SMS and QMS
For Airplane
Maintenance
JULY 28, 2010
Gerardo Hueto
Outline

Concept of Safety

SMS

QMS

Integration or Coordination

Example
USC
Concept of safety (Doc 9859)

Safety is the state in which the risk of harm to persons or property
damage is reduced to, and maintained at or below, an acceptable
level through a continuing process of hazard identification and risk
management.
USC
Safety Management System Definition
A Safety Management System (SMS) is a set of integrated
tools, policies, processes, and procedures used by
corporate management to fulfill their responsibility to
manage the safety risks associated with their
organization’s operations as a part of its overall business.
USC
ICAO Annex 6 Requirements

“…a safety management system acceptable to the State of the
Operator that, as a minimum:
 identifies safety hazards;
 ensures that remedial action necessary to maintain an acceptable
level of safety is implemented; and
 provides for continuous monitoring and regular assessment of the
safety level achieved.”

“An accepted safety management system shall clearly define lines of
safety accountability throughout the operator’s organization,
including a direct accountability for safety on the part of senior
management.”
USC
The components of SMS (ICAO)
•
•
•
•
Safety policy and objectives
Safety risk management
Safety assurance
Safety promotion
USC
What to include in an SMS?


Flight Operations and Maintenance (ICAO)
Other safety activities that could be included in SMS



Personnel safety
Environmental safety
It may also include

Dispatch, In-flight, Ramp, Fueling
USC
Maintenance SMS

Acceptable level of Safety?

Hard to define, but can use metrics

Maintenance metric examples

In-flight shut downs

Rejected take-offs (mechanical)

Write-ups after heavy checks

Number of MEL items (or fleet rate)

Flight delays due to maintenance?
USC
Maintenance Safety Metrics

Should be numerical:


Number of events/calendar time or departures
Should have performance targets:

% reduction of events in a certain period
USC
Hazard identification



ICAO hazard identification is Flight Operations oriented
Does not really focus on Maintenance hazards
But hazards in maintenance can pose risk to safety of
flight
USC
Maintenance - related accidents

An airplane failure caused by Maintenance may be:
Primary Cause of an accident.
Contributing Factor to an accident.
USC
Example: primary cause
Aloha Airlines - 1988
USC
Example: primary cause



Investigation findings:
Hundreds of cracks undetected prior to accident
Contributing factors:



Lack of resources
Fatigue
Lack of training
USC
Example: primary cause

Alaska Airlines Flight 261
 January 31, 2000
USC
Alaska Airlines Flight 261
Ascent from Puerto Vallarta
30000
Approximately 30 pounds
Pulling Force
Up to 50 pounds
Pulling Force
Pressure Altitude (ft)
25000
20000
Autopilot
Disconnect
15000
Stabilizer
Movement
Stops
10000
5000
0
13:36:00
13:44:00
13:52:00
14:00:00
Local Time (PST)
14:08:00
14:16:00
Click on CVR
Stabilizer moves beyond full nose down
30000
Above Maximum Airspeed
25000
Pressure Altitude (ft)
Extremely Loud Noise
20000
First
Dive
15000
“…kinda stabilized”
Cleared to descend
to 17,000 feet
10000
5000
Slats, Flaps Extended
Slats, Flaps Retracted
Sound of faint thumps
Alaska Airlines Flight 261
Final 12 Minutes
0
16:08:00
16:10:00
16:12:00
16:14:00
16:16:00
Local Time (PST)
16:18:00
16:20:00
Recovered
Jackscrew
Assembly
• Screw attached to
horizontal stabilizer
• Separated from acme
nut
• Nut thread remnants on
screw
Summary of Findings
• Material and structural conditions did not
contribute to the acme nut wear
• No grease in working area of the screw
• Grease not removed by ocean impact,
exposure, or recovery
• Jackscrew grease not contaminated
• The wear is caused by sliding contact and is
consistent with an unlubricated condition
• Torque tube fractured by low cycle fatigue
Lubrication:
The Procedure
• Gain access to
the tail
• Remove access
panels
Lubrication:
The Procedure
• Apply grease to
acme nut fitting with
grease gun until
grease exits out top
of acme nut
FAIRING
ACCESS
PANELS
GREASE GUN
Lubrication:
The Procedure
• Brush application of “light
coat of grease” onto
jackscrew threads
• Operate jackscrew “through
full range of travel”
BRUSH
Jackscrew Lubrication:
Alaska Airlines Interval Extension
YEAR
1987
1988
1991
1994
Alaska Airlines Interval
Manufacturer's Recommended Interval
1996
0
1000
2000
3000
FLIGHT HOURS
4000
End Play Check:
Alaska Airlines Interval Extension
YEAR
1985
1988
1996
Manufacturer's Recommended Interval
0
2000
4000 6000 8000 10000
FLIGHT HOURS
Example: primary cause


