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Successful Interventions8th October 2008 Presented byJohn McCollumBAE SYSTEMS Military Air SolutionsHead of Aircraft Maintenance & Maintenance Training

Royal Aeronautical Society Human Factors Group, Engineering (HFG:E)

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Contents

– BAE Systems MAS Background– Safety Exemplar challenge & where are you?– MAS Error Management Programme– Our System Challenge!– Successful Interventions– Our next steps towards a SMS– Summary

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Exemplar Challenge

– The Leadership of BAE Systems has committed The Company to an “exemplar” position on safety:

– This means zero tolerance on unsafe workplace and unsafe working practices to be delivered within each business through target driven performance improvements across both leading and lagging indicators.

– Includes the safety obligation with our Partners and Providers.

– Safety Culture is defined as an organisations values and behaviours, modelled by its leaders, and internalised by its team members”

– This means leading by example!

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Where are you?EXEMPLAR / GENERATIVE

Safety is how we do business round here

ADVANCED / PROACTIVE

We work on problems that we still find

STANDARD / CALCULATIVE

We have systems in place to manage all hazards

FOUNDATION / REACTIVE

Safety is important, we do a lot every time we have an accident

PATHOLOGICAL

Who cares as long as we’re not caught Based upon SHELL model

Incr

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ngly In

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ed

Incr

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ountabili

ty

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Where are you?

Time

Num

bers

of

Inci

dent

s

Technology

Systems

Culture

• Engineering• Equipment design• Design standards• Regulatory compliance

• Quality Systems• Human Factors/CRM• Error management systems• Competence• Risk Assessment

• Behaviours• Visible Leadership • Personal Accountability• Shared Attitudes• Safety as a profit centre

The Three “ages” of Safety Management

With permission: Why is HSE so Important? A business approach Prof. With permission: Why is HSE so Important? A business approach Prof. Patrick Hudson, Leiden University Modified by Baines & McCollum

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The MAS Programme

MEDA Training

Senior Mgt HF Training

HF Programme

EMS Training

Continuation Training

Safety Review Board

Safety Action Groups

SMS Training

2004 2005 20072006 2008

Reactive “Systems”

Proactive “Culture”

MEMS Report 700 +

MEDA Investigations 200 +

Initial HF Trained 2600 +

The Error Iceberg

The Error Iceberg

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Our System Challenge

– System within a system– 1000+ Initial HF trained are RAF and Sub-Con personnel – Different cultures & approaches– Different maturity of systems– Unite under flight safety– Sharing & influencing other Organisations approaches– MAOS helping the message– Partnered approach to policy, training & operation– Military forums now forming

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Successful Interventions

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Maintenance Model Example

(Proactive)(Reactive)

Adapted from Air France / Baines & Simmons / ICAO 9859

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Operational Risk Management in Maintenance

MEMS& others reports

Communications

OrganisationalFactors

HumanPerformanceLimitations

Skills,Training,

Competency

Job /Task/ Zone

Resources

DesignFactors

WorkingEnvironment

Leadership / Supervision

Planning &Preparation

BusinessManagement

Change

Fleet ErrorProvocative

Events

TechPubs &

Procedures

HAZARDIDENTIFICATION

Typical Hazard Considerations for Maintenance

Need to consider assessments by aircraft rectification lines and component bays, using personnel from these areas.

Hazard identification, assessment and control, should be an integral part of routine maintenance, rather than limited to project lifecycle phases and implicit personal action.

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The Basic Bow Tie Concept

Events andCircumstances Harm

CONSEQUENCES

Defences orSafety Controls or

Secondary Hazards ?

Undesirable event withpotential for harm or damage

Continuing Airworthiness activitiesMaintenance activities

Flight Operations activities

Top Event

Preventive Controls

Recovery Controls

HAZARD

Threat

Threat

Threat

RISK RESULTING INCAUSED BY

With permission: With permission: Baines & Simmons

Modified by McCollum

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Summary

– Successful Interventions can come from investing in HF learning, but you must be prepared for the journey.

– A successful Error Management System needs :-– Energy! – Just Culture led from the Top plus Opinion Leaders – Comprehensive investigations with loads of feedback / publicity

– Energy! – Feedback the investigations into your training– Then the toe in the water

– Energy!

– Then the deluge begins

– A Safety Management System can only start once you have a working HF and Error Management System – all about behaviour

– The system must integrate within the bigger system!

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