® sintef title · ® sintef sintef technology and society safety and reliability address: no-7465...

® SINTEFSINTEF Technology and SocietySafety and ReliabilityAddress: NO-7465 Trondheim,

NORWAYLocation: S P Andersens veg 5

NO-7031 TrondheimTelephone: +47 73 59 27 56Fax: +47 73 59 28 96

Enterprise No.: NO 948 007 029 MVA

REPORT NO. CLASSIFICATION

STF50 A05210 UnrestrictedCLASS. THIS PAGE ISBN

Unrestricted 82-14-03893-6ELECTRONIC FILE CODE

S:\3840\PRO\504031\Rapport\Report (final) docFILE CODE DATE _-

Report (final).doc 2006-02-28

SINTEF REPORTTITLE

Helicopter Maintenance

A follow-up study of the maintenance recommendations inNOU 2002: 17 "Helicopter Safety on the NorwegianContinental Shelf'

AUTHOR(S)

Ivonne Herrera, Helge Sandtorv

CLIENT(S)

Committee for Helicopter Safety on the Norwegian ContinentalShelfCLIENTS REF.

Jan BengtsonPROJECT NO

504031PROJECT MANAGER,(NAME, SIGN.) / 1ivoMemJ-rit^w

NO OF PAGES/APPENDICES

60/4CHECKED BY (NAME, Sjasg£ J

Erik Jersin^^^? / •APPROVED BY (NAME, POSITION, SIGN.) ^ >^n /

Lars Bodsberg, Research Manager"^ y/^^£^-«-vABSTRACT /

The Committee for the Review of Helicopter Safety on the Norwegian Continental Shelf was appointedby the Ministry of Transport and Communication in 2001. The results were presented in a Public Report(NOU) in September 2002 [NOU2002: 17 Hetikoptersikkerheten pa norsk kontinentalsokkel\. Amongother things, the report gave some recommendations regarding helicopter maintenance. These werefurther developed by a later appointed Committee for Helicopter Safety on the Norwegian ContinentalShelf, and the latter asked SINTEF to further evaluate the recommendations in a project by e.g.performing a brainstorming meeting with major stakeholders in helicopter manufacturing, operation andstatutory regulation.

The present report describes the process carried out, and the results of the brainstorming sessions. Inaddition, SINTEF has evaluated the outcome and suggested which further actions should be givenhighest priority, based on an evaluation of the scope, cost/benefit relationship and feasibility of theproposals.

KEYWORDS ENGLISH NORWEGIAN

GROUP 1 Safety SikkerhetGROUP 2 Helicopter HelikopterSELECTED BY AUTHOR Maintenance Vedlikehold

Recommendations Anbefalinger

2

EXECUTIVE SUMMARY The Committee for the Review of Helicopter Safety on the Norwegian Continental Shelf was appointed by the Ministry of Transport and Communication in 2001. The results were presented in a Public Report (NOU) in September 2002 [NOU 2002: 17 Helikoptersikkerheten på norsk kontinentalsokkel]. Among other things, the report gave some recommendations regarding helicopter maintenance. These were further developed by a later appointed Committee for Helicopter Safety on the Norwegian Continental Shelf, and the latter asked SINTEF to further evaluate the recommendations in a project by e.g. performing a brainstorming meeting with major stakeholders in helicopter manufacturing, operation and statutory regulation. Both the discussions in the brainstorming meeting and a following meeting with the Committee for Helicopter Safety on the Norwegian Continental Shelf revealed different opinions regarding the need for improvement of the maintenance programs. We therefore suggest that a more detailed assessment should be carried out in order to define more concrete and feasible actions. As a general conclusion the following three areas have been assessed as the most important to pursue:

1. Maintenance error analysis and applied Human Factors (HF) in maintenance. 2. Improve the communication of maintenance experience to the helicopter manufacturers in

order to improve the maintenance program. 3. Maintenance Continuation Training.

Within each of these areas a more specific plan for actions is proposed with an assessment of feasibility, cost/effort, timeframe and major stakeholders. One recommendation is that in the short term it would be worthwhile to carry out a screening study on the three topics listed above in order to uncover in more detail the challenges identified in this study.

3

TABLE OF CONTENTS

1 INTRODUCTION ...................................................................................................................4

1.1 BACKGROUND ....................................................................................................................4

2 ABBREVIATIONS .................................................................................................................5

3 APPROACH ............................................................................................................................5

3.1 PREPARING THE BRAINSTORMING SESSION .........................................................................5 3.2 THE BRAINSTORMING PROCESS...........................................................................................6

4 THE BRAINSTORMING RESULTS ...................................................................................7

4.1 SESSION 1 MAINTENANCE PROGRAM .................................................................................7 4.2 SESSION 2 HUMAN FACTORS ............................................................................................10 4.3 SESSION 3 MAINTENANCE EXPERIENCE COMMUNICATION................................................12 4.4 SESSION 4 EVALUATION OF CONTINUATION TRAINING ...................................................13 4.5 SESSION 5 RECRUITMENT OF MAINTENANCE PERSONNEL .................................................14 4.6 CLOSING THE MEETING: A CONCLUDING REMARK FROM THE HELICOPTER MANUFACTURER 15

5 INFORMATION FROM CAA UK AND CAA N ..............................................................15

6 NORWEGIAN HELICOPTER EMPLOYEES ASSOCIATION (NHF) INFORMATION ...........................................................................................................................16

7 CONCLUSIONS AND RECOMMENDATIONS ..............................................................17

7.1 SUMMARY OF RESULTS.....................................................................................................17 7.2 RECOMMENDATIONS FOR FURTHER WORK........................................................................17 7.3 PRIORITIZED FURTHER ACTIONS .......................................................................................20 7.4 .WORK PLAN ACTIVITIES AND EXPECTED RESULTS ...........................................................22 7.5 SCHEDULE, BUDGET AND FINANCE ...................................................................................25

REFERENCES………………………………………………………………………………….. 28 ANNEX I: Participants’ preliminary information and agenda…………………………...... 29 ANNEX II: SINTEF in short and outline of “Helicopter Study” 1 and 2........ ...................... 31 ANNEX III: Session participants................................................................................................ 41 ANEXX IV: An initiative in response to NOU 2002:17 Maintenance Function……………..47

4

1 Introduction The Committee for the Review of Helicopter Safety on the Norwegian Continental Shelf was appointed by the Ministry of Transport and Communication in 2001. The results were presented in a Public Report (NOU) in September 2002 [NOU 2002: 17 Helikoptersikkerheten på norsk kontinentalsokkel]. Among other things, the report gave some recommendations regarding helicopter maintenance. These were further developed by a later appointed Committee for Helicopter Safety on the Norwegian Continental Shelf, and the latter asked SINTEF to further evaluate the recommendations in a project by e.g. performing a brainstorming meeting with major stakeholders in helicopter manufacturing, operation and statutory regulation. The present report describes the process carried out, and the results of the brainstorming sessions. In addition, SINTEF has evaluated the outcome and suggested which further actions should be given highest priority, based on an evaluation of the scope, cost/benefit relationship and feasibility of the proposals. The brainstorming objective was to identify ideas to realize the maintenance recommendations offered in the Public Report NOU: 2002:17 by The Committee for Helicopter Safety on the Norwegian Continental Shelf [1]. This committee was established in 2003 by The Ministry of Transport and communications under the leadership of the Norwegian Civil Aviation Authorities (CAA N). The stakeholders represented in the brainstorming meeting were as follows:

• The two main offshore helicopter operators in Norway • One helicopter manufacturer • The CAA N, • The Norwegian Accident Investigation Board (AIBN), • The Norwegian Oil Industry Association (OLF), • The above mentioned Committee for Helicopter Safety, • Two research institutions.

1.1 Background The above mentioned report (NOU 2002:17) contains a list of potentials for improvement of the maintenance function:

Quote Chapter 1.4.3, Section 11, Maintenance function: < The Committee recommends that the Maintenance Steering Group (MSG) documentation is improved in cooperation between the helicopter manufacturers and the helicopter operators. In particular, there is a need to improve and communicate better to the helicopter operators the considerations inherent in the maintenance programs made by the manufacturers. The Committee recommends that the helicopter companies' maintenance concepts/-programs are improved and simplified in accordance with the Accident Investigation Board's report from the Norne-accident. The Committee recommends that the helicopter operators' experiences from maintenance must be more effectively communicated to the manufacturers for continuous improvement of maintenance programs.

5

The Committee recommends that Crew Resource Management (CRM) is introduced in maintenance and that necessary training in CRM and Human Factors is implemented. The Committee recommends that today's practice regarding continuation training is evaluated. Moreover, the helicopter operators should establish a program to improve recruitment of maintenance personnel. The helicopter operators should in this connection cooperate with the Norwegian Oil Industry Association's project for increased recruitment to oil- and gas business «A world of possibilities» >. Unquote

These recommendations are, as shown, of a fairly general character. Hence, the task of this project has been to address the main stakeholders in helicopter operations on the Norwegian Continental Shelf (NCS) to discuss the recommendations and suggest which of them, with possible neighborhood activities, would be most feasible and useful and to implement in the years to come.

