The MAA’s Defence Aviation Error Management project generates impressive early results
The Nimrod Review report in 2009 highlighted the potential benefits to Air Safety Management of a system for truly pan-Defence aviation error management.
The work necessary to implement such a system was launched by the Military Aviation Authority (MAA) in 2010 as the Defence Aviation Error Management System (DAEMS) Project to manage the necessary training, implementation and skills transfer, with technical support from a leading Air Safety company under a £2.3 million, 3½-year technical support contract. The Project will provide the specialist expertise needed to implement Error Management Systems (EMS) for all Delivery Duty Holders (DDHs) in support of their Air Safety Management Systems (ASMS), and those of their Operational Duty Holders (ODHs). It will include training for personnel in all '4 worlds'1 of Defence aviation to enable them to understand the concepts involved and to play their part in reporting and managing errors, hazards and near misses. The Project will also embed Human Factors (HF) and Error Management (EM) training in specialist training courses so that future generations in Defence aviation will come to regard this as normal business in managing safety.
The Baines Simmons DAEMS team at 29 Sqn the Typhoon Operational Conversion Unit, RAF Coningsby
The Technical Support contract for the DAEMS Project was placed with Baines Simmons Limited on 30 August 2011. