© 2006 Rolls-Royce plcThe information in this document is the property of Rolls-Royce plc and may not be copied or communicated to a third party, or used for any purpose other than that for which it is supplied without the express written consent of Rolls-Royce plc.This information is given in good faith based upon the latest information available to Rolls-Royce plc, no warranty or representation is given concerning such information, which must not be taken as establishing any contractual or other commitment binding upon Rolls-Royce plc or any of its subsidiary or associated companies.

Rolls-Royce’s Human Factors Approach An update:

John Anfield - Head of Learning & Development, Aero Repair & Overhaul

RAeS HF Conference – Bentley Priory - 18th October 2006

Joined for Q&A session by:

David Watkins - Director Quality & Process Excellence, AR&O

Alan Eccleston - Director of Engineering, AR&O

Sales

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Power systems for tomorrow’s new products

Boeing 787 V-22 A380 A400M Eurofighter JSF

DD(X) LCS Type 45 Dolphin Pipeline Fuel Cells

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A350 XWB

UT Design

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Presentation covers:

• Remind you of our HF Plans back in mid-2004

• Talk about what has been achieved over the past two years

• Share with you what has gone well and some lessons learnt

• Discuss our evaluation and return on Investment methods

• Talk about our next steps in our HF journey

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Phasing of our HF Training PlanFrom 2004-2007, and beyond

Design and Pilot ofManagement HF Training

Exec Event

May 2004 Dec 2004Oct 2004 Oct 2006Jun 2005

HF SteeringGroup Meetings

Jan 2007

vEmployee HF Training Programme – 2420 people

152 events Delivered by Baines-Simmons Ltd

Programme Covering Glasgow, Derby, Ansty and Bristol

Facilities, logistics and HR Admin provided from within Rolls-Royce

Facilities, logistics and HR Admin provided from within Rolls-Royce

MD’s Letter on HF sent out to all Employees

MD’s Letter on HF sent out to all Employees

Delivered Manager & TU TrgTo 195 + 11 in 18 events

Business Case AcceptedFinancial Budgets agreed

P.O. NDA & Contract

Business Case AcceptedFinancial Budgets agreed

P.O. NDA & Contract

MEDA TrainingFor Investigators

Communications Campaign

Design of HFContinuity Trg

HF Continuity & MEMS

MEMS

Conducting an HFTraining

Evaluation(Graduate)

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What was our total investment?

Employees’ and managers time off-job (circa 5,300 days) Human resources effort:

Steering Group Meetings(50 days) HF Mgt/Admin time (200 days) Investigations (80 days) Staff on specialist HF courses (65 days)

Cost of the HF/MEMS training circa £0.5m Implementing systems improvements - MEMS (IT 25 days) Feedback and publicity (90 days)

Quite an effort! Nearly 6,000 days off-job training

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MEMS Activity Dec 2004 – July 2006

No of MEMS Raised Cumulatively

0

20

40

60

80

100

120

140

Date

No

of M

EMS

East KilbrideCum

AnstyCum

BristolCum

DerbyCum

280 MEMS Raised in Total

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Ref. MEMS A060001

After engine sentencing, serviceable items are transferred to the kitting area in the Bellman Hanger. These items are placed in plastic bags and secured using staples. Concerns have been raised with local management that these staples are littering work areas and could contaminate engine parts and or assemblies, along with possible Heath and Safety issues. Instead of stapling we now use a bag sealer on plastic bags.  Ref. MEMS A060003 Issue raised by a production worker concerning the amount of rework and hence costs associated with the time and effort to remove excess braze from the above part (Vanes) on a regular basis.This is an old problem that has been around for circa 10 years. Concern also raised due to the effects on the operators of having to spend so much time blending off braze with the consequential HAVS (hand arm vibrations). Believed to be the highest reject item within the cell. 

Review of all steps in process mostly centred on cleanliness has led to a reduction in rework/blending from 76% to 16% with further planned improvements being progressed thru a Green Belt project and reduced HAVs risk.