2 Abbreviations ATA Air Transport Association of America CAA Civil Aviation Authorities CRM Crew Resource Management CT Continuation Training EASA European Aviation Safety Agency FAA Federal Aviation Authorities FOQA Flight Operational Quality Assurance HF Human Factors MSG Maintenance Steering Group MRM Maintenance Resource Management NCS Norwegian Continental Shelf NOU Norwegian Public Report NPA Notice of Proposed Amendment OLF The Norwegian Oil Industry Association VHM Vibration Health Monitoring

3 Approach

3.1 Preparing the brainstorming session To prepare and perform the brainstorming the following actions were performed by SINTEF upfront the brainstorming sessions: • The NOU recommendation was divided into five topics:

1. Improve the MSG documentation provided to helicopter operators 2. Introduce and implement CRM/HF in maintenance 3. Improve the communication of maintenance experience to manufacturers in order to improve the maintenance program. 4. Evaluate continuation training 5. Improve recruitment of maintenance personnel

• Information was acquired from the British Civil Aviation Authorities (CAA UK) regarding current status related to the NOU maintenance recommendation (see Chapter 5)

6

• Relevant organizations were invited to the brainstorming. Proposed brainstorming agenda and

information was mailed to the participants before the meeting (see Annex I).

3.2 The brainstorming process SINTEF started the meeting by making a presentation of the background for this brainstorming with e.g. a summary reference to two previous studies on offshore helicopter safety (see Annex II). Then, the attendants were split in two groups: One group to focus on topic 1 and 3 (see above) and another group focusing on topic 2, 4 and 5. The participants in each group are listed in Annex III. After each session in these two groups the result was presented in plenum for further comment and input. The brainstorming group sessions were carried out based on a formalized method; Nominal Group Technique [10], comprising the following steps:

1. Each member wrote down his/her ideas 2. All ideas were recorded 3. One idea at a time was clarified orally 4. New ideas were generated 5. Discussion 6. Ranking

The NOU recommendations were slightly reformulated to a question approach as shown for each topic presented in Chapter 4. The sessions were started with a round-the table discussion based on the NOU recommendations. As found appropriate in relation to the topic there were more time devoted to discussions on topic 1 and 3 compared to the other ones. A summary of some comments given during this discussion is included for each session chapter. Some of the comments were in the periphery of the topic, but nevertheless considered to be useful input to the process. In summary, each session contained the following: 1. Topic to be discussed from the NOU-report (five in total) 2. Comments given in the introductory discussions and plenary discussions 3. Prioritized ideas for improvement within each topic. NOTE: As only one helicopter manufacturer participated at the brainstorming meeting, some of the opinions expressed in this report may be slightly biased by the opinion of this manufacturer. After the initial discussion, the main ideas were summarized as shown in the tables given at the end of each session chapter. Each idea was given a rank from 1 to 3 by the attendants; 1 being the most important. From this ranking and a calculated score (see below), SINTEF has given a priority ranking of each idea from 1 to 3 (1 = highest priority) as shown in the tables. The different ideas are listed in descending order according to this priority ranking. The score calculation was based on summarizing a total score as follows:

Ranking no. 1 = score value 3 Ranking no. 2 = score value 2 Ranking no. 3 = score value 1 (Example: Ranking 1,2,2,3 gives a total score value of 8.)

7

The priority assessment in the classes 1, 2 and 3 are based on the following “engineering judgment”:

Priority Score 1 > 14 2 10 - 14 3 < 10

The result from the brainstorming process was later summarized in a SINTEF Memo and distributed to all the participants for comments. The comments received have been carefully reviewed by SINTEF and adapted in the final ‘summary of findings’ included in this report. Some time later, on November 30, the preliminary results were presented to The Committee for Helicopter Safety on the Norwegian Continental Shelf. The Committee commented the ideas and made an additional prioritization. These inputs are taken into account and summarized in Chapter 7 – Conclusions.

4 The brainstorming results The results from the different brainstorming sessions are reported in the following chapters 4.1 – 4.5.

4.1 Session 1 Maintenance Program

Topic session 1: How can the MSG documentation be improved and communicated in cooperation between the helicopter manufacturers and the helicopter operators? Propose measures to:

− Improve and communicate better to the helicopter operators the considerations inherent in the maintenance programs made by the manufacturers

− Improve and simplify the helicopter companies' maintenance concepts/-programs in accordance with the Accident Investigation Board's report from the Norne-accident.

The MSG-concept: The MSG-concept is a procedure to develop the scheduled maintenance tasks and intervals which are acceptable to the regulatory authorities, the operators, and the manufacturers. The scheduled maintenance task and interval details are developed by coordination with specialists from the operators, manufacturers, and the Regulatory Authority of the country of manufacture. The analysis starts with a criticality analysis of each main function and its associated equipment in order to define the so-called maintenance significant items. Then each of these items is analyzed as to applicable maintenance tasks based on a defined logic, and the total results are used to define a maintenance program for the whole aircraft. The concept was originally developed for fixed wing aircrafts and first applied on the Boeing 747 (Jumbo-jet). The concept has since been further developed and the latest version is denoted MSG-3. This version is widely used in the aircraft industry, notably for fixed wing aircrafts. A derivate of the concept, termed Reliability Centered Maintenance (RCM) has gained wide acceptance and application in many other industries, among others in the oil & gas industry in Norway.

8

The FAA states that for transport category of more than 33,000 pounds maximum certificated take-off weight, a Maintenance Review Board (MRB) could be agreed and Maintenance Review Report could be generated. As it has been impractical to combine MSG2 and MSG3, the FAA has responded with a policy stating that the latest MSG analysis procedures must be used for the development of Maintenance Review Board Report (MRBR) for all new or derivative aircraft. This policy, however, is implemented on a case-by-case basis. [12]. It is our understanding that helicopters have been delivered with a maintenance program that is not always based on MSG concept. Maintenance Program can be developed using similar techniques such as Failure Mode Effect and Criticality Analysis (FMECA). Once initial maintenance program is received by the operators, improvements of maintenance program are performed by means of MRB is a multidisciplinary board within the operators were technical performance is followed up using internal operators reports such as reliability reports. Recommendations regarding improvements are made by system specialists and decisions are made in the MRB. Recommendations could be improvements in the maintenance program, training, logistic etc. Comments expressed by the participants during the introductory discussions:

− The MSG recommendation in the NOU reads as follows: Quote 11 Maintenance function: The Committee recommends that the Maintenance Steering Group (MSG) documentation is improved in cooperation between the manufacturers and the helicopter operators. In particular, there is a need to improve and communicate better to the helicopter operators the considerations inherent in the maintenance program made by the manufacturers. Unquote

Do we know the reason for this recommendation, i.e. why the MSG concept should be applied for helicopters? It is not clear which considerations were the background for the inherent statement that it is necessary to improve the MSG documentation. The MSG system has worked excellent for several modern aircraft types, but the current version, MSG-3, has never been seriously applied to any helicopter type. The only real known application of this methodology was the use of the MSG-2 on the Boeing Chinook helicopter (BV-234), which turned out quite successful. (Referee’s comment: How can we acquire the lessons learned from this process?)

− The MSG-3 concept is under-utilized by helicopter manufacturers, notably in certifying new helicopters. The group process as recommended in the MSG-3 for defining a maintenance program including manufacturers, operators and regulatory bodies, is not utilized to its potential.

− The MSG-3 is not fitted for use on helicopters to the same extent as for fixed wings because helicopters normally have a different operating profile. However, the basic principles of the MSG-3 are applicable for helicopters, as well.

− There should be more initiatives from the manufacturers and regulatory bodies to adapt/utilize the MSG-3 concept. So far, it is not a requirement.

− The regulatory bodies have not focused much on maintenance, so far.

− A pan-European initiative might be useful in order to adapt the MSG-concept to helicopters (e.g. funded by the EU).

− Experiences are already exchanged in regular meetings between helicopter operators and manufacturers (3 – 4 times per year).

9

− The documentation from one manufacturer has been significantly improved by use of

electronic media (CD-ROM, Internet).

− The manufacturers’ updating of maintenance manuals based on operator input/request takes too long time. (The representatives from one manufacturer present agreed to this statement in some cases, but stated that safety related issues are incorporated very quickly.)

− Maintenance specifications from the manufacturers should be more specific. An example: A recommended maintenance task says: “Check bolt X”, but the manual does not tell which method should be used. (The representative from one manufacturer commented that it is true that some tasks should be more explicitly formulated, but technical publications are based on aeronautical know-how noticed in the manufacturer standard practices manual (same for all products' range)).

Table 1 gives the results of Session 1, ranked according to the procedure described in Chapter 3.2.

Table 1 – Ideas session 1 (MSG documentation and communication)

No. Ideas Ranking PriorityNew helicopters:

A. Group of experts defining the maintenance program policy to be requested by the CAA and others. The group should consist of operators, manufacturers/designers and authorities. The different type of operations should be evaluated.

1,1,1,2,2,2,3,4 Score: 17

1

B. Make new derivates of existing helicopter types subject to MSG-3 analyses in cooperation with the operators. All offshore helicopter operators should cooperate in a separate forum.

