1 Successful Interventions 8th October 2008 Presented by John McCollum BAE SYSTEMS Military Air Solutions Head of Aircraft Maintenance & Maintenance Training Royal Aeronautical Society Human Factors Group, Engineering (HFG:E)

2 Contents –BAE Systems MAS Background –Safety Exemplar challenge & where are you? –MAS Error Management Programme –Our System Challenge! –Successful Interventions –Our next steps towards a SMS –Summary

3 Introduction BAE Systems is the premier global defence and aerospace company delivering a full range of products and services for air, land and naval forces, as well as advanced electronics, information technology solutions and customer support services. With approximately 100,000 employees worldwide, BAE Systems' sales exceeded £15.7 billion (US $31.4 billion) in Key Facts - 3rd largest global defence company - 6th largest US defence company - 100,000 highly skilled people - Global capability - Customers in over 100 countries - Annual sales exceed £15.7 billion - Annual R&D exceeds £1.4 billion - More than 100 new inventions every year

4 Breadth of capabilities –Air Sector: advanced air capability through major aircraft programmes, in US and Europe. –Naval Sector: broad naval capability through a range of warship, submarine, auxiliary vessel programmes and naval armaments. –Land Sector: second largest manufacturer of armoured fighting vehicles and artillery systems. –Electronics, Intelligence and Integrated Systems: integrated capability in the electronic warfare and systems sector, from high tech sensors to command systems and homeland security. –Through-life Support: broad range of through-life support solutions around the world, from information technology operations management to platform repair and maintenance. –Commercial Aerospace: leading provider of systems for large commercial aircraft and regional jets.

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6 Exemplar Challenge –The Leadership of BAE Systems has committed The Company to an “exemplar” position on safety: –This means zero tolerance on unsafe workplace and unsafe working practices to be delivered within each business through target driven performance improvements across both leading and lagging indicators. –Includes the safety obligation with our Partners and Providers. –Safety Culture is defined as an organisations values and behaviours, modelled by its leaders, and internalised by its team members” –This means leading by example!

7 Where are you? EXEMPLAR / GENERATIVE Safety is how we do business round here ADVANCED / PROACTIVE We work on problems that we still find STANDARD / CALCULATIVE We have systems in place to manage all hazards FOUNDATION / REACTIVE Safety is important, we do a lot every time we have an accident PATHOLOGICAL Who cares as long as we’re not caught Based upon SHELL model Increasingly Informed Increased Trust and Accountability

8 Where are you? Time Numbers of Incidents Technology Systems Culture Engineering Equipment design Design standards Regulatory compliance Quality Systems Human Factors/CRM Error management systems Competence Risk Assessment Behaviours Visible Leadership Personal Accountability Shared Attitudes Safety as a profit centre The Three “ages” of Safety Management With permission: Why is HSE so Important? A business approach Prof. With permission: Why is HSE so Important? A business approach Prof. Patrick Hudson, Leiden University Modified by Baines & McCollum 8

9 The MAS Programme MEDA Training Senior Mgt HF Training HF Programme EMS Training Continuation Training Safety Review Board Safety Action Groups SMS Training Reactive “Systems” Proactive “Culture” MEMS Report MEDA Investigations Initial HF Trained

10 Our System Challenge –System within a system –1000+ Initial HF trained are RAF and Sub-Con personnel –Different cultures & approaches –Different maturity of systems –Unite under flight safety –Sharing & influencing other Organisations approaches –MAOS helping the message –Partnered approach to policy, training & operation –Military forums now forming

11 Successful Interventions

12 Our next steps towards a Safety Management System –SMS is proactively managing safety in a systematic way –Identifies safety hazards –Ensures that remedial action necessary to maintain an acceptable level of safety is implemented. –Provides continuous monitoring and regular assessment of the safety level achieved. –Aims to make continuous improvement to the overall level of safety –Provides a transparent, recorded system to manage safety and deserves at least the same degree of care that would be applied to a financial management system. –Instead of answering the question “Are we safe?” with “As far as I know” we will be able to answer “Yes because of our SMS!”.

13 Benefits of a Safety Management System –A reduction in accidents, damage and injuries –Long term cost efficiencies –Competitive advantage for the business –Provision of evidence of effective management of risks to ensure safe manufacture & maintenance –Elevation of standard of safety management, which should reduces insurance premiums when implemented effectively –Improved morale within the Organisation –Compliance with all current regulations –GOOD FOR SAFETY, GOOD FOR BUSINESS

14 Maintenance Model Example (Proactive)(Reactive) Adapted from Air France / Baines & Simmons / ICAO 9859

15 Operational Risk Management in Maintenance HAZARD IDENTIFICATION Tech Pubs & Procedures Fleet Error Provocative Events Business Management Change Planning & Preparation Leadership / Supervision Working Environment Design Factors Resources Job /Task / Zone Skills, Training, Competency Human Performance Limitations Organisational Factors Communications MEMS & others reports Typical Hazard Considerations for Maintenance Need to consider assessments by aircraft rectification lines and component bays, using personnel from these areas. Hazard identification, assessment and control, should be an integral part of routine maintenance, rather than limited to project lifecycle phases and implicit personal action.

16 The Basic Bow Tie Concept Events and Circumstances Harm CONSEQUENCESCONSEQUENCES Defences or Safety Controls or Secondary Hazards ? Undesirable event with potential for harm or damage Continuing Airworthiness activities Maintenance activities Flight Operations activities Top Event Preventive Controls Recovery Controls HAZARDHAZARD Threat RISKRESULTING INCAUSED BY With permission: With permission: Baines & Simmons Modified by McCollum

17 Summary –Successful Interventions can come from investing in HF learning, but you must be prepared for the journey. –A successful Error Management System needs :- –Energy! –Just Culture led from the Top plus Opinion Leaders –Comprehensive investigations with loads of feedback / publicity –Energy! –Feedback the investigations into your training –Then the toe in the water –Energy! –Then the deluge begins –A Safety Management System can only start once you have a working HF and Error Management System – all about behaviour –The system must integrate within the bigger system!

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