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Airline Reliability Program & SMS – Reactive to Predictive IATA Maintenance Symposium Miami September 2015
Darren Cook Manager Quality & Safety Maintenance Operations & Part 145 QANTAS Engineering
Getting it Right
So this is what getting it right looks like
1
But Sometimes We Get It Wrong
2
Question 1 Could this have been prevented? I think we can all agree and say:
YES 3
Question 2 Can such an incident be predicted? Hmmmmmmmm Well that is another question altogether
4
Reactive Error Management
Traditional learning comes from a Reactive process
But, can we learn what the underlying and causal factors are before such an event occurs? 5
Reactive to Predictive – Let’s Consider the Possibilities • What we have learnt from 100 Years of Aviation • What influence has our own maintenance & safety culture had • Changes made in maintenance culture – last ten years • Moving to Proactive Error & Violation Management •
Effects on Reporting & Risk
• The Challenge – moving from Reactive to Proactive to Predictive • Mitigation by Risk • Predictive Mitigation Example • Conclusion
6
Firstly Let’s Consider What We Have Already Learnt What have we learned over 100 years of Aviation
Human Beings & Aeroplanes
don’t always go well together 7
Safety/Complexity – Trade Off
8
So let’s Have a Look Back in Time Queensland and Northern Territory Aerial Services (QANTAS) was registered in 16 November 1920. • • • •
1 Chairman (he had the money) 2 Pilots 1 Mechanic 1 Aeroplane
9
So let’s Have a Look Back in Time Trans Australian Airlines (TAA) born from the Australian National Airways Commission
Lester Brain.1st General Manager
• • •
2 DC3s Ex Qantas Operations Manager Government Backing Arthur Coles – Commission Chairman
10
DC4 Skymaster 1946
Aircraft Maintenance Culture • Early Years - Big Country/Big World - Long Distances - Maintenance Must do became “Can Do”
11
Aircraft Maintenance Cultural Heritage – Complexity in People In Australia
12
12
Aircraft Maintenance Cultural Heritage – Complexity in People From Overseas
13
13
Understanding Maintenance Culture Training & Experience National Culture Professional Culture Company culture Management Behaviour Reporting Culture Just Culture Change Management 14
Aircraft Maintenance Cultural Heritage – Maintenance Error • Historical Approach
Maintenance Event
Maintenance Event Caused by Error
Who made the Error
Punitive Action 15
15
Aircraft Maintenance Cultural Heritage – Non Reporting Culture • Results of Historical Approach: - Hiding Errors due to fear of punitive action - Hiding Errors due to embarrassment - Hiding Errors due to Pride - No reporting of safety and quality issues - Reporting to Regulator via confidential reporting - No organisational learning or accountability
16
16
Now Then – What about the last Ten Years in QANTAS Engineering Safety Management From these beginnings
To 2005
17
Getting It Right – The Beginning Moving from Reactive to Proactive A few examples of proactive measures in Qantas Engineering:
• Human Factors and Error Management Training including management.
• Just Policy and culpability • Reporting System including confidential system
• New Error Investigation Training and Practices 18
Non Technical Skills Training – Awareness Proceeds Behavioural Change - Proactive
19
Investigating Links People and Procedures
People and Machines
People and People
20
People and Environment
Moving from Reactive to Proactive QANTAS Engineering
The Beginning
Enhanced Programs (Proactive)
(Reactive)
21
21
The Story so Far – QANTAS Engineering No Programs
The Beginning
Enhanced Programs
8000 7000 6000
Reporting
High Medium
5000 Low Risk
4000 3000
Very Low
Risk
2000 1000 0 2004
2005
2006
2007
2008
2009
2010
2011
2012 22
Paper Based Reported Occurrences
Online Based Reported Occurrence
The Story so Far – QANTAS Engineering Reporting has stabilized (2.3 reports per person per year)
Risk Level has now plateaued
•23
23
Maintenance Risk Plateau Level of Risk
24
Moving from Reactive to Proactive and Predictive – QANTAS Engineering
The Beginning
Enhanced Programs
The Challenge (Predictive)
(Proactive) (Reactive)
25
25
The Challenge - Moving to Predictive
What are the elements required?
•26
26
Moving to Predictive Requires Data
?
?
?
?
?
?
?
?