Examples of MEMS

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Some Further Examples of MEMS

Location Date Raised Brief Description

Ansty 8-May-2006 Compressor Rotor found built with two group A parts which could not be adequately traced. These items have passed through inspection areas without query

East Kilbride 12-May-2006 Engine SAP Structure has two different R.I.s linked to it, giving contradictory instructions

Derby 12-Jun-2006 Wrong grade of Alumina grit was used on HP Compressor casing

Derby 5-Jul-2006 Tooling labelling – incorrect lift points and C of G shown

East Kilbride 19-Jul-2006 Engine manual states that when the LP Turbine shaft is stripped to piece part level, the aluminium paint coating must be removed prior to MPI inspection, and then the shaft recoated, this step was not carried out.

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Evaluation & ROI- How do we know when it is working?

Heightened employee attitude towards HF and safety issues, with a measurable, positive effect up to 24 months after their initial HF Training

HF is in everyone’s vocabulary now: TU, Ops, Quality, Finance, HR etc

Trust and openness is evident in daily interactions

Quantified by nearly 300 MEMS reports, many avoiding errors/costs

Discipline is now guided by a Just Culture & Culpability policy

HF is a Standing Agenda item on our Quality Board

Expectation in years 3-5 of our campaign that the true ROI of HF will be seen

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11.Q2. Since completing the Human Factors course, what impact (if any) is there on the way you go about performing your duties?

• I now consider the HF impact on my team when travelling to/from remote jobs to ensure adequate rest

• Can see how minor errors can be the root cause of larger incidents/accidents

• I am more thorough with repetitive work to avoid complacency creeping in.

• Greater awareness of when things are wrong and more confidence to report issues, MEMS system useful.

• I have raised a MEMS report where lack of tooling prevents us following procedure

• I haven’t reported anything yet, but can see that MEMs is a good tool to voice your concerns

• Shift handover is now better controlled

Q3. Can you identify an example where a potential incident was avoided due better understanding of Human Factors and the Error Zone?

•Tiredness and lack of knowledge could have caused an incident but took a break and then completed task

• Fan blades launched into the wrong cleaning process, prevented escape into service of three engines

• We have Improved the tooling for Trent 800 IP compressor strip and build

• Our mechanics are more aware of environment – we stopped work on A/c outside in harsh conditions

• Check of modification state early in the build process found redundant parts that would have had a major impact after test – we avoided a customer complaint

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YearYear

Knowledge Knowledge and and

expectations expectations wrt the wrt the MEMSMEMS

Our Next steps? – Critical point in time regarding Return on Investment

2003 2004 2005 2006 2000 20102007 2008

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13Concept of an effective HF Continuity Campaign for the Long-Term

General Background

Communications Campaign

Posters and Coasters

Internal Magazine Articles

Newsletter

Feedback

Learning

Points

Newsletter

Feedback

Learning

Points

Newsletter

Feedback

Learning

Points

Newsletter

Feedback

Learning

Points

HF/MEMS Clinic

Trg Course/Managers

HF Continuity

Trg Course/Employees

Global HF Feedback Systems

New Starters HF programme

Incident IncidentHazard Reports Hazard Reports Hazard Reports

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What we got right: What could have been better:

HF Steering Group: Ops/Qual/Trg ShoMe Safety Surveys

Training our Managers/TU first Communications and newsletters

Trained for both Civil & Military MEDA training given too early

The AR&O Exec HF Event Line Manager Ownership of MEMS

Our MD’s letter to employees Car park issue clean up rate

Chose a World class vendor Paper route for MEMS

Trained staff & works together

Customised HF programme

Just Culture document, TU agreed

Shift & Task Handover Procedure

Formal AROP Quality Procedure

On line MEMS – for 2 years

Extension to non EASA 145 areas

In Summary:

Thanks for listening.We will be happy to take your questions in the morning Q&A

session