Comment by Steve Bentley, who has spent more than 25 years as a quality professional within the commercial environment and over 45 years’ experience in commercial aviation.
“After more than 45 years in Commercial Aviation you start to understand that there are many factors or precursors, which can contribute to Accidents and Incidents, also that there is never any permanent fix to this story. It is apparent that the old adage what comes around goes around. We see the same exposures repeat.”
You may buy into the above as being a true reality or you may require persuading as to the veracity of the above comment.
So what does Information regarding Accidents give us?
Essentially hindsight is as good as 20 – 20 vision in that it allows us to understand in a definitive way, which is not possible when we are speculating about potential events. The big difference between QMS and SMS is the QMS is a tangible “real” evidence based experience whereas SMS is a subjective assessment analyzing potential risk and developing appropriate mitigations based on this understanding.
The purpose of this comment is not to consider SMS but to focus only on QMS – When we consider an event which has taken place we can ask ourselves a number of questions .
Whenever we consider in the aftermath of an event the potential role of Quality Assurance we move a step in the right direction (conversely if we ignore this philosophy we miss the opportunity)
Case Study Japan Airlines Flight 123 – tragedy (see you tube for details)
Think how Quality could have impacted this:
1/ CAMO oversight
The replacement of the lower 1/3 of the rear pressure bulk head was not a terminated task – it had a life !
This fact was overlooked by the CAMO system and led to the A/C exceeding the limitation by more than 1000 landings – sadly the suicide of the CAMO manager added to the tragedy – My Take on this is that the Quality Assurance Process has the potential to ensure the business areas are functioning correctly – not tick the box audits but real understanding !
Multiple times the Affected Zone was inspected by maintenance staff – but to what standard – Clearly a major spliced repair covered in Thiokol sealant required at some point a detailed inspection but not was forthcoming. – My take on this is that Quality Assurance missed the opportunity to consider in detail the effectiveness of the Maintenance Staff Inspection training program – how is it assessed and how is it measured for effectiveness.
One way is for In service inspections following C check inspections for example to be carried out by competent quality assurance professionals to add confidence to the process.
Why did the event happen?- Essentially it will be related to a number of repeating factors (some of which are shown below)
a)Related to the Personal Performance – Human Factors for example Fatigue – Complacency- Stress
b) Related to Manpower – Numbers – Training – Competency
c) Related to Procedures and Processes – Weak – Insufficient – Not understood
d) Related to Equipment and Material – Shortages – Insufficient – Poor Quality
So why does it Involve Quality?
Organisations are required to have a compliance quality assurance program, this is not news, but what is news is how does the organisation measure the effectiveness of the quality assurance process.
Here are a few indicators
1/ The regulator performs an audit and finds several issues
– No problem we fix the issues, they are not major so what’s the problem?
2/ We carry out audits in accordance with our checklists which are part of our approved QMS – We have findings (off course) and the corrective actions are passed to the business area owner for appropriate resolution.
3/ We see over a number of years similar findings repeat in various business areas
So Let’s Review the above and Comment
1/ If the regulator finds problems or issues the first question is why did we not know about this before hand – effectively this becomes a “heads up” regarding internal issues regarding the effectiveness of the quality system.
Resolution 1 – Any external finding should initiate significant internal action to understand the exposure and viability of the QMS in the questioned area. Use Root cause techniques to ensure all elements are address.
2/ The Quality Assurance function may be considered as Independent (even “bolt on” – what does this mean?)- Essentially it means that internal quality audits should identify few if any problems and if it does something is going wrong in the underlying business area.
Resolution 2 – As a function of creating a finding the recipient (auditee) is responsible to identify the root cause and to address the underlying exposure. For this to happen correctly the QA auditor MUST have the competence to also identify the root cause (to the highest possible standard) – consider if the problem is not addressed correctly it will simply return in another way or shape but it WILL return).
3/ What to do with findings which repeat?
Resolution 3 – We have to be able to analyze in depth, to understand the extent of the exposure and to provide support to the business area owners and accountable executive to implement appropriate change.
Effective Quality Professionals understand the above and are able to accommodate similar activities within there behaviour. They also understand it is not the job of Quality Assurance to tell people what to do – rather to tell them what is wrong and to provide support and guidance to enable effective resolution.
Summary
The role of Quality Assurance is primarily to ensure compliance both with External Regulatory requirements and Internal Organisation requirements. However the reality of what looks ok today often looks quite different after an incident and a visit by the NTSB or AAIB or other such organisation.
If you are currently employed as a Quality Professional how satisfied are you with the strength of your Quality System.
www.sassofia.com offers more than 25 different EASA regulatory compliant and competence building Quality Assurance Training Courses – for further information please email: office@sassofia.com
