of physical entry and moving around within the tank, the additional challenge of multiple hazards including health and safety hazards, most notably oxygen deficiency, flammability, explosion and the toxic effects of fuel vapours.

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Comments by Steve Bentley MD Sofema Aviation Services www.sassofia.com

Introduction

As a precursor to the introduction of Regulation 376/2014 EASA identified shortcomings related to Aviation Occurrence Reporting and proposed in 2010 a new regulation which in compliance with ICAO objectives moved the focus from a ‘reactive’ system to a pro-active, risk and evidence based system.  It also acknowledges that safety occurrence data is vital to allow for the timely identification and management of potential safety hazards and acts upon this before these hazards turn into an actual accident. 

EASA introduced EU Regulation 376/2014, (repealing EU directive 2003/42/EC), which came into force on 15th Nov 2015. The regulation provides additional safeguards to address the lack of protection of the reporters, the lack of harmonisation in the occurrence data collection and integration (leading to low quality reports and incomplete information), as well as insufficient requirements regarding safety analysis and the resulting recommendations.

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Introduction

Effective safety reporting of hazards by operational personnel is an important cornerstone of the management of safety. Therefore, an operational environment in which operational personnel have been trained and are constantly encouraged to report hazards is the prerequisite for effective safety reporting.

The ICAO requirements require that aviation service providers develop and maintain, within the scope of their SMS, a formal process for collecting, recording, acting on and generating feedback about hazards in operations. The process shall be based on a combination of reactive, proactive and predictive methods of safety data collection. 

Best Practice Considerations

Consider the following as best practice objectives regarding the delivery of an optimize and effective Safety Management System.

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Sofema Aviation Services www.sassofia.com looks at the ICAO Data Reporting System

ADREP Introduction

The Accident/Incident Data Reporting (ADREP) is operated and maintained by ICAO.

The ADREP system receives, stores and provides States with occurrence data that will assist them in validating safety.

In this context, the term ‘occurrence’ includes both accidents and incidents.

The system was established in 1976 but has evolved to meet changes in information technology and the aviation industry. The version of the ADREP system in current use is ADREP 2000.

Annex 13 to the Chicago Convention — Aircraft Accident Investigation - contains Standards which require Contracting States to report to the International Civil Aviation Organisation (ICAO) information on all aircraft accidents which involve aircraft of a maximum certificated take-off mass of over 2 250 kg.

The Organisation also gathers information on aircraft incidents considered important for safety and accident prevention.

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Risk Assessment

Driven by ICAO Annex 19 Identifying, Assessing, and Mitigating Risk is at the epicentre of an effective Aviation Safety Management System (SMS).

The challenge is to ensure that Safety Risk Assessment is performed in a genuine way with tangible benefits as a measurable outcome. The consequence of a risk can usually be expressed in several ways and these will affect the assessment of severity and likelihood, requiring care competence and diligence on the part of the analysts. 

Delivering Effective Risk Assessment Requires?

When considering Risk the challenge will always be related to the subjectivity of the perceived exposure. Therefore a broad range of contributors to the Risk Assessment Process is highly beneficial including.

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Considering ICAO Definition of Safety

ICAO Annex 19 defines safety as ‘the state in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level’ and safety performance as ‘a service provider’s safety achievement as defined by its safety performance targets and safety performance indicators’.

Challenges to Establish Confidence in Safety Performance?

Whilst it is usual for safety metrics to focus on serious incidents and accidents it is also possible to gain a false impression regarding the overall level of safety due in part to a system with a low number of high consequence negative outcomes, means the low frequency of such outcomes may give the wrong impression that your system is safe.

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