1 successful interventions 8th october 2008 presented by john mccollum bae systems military air...
TRANSCRIPT
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Successful Interventions8th October 2008 Presented byJohn McCollumBAE SYSTEMS Military Air SolutionsHead of Aircraft Maintenance & Maintenance Training
Royal Aeronautical Society Human Factors Group, Engineering (HFG:E)
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Contents
– BAE Systems MAS Background– Safety Exemplar challenge & where are you?– MAS Error Management Programme– Our System Challenge!– Successful Interventions– Our next steps towards a SMS– Summary
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Exemplar Challenge
– The Leadership of BAE Systems has committed The Company to an “exemplar” position on safety:
– This means zero tolerance on unsafe workplace and unsafe working practices to be delivered within each business through target driven performance improvements across both leading and lagging indicators.
– Includes the safety obligation with our Partners and Providers.
– Safety Culture is defined as an organisations values and behaviours, modelled by its leaders, and internalised by its team members”
– This means leading by example!
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Where are you?EXEMPLAR / GENERATIVE
Safety is how we do business round here
ADVANCED / PROACTIVE
We work on problems that we still find
STANDARD / CALCULATIVE
We have systems in place to manage all hazards
FOUNDATION / REACTIVE
Safety is important, we do a lot every time we have an accident
PATHOLOGICAL
Who cares as long as we’re not caught Based upon SHELL model
Incr
easi
ngly In
form
ed
Incr
ease
d Tru
st a
nd Acc
ountabili
ty
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Where are you?
Time
Num
bers
of
Inci
dent
s
Technology
Systems
Culture
• Engineering• Equipment design• Design standards• Regulatory compliance
• Quality Systems• Human Factors/CRM• Error management systems• Competence• Risk Assessment
• Behaviours• Visible Leadership • Personal Accountability• Shared Attitudes• Safety as a profit centre
The Three “ages” of Safety Management
With permission: Why is HSE so Important? A business approach Prof. With permission: Why is HSE so Important? A business approach Prof. Patrick Hudson, Leiden University Modified by Baines & McCollum
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The MAS Programme
MEDA Training
Senior Mgt HF Training
HF Programme
EMS Training
Continuation Training
Safety Review Board
Safety Action Groups
SMS Training
2004 2005 20072006 2008
Reactive “Systems”
Proactive “Culture”
MEMS Report 700 +
MEDA Investigations 200 +
Initial HF Trained 2600 +
The Error Iceberg
The Error Iceberg
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Our System Challenge
– System within a system– 1000+ Initial HF trained are RAF and Sub-Con personnel – Different cultures & approaches– Different maturity of systems– Unite under flight safety– Sharing & influencing other Organisations approaches– MAOS helping the message– Partnered approach to policy, training & operation– Military forums now forming
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Successful Interventions
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Maintenance Model Example
(Proactive)(Reactive)
Adapted from Air France / Baines & Simmons / ICAO 9859
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Operational Risk Management in Maintenance
MEMS& others reports
Communications
OrganisationalFactors
HumanPerformanceLimitations
Skills,Training,
Competency
Job /Task/ Zone
Resources
DesignFactors
WorkingEnvironment
Leadership / Supervision
Planning &Preparation
BusinessManagement
Change
Fleet ErrorProvocative
Events
TechPubs &
Procedures
HAZARDIDENTIFICATION
Typical Hazard Considerations for Maintenance
Need to consider assessments by aircraft rectification lines and component bays, using personnel from these areas.
Hazard identification, assessment and control, should be an integral part of routine maintenance, rather than limited to project lifecycle phases and implicit personal action.
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The Basic Bow Tie Concept
Events andCircumstances Harm
CONSEQUENCES
Defences orSafety Controls or
Secondary Hazards ?
Undesirable event withpotential for harm or damage
Continuing Airworthiness activitiesMaintenance activities
Flight Operations activities
Top Event
Preventive Controls
Recovery Controls
HAZARD
Threat
Threat
Threat
RISK RESULTING INCAUSED BY
With permission: With permission: Baines & Simmons
Modified by McCollum
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Summary
– Successful Interventions can come from investing in HF learning, but you must be prepared for the journey.
– A successful Error Management System needs :-– Energy! – Just Culture led from the Top plus Opinion Leaders – Comprehensive investigations with loads of feedback / publicity
– Energy! – Feedback the investigations into your training– Then the toe in the water
– Energy!
– Then the deluge begins
– A Safety Management System can only start once you have a working HF and Error Management System – all about behaviour
– The system must integrate within the bigger system!
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