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the interfaces between workers (such as between maintenance personnel and flight crews, between
personnel of different trades, or between staff on changing work shifts) to avoid problems “falling through the
cracks”. Chapter 10 discusses methods for maintaining safety oversight, including the conduct of regular
safety audits.
19.2.14 Change is inevitable in the aviation industry, and the maintenance area is no exception. The
Director of Maintenance may require that a safety assessment be carried out in respect of any significant
changes in the maintenance organization. Circumstances that might warrant a safety assessment include a
corporate merger, and introduction of a new fleet, equipment, systems or facilities. Consequently, the need
for any adjustments can be identified and corrected.
19.2.15 The maintenance SMS should be regularly evaluated to ensure that expected results are
being achieved. Programme evaluation should provide satisfactory responses to such questions as:
a) To what extent has management succeeded in establishing a positive safety culture?
b) What are the trends in hazard and incident reporting (by technical trade, by aircraft fleet, etc.)?
c) Are hazards being identified and resolved?
d) Have adequate resources been provided for the maintenance SMS?
19.3 MANAGING PROCEDURAL DEVIATIONS IN MAINTENANCE
19.3.1 The maintenance system includes not only the AMEs on the shop floor but also all the other
technicians, engineers, planners, managers, stores keepers and other persons that contribute to the
maintenance process. In such a broad system, procedural deviations and errors in maintenance are
inevitable and pervasive.
19.3.2 Accidents and incidents attributable to maintenance are more likely to be caused by the actions
of humans than by mechanical failure. Often, they involve a deviation from established procedures and
practices. Even mechanical failures may reflect errors in observing (or reporting) minor defects before they
progress to the point of failure.
Chapter 19. Aircraft Maintenance 19-5
19.3.3 Maintenance errors are often facilitated by factors beyond the control of the AME, for example:
a) information required to do the job;
b) equipment and tools required;
c) aircraft design limitations;
d) job or task requirements;
e) technical knowledge or skill requirements;
f) factors affecting individual performance (i.e. SHEL factors);
g) environmental or workplace factors;
h) organizational factors such as corporate climate; and
i) leadership and supervision.
19.3.4 Safe maintenance organizations foster the conscientious reporting of maintenance errors,
especially those that jeopardize airworthiness, so that effective action can be taken. This requires a culture
in which staff feel comfortable reporting errors to their supervisor once the errors are recognized.
19.3.5 New systems are being developed for managing procedural deviations (and errors) in aircraft
maintenance. Typically, these systems are a subset of an overall maintenance SMS and exhibit the
following characteristics:
a) They encourage uninhibited reporting of occurrences that would not otherwise be required to be
reported.
b) They provide training for staff on the purpose and procedures for using the maintenance SMS,
including clear definition of departmental disciplinary policies (e.g. disciplinary action should only be
necessary for instances of recklessness or wilful disregard of promulgated instruction on
procedures).
c) They conduct competent safety investigations of reported errors.
d) They seek appropriate safety action in follow-ups to identified safety deficiencies.
e) They provide feedback to the workforce.
f) They provide data suitable for trend analysis.
Maintenance Error Decision Aid (MEDA)
19.3.6 One tool for managing procedural deviations in maintenance is the Maintenance Error Decision
Aid (MEDA) developed by The Boeing Company. MEDA provides the first-line supervisor (and the SM) with
a structured method for analysing and tracking the factors leading to maintenance errors and for
recommending error prevention strategies.
19-6 Safety Management Manual (SMM)
19.3.7 In the MEDA process there are five basic steps, namely:
a) Event. Following an event, it is the responsibility of the maintenance organization to select the errorcaused
aspects that will be investigated.
b) Decision. After fixing the problem and returning the aircraft to service, the operator decides if the
event was maintenance-related. If yes, the operator performs a MEDA investigation.
c) Investigation. Following a structured form (specifically designed for MEDA), the operator carries
out an investigation. The investigator records general information with respect to the aeroplane,
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Safety Management Manual (SMM) 安全管理手册(149)
