Key Safety of Flight
Issues in Aviation
Maintenance
Joseph Barclay
Vice Chairman - MAC
Flight Safety Foundation
www.flightsafety.org
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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.”
www.flightsafety.org
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The Impact to Flight Safety
• The Maintenance
Role in Safety of
Flight
• The Need for
Comprehensive
Review of
Maintenance Issues
Affecting Flight
Safety
www.flightsafety.org
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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
AeroSafety World in
2006
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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
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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
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What Are The Maintenance Issues?
• MAC reviewed
maintenance accident
history
• 4 “High Level” issues
identified
• Review of existing
work on these key
issues
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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?
www.flightsafety.org
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Professionalism in Aviation Maintenance
• Professionalism –
Marks of our
Profession
–
–
–
–
Conduct
Methods
Character
Ethical
Responsibilities
– Standards
-PAMA
www.flightsafety.org
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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
www.flightsafety.org
10
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?
www.flightsafety.org
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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
www.flightsafety.org
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Leadership and
Safety Culture
Ed MacAskill - MAC Member
Brad Brugger – MAC Member
www.flightsafety.org
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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
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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
www.flightsafety.org
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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
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Understanding our Safety Culture
What type of Safety Culture do we have?
Secretive
www.flightsafety.org
Blame
Reporting
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Just
Understanding our Safety Culture
Reporting
System of
accountability that
best supports a
safety culture
www.flightsafety.org
What is a “Just” Culture?
Blame-Free
Culture
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Punitive
Culture
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
Individual
Accountability
System
Design
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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
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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
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Safety Management System
www.flightsafety.org
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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.
www.flightsafety.org
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Conclusion
Behavior
Performance
Safety Climate
Temporal Impacts
Leadership
Safety Strategies
Safety Legends
Organizational/Personnel Values
Unquestioned Assumptions
*St. Louis University, Parks College – Safety Culture Pyramid
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THANK YOU!
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