1,1,1,2,2,3,3 Score: 15

1

C. Make the MSG-3 a recommendation for all new designs launched on the civil market.

1,1,2,2,3,3,3 Score: 13

2

D. Consider implementing ”Maintenance Awareness Design” (a concept presented by SINTEF at the meeting)

2,3,3,3 Score: 5

3

Existing helicopters: E. Review the total MSG process; its purpose, mandate and

authority. 1,1,1,2,2,3,5 Score: 14

2

F. Establish a steering group to analyse the Super Puma and the S-92 maintenance program in relation to MSG-3.

1,1,2,2,3,3,3 Score: 13

2

G. Define concrete requirements regarding maintenance program improvements; more precise and practical project definition

1,1,2,2,2,3 Mean: 13

2

H. Manufacturer should be on site when defining concrete maintenance programs, or maintenance tasks.

1,3,3,3,3 Mean: 7

3

10

4.2 Session 2 Human Factors Topic session 2: Suggest how Crew Resource Management (CRM / Maintenance Resource Management MRM) can be introduced in maintenance? - Suggest how the necessary training in CRM / MRM and Human Factors can be

implemented. - What are the main preconditions for success? Comments on the current situation: All personnel involved in helicopter operations for one of the helicopter operators have training in CRM (inclusive maintenance). In general, there is an open culture with regard to incident reporting. An important factor is a non-punitive policy. It was pointed out that even if CRM and Human factors training is applied, it is still required that the CRM/MRM concept is implemented as an integrated part of daily routines. There are still improvements that can be addressed: • The effects of organizational changes should be taken into account by CRM. • Improvements should be initiated not only on the basis of identified mistakes, but from

documentation of good practices as well. • Increase the focus on analysis of minor incidents to ensure work quality and early

identification of maintenance failures. Consider improving checklists. • There is a need for a system that protects personnel who reports human failures in

maintenance. If not, there is a risk for psychological stress leading to less effective work. • The CRM concept implemented in the organization should allow identification of different

human performances and limitations. “Recognize where others suffer and ensure that this does not jeopardize the personal or the aviation safety” (ref. 1).

• Focus on planning and accomplishment of maintenance work. • Human factors in maintenance should take into account that normal work situations include

several breaks / interruptions that may contribute to omission of tasks. • Human limitations, i.e. stress, should be taken into account. • Analysis of maintenance routines should be carried out to avoid “traps”. Recommendations: • Focus on HF/CRM, learning about normal operations, documenting best practice • Focus on root causes in non-compliance reports • Ensure active communication through the organization • Define the responsible person in cases where several people are working in a team • Aim at an open reporting culture (i.e. no risk of penalty; individual reporting must be allowed

to be anonymous) • Improve the work handover procedures • Enhance stress awareness, and also be aware of “lazy periods” • Establish/improve continuation training in HF • Pay more attention to human behavior and personal limitations • Analyze the technicians’ needs for support

11

• Maintenance documentation must be easy available, logic and sufficiently clear. (Maintenance

procedures must be clear, defined, and simple enough to follow up.) • Duplicated inspection may make a false impression of safety • Focus on identification of critical elements in today’s maintenance operations to adapt the

CRM concept to helicopter needs. • Operational CRM should be adopted to the maintenance organization • Carry out fault/trend analysis in the organization to identify organization specific elements,

both incidents and culture in general • Encourage and facilitate the establishment of effective HF departments in maintenance

organizations, including access and influence to the organization’s decision making structure • Encourage understanding of the differences between the CRM theory and the actual work

practice. This may improve the implementation of CRM. • Accept that procedures are not always adhered to and focus on causes and improvements • With regard to the VHM/HUMS: introduce “FOQA” in maintenance • Define CRM in helicopter • Evaluation of HF/CRM • Develop indicators on HF/maintenance performance • Manufactures should provide statistics on HF performance • Introduce training in HF root cause investigation • Introduce workshops; HF in maintenance


Table 2 – Ideas from Session 2 (Crew Resource Management in maintenance)

No. Ideas Ranking Priority A. Increase focus on HF/CRM in areas such as:

Knowledge about normal operations Documentation of “best practices” Stress awareness Human behaviour and physical and psychological limitations Operational adoptions of the CRM concept Evaluate how the existing CRM methodology “fits” helicopter maintenance

2,3,1,1,2,1,1,3,1,2,1 Score: 26

1

B. Maintenance error analysis: Focus on root causes in non-compliance reports Establish an open report culture (i.e. no risk of penalty; individual reporting must be allowed to be anonymous) Implement faults analyses/trend analyses Improve reporting Identify indicators on HF/maintenance Training in HF root cause investigation

1,3,2,1,3,1,2,1,2 Score: 20

1

C. HF responsibilities and organisation: Encourage and facilitate the establishment of effective HF departments in maintenance organizations, including access and influence to the organizations’ decision making structure. Maintenance procedures must be clear, defined, and simple enough to follow up

3,2,1,2,2,3 Score: 11

2

12

No. Ideas Ranking Priority D. Promote active communication of CRM issues in

maintenance organizations 3,2,2,3 Score: 6

3

E. Increase knowledge and use of helicopter manufacturers’ HF statistics

2,1 Score: 5

3

F. Compare HF syllabus between requirement and operators

1,2 Score: 5

3

G. Maintenance documentation must be easily available, logical and clear

3,1,5 Score: 4

3

H. Define clearly work responsibility in team work situations

3 Score: 3

3

I. Improve handover procedures 4,3,4,4 Score: 2-3

3

J. Analyse the technician’s needs for organizational support

Score: 0 -

H. Duplicated inspection (redundancy) may offer “false safety”

Score: 0 -

4.3 Session 3 Maintenance experience communication Topic session 3:

How can the helicopter operators' experiences from maintenance be communicated more effectively to the manufacturers for continuous improvement of maintenance programs? Opinions expressed during the introductory discussion: − The communication between operators and manufacturers is seemingly acceptable (one

operator’s statement)

− An important communication arena is face-to-face meetings among the operators of the same helicopter type (e.g. Super Puma) and the manufacturer.

− An example of present meeting schedule between the operators and one manufacturer: Technical meetings twice a year, reliability meetings 4 times a year plus additional ad hoc meetings

− Feedback from the operators takes too long time before being implemented in the manufacturer’s maintenance procedures. (Manufacturer’s comment: In general we agree, but safety issues are handled urgently. Issues with mainly economical consequences may take longer time.)

− Maintenance instructions are sometimes too difficult to interpret. They should be specific and precise as to what to do (ref.: the NORNE accident), so that a maintenance mechanic will know exactly what to look for and eventually how to correct any technical discrepancy.

− The clarity of maintenance documentation differs between the manufacturers.

− Better means for communication, including feedback of experiences, should be pursued (e.g. by means of web-based technology)

− Are we (the helicopter operators) best in class? A benchmarking exercise could be useful to exploit this issue

13

− The attendant manufacturer maintains a reliability database for each helicopter type with some

input data from the operators. However, this does not contain all details from operations as logged in the operator’s maintenance logs.

− Though several useful communication channels exist, it does not seem to be an overall industry framework and objective for this communication. May be we need to widen the scope of the NOU statement for this session.


Table 3 – Ideas from Session 3 (Feedback of maintenance data)

No. Ideas Ranking Priority

A. Feed-back from the operators should be more rapidly implemented in all the relevant maintenance documentation. Improve the format of the information? Benchmarking is needed.

1,1,1,1,1,1,1,1,1,1,1,3

Score: 34

1

B. The maintenance documentation should be simplified. 1,2,2,2,2,2,2,2,2,2,2,2

Score: 25

1

C. Give the mechanics what they need to know, and no more.

1,2,2,3,3,3,3,3,3,3

Score: 16

1

4.4 Session 4 Evaluation of Continuation Training Topic session 4: [NOU Quote]: The Committee recommends that today's practice regarding continuation training (CT) is evaluated. [Unquote]

- What is the present situation? - What more can be done? - What are the main preconditions for success?

The present situation: It was agreed that continuation training should include the following subjects: • Changes in the organization • New equipment / improved systems • New procedures • Human factors • Feedback on quality changes • Department meetings (section manager meetings with action points) • Periodical technical training • Training on systems • Incident information/follow-up

14


Table 4 – Ideas from Session 4 (Continuation training - CT)

No. Suggested tasks Ranking Priority A. Increase the sharing of experience between operators 1,1,1,1,1,1,2,3

Score: 23 1

B. Benchmarking of CT 1,1,1,2,3,3 Score: 13

2

C. Evaluation of pedagogical approaches to CT 1,1,2,2,2,4 Score: 13

2

D. Evaluation of CT regarding procedures 1,1,2,2,3,5 Score: 11

2

E. Periodical training with regard to new technology (e.g. e-learning)

1,1,2 Score: 8

3

F. CT should be arranged frequently 1,2,4 Score: 6

3

G. CT standardisation 1,2,3 Score: 6

3

H. Clarify who should decide the frequency of CT training 1,2,3 Score: 6

3

I. Sharing experiences regarding training , i.e. between offshore helicopters and others

2,2,3 Score: 5

3

J. Treat CT questions at the MRB meetings 2,3,3 Score: 4

3

K. Utilize the quality audits 2,3,3 Score: 4

3

4.5 Session 5 Recruitment of maintenance personnel Topic session 5: How can the helicopter operators establish a program to improve recruitment of maintenance personnel?

