Aircraft Maintenance Technology

APR-MAY 2018

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AIRLINE MEDA investigators are trained to apply some specific techniques to help the person being interviewed to remember and communicate while following a structured process during the interview. AN IMPORTANT TOOL IN A SAFETY MANAGEMENT SYSTEM Safety management systems (SMS) at airlines and maintenance organizations around the world have advanced rapidly in the past decade. Risk management, one major component of an SMS, requires that safety of flight hazards be identified, that the hazards be assessed for risk, and that unacceptable risk be mitigated to acceptable levels. Among the three approaches for identifying hazards (reactive, proactive, and predictive), event investigation is mainly responsible for identifying and communicating human performance issues within an organization. Boeing MEDA has been an important tool in the SMS reactive hazard identification process. It helps an organization systematically determine the hazards or contributing factors to events, and, based on these findings, allows the organization to develop and monitor a comprehensive fix. A CONNECTION TO MANAGING HUMAN BEHAVIORS IN A JUST CULTURE Both errors and violations can contribute to maintenance events. They often occur together to produce an unwanted outcome. MEDA investigators are trained to recognize errors, violations, and different types of violations (routine, situational, or exceptional), and investigate the preceding cause(s) to the errors and violations. In the next revision of MEDA Results Form, a new section will be added to help to document errors and different types of violations, which require different mitigation strategies. This new addition will offer a connection to how different human behaviors should be managed within a Just Culture: 1. Human errors — "To err is human …" Human errors should be managed through consoling and other actions such as changes in processes, procedures, training, design, and environment. Upon close examination, repetitive human errors may warrant punitive actions. 2. At-risk behaviors (routine and situational violations) — "To drift is human …" At-risk behaviors should be managed through coaching and the following: • Removing incentives for at-risk behaviors • Creating incentives for healthy behaviors • Increasing situation awareness Upon close examination, repetitive situational violations may warrant punitive actions. 3. (Occasional) Reckless behavior Accountability rests wholly with the individual who chooses the reckless act. HARNESS THE POWER OF VISUAL COMMUNICATION A map or a diagram offers a level of information density that words and sentences alone cannot offer. For example, the amount of information that is captured and easily communicated on a single street map. Traditional written investigation reports do not illustrate causal relationships well. In the past few years, Boeing has been recommending a MEDA best practice — upon completion of an investigation, use a diagram to visualize and document causal relationships discovered in the investigation and produce "the big picture view." The diagram is also a great communication tool and helps to preserve the learning through the investigation. In the next revision of MEDA Results Form, a new section will be added to offer a template for constructing the causal relationships discovered in the MEDA investigation. MEDA BEST PRACTICES Several factors contribute to MEDA's wide adoption and acceptance: • The Boeing Company has been offering continuous and consistent support. For instance, between January 2012 and March 2018, 75 ses- Process A Process B Process C Process D Process E Contributing Factor Value 01 Quality of support from (technical) organizations 03 Not enough staff 04 Corporate change/restructuring 06 Work process/procedure incorrect 07 Work process/procedure not followed 08 Work process/procedure not documented 09 Work group normal practice FIGURE 2. An example of data evaluation based on MEDA at LHT. 10 APRIL/MAY 2018 AIRCRAFT MAINTENANCE TECHNOLOGY

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