January 03, 2017

sasadmin

A discussion document from Steve Bentley MD of Sofema Aviation Services www.sassofia.com

MEMS versus SMS

Lets consider the role of MEMS, which is essentially a reactive tool. For example, Boeing Maintenance Error Decision Aid (MEDA) was developed specifically as a tool to help understand the contributing factors related to a given incident or event.

SMS on the other hand is intended to be developed as a “proactive” organisational tool, which is used to identify hazards and to assess the risk or exposure associated with the hazards.

With this information it becomes possible to develop appropriate mitigation (A mitigation is simply a recommendation to the business area owner to make a change which will lower the perceived risk).

We say “perceived” risk because the assessment is subjective – means it is based on opinion (ok an educated guess), which is why we also need organisation tools to measure risk.

Why do Organisations “under perform”

Well first we have to agree that they do in fact under perform.

Please consider the following questions:

1/ Are you happy that as an Organisation you have assessed the Risk and exposure across the business to reduce it to its minimum exposure within the context of the organisations “reasonable” expectations (Here we reference the term as low as reasonably practicable ALARP).

2/ Are you happy with the level of reporting within the organisation? not just the events, which have happened,l but also the “nearly events” how are you measuring the effectiveness of your internal reporting system? As a general guy for every Mandatory Occurence Report (MOR) or Service Difficulty Report (SDR).
There will be a further 30 events, which should be reported into the internal system, and possible 300 “nearly but not quite events”, which can be understood as an exposure.

3/ Are you managing the competence of all front line and key staff to an organisational standard? How are you measuring the effectiveness of this standard?

4/ How strong are the internal procedures and processes? Again how are we measuring the “success” of our procedures (Do we audit for performance or only compliance?)?

So lots of things to consider and off course potentially lots of exposure

We do not mean to create situations, which cause accidents or even worse fatalities – but it happens and will continue to do so ……why ?

Consider a couple of documented events:

1/ Aeroperú Flight 603 was a scheduled flight from Miami International Airport in Miami, Florida (KMIA) to Comodoro Arturo Merino Benítez International Airport in Santiago, Chile (SCEL), with stopover in Peru. On 2 October 1996, the aircraft flying the final leg of the flight crashed, killing all on board.

The aircraft had been washed and a “mechanic” had covered all static orifices with Duct Tape. The aircraft took off at night and the crew were unable to understand what was happening and lost control of the aircraft.

A completely serviceable aircraft crashes into the ocean with the loss of 70 lives.

2/ ValuJet Flight 592 was a regularly scheduled flight from Miami International Airport to Hartsfield-Jackson Atlanta International Airport. On May 11, 1996, the ValuJet Airlines McDonnell-Douglas DC-9 operating the route crashed into the Everglades about 11 minutes after taking off from Miami as a result of a fire in the cargo compartment caused by improperly stored Company spares (Co-MAT), killing all on board.

Expired Chemical Oxigen Generators were loaded still primed into the forward cargo compartment of the DC9 aircraft Several Generators activated causing a chain reaction.
which caused an inferno which brought down the aircraft into the florida everglades with the loss of 110 lives.

In both of these cases the root can be traced to poor or weak procedures and whilst the direct cause is human error we have a number of contributory factors which focus on How the organisation is managing its systems and processes.

When we look back with hindsight we can see clearly all elements, which have together conspired to create the pre-cursor,s which allow the event to happen.

However, it is too late when “something” has happened.

The Role of EASA within MEMS – SMS What is the Story

Unfortunately EASA scores a last in class – why?

Because all 145 Organisations should have had (To comply with ICAO) an effective SMS – MEMS system in place since January 2009 that this is often not the case is a reflection of the incomplete regulatory environment.

With the issue of amendment NPA 2013/01 EASA attempted to introduce regulations which would align EASA Part 145 with the requirements of ICAO annex 6 & 8 and subsequently ICAO Annex 19.

Unfortunately the NPA was withdrawn and 4 years later we are still waiting.

Do we have to be told to do Something ?

You would think not and it is here we can make a difference.

It is not expensive to commit an organisation to an integrated SMS/MEMS process all it takes is leadership and a willingness to implement a real and effective system.

Too many organisations unfortunately have “bought the SMS book” and keep it on the shelf.

Please consider

How many times have you amended your SMS documentation since the launch of your SMS Program ?

How are you measuring the effectiveness if your SMS training ?

If you are an operator how are you measuring the exposure if the 145 maintenance organisation working on your aircraft?

Final Comments

Where there is a will there is a way – means a small change of mindset can result in a significant reduction in exposure which on a good day can also generate financial benefits be reducing losses and improving efficiency across the business areas.

Sofema Aviation Services has been delivering SMS & MEMS Training since 2008. During 2016 more than 2500 students received training from Sofema Aviation Services (www.sassofia.com) and EASAonline (easaonline@sassofia.com).

For details of available courses and consultancy please see the website or email office@sassofia.com