NOU, Quote: The helicopter operators should in this connection cooperate with the Norwegian Oil Industry Association's project for increased recruitment to oil- and gas business «A world of possibilities».Unquote

The NOU claims that loosing competence due to personnel retirement causes a general lack of knowledge in the long run, and expresses worry about the future. On the other hand, experience transfer from older to new personnel is generally experienced to be good. Furthermore, the reduction of the armed forces and training programmes will cause reduced recruitment. It was pointed out that the helicopter operators should respond to the recommendation identified by the NOU regarding recruitment of maintenance personnel. However, during the brainstorming

15

it was stated that the operators have not experienced these previously foreseen problems regarding recruitment of maintenance personnel.


Table 5 – Ideas from Session 5 (Recruitment of maintenance personnel)

No. Ideas Ranking Priority A. The helicopter operators must be more proactive in

the future, trainee programmes should be considered 1,1,1,1,1,2,2,2,3 Score: 22

1

B. Focus on basic schools; make them attractive (there are 4 schools, AIS St.)

1,2,2,2,2,2,2,3,3,3 Score: 18

1

C. Be aware of higher technical complexity in education and training

1,1,1,2,2,3 Score: 14

2

D. Assess if recruitment of maintenance personnel really is a problem

1,1,1,2,3,3 Score: 13

2

E. Structure and define the problem: Recruitment? 1,1,1 Score: 9

3

F. Evaluate the national system for training technicians 1,2,3,3,3 Score: 8

3

G. Conduct benchmarking regarding recruitment approaches

1,2,3,3 Score: 7

3

4.6 Closing the meeting: A concluding remark from the helicopter manufacturer During the summing-up session at the end of the meeting, the representatives from the attendant helicopter manufacturer expressed the following general concern about the results of the brainstorming sessions: • The majority of the ideas and suggestions which were generated during the day would have to

be much more precise and clearly expressed for the manufacturer to be able to implement them. The ideas expressed during the brainstorming sessions will be considered as general operator’s remarks. No specific actions are launched by the attendant helicopter manufacturer following this session; should an action be launched, a dedicated meeting will have to take place for precise definition.

5 Information from CAA UK and CAA N After the NOU was published the regulations have been further developed regarding maintenance data, continuation training and human factors training in maintenance. Thus, for example, the EASA in paragraph 145.A.45, Maintenance data, in Part 145, item (c), and the AMC covering the same subject, put forward the following requirement to the maintenance organizations:

Quote (c) The organisation shall establish procedures to ensure that if found, any inaccurate, incomplete or ambiguous procedure, practice, information or maintenance instruction contained in the maintenance data used by maintenance personnel is recorded and notified to the author of the maintenance data. AMC 145.A.45(c) Maintenance data

16

1 The referenced procedure should ensure that when maintenance personnel discover inaccurate, incomplete or ambiguous information in the maintenance data they should record the details. The procedure should then ensure that the Part-145 approved maintenance organisation notifies the problem to the author of the maintenance data in a timely manner. A record of such communications to the author of the maintenance data should be retained by the Part-145 approved organisation until such time as the type certificate holder has clarified the issue by e.g. amending the maintenance data. 2 The referenced procedure should be specified in the maintenance organisation exposition. Unquote

Although the author of the maintenance data is not required to give feedback to the reporter, this is common practice. Furthermore, the regulations now require procedures and training in the application of human factors in maintenance, as well as continuation training. There is training in the applicability and development of maintenance and reliability programs. CAA UK has published CAP 716 to give guidelines to the operators in the application of HF in maintenance. The CRM concept was adapted to maintenance through Maintenance Resource Management (MRM). The FAA has published an Advisory Circular (AC) 150-72 that provides information regarding Maintenance Resource Management Training.

6 Norwegian Helicopter Employees Association (NHF) information Responsibilities for Part 145 and Part M organizations should be mentioned. At the time that the NOU was published, there was only one organization responsible for helicopter maintenance. For the time being, helicopter operators (Part M) are responsible for the airworthiness of the helicopters. The Part 145 organization is responsible to carry out maintenance activities contracted by Part M. There are some challenges in relation to helicopter maintenance: • Maintenance error reporting; there are different practices regarding reporting. Some

organizations have a common reporting system other organizations have a reporting systems for each department within the organization. There is a potential regarding learning from each other and development of best practice regarding maintenance error reporting, analysis and management.

• Training challenges when technology is complex and more reliable. Failures occur some times very seldom and it is a challenge to maintain troubleshooting competence among technical personnel. In addition, technicians require competence for different types of helicopters. To maintain technician competence there is a need to intensify use of different techniques e.g. Computer Based Braining (CBT).

17

7 Conclusions and recommendations

7.1 Summary of results SINTEF has made an independent summary of the various ideas revealed at the brainstorming sessions and evaluated the ideas as to feasibility, priority and cost/benefit. We have also tried to address synergy effects between the many ideas proposed, even if some of them have not been listed with the highest priority initially. Within the scope of this study it has not been possible to address all issues in detail, and it is assumed that the major stakeholders within helicopter operations offshore will participate in a further process as to prioritization and implementation of the suggested ideas. Figure 1 gives a summary of all the proposed ideas from the brainstorming sessions for each of the five main topics discussed. The colors of the box frames indicate the priority of each idea (green = priority 1 - highest, orange = priority 2, blue = priority 3 - lowest). An assessment of the feasibility and assumed effort of each task with priority 1 and 2 has been summarized in Table 10. As to the columns of this table the following should be noted: Column heading: Meaning: Time horizon An estimate of the time it may take to get this action carried out. Stakeholders The major parties that need to be involved. The involvement from each

party will necessarily depend on the task and how the task force is being organized

Estimated effort or cost1

A relative coarse ranking between the different tasks. A final cost estimate is depending on a more specific plan as to e.g. scope and organization

Related task Task that are closely related and which may be wholly or partly integrated Figure 2 gives an overview of the ideas prioritized by the Committee for Helicopter Safety on the Norwegian Continental Shelf at the meeting November 30 (see Chapter 3.2).

7.2 Recommendations for further work The process so far has revealed several ideas within the area of maintenance, and it is obvious that not all, even those of the highest priority, can be effectuated in one go. SINTEF has therefore tried to make an overall judgment of the various ideas proposed based on the summaries presented above and an assessment of the feasibility and cost associated with each task. For each of the five main areas our impression of paramount needs for improvement, and recommendations for concrete actions, are synthesized as follows:

7.2.1 Topic 1: Improve the MSG documentation provided to helicopter operators a) The impression from the discussion of the use of the MSG-concept for helicopters is as follows:

1 A relative ranking estimated by SINTEF. In order to assess the actual cost of the task, the activities and the effort/cost by each party have to be more specifically defined.

18

− The current version of the MSG-concept (MSG-3) is primarily developed for fixed wing

and therefore not fully applicable to helicopters. One example (Boeing Chinook, MSG-2) seems to indicate that the MSG-concept can be used beneficially for helicopters in spite of not having a tailored helicopter MSG-version available2. The manufacturer present also stated that they used the MSG-concept “to some extent”.

− From the operators’ point of view they would like to see a more extended MSG-analysis

delivered with each new helicopter and derivatives of existing helicopter types.

− There is a need for improvement of the use of MSG for existing, as well as new helicopter types. For existing types the Super Puma and the Sikorsky S-92 were highlighted.

− There seems to be no official requirements on the use of the MSG-concept, notably as part

of the documentation delivered from the manufacturers. A common approach to this would be desirable.

b) Recommended actions to achieve the improvement objectives mentioned are as follows:

1) Carry out a closer evaluation of how the MSG-concept and/or maintenance programs are currently used. In the brainstorming process only general statements were given on this topic. This is a task that could be done by an independent organization in close cooperation with the manufacturers, operators and, to some extent, the authorities. 2) Use the current MSG-concept (MSG-3) more extensively for helicopters, in particular for the Super Puma and S-92. This task should mainly be carried out done by the manufacturers. 2) Carefully analyze the MSG-3 concept as to the lack of tailoring and applicability for offshore helicopter operations. The outcome of this might be a version of the MSG-3 that would be more applicable to helicopter design and operation than the current version. This task is of a more long-term character and needs cooperation between the manufacturer, the operators and the authorities with possible facilitator involvement by an independent organization.

7.2.2 Topic 2: Introduce and implement CRM/HF in maintenance a) The impression from the discussion on the use of the CRM/HF concept for helicopters is as follows:

− After the NOU was issued, several changes have occurred. Training in Human Factors has been introduced and implemented. Special training related to human factors and investigation of undesired events have been carried out.

− CRM adapted to maintenance has been implemented in some organizations.

− Even if regulations and organizations have implemented training in Human Factors in

maintenance, it was pointed out that focus on this issue is required to integrate human factors elements at all maintenance activities.

