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Joseph Barclay

Vice Chairman - MAC

Flight Safety Foundation

Key Safety of Flight Issues in Aviation Maintenance

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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.”

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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

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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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• 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

Flight Safety Foundation in Maintenance

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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?

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Professionalism in Aviation Maintenance

• Professionalism – Marks of our Profession – Conduct– Methods– Character– Ethical

Responsibilities– Standards

-PAMA

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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

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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?

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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

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Ed MacAskill - MAC Member

Brad Brugger – MAC Member

Leadership and Safety Culture

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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

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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

Secretive JustReportingBlame

What type of Safety Culture do we have?

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Understanding our Safety Culture

What is a “Just” Culture?

Blame-Free Culture

System of accountability that

best supports a safety culture

Punitive Culture

Rep

ort

ing

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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

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Individual Accountability

System Design

Organizational Values

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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

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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.

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Conclusion

Organizational/Personnel ValuesUnquestioned Assumptions

LeadershipSafety StrategiesSafety Legends

Safety ClimateTemporal Impacts

BehaviorPerformance

*St. Louis University, Parks College – Safety Culture Pyramid

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THANK YOU!