Loss of pitch control due to the in-flight failure of the horizontal
stabilizer trim system jackscrew assembly’s acme nut threads caused
by excessive wear due to insufficient lubrication.
Contributing factors
 Airline extended lubrication interval and FAA approval of that
interval.
 Airline extended end-play check interval and FAA’s approval of the
interval.
 Acme nut zerk fitting was clogged with hardened grease residue.
USC
SMS and QMS

Quality is the degree to which a system consistently
meets specified requirements, satisfies stated needs, or
produces desired outcomes
USC
SMS and QMS

ICAO

Document 9859, Section 7.6
 SMS focuses on the safety, human and organizational aspects of an
organization (i.e. safety satisfaction); while QMS focuses on the
products and services of an organization (i.e. customer satisfaction)

..”ICAO safety management SARPs included in Annexes 1, 6, 8, 11 and 14…are limited to SMS.
There are no ICAO requirements…with regard to QMS, with the sole exception of a requirement
for approved maintenance organizations (AMO) in Annex 6, Part I, Chapter 8”
USC
SMS and QMS

Quality Control


Quality Assurance


Rejection Review
Findings Review
Quality Review Process


Quality Review Board
Reliability Review Board
USC
SMS and QMS

Acceptable level of Quality?


Metrics

Nature of rejections/findings

Operational

Both should be numerical and have performance targets
AloQ alignment with AloS?

Coordinated Metrics, Risk Matrix

Shared Objectives
USC
SMS and QMS

Options



Integrate or Coordinate
Pros / Cons
In a Large Carrier


QMS reviewed by CASS (Continued Analysis and Surveillance
System)
SMS can be integrated or coordinated with CASS
USC
RISK MATRIX
PROBABILITY
SEVERITY
CATASTROPHIC
CRITICAL
MARGINAL
A
I
B
C
D
SEVERE
SEVERE
E
2
II
HIGH
III
MEDIUM
2
3
4
3
4
5
LOW
NEGLIGIBLE
IV
LOW
3
4
NEGLIGIBLE
5
5
30
RISK ASSESSMENT MATRIX
Potential Consequence of the Incident
Increasing Probability
A
Rating
Env'ment
Assets
No
injury
Zero
Effect
Zero
damage
1
Slight
injury
Slight
Effect
Slight
damage <
US$ 10K
2
Minor
injury
Minor
Effect
3
Serious Localised
injury
Effect
4
Single
fatality
5
Multiple
fatality
0
People
Major
Effect
Massive
Effect
Reputation
B
Unknown but Known
possible in
in aviation
the aviation
industry
industry
D
reported
> 3x / yr.
in Comp.
E
reported
> 3 X / yr.
in location
No Impact
Slight
Impact
Minor
damage <
US$ 50K
Limited
Impact
Local
damage <
US$ 250K
Industry
Impact
Major
damage <
US$ 1M
National
Impact
Extensive
damage >
US$ 1M
International
Impact
3
gh
u
ro -MS
h
T E
e HS
g
s
a l
k
an ma ure
M or ed
ris
e
N oc
at
r
r
p
po on
r
o cti
c
in du ure
re eas
m
le
b
a
er
l
to
In
2
1
USC
SMS Presentation.ppt
C
happened
before in
Company
31
Example: SMS and QMS Coordination
Source
Findings / Audits
ASAP
Self Disclosure
MSR
Risk Level
Average
Low
High
Corrective Actions
In-Progress
Closed
Jul 20XX Rolling 20XX
7/5
3
241 / 96
11
2
4
1
40
20
0
g
u
A
O
ct
c
e
D
b
Fe
r
p
A
n
u
J
Jul 20XX Rolling 20XX
2
2
3
2
1
3
Jul 20XX Rolling 20XX
16
3
417
* Rate per 1000 Revenue Departures
Qty Distribution
Risk
X
X
1.2.3 Maintenance Log / Recording Requirements
1.2.1 Airworthiness Release or Log Book Entry
X
1.2.2 Major Repairs and Alterations Records
Low
Medium
High
Analysis:


Correlation between findings, safety reports, and operational events
Action Items:



Who:
USC
Due:
Status:
SMS and QMS: Education and Training




Prior to Implementation
During Deployment Phase
Ongoing after SMS is in Place
Dealing with Interfaces



Vendors
Other Operational Areas
Providing Feedback


To Individuals
To Other Departments
USC
SMS and QMS

Questions?
USC