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when the maintenance and the event occurred, the event that precipitated the investigation, the
error that caused the event, the factors that contributed to the error and possible prevention
strategies.
d) Prevention Strategies. Management reviews, prioritizes, implements and then tracks prevention
strategies (process improvements) in order to avoid or reduce the likelihood of similar errors
occurring in the future.
e) Feedback is provided to the maintenance workforce in order for AMEs to know that changes have
been made to the maintenance system as a result of the MEDA process. Management is
responsible for affirming the effectiveness of employees’ participation and validating their
contribution to the MEDA process by sharing investigation results with them.
19.3.8 Appendix 2 to this chapter provides a more detailed description of MEDA.
19.4 SAFETY MANAGER’S CONCERNS
19.4.1 A company SM will often face challenges in providing sound advice to senior management on
the maintenance portion of the SMS — especially if the SM’s background is not in aircraft maintenance.
Some challenges include:
a) understanding safety management in the context in which maintenance work is carried out;
b) developing personal credibility, especially in acquiring sufficient knowledge of accepted safe
industry work practices and maintaining currency with respect to industry developments in aircraft
maintenance. (One way for the SM to better understand the complex nature of aircraft maintenance
is to consult with maintenance managers and become familiar with the various facets of the MEDA
checklist.);
c) developing and maintaining effective working relationships with:
1) managers accountable for aircraft maintenance and for integrating maintenance safety into the
overall corporate SMS; and
2) potential technical advisers;
d) developing a synergy among maintenance personnel and other participants in the SMS;
e) developing a spirit of cooperation and routine coordination of activities between flight operations and
maintenance, particularly on such matters as adequacy of discrepancy reporting, or operating an
FDA system;
Chapter 19. Aircraft Maintenance 19-7
f) providing timely and credible analysis of safety data gathered through the various tools used for
hazard identification; and
g) obtaining the participation and commitment of the maintenance department on company safety
committees.
19.4.2 In reviewing the effectiveness of safety management in maintenance, SMs should pay
particular attention to such issues as:
a) adequacy of maintenance documentation;
b) quality of communications up and down, as well as laterally within the maintenance organization;
c) environmental factors affecting human performance;
d) quality of training, both for job-related knowledge and technical skills;
e) error reporting and trend analysis systems aimed at the identification of systemic hazards;
f) the means for effecting any necessary changes to reduce or eliminate identified safety deficiencies;
and
g) the existence of an error-tolerant and non-punitive safety culture.
— — — — — — —
19-APP 1-1
Appendix 1 to Chapter 19
MAINTENANCE WORKING CONDITIONS
1. Listed below are some of the typical issues impacting on the working conditions under which aircraft
maintenance is carried out:
a) Organizational issues:
1) time pressures to sustain on-time departures and around-the-clock operations;
2) ageing aircraft requiring intensive inspections for fatigue, corrosion, overall condition, etc.;
3) new technologies requiring new tools, new work procedures, costly retraining, etc.;
4) “fix-it” focus to stay on schedule (e.g. replacing broken parts without determination as to why
they failed — perhaps due to poor design or incorrect assembly);
5) airline expansions and mergers (e.g. combining maintenance departments with different work
practices and safety cultures);
6) outsourcing of services to subcontractors (e.g. for heavy maintenance and overhaul);
7) unwitting introduction of (lower cost, substandard) bogus parts, etc.; and
8) licensing of AMEs for different aircraft, aircraft generations, types and manufacturers;
b) Work site conditions:
1) aircraft designs that are not user-friendly from a maintenance perspective (for example,
cramped access to components and inappropriate height off the ground);
2) control of aircraft configurations (which are continually subject to modifications) versus
standardization of maintenance tasks and procedures;
3) availability (and accessibility) of spares, tools, documentation, etc.;
4) requirements for having ready access to voluminous technical information, and the need for
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Safety Management Manual (SMM) 安全管理手册(150)