2 SINTEF has initiated an effort in order to get more information about the learning outcome from this application.

19

b) Recommended coordinated actions to achieve the improvement objectives mentioned are as follows:

1) Focus on human factors areas such as knowledge about normal operation. Evaluation of the existing CRM methodology has been introduced and practiced in maintenance. In addition, it is required to improve maintenance error analysis. This includes analysis of fault trends and training in HF root cause identification. 2) Definition of Human Factors responsibilities within the organization. It was pointed out that it should be clearly stated who is responsible for the follow-up of human factor issues related to maintenance. The responsible should obtain direct access to the decision making process within the organization. 3) Other ideas, such as more effective communication of human factors issues, improving knowledge regarding HF statistics, appointing maintenance team responsible person(s) and improvement of handover procedures are given lower priority.

7.2.3 Topic 3: Improve the communication of maintenance experience to manufacturers in order to improve the maintenance program. a) The impression from discussion on the use of the MSG-concept for helicopters is as follows:

− There seems to be several communication channels between the operators and the manufacturers that work acceptable today, but an overall industry framework for this communication would be useful.

− Maintenance instructions from the manufacturers should in general be more specific with

fewer requirements for operator interpretation. − It takes too long time to get maintenance procedures updated by the manufacturers when

the operator reports specific problems that may need revision of maintenance routines and/or intervals. An exception to this is feedback that - according to the manufacturer’s judgment - has a direct effect on flight safety.

− The discussion on this issue was limited by the fact that on only one manufacturer was

present. A benchmarking including other relevant manufacturers would therefore be desirable.

b) Recommended coordinated actions to achieve the above mentioned improvement objectives can be summarized as follows (several of the ideas were all given a relative high priority):

1) The manufacturers should find ways to more quickly update and inform the operators on changes in maintenance procedures and/or maintenance intervals based on experiences/ feedback from the operators. 2) The maintenances instructions from the manufacturers should be more specific and adapted to the available maintenance time and capability of the maintenance technicians. This is a typical task for the manufacturer, but should also be based on requirements/ recommendations from the operators.

20

3) An overall framework for feedback and utilization of operator’s experience might be desirable. A benchmarking of differences between operators and/or manufacturers is recommended. This should be a coordinated effort by the manufacturers, operators, authorities and possibly an independent organization as facilitator.

7.2.4 Topic 4: Evaluation of continuation training. a) The impression from discussion on Continuation Training for helicopters is as follows:

− Continuation Training is provided and executed according to regulation requirements. However, it is our impression that Continuation Training is mainly used to cover the technical aspects of maintenance.

b) The recommended coordinated actions to achieve the improvement objectives mentioned are as follows:

1) Operator should meet to share experience regarding this aspect 2) An evaluation of continuation training should be performed, including benchmarking. In addition, different pedagogical methods and use of new technology should be analyzed.

7.2.5 Topic 5: Improve recruitment of maintenance personnel a) The result from the brainstorming session listed some specific aspects, but seemingly of more general educational character:

− The main focus was to promote the need for technically skilled people in the basic schools for training of helicopter technicians and to be proactive as to trainee programs. So far, the operators have not experienced any recruitment problems, and hence NOU’s prediction in this case has not been fulfilled.

b) Recommended further actions: No specific actions are recommended, apart from a yearly OLF evaluation on possible changes in the trend on this issue. It is important that changes in trend are discovered early as it takes many years to educate and train people to the high skill level required for helicopter maintenance.

7.3 Prioritized further actions Based on the brainstorming and discussion at the meeting in the Committee for Helicopter Safety on the Norwegian Continental Shelf the topics 2, 3 and 4 have been identified as the most important to address for further actions (see Figure 2). • In relation to these topics, it is recommended to effectuate a project regarding Maintenance

Error Analysis. The main objective of such a project should be development and validation of practical techniques to improve analysis of maintenance errors

21

During the meeting in the Committee for Helicopter Safety on the Norwegian Continental Shelf, it was pointed out that several developments in relation to Human Factors in maintenance have occurred since the publication of the NOU. Even if regulations and operators’ practice have adopted Human Factors knowledge in maintenance operations, it was agreed that there are still challenges related to integration of human factors into individual jobs. Therefore, it is recommended to perform activities to disseminate best practice among the industry. If resources are available we suggest a second project focusing on: • A better understanding of how to implement the Human Factors concept in Helicopter

Maintenance • Development of mechanisms to ensure effective integration of Human Factors in Helicopter

Maintenance • Promoting and support industry in sharing experience regarding Human Factors and

Continuation Training.

Note that the CAA-UK has been strongly involved in the development of applied Human Factors in maintenance. Hence, a close collaboration with the British sector should be considered to avoid duplication of work. Regarding maintenance programs (e.g. MSG-3) and cross-fertilization of maintenance experience between operators and manufacturers, there were some differences in opinions on the need for improvements. We therefore suggest that a more detailed assessment should be carried out to define concrete follow up actions. The objective should be to specify in more detail the inherent challenges, and get a better consensus in the industry on what are the specific improvements that would be beneficial across the whole industry. This would also provide a better ground for defining the scope, extent and organization of the actions defined as desirable. A short term activity, a screening study should be effectuated, mainly by involvement of the manufacturers and operators with focus on the following:

− The operators should clearly define the need for a more tailor-made MSG-concept, or other general maintenance program standard for helicopters, and requirements on its use by the manufacturers.

− Benchmarking of maintenance experience reporting from the operators to the

manufacturers, and the feedback from the manufacturers on maintenance changes/updating.

In order to promote improvement of communication between operators and manufacturers in relation to feedback of maintenance experience and improvements on maintenance program, the Norwegian CAA proposed to establish a procedure is established to follow up communication between manufacturers and helicopter operators. The Norwegian CAA could verify the feedback of maintenance data between operators and manufacturs’ response as part of their normal inspection activities. It is recommended that this procedure is developed in close cooperation between operators and manufactures. In addition, it is advised that other relevant aviation authorities are informed of this process. It is recommended that the Committee for Helicopter Safety on the Norwegian Continental Shelf discuss and make a decision regarding presentation “Managing the risk during the introduction to service of a new helicopter type - An initiative to response NOU 2002:17 Maintenance Function [13] annexed to this report

22

7.4 .Work plan activities and expected results Helicopter operators and maintenance organizations have experience and there is a potential regarding learning from each other and development of best practice. The activities proposed below take into account industry involvement, to avoid work duplication and to support progress beyond current status. We have based our work plan on the proposed project and objectives defined in 7.3. The following activities are proposed: A. Maintenance Error Analysis and human factors 1. Project title: Learning from maintenance errors

The main objective of the project is to develop and validate techniques regarding maintenance error analysis. Figure 3 summarizes recommended activities to achieve the overall objective.

Workshop: operators, regulators,

research institutions

Pilot: operators, regulators,


Workshop: operators, regulators,


Activity 1State of the art of Maintenance error reporting and analysis

Deliverable 1: Document review of current knowledge

Activity 2Specification of helicopter operators needs

Deliverable 2: Document requirements for application of maintenance error reporting and analysis in helicopter maintenance

Activity 3Concept development

Deliverable 3: Manual for Maintenance error reporting and analysisin Helicopter Maintenance

Activity 4Concept validation

Deliverable 4: Recommended practice regarding maintenance error analysis in Helicopter Maintenance

Activity 0Project

Management

Activity 5Dissemination and exploitation

Deliverables 5: Handbook, workshop regarding maintenance error in Helicopter Maintenance

Figure 3 - Learning from maintenance errors activities

Activity 0 : Project Management This activity will support coordination of the activities, schedule the work and reporting to the Helicopter Safety Committee. Activity 1 : State of the art This activity should at least answer two questions: What are regulators initiatives to improve and facilitate maintenance error analysis and which tools and methods are available to improve maintenance error analysis.

23

• This activity contains the following tasks:

- Review regulations regarding maintenance error reporting and analysis - Review current methods and tools

• Duration: 2 months • Deliverable: Document review of current knowledge that describes key findings

regarding potential improvements Activity 2 : Specification of operators needs Results from workshop on helicopter maintenance and activity 1 will be used as an input for this activity. In addition, based on interviews with key personnel and an additional workshop, this activity should answer the following questions: a). How do helicopter operators perform maintenance error analysis and b). How are incidents reduced through maintenance error analysis.

• This activity contains the following tasks: - Prepare a questionnaire, identify key personnel and perform interviews - Prepare and perform a workshop - Review information gathered in this activity, analyse and discuss the results and conclude

• Duration: 2 months • Deliverable: Document requirements for the application of HF in helicopter

maintenance Activity 3 : Concept development This activity should focus on development of concept for maintenance error analysis. The following question is addressed in this activity: Which techniques and tools should be used by helicopter operators to improve maintenance error analysis.

• This activity contains the following tasks: - Based on results from activity 1 and 2 above develop improved concept for maintenance error analysis

• Duration: 3 months • Deliverable: Draft manual regarding maintenance error analysis

Activity 4 : Concept validation This activity consists of a verification exercise. In close cooperation with operators and regulator two cases will be selected to validate proposed tools and techniques. Lessons learned will be used to update the manual developed in activity 3

• Duration: 2 months • Deliverable: Draft version - Manual learning from maintenance error –

recommended tools and techniques for helicopter operation Activity 5 : Dissemination and exploitation

• A handbook will be prepared and a workshop will be arranged as a training activity and to exchange experience between operators, regulator and research.

