V2-1 FR Aviation Group FR Aviation Group Marc Bailey Marc Bailey
FR Aviation Group Marc Bailey
Dec 31, 2015
FR Aviation Group Marc Bailey. FRA – A Maintainer’s Perspective. An alternative model of defence. FRA – A Maintainer’s Perspective. An alternative model Impact of initiative pressures. FRA – A Maintainer’s Perspective. An alternative model Impact of initiative pressures Culture shift. - PowerPoint PPT Presentation
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FR Aviation GroupFR Aviation GroupMarc BaileyMarc Bailey
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative model of defenceAn alternative model of defence
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures Culture shiftCulture shift
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures Culture shiftCulture shift A reckless actA reckless act
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures Culture shiftCulture shift A reckless actA reckless act Integration of MEMS Integration of MEMS
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures Culture shiftCulture shift A reckless actA reckless act Integration of MEMS Integration of MEMS Maintaining momentum during introductionMaintaining momentum during introduction
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FRA – A Maintainer’s PerspectiveFRA – A Maintainer’s Perspective
An alternative modelAn alternative model Impact of initiative pressuresImpact of initiative pressures Culture shiftCulture shift A reckless actA reckless act Integration of MEMS Integration of MEMS Maintaining momentum during introductionMaintaining momentum during introduction What can encourage participants?What can encourage participants?
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An alternative modelAn alternative model
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An alternative modelAn alternative model
Classic defence barriersClassic defence barriers
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Classic Model of DefencesClassic Model of Defences
Defensive Strategies Against Contributing Factors
ErrorPreventPrevent
EventEvent
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An alternative modelAn alternative model
Classic defence barriers
Is the model more dynamic in realityIs the model more dynamic in reality
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Dynamic EnvironmentDynamic Environment
Competing Initiatives
Culture Regulator
Defensive strategies against contributory factors
External Forces
ErrorError
ErrorError
EventsEvents
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External ForcesExternal Forces
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External ForcesExternal Forces
A programme snapshotA programme snapshot
• Health & Safety 5-star awardHealth & Safety 5-star award
• New integrated IT developmentNew integrated IT development
• Environmental accreditationEnvironmental accreditation
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External ForcesExternal Forces
A programme snapshotA programme snapshot
• Health & Safety 5-star award
• New integrated IT development
• Environmental accreditation
• Part 21 subpart G & JPart 21 subpart G & J
• Part 147Part 147
• Part 145Part 145
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External ForcesExternal Forces
A programme snapshotA programme snapshot
• Health & Safety 5-star awardHealth & Safety 5-star award
• New integrated IT developmentNew integrated IT development
• Environmental accreditationEnvironmental accreditation
• Part 21 subpart G & JPart 21 subpart G & J
• Part 147Part 147
• Part 145Part 145
• Life Cycle ManagementLife Cycle Management
• Shift to E-DocumentsShift to E-Documents
• Proline 4 modification ProgrammeProline 4 modification Programme
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External ForcesExternal Forces Evidence of pressure, key metrics in QMSR (NCR- volume)Evidence of pressure, key metrics in QMSR (NCR- volume)
Target 40
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External ForcesExternal Forces Evidence of pressure, key metrics in QMSR (Audit- Tailback)Evidence of pressure, key metrics in QMSR (Audit- Tailback)
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Culture ShiftCulture Shift
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Culture ShiftCulture Shift Time to change culture 5 – 7 yearsTime to change culture 5 – 7 years
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Culture ShiftCulture Shift Time to change culture 5 – 7 yearsTime to change culture 5 – 7 years Clarity of purpose and maintaining that clarity in small to medium Clarity of purpose and maintaining that clarity in small to medium
organisationsorganisations
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Culture ShiftCulture Shift Time to change culture 5 – 7 yearsTime to change culture 5 – 7 years Clarity of purpose and maintaining that clarity in small to medium Clarity of purpose and maintaining that clarity in small to medium
organisationsorganisations Where are we starting from?Where are we starting from?
• OLD EXPECTATIONSOLD EXPECTATIONS• Apprenticed engineersApprenticed engineers• Clear trade understandingClear trade understanding• Company loyaltyCompany loyalty• Airmanship and professional prideAirmanship and professional pride
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Culture ShiftCulture Shift Time to change culture 5 – 7 yearsTime to change culture 5 – 7 years Clarity of purpose and maintaining that clarity in small to medium Clarity of purpose and maintaining that clarity in small to medium
organisationsorganisations Where are we starting from?Where are we starting from?
• OLD EXPECTATIONSOLD EXPECTATIONS• Apprenticed engineersApprenticed engineers• Clear trade understandingClear trade understanding• Company loyaltyCompany loyalty• Airmanship and professional prideAirmanship and professional pride
• NEW EXPECTATIONSNEW EXPECTATIONS• Significant reduction in full apprenticeshipsSignificant reduction in full apprenticeships• Full licence – difficult to phase inFull licence – difficult to phase in• Expectation of several employers through lifeExpectation of several employers through life• Open learning, less structure, and reduced disciplineOpen learning, less structure, and reduced discipline• Shift in Society's valuesShift in Society's values
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A Reckless ActA Reckless Act
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A Reckless ActA Reckless Act What everyone needs in a human factors programmeWhat everyone needs in a human factors programme
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A Reckless ActA Reckless Act
During re-build phase of LH wing During re-build phase of LH wing tank inboard area, Tank Devils tank inboard area, Tank Devils Supervisor noted a hacksaw cut in Supervisor noted a hacksaw cut in clamp. clamp.
