January 10, 2019


Considering the role of Maintenance Error Decision Aid (MEDA) within the context of an effective Maintenance Error Management System Process

An Effective MEMS system not only provides a mechanism for conducting thorough and consistent investigations, the outcome of which identifies both the root cause and contributing causes related to a specific maintenance event.

Over the last decades, we have come to understand that a significant number of very serious flight safety events have been caused by Maintenance Error.

The Process of Error Investigation

A typical MEMS process provides for a logical course the investigator can take to determine causal factors following a maintenance event.

By determining the root cause and contributing factors of an error will provide valuable insight into the causal characteristics of an event and lead to the development of appropriate mitigations.

Analysing a Maintenance Error or problem may provide a focus on the individual or maintenance crew or may point to a systemic problem that requires changes to policies or procedures.

The Business Value of MEMS

Financial Data is not usually available in the aftermath of Maintenance Error however empirical data and other evidence suggests that there are significant costs related to the need for rework as well as cost impacts related to on-time performance and other exposures.

As well as lost revenue, reputational damage may occur following adverse publicity related to maintenance errors.

What does an effective Maintenance Error Management System Deliver?

a) A structure which identifies a documented process as well as the various roles and responsibilities to deliver an effective organisational MEMS.

b) To manage a process to ensure competence throughout the organisation related to the management, oversight, and delivery of MEMS including the investigator’s skills in effective interview techniques as well as achieve confidence in managing challenging situations.

c) The ability to focus on an understanding of contributing factors related to events, so we can strive to build resilience into the aircraft maintenance system and learn from previous events.

d) The ability to deliver an effective process which contributes to an organisational culture in which error reduction can succeed.

e) The ability to Gather Data and to perform effective analysis allowing a deep understanding of Direct, Contributing and Root Causes together with the development of appropriate mitigations.

Developing Champions / Subject Matter Experts

Creating a small group of dedicated human factors ‘champions’ who are in receipt of “formal training in human factor principles” can be highly beneficial. Such a group drawn from within the Maintenance, Safety, and Quality departments can deliver a core response to the MEMS objectives of the organisation.

Causal Questions to be Considered

a) Were there enough barriers in place to prevent the escalation of the event, and whether the barriers functioned as intended?

b) How effective was the organisational communication process and did a breakdown in communication play a role in the precursors of the event?

c) How many human factors were at play? (for example was the task perceived to be monotonous in some way?)

d) Was all required technical and accomplishment instructions provided in a correct and unambiguous way?

Support for Developing Your “In-company” MEMS Program

Sofema Aviation Services offers Training, Support and Guidance to help you understand, develop and implement an Effective Error Management Systems to deliver the safest possible organization process.

For additional information please see www.sassofia.com or www.sofemaonline.com or email office@sassofia.com


Maintenance Error Decision Aid (MEDA), Maintenance Error Management System, MEMS