• Duration: 2 months • Deliverable: Workshop and a paper to be published in an international conference

summarizing leassons learned and recommended practices to helicopter operators regarding maintenance error analysis

24

2. Project title: Human factors and helicopter maintenance

If resources are available, a second project is proposed. The main objective of the project should focus on integration of human factors into maintenance work. Figure 4 summarizes recommended activities to achieve the overall objective.

Figure 4 - Integration of Human Factors in Helicopter Maintenance

Activity 0 : Project Management This activity will support coordination of the activities, schedule the work and reporting to the Helicopter Safety Committee. Activity 1 : State of the art This activity contains the following tasks: - Review researcn on Human Factors aspects in Helicopter Maintenance * - Review regulations regarding human factors in maintenance - Review current methods and tools

• Duration: 2 months • Deliverable: Document review of current knowledge that describes key findings

regarding potential improvements * Note that the CAA-UK has been strongly involved in the development of applied Human Factors in maintenance. Hence, a close collaboration with the British sector should be considered to avoid duplication of work.

Activity 2 : Specification of operators needs Preparation of questionnaire in close cooperation with operators is the main task in this activity, Interview key personnel regarding Human Factors in Helicopter Maintenance.

• Duration: 2 months • Deliverable: Questionnaire

25

Activity 3 : Survey regarding integration of human factors into maintenance A survey based on questionnaire prepared in activity 2 is carried out and results are analyzed. For the highest priority aspect, this activity will provide concrete recommendation regarding integration of human factors in helicopter maintenance.

• Duration: 3 months • Deliverable: Document current status of human factors integrated into Norwegian

helicopter maintenance operations and recommendation to improve integration of human factors in helicopter maintenance

Activity 4 : Operators response

Operator’s response and future activities are summarized in this activity. • Duration: 2 months • Deliverable: Pilot improving human factors integration into maintenance activities

B. Maintenance programs and exchange of maintenance experience Conduct a screening study to better explore the need for, and detailed requirements for, improvement of maintenance program. This study should focus on:

- The need for a more tailor-made MSG-concept, or another general maintenance program standard for helicopters, and requirements for its use by the manufacturers

- Benchmarking of maintenance experience reporting from the operators to the manufacturers, and the feedback from the manufacturers on maintenance changes/updating.

It has been suggested that the Norwegian Civil Aviation Authority together with the operators establish a procedure to follow up exchange of maintenance experience between manufacturers and operators. Civil Aviation inspectors should be able to use this procedure during normal inspections.

7.5 Schedule, budget and finance The proposed time schedule and budget is an estimate after contract award. A. 1. Learning from maintenance errors - maintenance error analysis* Time schedule: Between 6 and 9 months. Scheduled is proposed below Table 6 –Learning from maintenance error activity plan

Activity Month 2 Month 4 Month 6 Month 8 Month 10

0. Management ------------------------------------------------------------------------∆

1. State of the art -----------∆

2. Operators needs ---------------∆

3.Techniques, tools --------------------∆ ----------∆

4.Validation -----------∆

5.Dissemination -----------∆

26

* Estimated cost: NOK 690.000 as described below Table 7 –Learning from maintenance error activity cost

Activity Cost in NOK (without MVA)

0. Project management 40.000

1. State of the art (incl. Kick-off meeting) 100 000

2. Operators needs 150.000

3.Development of techniques and tools 200.000

4. Validation and review of techniques 100 000

5. Dissemination and exploitation 60 000

Travel 40 000

Total 690 000 2. Human Factors in Helicopter Maintenance * Time schedule: Between 5 and 6 months. Scheduled is proposed below Table 8 –Integration of Human Factors in helicopter jobs

Activity Month 1 Month 2 Month 3 Month 4 Month 5

0. Management ------------------------------------------------------------------------∆

1. State of the art -----------∆

2. Questionnaire ---------------∆

3.Survey --------------------∆ ----------∆

4.Operators response -----------∆

* Estimated cost: NOK 450.000 as described below Table 9 –Integration of Human Factors in Helicopter Maintenance

Activity Cost in NOK (without MVA)

0. Project management 20.000

1. State of the art 100 000

2. Questionnaire / Interview 100.000

3.Survey and analysis 140.000

4. Operators response 50 000

Travel 40 000

Total 450 000

27

B. Maintenance programs and exchange of maintenance experience * This is a task that mainly needs cooperation between regulator, operators and manufacturers with possible facilitator involvement by an independent organization. It is recommended as a short term solution that the regulator develop a procedure that follow-up communication of maintenance experience between operator and manufacturer and its implication on maintenance activities. If an independent organization is decided, the estimated cost of the screening study is NOK 200.000

28

Figure 1 - Summary of all initially proposed ideas

29

Figure 2 - Summary of all ideas including the Helicopter Safety Committee prioritization

30

Table 10 - Feasibility assessment of ideas rated with the highest priorities (i.e. priority 1 or 2) Main brainstorming topic

Proposed ideas Pri-ority

Time horizon

Task category

Stakeholders Estimated effort or cost3

Related task

Comment

1.1 MSG Documentation – new helicopters

A. Defining maintenance program policy to be requested by CAA and others adapted to different operation profiles

1 2 – 3 years Develop-ment

Manufacturers, Operators, Authorities

High 1.1-G Would need a coordinated effort by several parties. Initially the objective of this task needs to be better defined.

B. MSG-3 analyses for derivatives of existing helicopter types

1 <1 year Analysis Manufacturers with possible input from the Operators

Medium 1.1-F Mainly an effort to be done by the Manufacturers with operational input from the Operators.

C. Make MSG-3 a recommendation for all new designs on the civil market

2 < 1 year Regula-tion

Authorities, Manufacturers, Operators

Low 1.1-F Mainly a requirement to be made by the operators (and authorities?) towards the manufacturers. (Priority for this task a bit lower than for A and B).

1.1 MSG Documentation – existing helicopters

E. Review the utilization of the MSG-process for helicopters

2 1 – 2 years Study Facilitator organization with input from the Operators and Manufacturers

Medium 1.1-A Would need an independent organization to reveal the status of MSG-use by manufacturer and operators.

F. Analyze the S-92 and the Super Puma maintenance in relation to MSG-3

2 <1 year Analysis Manufacturers with possible input from the Operators

Medium 1.1-B,C Mainly an effort to be done by the Manufacturers with operational input from the Operators. Similar to task B.

G. Define improved maintenance program requirements

2 2 – 3 years Develop-ment

Manufacturers, Operators, Authorities

High 1.1-A Would need a coordinated effort by several parties. Initially the objective of this task needs to be better defined. Similar to task A.

2. CRM/HF A. Focus on HF 1 <1 year, continuous

Study Operators, Authorities

Low Project approach in several stages. The first stage consists in mapping HF elements implemented and status.

B. Maintenance error analysis

1 <1 year, continuous

Method Operators, Authorities

Medium

3 A relative ranking estimated by SINTEF. In order to assess the actual cost of the task, the activities and the effort/cost by each party have to be more specifically defined.

31

Main brainstorming topic

Proposed ideas Pri-ority

Time horizon

Task category

Stakeholders Estimated effort or cost3

Related task

Comment

C. HF responsibilities 2 <1 year Regula-tion

Operators, OLF

Medium The operator to establish HF department/responsibility within the organization including access to the decision making level.

3.1 Feedback of maintenance data

A. More rapidly implementation of feed-back from the operators into maintenance documentation. Benchmarking needed.

1 < 1 year Improving current practice

Manufacturers, Operators

Low/ Medium

Establish an improved and faster communication and documentation system for operator experiences

B. Simplification of maintenance documentation


Manufacturers Low 3.1-C

C. Describe maintenance task more precisely


Manufacturers Low

4.1 Continuation training (CT)

A. Increase sharing of experience between operators


Manufacturers Low 3.1-A

B. Benchmarking CT 2 < 1 year Study Manufacturers Low C. Evaluation of approaches

to CT 2 < 1 year Study Manufacturers Low

D. Evaluation of CT regarding procedures

2 < 1 year Study practice

Manufacturers Low

32

References 1. Norwegian Public Report, Helicopter Safety on the Norwegian Continental Shelf. NOU

2002:17 2. Norne Accident Norwegian Report 47/2001 dated 09. November 2001 3. EASA Annex I PART 145. 4. EASA Annex II Acceptable Means of Compliance to PART-145 5. EASA Annex III Guidance Material to PART-145 6. ATA MSG3 Operator/Manufacturer Scheduled Maintenance Development. Revision 2003 1. 7. CAP 716 Aviation Maintenance Human Factors (EASA / JAR 145 Approved Organizations)

Guidance Material on the UK CAA Interpretation of Part-145 Human Factors and Error Management Requirements. 18 December 2003.

8. FAA Advisory Circular AC 120-72. Maintenance Resource Management Training. 9. JAR 145 NPA-12 Human Factors in Maintenance, Presentation to Industry, February/March

2002. Jim Done CAA UK. 10. Regulations and Human Factors in Maintenance “A CAA Perspective”. Dave Lewis.

Cranfield. March 2003. CAA UK. 11. Carl M. Moore: Group techniques for idea building. Sage publications, Newbury Park, 1987. 12. Maintenance Review Board Procedures, Federal Aviation Authority (FAA) Advisory Circular

(AC) NO. 121-22A, 3/7/97 13. Sikorsky S92 – Managing the Risk During the Introduction to Service of a New Helicopter

Type – An initiative in response to NOU2002:17 Maintenance Function, MAP Aircraft Project AS, Martin Purvis, 01. April 2004.

