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145 MRO Briefing on MOR & PBO

Mark Panton12/02/2018

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CAW MORs Review

▪ Why are we changing?

▪ EU 376/2014 has changed focus - Implications for Organisations▪ Require an internal reporting system

▪ Occurrences must go onto a database

▪ Database must be compatible with ECCAIRS

▪ Report occurrences to the CAA within 72 hours

▪ Report initial analysis and actions within 30 days

▪ Report final analysis results within 3 months

▪ Better Intelligence for CAA▪ Don’t want to loose valuable information from the MORs

▪ Reduce the focus onto a smaller number of ‘higher risk’ events, improve the MOR ‘picture’ for

an aircraft type / organisation

▪ Maintain the overall MOR ‘picture’ for Surveyors – reduce the ‘progress chasing’ activity

▪ Highlight where the organisations are not managing their responsibilities

▪ Surveyor better equipped for MOR audit

36-Apr-17 3CAA CONFIDENTIAL

0

5000

10000

15000

20000

25000

30000

2,014 2,015 2,016 2,017

16033

18432

29250

5538

2326 28902222

671

All CAA -MORs Investigated vs Closed on Receipt

SDD

Non-SDD

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

2,014 2,015 2,016 2,017

87.33% 86.45%

92.94%89.19%

12.67% 13.55%

7.06%10.81%

All CAA -MORs Investigated vs Closed on Receipt

SDD

Non-SDD

CAW MORs Review

Across SARG Approximately 10% of MORs are Opened for Investigation

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10 1 2 41 1

399

2 4 27126

7 1 1 7 1 1

474

2016Airworthiness MORs Open for Investigation /

Primary Error Factor

Total

Of the 1105 MORs opened to AW in 2016• 474 – Technical Malfunction• 399 - Maintenance• 41 – Design Manufacture• Total 854 or 77% of the AW Total

If we look at total MORs submitted for thoseThree PEF in 2016• 3245 – Technical Malfunction• 946 - Maintenance• 133 – Design Manufacture• Total 4324

CAW MORs Review

Across Airworthiness Approximately 20% of MORs are Opened for Investigation

Double SARG Average

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CAA – CAW, Managers,

Principals and SurveyorsMOR Process

Organisation

Report Event72 hours

Event

Org Update30 Days

InitialInvestigation

Investigation

Investigation

Org Closure• Root Cause• Corrective Action• Safety Risk Classification

3 Months

Safety ActionFeedback

System

Safety ActionMonitoring

Effectiveness

SAG

OrganisationDatabase

Aware ofMOR

Open -MORs of

Safety Significance

Surveyor Awareness via weekly automated

report - decision Engage Directly

Or Monitor Investigation

Outcome

MC Awareness

SurveyorReview / Accept

Organisations Proposed Closure

MC Assessment‘Pop Up’; Board Report;Weekly / Monthly MCNormal MOR Process

Share info withEASANAA’s

Trend –Common events, themes

OrgOpen / Close

6

Where We Are

20% - Open

80% - CoR

Limited / Reactive Trending

CAW MORs Review – Target

20%

80%

Where We Are Heading

Approx. -10% - Open

Approx. 90% - CoR

▪ Comprehensive Trending over 100% of the MORs

▪ Surveyor / MC Reports

10%

90%

Surveyor / MCReport

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▪ Developing ‘Rules & Guidelines’ - DRAFT

CAW MORs Review – What Have We Done?

MOR Subject Open for Investigation Closed on Receipt Trending NotesEngine IFSD Yes YESSignificant Smoke/fumes and all Fire events Fire Events Smoke & Fumes

(unless Significant)YES

False Fire warnings - engine / gearbox / other

YES YES

Chip' Detection Warnings - Helicopters / Fixed Wing

Only if significant - i.e. major main gearbox issue YES YES

Tooling events YES YESMaintenance error/incorrect maintenance

YES YES

Relevant MRO to be identified for trending.Taxonomy classification - consistenet with MEDA Classification

Landing gear fails to operate properly • Failure to extend (Open for Investigation)

• Failure to retract (CoR Trended)• Failure to extended normal system (CoR Trended)

YES

System's Failures (Electrical / Nav / Comms / Hydraulic / Press)

Multiple / Cascade failures -with significant increase in pilot workload / percieved risk

Single system failures on multi-system aircraft /

helicopters YES

Flying controls Significant failures / risk -Primary Flight Controls Systems

Failures / Secondary Flight Controls Systems YES

Overruns – Maintenance and or ADsYES YES

Subject to the event being identified and properly managed

Failure of emergency equipment - Oxygen / evacuation slides etc.

YES YES

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▪ Trending - Various Options / Level of Detail

CAW MORs Review – What Have We Done?

0

10

20

30

40

50

60

59

23

8 7 7 6 5 5 4 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1

Trending - Developed from Examples

Total

9

▪ Trending – Sharepoint – 1 - Organisation

CAW MORs Review – What Have We Done?

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▪ Trending – Sharepoint – 2 – ATA / Aircraft

CAW MORs Review – What Have We Done?

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Regulatory SMS ICAO Annex 19

Ris

k ex

po

sure

Control effectiveness

1

13 of 47 AW SRP risks were identified (including holding pen);Approximately 28% of the total;

13 34

0% 50% 100%

Organisation A AW Risks

8

122

5 743

6

119

10

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Heat map ref.