It is understood a Tank Devils It is understood a Tank Devils mechanic installed a structural mechanic installed a structural stanchion without passing the stanchion without passing the clamp over the stanchion first, clamp over the stanchion first, subsequently the clamp was cut to subsequently the clamp was cut to install it. A check on the RH wing install it. A check on the RH wing revealed the stanchion to berevealed the stanchion to bein place without either upper or in place without either upper or lower clamp.lower clamp.
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A Reckless ActA Reckless Act
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A Reckless ActA Reckless Act What everyone needs in a human factors programmeWhat everyone needs in a human factors programme
Interesting on many levelsInteresting on many levels
• Why do it , no real pressure on the task , not AOGWhy do it , no real pressure on the task , not AOG
• Running away!Running away!
• Response from executivesResponse from executives
• NAA responseNAA response
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Integration of MEMSIntegration of MEMS We are trying to emphasise today “Human Factors in We are trying to emphasise today “Human Factors in
maintenance” but MEMS is only part of an existing maintenance” but MEMS is only part of an existing systemsystem
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Integrated Reporting SystemIntegrated Reporting System
Reporting
HazardReport
MEMSDatabase
SDAUEnquiry
IncidentReporting
NCR’s QFR’s QDA’s DCR’s
UK MEMSDatabase
MORDatabase
Feedback Loop
Q-Pulse
Access Access
MedaInvestigation
MEDAAction
AirworthinessReview Board
NAAOpen Loop
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Integration of MEMSIntegration of MEMS We are trying to emphasise today “Human Factors in We are trying to emphasise today “Human Factors in
maintenance” but MEMS is only part of an existing maintenance” but MEMS is only part of an existing systemsystem
We need for it to become integrated into the fabric of We need for it to become integrated into the fabric of the systemthe system
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Integration of MEMSIntegration of MEMS We are trying to emphasise today “Human Factors in We are trying to emphasise today “Human Factors in
maintenance” but MEMS is only part of an existing maintenance” but MEMS is only part of an existing systemsystem
We need for it to become integrated into the fabric of We need for it to become integrated into the fabric of the systemthe system
Accelerating our learning by sharing - UKMEMSAccelerating our learning by sharing - UKMEMS
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Integration of MEMSIntegration of MEMS
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Integration of MEMSIntegration of MEMS
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Integration of MEMSIntegration of MEMS
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Integration of MEMSIntegration of MEMS We are trying to emphasise today “Human Factors in We are trying to emphasise today “Human Factors in
maintenance” but MEMS is only part of an existing maintenance” but MEMS is only part of an existing systemsystem
We need for it to become integrated into the fabric of We need for it to become integrated into the fabric of the systemthe system
Accelerating our learning by sharing - UK MEMSAccelerating our learning by sharing - UK MEMS
Integration of initiativesIntegration of initiatives
• Not competing with toolsNot competing with tools
• Closer liaison between all initiativesCloser liaison between all initiatives
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Momentum During IntroductionMomentum During Introduction
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
Feedback and quick wins (car park)Feedback and quick wins (car park)
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
Feedback and quick wins (car park)Feedback and quick wins (car park)
Dealing with Just Culture slipsDealing with Just Culture slips
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
Feedback and quick wins (car park)Feedback and quick wins (car park)
Dealing with Just Culture slipsDealing with Just Culture slips
Time versus operational limitationsTime versus operational limitations
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
Feedback and quick wins (car park)Feedback and quick wins (car park)
Dealing with Just Culture slipsDealing with Just Culture slips
Time versus operational limitationsTime versus operational limitations
Quality of facilitation is keyQuality of facilitation is key
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Momentum During IntroductionMomentum During Introduction Initiative resistance – prevent overloadInitiative resistance – prevent overload
TNA split and support staff buy inTNA split and support staff buy in
Feedback and quick wins (car park)Feedback and quick wins (car park)
Dealing with Just Culture slipsDealing with Just Culture slips
Time versus operational limitationsTime versus operational limitations
Quality of facilitation is keyQuality of facilitation is key
Overcome reporting reluctanceOvercome reporting reluctance
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What Can Encourage Participants ?What Can Encourage Participants ? Undertake MEDA investigations at every opportunityUndertake MEDA investigations at every opportunity
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What Can Encourage Participants ?What Can Encourage Participants ? Undertake MEDA investigations at every opportunityUndertake MEDA investigations at every opportunity
Good examples needed to feed continuation trainingGood examples needed to feed continuation training
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What Can Encourage Participants ?What Can Encourage Participants ? Undertake MEDA investigations at every opportunityUndertake MEDA investigations at every opportunity
Good examples needed to feed continuation trainingGood examples needed to feed continuation training
PR at every opportunityPR at every opportunity
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What Can Encourage Participants ?What Can Encourage Participants ? Undertake MEDA investigations at every opportunityUndertake MEDA investigations at every opportunity
Good examples needed to feed continuation trainingGood examples needed to feed continuation training
PR at every opportunityPR at every opportunity
Rejuvenate suggestion schemeRejuvenate suggestion scheme
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SUMMARYSUMMARY Reflect on alternate model “HF Russian Roulette”Reflect on alternate model “HF Russian Roulette”
Initiative pressures – Internal and ExternalInitiative pressures – Internal and External
Culture shiftCulture shift
Reckless acts Reckless acts
Integration of MEMSIntegration of MEMS
Momentum and encouragementMomentum and encouragement
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Q&AQ&A
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