Rotorcraft Industry Seminar

7 September 2017

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Please note this information is to be used for safety discussions only and is not to be shared outside of the operator

CAP 1145 History

and A31 Update David Malins

7th September 2017

Why? – A31 and A26 CAP 1145 a Safety Review of Offshore Helicopter Operations was initiated in Sept 2013 and reported on in 2014. The review focussed on all aspects of Helicopter Commercial Air Transport including:

CAP 1145

Regulatory Framework

Passenger Safety and

Survivability

Operations Airworthiness

Helicopter Safety

Research

• Ditching and water impact

• Sea State limitations

• EBS Cat A • XBR escapes

• Air Traffic Management and Communications

• Weather and Meteorology

• Pilot Training and Performance

• Certification requirement development

• Failures resulting in “Land Immediately” requirement

• Critical Parts • VHM • Human Factors OFFICIAL SENSITIVE

Actions A31 and A26

CAP 1145

Airworthiness

• 8 Actions (A) from CAP 1145 were assigned to Airworthiness within the CAA

• Actions A31 and A26 are ongoing actions on the CAA and Industry.

Airworthiness

A23 A24 A26 A27 A28 A29 A30 A31

A26

A31

CAA Airworthiness will meet with offshore operators periodically to compare the trends of MORs with operator in service difficulty / reliability data to ensure that the complete risk picture is captured, addressed and that the desired outcomes are being achieved.

The CAA will form an Offshore Maintenance Standards Improvement Team with the offshore helicopter operators with the objective of reviewing the findings at Annex F to the CAA Strategic Review of the Safety of Offshore Helicopter Operations and making proposals to achieve a step change in maintenance standards.

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2013 2014 2015 2016 2017

History and Progress

Accidents

Transport Select Committee

CAA

A31

A31 Initial meeting with

Offshore Operators held in

Aberdeen

A31 CAMO Meetings initiated

A31 Industry working group

held at BA Heathrow.

Industry agrees 4 common themes

A31 Introduced to Production meetings

A31 Onshore Helicopter Group

initiated

04/10

17/10 22/09 15/05 28/06

24/05

A31 Large MRO initial meeting

A31 Part 147 initial meeting

13/06

A31 Corporate 145 Meetings initiated

Q1 31/01 20/02

CAA issue CAP 1145. 32 Actions

and 25 Recommendations

made

24/09

CAA launches Offshore Safety

review. CAP 1145 will become the

reference

CAA issue CAP 1243. Progress report on the action of CAP

1145.

31/09 31/01

CAA issue CAP 1386. Progress report on the action of CAP

1145.

CAA issue CAP 1367. Aircraft maintenance

Incident Analysis. Relates to action

A30. 3 Actions placed on CAA

regarding Human Performance

CAA Establish A31 Governance Group

01/08

Transport Select Committee visit Aberdeen for 1st Stage of inquiry

27/01

Transport Select Committee visit

Aberdeen for 2nd Stage of inquiry

17/03

27/10

Transport Select Committee issues report following

sessions

G-WNSB ditches on approach to

Sumburgh.

23/08

29/04 28/12

LN-OJF Accident in Turoy, Norway

G-WNSR. Loss TR Authority Incident

What do we know? – Compliance Drift

1. Compliance Drift – From Oversight Organisation and product non-compliance against the maintenance regulations appear to be relatively consistent. Drift occurs through a maturing life cycle. Organisational changes, repetitive non-conformances, due to lack of root cause identification and corrective actions all contribute to drifting from regulatory standards.

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What do we know? – Human Performance

2. Human Performance - CAP 1367 Identified the historical issues with regard to Maintenance Error, Human Performance and the contributing factors to in service reported MOR’s. ?

Are these still the keys areas of maintenance error? • Installation Error • Approved data – Not

followed • Servicing Errors • Poor maintenance

Practices • Poor Inspection

standards • Misinterpretation of

data • Poor Trouble Shooting

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What do we know? – Maintenance Performance 3. Human Performance – SME reviews Two specific reviews relating to individual helicopter types suggest 12-13% of MOR’s Primary Error Factors are related to Maintenance induced events

EC135 Primary Error Factor Grading

3rd Party

No Fault

Pilot

Design / Manufacture

Maintenance

Technical Malfunction (A/C)

0% 12%

12% 1% 3%

72%

MD 900 Primary Error Factor Grading

3rd Party

Design / Manufacture

Maintenance

Other Flight Crew

Pilot

Part not installed , 1

Maintenance Overflown, 1

Incorrect part installed , 1

Incorrect Installation, 2

Incorrect assembly, 4

Break in task, 2

Tool Control/loose Articlecheck, 1

Procedure not followed, 3

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Maintenance Standards Improvement Team (MSIT) – Aims & Objectives