AW Code AW Sector Description Current score

1 SR-AW-005 Fixed wing maintenance Production Planning 3x2 Low

2 SR-AW-007 Fixed wing maintenance Tool control 3x2 Low

3 SR-AW-016 Propulsion & Production Supplier Risk Protocols 3x2 Low

4 SR-AW-018_A Fixed wing maintenance Incomplete Maintenance - Aeroplanes 3x2 Low

5 SR-AW-019 Fixed wing CAMO Maintenance Programme Control 3x2 Low

6 SR-AW-027 Fixed wing CAMO Poor/inconsistent Part M definition of... 2x2 Very Low

7 SR-AW-043 Fixed wing CAMO Incorrectly Issued ARC's and NARC's by... 3x2 Low

8 SR-AW-044 Cross capability Accountable Manager and Post Holder... 4x2 Low

9 SR-AW-045 Cross capability Lack of Organisational Resilience 4x2 Low

10 SR-AW-046 Cross capability Resource Competence 3x3 Medium

11 SR-AW-047 Cross capability Human Factors and Fatigue Risk Management in... 4x2 Low

12 SR-AW-048 Cross capability Lack of or limited Type Certificate Holder... 3x3 Medium

13 SR-AW-049 Cross capability Unrecorded Defects - Engineering and Flight... 2x3 Low

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Regulatory SMS ICAO Annex 19

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Performance based oversight

PBO support reports

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Performance based oversight

Occurrence reports (Top-10) Oversight activity

Area of standard: nr of findings/proportion of level 1 or 2A 145.A.65 Procedures & Quality

M.A.708 Continuing airworthiness management

M.A.305 Aircraft Continuing Airworthiness Record System

145.A.35 Certifying staff and support staff

145.A.30 Personnel Requirements

145.A.45 Maintenance data

145.A.50 Certification of maintenance

145.A.40 Equipment, tools and material

145.A.55 Maintenance and airworthiness review records

M.A.403 Aircraft defects

Documentation - Incomplete

Process - Incorrect Version In Use

Organisation - Ineffective Quality/Compliance System

Process - Ambiguous

Organisation - Ineffective Management System

Documentation - Incorrect (Documentation)

Personnel - Human Error

Process - Incorrect (Process)

Process - Procedure Not Followed

Personnel - Competence or Capability

Root cause: nr of findings/proportion of level 1 or 2A findings

Identified via analysis of occurrence reports

Reliability of parts, components or systems

Maintenance - action - process or procedure

Maintenance - action - other or undetermined

Maintenance – documentation or data

Maintenance - action - tool control and/or FOD

Oversight of contracted maintenance

Type Certificate holder support - limited, reactive

Maintenance – effectiveness of maint. programme

Maintenance - action - break in task

Maintenance - action - coordination

Design - part, component or system

Maintenance - planning

Maintenance - control of spares/parts

Maintenance - training/competency

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▪ Reliability of parts, components or systems - loss of function, malfunction or failure

▪ Lack of, incorrect or inadequate action or procedure - maintenance -assembly/installation - incorrect configuration/positioning/mis-routed or mis-rigged

▪ Lack of, incorrect or inadequate action or procedure - maintenance -assembly/installation - tool or object control

▪ Lack of, incorrect or inadequate action or procedure - maintenance - servicing

▪ Lack of, incorrect or inadequate action or procedure - maintenance - repair

▪ Lack of, incorrect or inadequate action or procedure - maintenance -assembly/installation – incorrect part installed

▪ Lack of, incorrect or inadequate action or procedure - OEM -assembly/installation/repair – incorrect configuration/positioning/mis-routed or mis-rigged

▪ Lack of, incorrect or inadequate action or procedure – maintenance assembly/installation - task not completed

▪ Lack of, incorrect or inadequate action or procedure - maintenance – parts missing, incorrect, disconnected or not connected

▪ Lack of, incorrect or inadequate action or procedure - maintenance –

other, unknown or undetermined

▪ Lack of, incorrect or inadequate action or procedure – maintenance

- assembly/installation - task not performed or overdue

SummarySummary of airworthiness-related occurrences

Temporary or permanent loss of function, malfunction or failure of parts, components or systems (includes warnings)

1. Increased workload

2. Operational effects (rejected take-off, go-around, return or

diversion)

3. Declared emergency

4. No effect - detected before flight or during maintenance

5. Other, undetermined, minor or no effect

6. Passengers (disembarked or evacuated)

2%; 4

12%; 24

22%; 42

24%; 47

40%; 77

66%; 128

0 50 100 150

6

5

4

3

2

1

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Deep dive reviews

Aircraft Product Component System

Manufacturer Safety risk Operator Organisation

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o Complete Current AW Review of Open MORs - Ongoing

o Develop Surveyor & MC Reports – Sharepoint Access – Completed

o Surveyors – continue to have an opportunity to agree Open / Closed classification - Completed

o Develop Process - Monitor All Airworthiness MORs – with CAW (circa 600/month) - Ongoing

o Feedback process to SSC/SDD to applying consistent taxonomy – Required to Automate Trending - Ongoing

o Review Event Classification - Liaison with SDD – align understanding between SSC & AW (Development of Risk Rating) - Ongoing

o Develop Techniques for Trending – ISP Function - Ongoing

Next Steps

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Thank You