- o0o -

33

Annex I

Participants’ preliminary information and agenda

Preliminary study ref. Helicopter Safety Maintenance Recommendation NOU 2002: 17 - Brainstorming Session -

Session objective: To identify possible solutions to carry out maintenance recommendations identified by NOU 2002:17: Recommendations: 1. ” The Committee recommends that the Maintenance Steering Group (MSG) documentation is

improved in cooperation between the helicopter manufacturers and the helicopter operators. There is a need to improve and communicate better to the helicopter operators the considerations inherent in the maintenance programs made by the manufacturers. The Committee recommends that the helicopter companies' maintenance concepts/-programs are improved and simplified in accordance with the Accident Investigation Board's report from the Norne-accident.

2. The Committee recommends that the helicopter operators' experiences from maintenance must be more effectively communicated to the manufacturers for continuous improvement of maintenance programs.

3. Crew Resource Management (CRM) is introduced in maintenance and that necessary training in CRM and Human Factors is implemented.

4. Today's practice regarding continuation training is evaluated. 5. The helicopter operators should establish a program to improve recruitment of maintenance

personnel. The helicopter operators should in this connection cooperate with the Norwegian Oil Industry Association's project for increased recruitment to oil- and gas business «A world of possibilities».”

Session expected result: Priority list including solutions, timeframe, cost aspects Participant preparation: Helicopter operators, manufacturer and authorities: to prepare a short informal presentation regarding status, solutions and challenges related to the subjects above max 10 minutes for each organization. (Presentations to be used during discussions as required).

34

Annex I

Preliminary study ref. Helicopter Safety Maintenance Recommendation NOU 2002: 17

- Brainstorming Session -

Agenda

Monday 07 November 2005

SINTEF Technology and Society, S.P. Andersens vei 5 , Room : Skuld

Helicopter manufacturer, regulation authorities, operators, customer and researchers bringing together competence and experience to improve safety. The objective of this event is to identify possible solutions to carry out maintenance recommendations identified by NOU 2002:17. Time Subject Subject 09:30 Welcome and short participants presentation Background -Brainstorming opening 10:30 Session 1

Discuss: Improve Maintenance Steering Group (MSG) documentation

Session 2 Discuss: Crew Resource Management (CRM) in maintenance and Human Factors

11:30 Plenary presentation 12:00 Lunch 12:45 Session 3

Discuss: Helicopter operators' experiences from maintenance must be more effectively communicated to the manufacturers

Session 4 Discuss: 4. Today's practice regarding continuation training

14:00 Plenary presentation 14:45 Coffee / Fruit Break 15:00 Session 5

Discuss: Improve recruitment of maintenance personnel.

Session 6 If necessary a separate session will be arrange

16:00 Plenary presentation 16:30 17:00

Closing

35

ANNEX II

(blank)

1

Technology and Society

SINTEF in short

About us:Scandinavia's largest independent multidisciplinary research organisation. Contracts for industry and the public sector generate more than 90% of income.

The vision:Technology for a better society

Collaboration:SINTEF collaborates closely with the Norwegian University of Science and Technology (NTNU) and the University of Oslo (UiO).

Locations:SINTEF has 1700 employees, 1350 in Trondheim and 350 situated

The Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology


Safety and Reliability DepartmentObjective

Develop knowledge, methods, databases, guidelines and standards for improving safety, reliability, maintainability and quality performance

2


Background

“Helicopter Safety Study” no. 1 (1990):The average Fatal Accident Rate (here: fatalities per 100 million person flight hours) 1966-1990 was approx. 10 times higher than for scheduled airlines. A risk reduction of 40% within 2005 was considered achievable.Priority no. 1 should be to improve the technical reliability, mainly by means of HUMS.


“Helicopter Safety Study” no. 2 (“HSS-2”, 1999):

The Fatal Accident Rate (here: fatalities per 100 million person flight hours) 1990 - 1999 was reduced by approx. 50 per cent compared to the previous period.The improved safety is mainly due to:- the installation of HUMS (a vibration monitoring system)- improved radar and radio coverage- separation of flight routes- implementation of QA/QM systems- several new types of helicopters- improved aircraft crashworthiness and stability on sea.

Cont….

3


“Helicopter Safety Study” (“HSS-2”, 1999) (cont.):

The risk level in 1999 was still considered too high compared to scheduled airlines. A further risk reduction was considered achievable.Priority should be given to the improvement of both the technical and the operational reliability.


What happened after “HSS-2” (1999)July 2000: The Ministry of Transport and Communications appointed The Committee for the Review of Helicopter Safety on the Norwegian Continental Shelf. June 2001: Official Publication (NOU 2001: 21):Helicopter Safety on the Norwegian Continental Shelf - Part 1: Organizing of the public authorities’ involvement.September 2002: Official Publication (NOU 2002: 17): Helicopter Safety on the Norwegian Continental Shelf - Part 2: Trends, objectives, risk influencing factors and preferred measures.June 2003 : Follow-up by CAA-N through The Committee for Helicopter Safety on the Norwegian Continental Shelf.

4


What happened after “HSS-2” (1999)July 2000: The Ministry of Transport and Communications appointed The Committee for the Review of Helicopter Safety on the Norwegian Continental Shelf. June 2001: Official Publication (NOU 2001: 21):Helicopter Safety on the Norwegian Continental Shelf - Part 1: Organizing of the public authorities’ involvement.September 2002: Official Publication (NOU 2002: 17): Helicopter Safety on the Norwegian Continental Shelf - Part 2: Trends, objectives, risk influencing factors and preferred measures.June 2003 : Follow-up by CAA-N through The Committee for Helicopter Safety on the Norwegian Continental Shelf.


Method based on Risk Influencing Factors (RIFs)

5


AIR TRAFFIC / AIR NAV. SERVICE ORGANISATIONS

2.3

HELIDECK / HELIPORT OPERATORS

2.4

3. REGULATORY AND CUSTOMER RELATED

RIFs

R I

S K

I

N F

L U

E N

C I

N G

F A

C T

O R

S (

R I

F)


3. R

EGU

LATO

RY

AN

D

CU

STO

MER

REL

ATE

D

6


Helicopter Safety Objectives 2000 – 2010(NOU Part 2, also adopted by the new committee)

Vision:The passenger transport shall not result in any fatalities or serious personal injuries.Main goal:The total probability of fatalities shall at least be halved during the period 2000 –2010, compared to the former ten-year period (1990 – 2000).



Secondary goals:No. 1: The 5-year floating average shall not exceed 1,0 fatalities per million person flight hours (pax and crew) for any year during the period 2000 – 2010.

No. 2: The number of accidents and serious incidents shall be continuously reduced and the floating average shall not exceed 15 per million flight hours for any year or any helicopter operator.

7



Secondary goals:No. 3: Emergency landing on sea shall not lead to any fatalities due to drowning or thermal loss.

No. 4: Perceived risk shall be continuously reduced and not lead to serious personal problems for the passengers.

No. 5: The risk exposure due to the helicopter transport shall be continuously reduced for the most exposed personnel (particularly due to shuttling, commuting and “bussing”).

I:/KLADD/EJ/SEVILLA TU 4


13 relevant Recommendations to achievethe Safety Objectives, comprising:

1. Co-operation in helicopter safety issues2. Helideck design3. Helicopter crashworthiness4. Stability on sea5. Flight Operational Quality Assurance (FOQA)6. Navigational aids for offshore approach7. Airborne Collision Avoidance System (ACAS),

based on ICAO Cat. 2

8


8. Vibration Health Monitoring (VHM) System(HUMS etc.)

9. Air Navigation Service (ANS):a. Criteriab. Air Traffic Control (ATC)c. Responsibility & classification of air spaced. Military exercises & training flightse. Notification of mobile offshore unitsf. Communication (VHF / UHF coverage)g. Flight monitoring (M-ADS equipment &

data access)


10. Simulator training11. The maintenance function

(MSG, CRM / MRM etc.)12. The meteorological services 13. Engine performance (Class 1)

- o0o -

9


AIR TRAFFIC / AIR NAV. SERVICE ORGANISATIONS

2.3

HELIDECK / HELIPORT OPERATORS

2.4

3. REGULATORY AND CUSTOMER RELATED

RIFs

R I

S K

I

N F

L U

E N

C I

N G

F A

C T

O R

S (

R I

F)


Maintenance

11. Maintenance function: The Committee recommends that the Maintenance Steering Group

(MSG) documentation is improved in cooperation between the helicopter manufacturers and the helicopter operators. In particular, there is a need to improve and communicate better to the helicopter operators the considerations inherent in the maintenance programs made by the manufacturers. The Committee recommends that the helicopter companies' maintenance concepts/-programs are improved and simplified in accordance with the Accident Investigation Board's report from the Norne-accident. The Committee recommends that the helicopter operators' experiences from maintenance must be more effectively communicated to the manufacturers for continuous improvement of maintenance programs.

10


Maintenance (cont)

The Committee recommends that Crew Resource Management (CRM) is introduced in maintenance and that necessary training in CRM andHuman Factors is implemented.