•27
27
Event Reporting Event Reporting
• • • • • • •
Easy to Use (online) Employees given time to report Employees allowed to report Provide employees feedback on reporting Risk rate reports Prioritise Ensure Just Culture policy is used
•28
28
Data Sharing Partnerships
Airlines & Manufacturers
Regulators & Other Industry
World Data
•29
29
Existing Database • Safety Investigations
• Maintenance Error Investigations • Audits • Other relevant database information
Existing Data
•30
30
What is the Data Trying to Say •MEDA Investigation Data Base FI/Test/Inspec Error 55 13%
What is the Data Trying to Say • MEDA Codes Investigations Data base
Number of Causes 0
20
40
60
80
100
120
111
A.4. Inadequate (Info) 68
K. Other Issues
67
A.8. Information not used (Info) H.7. Work Process/Procedure
65 62
F.6. Complacency 56
F.3. Time constraints
Existing Data
48
F.8. Workplace distractions/interrupts J.2. Between Engineers (Communication)
42
F.9. Memory lapse (Forgot)
41
•32
32
Bow Tie Methodology
• Direct potential to cause a “Top Event”, which may release/ change the desired state of the hazard
• The thing we want to do or use • Need to maintain control over this as it is potentially dangerous
HAZARD
CONSEQUENCE THREAT
Threat Barrier
Recovery Measure
Threat Barrier
LOSS / DAMAGE
• Loss/damage to People, Environment, Assets/Value, Reputation, etc
• The point where control is lost • This event does not actually cause the damage (the “consequence” does)
TOP EVENT
THREAT CONSEQUENCE Threat Barrier
Threat Barrier Recovery Measure
ESCALATION FACTOR
Recovery Measure • Has potential to cause damage or harm (but is not the actual loss or damage)
• Potential to defeat or reduce effectiveness of control
Escalation Factor Control
LOSS / DAMAGE
ESCALATION FACTOR
Escalation Factor Control
33
Bow Ties can shift along the causal chain Zoom level • The focal point (Top Event) is a choice (it is not fixed) • Find a natural starting point (ie, normal vs out of control) • Start at the macro level and ‐ drill down (zoom in / out) ‐ slide along the sequence of events (point in time)
Point In Time
Point In Time “RISK”
event that has potential to occur
Maintenance
Operations
Incident
Crisis Response
34
Risk Assessments & Risk Modelling
Risk Assessment & Modelling •35
35
Risk Assessments & Risk Modelling
•36
36
Observations, Surveillance, & Gut Feel Audits
Cross Port Audits Surveillance Programs Maintenance LOSA Program
Self Audits
Observations and Surveillance
Internal & External Audit Results
Focus Groups
Maintenance Airworthiness Controller Program •37
37
Moving to Predictive Requires Data Audits
Event Reporting
Airlines & Manufacturers
Observations & Surveillance
Regulators & Other Industry
Risk Assessment & Modelling
World Data Existing Data •38
38
Review data to build a Profile • Build a Profile • Assess the risk • Where required apply a Change Management Plan • Mitigate using Hierarchy of Risk Control • Review and adjust • Stay the course •39
39
Mitigate Using Hierarchy of Risk Controls More desirable • Eliminate
Risk Assess
• Substitute • Engineer • Administration • Personal protective equipment Less desirable 40
Predictive Mitigation Example – A330 •
A330 Nose Landing Gear Full Service
•
Error Prone Task
•
Reports and Investigations show complexity in task leading to possible incorrect servicing.
•
Training package now imbedded within the task.
•
At the time of the task, engineers attend training specifically for the task.
•
Task briefing on job prior to commencing
41
Predictive Mitigation Example – A330
42
Conclusion – Just Policy Just Policy
• Must have a Just Policy and Procedure • Consistently applied across all activities • Consistently applied across the whole company • Actions based on behaviours not the outcomes 43
Conclusion – Event Investigation Event Reporting
• Easy to report • Give people time to report • Risk assess and prioritise • Provide feedback to reporter
• Prioritise Investigations • Trained & Skilled Investigators • Consistency across investigations • Recommendations that provide higher level controls (Risk Control Hierarchy) • Greater analysis of event data for continuous improvement
45
45
Conclusion – Leadership & Management Commitment
Leadership & Management Commitment
• Out of the book & into action • Providing clear vision on safety & what safety looks like • Providing financial commitment • Applying transparent change management • Challenge own behaviours, systems, and procedures 46
Predictive Safety and Error Management •
Better Analysis of data from: • Reporting • Partnership Data sharing
The Challenge
• World wide industry • Existing data • Risk Assessment & Error Modelling • Observations & Surveillance • Audit data 47
Predictive Safety and Error Management •
Becoming more Proactive and even predictive: • Error Prone Tasks • Error Prone Situations
The Challenge
•
Provide Mitigation Strategies: • At the time we need them • Build redundancy into maintenance functions • Driving Human Factors out of the classroom
•
Risk Management Hierarchy into mitigation strategies 48