Regulators OEMS

Engineers Organisations

Improving Supervision & Production

Planning

Implementing a Safety Culture & Ensuring Engineer Responsibility

Improving the Effectiveness and Adoption of Procedures/Processes/Task

Cards

Improving Competency Assessment / Training & Induction

A31 MSIT

Step Change in Maintenance Standards

Industry Change

Improve and Sustain Higher

Standards – Beyond Compliance

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Group Establishment

47 Organisations representing all sectors of the Industry

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Improving Supervision &

Production Planning

Implementing a Safety Culture

& Ensuring Engineer Responsibility

Improving the Effectiveness and Adoption of

Procedures/Processes/Task Cards

Improving Competency Assessment / Training &

Induction

A31 MSIT

Step Change in Maintenance

Standards

Where the improvements fit

CAMO Performance

Attitudes and behaviour of staff

Tool Control

Maintenance Data

Commercial Pressures

Role of the LAE including personal development

Production Planning – Consistency and best

practice

Organisation adoption and assessing of competence

Engineering Apprenticeship

CAA visibility to shop floor staff

Accountable Managers – understanding Part M role

Resourcing Levels & Competence

Reliability programmes and implementation – Standardisation

Maintrol- Function and Responsibility

Corporate 145

Onshore Helicopters

CAMO

Offshore Helicopters

Engineering Competency. Training, Knowledge, skills,

attitude and culture in changing regulatory

environment

Management of human error. Human factors and

fatigue risk management in maintenance

Maintenance data. Interpretation and

ambiguity. Improving feedback and change loop

structure for correcting errors. Standard format of

data for critical and complex tasks.

• Improved communications- Promoted Skywise app • Shared information, guidelines on Production Planning • Shared information of Apprenticeships, Part 147 initiatives

– how industry must sustain a future workforce. • Shared Bow-Tie Strategy on Part M providing unachievable

workscope to Part 145’s • Increased shop floor engagement – offered to support

industry continuation training • Sharing of data – MOR, GOR’s – The need for industry to

report – consistently to allow learning • Shared findings on competency – Areas for improvement • Engaged on Leadership development programmes –

What’s best for the future of the industry?

What have has collaboration achieved?

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Driving Positive Change – The Challenge

So Industry and the Regulator have identified the issues, what are the challenges we face to drive positive, sustainable change?

What do you think?

Setting Group

Objectives

Resource to support

activity

Best Practice

Guidance Material

Rule changes

Develop trust and

engagement

Top Down and

bottom up

Communications

Wider Industry

Across Working Groups

Group Synergies Sharing

knowledge

Sharing best

practices

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Please note this information is to be used for safety discussions only and is not to be shared outside of the operator

A26 Update

Setting the Scene

CAP 1145

Airworthiness

A26

CAA Airworthiness will meet with offshore operators periodically to compare the trends of MORs with operator in service difficulty / reliability data to ensure that the complete risk picture is captured, addressed and that the desired outcomes are being achieved.

Group Data Sources

Offshore Helicopters MORs Top 5 In Service Issues Some Reliability Q Pulse compliance data Surveyor knowledge/insight

Onshore Helicopters MOR’s Q Pulse compliance date Surveyor knowledge/insight

? How can the CAA Support the wider

industry sectors within the context of A26?

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What the CAA have learned from MOR’s reviews?

We can determine

Key areas of Technical Issues for

aircraft type

Trends with Human

Performance

Primary causes of Technical

Issues

What the CAA act upon

Quality

Facts

Trending can be weak in

certain areas

Severity Grading –

Generally C & D’s

ATA coding

Quality and quantity of reports for

comparable events differ

Certain failure modes may

not be reported

Subjectivity in reporting of

events

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Q Pulse ECCAIRS

Robberies Near

misses

TDR IFSD’s

MTBUR

HUM’s Alerts

RTB’s

Service Difficulties

Utilising industry data - Actionable Intelligence

How can we improve our industry risk picture?

MOR’s Oversight

Additional Data Sources

Reliability

TSRB/GOR’s

SAG/FOR’s

Historical

Live

Reactive

MTBUR – Mean Time Between Unscheduled Removal TDR – Technical Dispatch Reliability RTB – Return to Base IFSD – In Flight Shut Downs HUMS- Health and Usage Monitoring System

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MOR’s Oversight

Where can we utilise the information?

Q Pulse ECCAIRS

High

Medium

Low

Increase visibility of all industry risks – Bring high risks above the surface

Review risks through Regulatory Safety Management Systems (RSMS)

Act on high risks event -

Escalate – high risks

Allocate – to the appropriate stakeholder

Mitigate – Drive

action to reduce likelihood and

severity

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What have has collaboration achieved?

• Developed an improved MOR review process • KPI’s - comparable reporting levels per entities • SPI’s - Maintenance Error, Tooling Events, False

Warnings, Fire, Significant Smoke and fume, Chip Detection Warnings, MGB oil leaks, Pitot Blockages, Maintenance and AD overruns

• Continued to develop relationship with EASA through 6 monthly industry sector review meetings. • EASA now confirmed attendance to next Offshore

Meeting in November • Agreed regulator representation at OEM MRB meeting

(Offshore Operators) • Improved and standardised some data collection – Offshore

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Next Steps

Engage with industry to develop meaningful data sets

• Reliability • Technical

Malfunction

Data Sets SPI’s Engagement

Further development of SPI’s on MOR Reviews • Risk related

monitoring

Engage with relevant bodies to address risks

• EASA • Manufacturers • Operators

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Your Questions

&

Thank you

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