1. SMS and QMS For Airplane Maintenance JULY 28, 2010 Gerardo Hueto

2. USC Outline  Concept of Safety  SMS  QMS  Integration or Coordination  Example

3. USC Concept of safety (Doc 9859)  Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management.

4. USC Safety Management System Definition A Safety Management System (SMS) is a set of integrated tools, policies, processes, and procedures used by corporate management to fulfill their responsibility to manage the safety risks associated with their organization’s operations as a part of its overall business.

5. USC ICAO Annex 6 Requirements  “…a safety management system acceptable to the State of the Operator that, as a minimum:  identifies safety hazards;  ensures that remedial action necessary to maintain an acceptable level of safety is implemented; and  provides for continuous monitoring and regular assessment of the safety level achieved.”  “An accepted safety management system shall clearly define lines of safety accountability throughout the operator’s organization, including a direct accountability for safety on the part of senior management.”

6. USC The components of SMS (ICAO) Safety policy and objectives Safety risk management Safety assurance Safety promotion

7. USC What to include in an SMS?  Flight Operations and Maintenance (ICAO)  Other safety activities that could be included in SMS  Personnel safety  Environmental safety  It may also include  Dispatch, In-flight, Ramp, Fueling

8. USC Maintenance SMS  Acceptable level of Safety?  Hard to define, but can use metrics  Maintenance metric examples  In-flight shut downs  Rejected take-offs (mechanical)  Write-ups after heavy checks  Number of MEL items (or fleet rate)  Flight delays due to maintenance?

9. USC Maintenance Safety Metrics  Should be numerical:  Number of events/calendar time or departures  Should have performance targets:  % reduction of events in a certain period

10. USC Hazard identification  ICAO hazard identification is Flight Operations oriented  Does not really focus on Maintenance hazards  But hazards in maintenance can pose risk to safety of flight

11. USC Maintenance - related accidents  An airplane failure caused by Maintenance may be: Primary Cause of an accident. Contributing Factor to an accident.

12. USC Example: primary cause Aloha Airlines - 1988

13. USC Example: primary cause  Investigation findings:  Hundreds of cracks undetected prior to accident  Contributing factors:  Lack of resources  Fatigue  Lack of training

14. USC Example: primary cause  Alaska Airlines Flight 261  January 31, 2000

15. Stabilizer Movement Stops Stabilizer Movement Stops Autopilot Disconnect Autopilot Disconnect Up to 50 pounds Pulling Force Up to 50 pounds Pulling Force Approximately 30 pounds Pulling Force Approximately 30 pounds Pulling Force Alaska Airlines Flight 261 Ascent from Puerto Vallarta

16. First Dive First Dive Above Maximum Airspeed Extremely Loud Noise Alaska Airlines Flight 261 Final 12 Minutes Alaska Airlines Flight 261 Final 12 Minutes Click on CVR Stabilizer moves beyond full nose down “…kinda stabilized” Cleared to descend to 17,000 feet Cleared to descend to 17,000 feet Slats, Flaps Extended Slats, Flaps Retracted Sound of faint thumps

17. Recovered Jackscrew Assembly Screw attached to horizontal stabilizer Separated from acme nut Nut thread remnants on screw

18. Summary of Findings Material and structural conditions did not contribute to the acme nut wear No grease in working area of the screw Grease not removed by ocean impact, exposure, or recovery Jackscrew grease not contaminated The wear is caused by sliding contact and is consistent with an unlubricated condition Torque tube fractured by low cycle fatigue Material and structural conditions did not contribute to the acme nut wear No grease in working area of the screw Grease not removed by ocean impact, exposure, or recovery Jackscrew grease not contaminated The wear is caused by sliding contact and is consistent with an unlubricated condition Torque tube fractured by low cycle fatigue

19. Lubrication: The Procedure Gain access to the tail Remove access panels Gain access to the tail Remove access panels

20. Lubrication: The Procedure Apply grease to acme nut fitting with grease gun until grease exits out top of acme nut FAIRING ACCESS PANELS GREASE GUN

21. Lubrication: The Procedure Brush application of “light coat of grease” onto jackscrew threads Operate jackscrew “through full range of travel” Brush application of “light coat of grease” onto jackscrew threads Operate jackscrew “through full range of travel” BRUSH

22. Jackscrew Lubrication: Alaska Airlines Interval Extension Manufacturer's Recommended Interval Alaska Airlines Interval

23. End Play Check: Alaska Airlines Interval Extension Manufacturer's Recommended Interval

24. USC Example: primary cause  Loss of pitch control due to the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads caused by excessive wear due to insufficient lubrication.  Contributing factors  Airline extended lubrication interval and FAA approval of that interval.  Airline extended end-play check interval and FAA’s approval of the interval.  Acme nut zerk fitting was clogged with hardened grease residue.

25. USC SMS and QMS  Quality is the degree to which a system consistently meets specified requirements, satisfies stated needs, or produces desired outcomes

26. USC SMS and QMS  ICAO  Document 9859, Section 7.6  SMS focuses on the safety, human and organizational aspects of an organization (i.e. safety satisfaction); while QMS focuses on the products and services of an organization (i.e. customer satisfaction) ..”ICAO safety management SARPs included in Annexes 1, 6, 8, 11 and 14…are limited to SMS. There are no ICAO requirements…with regard to QMS, with the sole exception of a requirement for approved maintenance organizations (AMO) in Annex 6, Part I, Chapter 8”

27. USC SMS and QMS  Quality Control  Rejection Review  Quality Assurance  Findings Review  Quality Review Process  Quality Review Board  Reliability Review Board

28. USC SMS and QMS  Acceptable level of Quality?  Metrics  Nature of rejections/findings  Operational  Both should be numerical and have performance targets  AloQ alignment with AloS?  Coordinated Metrics, Risk Matrix  Shared Objectives

29. USC SMS and QMS  Options  Integrate or Coordinate  Pros / Cons  In a Large Carrier  QMS reviewed by CASS (Continued Analysis and Surveillance System)  SMS can be integrated or coordinated with CASS

30. 30 PROBABILITY ABCD SEVERITY I II III IV CATASTROPHIC CRITICAL MARGINAL NEGLIGIBLE 23 4 234 5 3455 SEVERE NEGLIGIBLE LOW RISK MATRIX E HIGH MEDIUM LOW SEVERE

31. USC 31

32. USC * Rate per 1000 Revenue Departures High1.2.2 Major Repairs and Alterations RecordsX Medium1.2.1 Airworthiness Release or Log Book EntryX Low1.2.3 Maintenance Log / Recording RequirementsX RiskDistributionQty Example: SMS and QMS Coordination 42Self Disclosure Rolling 20XXJul 20XXCorrective Actions Rolling 20XXJul 20XXRisk Level 41716Closed 3In-Progress 12Low 33High 22Average Rolling 20XXJul 20XXSource 1MSR 113ASAP 241 / 967 / 5Findings / Audits

33. USC SMS and QMS: Education and Training  Prior to Implementation  During Deployment Phase  Ongoing after SMS is in Place  Dealing with Interfaces  Vendors  Other Operational Areas  Providing Feedback  To Individuals  To Other Departments

34. USC SMS and QMS  Questions?