Historically incident and accident investigation where skewed in the direction of understanding the employee who made the error āThe Culpritā.
Without a MEDA type process the organization typically lacks the management processes to deal with the employee in a āJust and Fairā way, often resulting in discipline which may be considered unfair and often results in the employee becoming defensive.
As a result little added value is obtained, also opportunities are missed including fundamental elements connected with organizational process which may have contributed to the error. This can even be exacerbated by the insistence of re-training which adds little to the process as the underlying issues were often connect more with culture than knowledge.
A previous Human Factors (HF) Study showed that only around 4% of Aviation Maintenance incidents where directly related to knowledge issues).
Even a process may be found within organisations known as āblame and trainā where a cycle of such events can be seen to exist, discover a problem, blame an Individual, retrain and so on to repeat with the next employee.
What was required was a process to interrupt this ineffective process.
The Aviation Maintenance Error Decision Aid (MEDA) process was developed by Boeing and brought a new way of thinking to the investigation process.
Firstly that Maintenance Staff do not intentionally commit errors, in fact the opposite they take pride in their work. Ā Once we accept that even the best mechanic is capable of making a mistake and this fact may not directly have a bearing on the personās competence, the cultural relationship is able to take on a different dimension. In such a relationship it becomes possible to fully explore all causal and contributing factors in a more effective way.
Secondly, that in any event there is typically a contribution of Multiple Factors some of which may in fact be considered latent which contribute to the event. Once the employer is able to step back from the immediate need to apportion blame a much more effective analysis and root cause determination process may be undertaken. Against this background co-operation from the employee is much more forthcoming and the āblameā focuses instead not on the employee but on the organisations process and procedures.
Thirdly is the understanding that most of these factors can in fact be managed. Once we understand a weakness then the process may be changed and associated procedures strengthened or omissions address. Issues concerning tooling equipment and facilities also addressed.
Aviation Maintenance Error Decision Aid Training supports the Knowledge that typically it is a chain of events which leads to an accident, removing one or more of the links is often enough to actually prevent the error. If we can encourage people to report also ānearlyā accidents we can become proactive and avoid such in the first place.
Sofema Aviation Services offers 2 and 3 day MEDA Training programs as well as MEDA Training for Trainers.
For additional details please see: www.sassofia.com or email: office@sassofia.com.
Tags:
Aviation Maintenance Error Decision Aid, Human Factors, MEDA, MEDA Training for Trainers, Sofema Aviation Services