The Committee recommends that today's practice regarding continuation training is evaluated. Moreover, the helicopter operators shouldestablish a program to improve recruitment of maintenance personnel. The helicopter operators should in this connection cooperate with the Norwegian Oil Industry Association's project for increased recruitment to oil- and gas business «A world of possibilities».

36

Annex III

Session participants

Name Organization Session No. 1

Session No. 2

Session No. 3

Session No. 4

Sven Ove Retland, Helge Anonsen,

CHC Helikopter Service AS

X X

X

X

Sverre Furuseth Civil Aviation Authority Norway

X X

Bente Rønnestad Committee for Helicopter Safety

X X

Guilhem Monti, Georges Devilliers

EUROCOPTER

X X

X X

Cathrine Dekko Kjell Ostnes X X Tor Nørstegård

Norwegian Accident Investigation Board (AIBN)

X X

Tormod Veiby

Norsk Helikopter AS

X X

Representant Norwegian Helicopter Technicians Association (NHF)

X X

Sverre Austrheim Erling Munthe-Dahl

Norwegian Oil Industry Association (OLF)

X X

X X

Marvin Rausand, Jørn Vatn

Norwegian University of Science and Technology (NTNU)

X

X

X X

Ivonne Herrera, Erik Jersin, Helge Sandtorv Camilla Tveiten

SINTEF X X

X X

X X

X X

Mads Grahl-Madsen

SINTEF PL X X

Kenneth Petterson University of Stavanger

X X

37

ANNEX IV

(blank)

MAP Aircraft MAP Aircraft Projects Projects ASAS1 April 20041 April 2004

Sikorsky S92Sikorsky S92

Managing the Risk Managing the Risk During the Introduction to Service of a New During the Introduction to Service of a New

Helicopter TypeHelicopter Type

An initiative in response toAn initiative in response toNOU 2002: 17NOU 2002: 17

Maintenance FunctionMaintenance Function

1 April 20041 April 2004 Martin PurvisMartin Purvis

Presentation to Luftfartstilsynet 1 April 2004Presentation to Luftfartstilsynet 1 April 2004

•• IntroductionsIntroductions•• Objective of meetingObjective of meeting•• NOU 2002: 17 Analysis and recommendations NOU 2002: 17 Analysis and recommendations

regarding the maintenance functionregarding the maintenance function•• The imminent introduction of the Sikorsky S92The imminent introduction of the Sikorsky S92

-- the challenges and the opportunitythe challenges and the opportunity•• A response to the NOU recommendationsA response to the NOU recommendations•• The interests and roles of the various partiesThe interests and roles of the various parties•• The way forwardThe way forward


MAP Aircraft Projects ASMAP Aircraft Projects AS

•• Independent consultant and project Independent consultant and project management specialising in helicopter management specialising in helicopter maintenance managementmaintenance management

•• Established contacts with the operators, Established contacts with the operators, manufacturers, oil company and employee manufacturers, oil company and employee representatives and the authoritiesrepresentatives and the authorities

•• Access to specialist expertise, current knowledge Access to specialist expertise, current knowledge and management resource as requiredand management resource as required

•• Stavanger Stavanger based based


Objective of todayObjective of today’’s meetings meeting

•• To present my thoughts and views regarding To present my thoughts and views regarding practical activities which can address the practical activities which can address the concerns outlined in the NOU report regarding concerns outlined in the NOU report regarding the maintenance functionthe maintenance function

•• To determine if the suggested activities are To determine if the suggested activities are considered to address the intention of the NOU considered to address the intention of the NOU report recommendationsreport recommendations

•• To better understand the roles and interests, in To better understand the roles and interests, in particular NOU Samarbeidsforum / LTparticular NOU Samarbeidsforum / LT

•• To discuss possible ways of proceeding To discuss possible ways of proceeding


NOU 2002: 17 Analysis regarding the NOU 2002: 17 Analysis regarding the maintenance function (5.2.6)maintenance function (5.2.6)

•• Risk affecting factors with negative impact on Risk affecting factors with negative impact on helicopter safetyhelicopter safety

•• Reporting and analysis of incidents Reporting and analysis of incidents -- scope for scope for improvement within operatorsimprovement within operators

•• Criticality analysis by manufacturer Criticality analysis by manufacturer -- lackinglacking•• Dissemination of criticality assessment Dissemination of criticality assessment -- poorpoor•• Increasing complexity of helicoptersIncreasing complexity of helicopters•• Increasing willingness to coIncreasing willingness to co--operation between operation between

operator, authority and manufacturer operator, authority and manufacturer


NOU 2002: 17 Recommendations regarding the NOU 2002: 17 Recommendations regarding the maintenance function (6.11)maintenance function (6.11)

•• Maintenance Steering Group (MSGMaintenance Steering Group (MSG--3) process3) process•• Improved communication of background Improved communication of background

analysis with operatorsanalysis with operators•• Maintenance Programme improvement and Maintenance Programme improvement and

simplificationsimplification•• Transfer of experience from operators to aircraft Transfer of experience from operators to aircraft

manufacturersmanufacturers•• CRMCRM•• Continuation TrainingContinuation Training


The Introduction of the Sikorsky S92The Introduction of the Sikorsky S92-- the challengesthe challenges

•• Hostile environment and high utilisation will soon Hostile environment and high utilisation will soon move the operation beyond the knowledge basismove the operation beyond the knowledge basis

•• The manufacturerThe manufacturer’’s design analysts will be s design analysts will be swamped with information swamped with information -- HUMSHUMS

•• The operators personnel will be unfamiliar with The operators personnel will be unfamiliar with the product, documentation and the failure the product, documentation and the failure characteristicscharacteristics

•• The risk during the initial period of operation of The risk during the initial period of operation of any new product is greater than at maturityany new product is greater than at maturity


The Introduction of the Sikorsky S92The Introduction of the Sikorsky S92-- the opportunitythe opportunity

•• The design standard incorporates significant The design standard incorporates significant safety related improvementssafety related improvements

•• The design analysis includes a comprehensive The design analysis includes a comprehensive safety assessmentsafety assessment

•• The manufacturer needs to commit development The manufacturer needs to commit development resource during the initial years of serviceresource during the initial years of service

•• The manufacturer is positive to operator/ The manufacturer is positive to operator/ manufacturer/authority comanufacturer/authority co--operationoperation

•• The operators and authority need to commit The operators and authority need to commit resource to the introduction of a new typeresource to the introduction of a new type


The Introduction of the Sikorsky S92The Introduction of the Sikorsky S92-- the opportunitythe opportunity

•• The need for systematic management of the The need for systematic management of the inherent risks is knowninherent risks is known

•• The preThe pre--requisites are in placerequisites are in place

•• The opportunity is nowThe opportunity is now


A response to the NOU recommendationsA response to the NOU recommendations

•• A Maintenance A Maintenance ReviewReview Steering Group for the Steering Group for the Norwegian operations of the S92 with Sikorsky, Norwegian operations of the S92 with Sikorsky, Norsk, CHC HS and CAANorsk, CHC HS and CAA--N participationN participation–– Review of the maintenance planning document and Review of the maintenance planning document and

supporting analysis to arrive at a common AMP basis supporting analysis to arrive at a common AMP basis for both operatorsfor both operators

–– Occurrence Review Board encompassing all Occurrence Review Board encompassing all Norwegian operations for all air safety and ground Norwegian operations for all air safety and ground occurrencesoccurrences

–– Common Maintenance Review Board addressing Common Maintenance Review Board addressing airworthiness issues and AMP developmentsairworthiness issues and AMP developments


A response to the NOU recommendationsA response to the NOU recommendations

•• A coA co--ordinated programme which accommodates ordinated programme which accommodates the individual needs of operators and authority the individual needs of operators and authority during the preduring the pre--startstart--up phase and ensures up phase and ensures effective communication and sharing of effective communication and sharing of knowledge knowledge

•• Closer involvement of the manufacturer into the Closer involvement of the manufacturer into the operation to achieve a better mutual operation to achieve a better mutual understanding and exchange of knowledgeunderstanding and exchange of knowledge

•• Improved Improved samarbeidsamarbeid


The interests and roles of the various partiesThe interests and roles of the various parties

•• Luftfartstilsynet, FAA and JAALuftfartstilsynet, FAA and JAA•• The operators The operators -- Norsk and CHC HSNorsk and CHC HS•• SikorskySikorsky•• NOU SamarbeidsforumNOU Samarbeidsforum•• OLF OLF -- Statoil and Norsk HydroStatoil and Norsk Hydro•• Employee representativesEmployee representatives•• MAP Aircraft Projects ASMAP Aircraft Projects AS


The way forwardThe way forward

•• To lead the way to ensure that the risks To lead the way to ensure that the risks associated with the introduction to service of the associated with the introduction to service of the Sikorsky S92 helicopter are identified, made Sikorsky S92 helicopter are identified, made known and addressed with appropriate priority known and addressed with appropriate priority in the various organisationsin the various organisations

•• Thus ensure that risks are managed to a Thus ensure that risks are managed to a minimumminimum

® sintef title · ® sintef sintef technology and society safety and reliability address: no-7465...

Documents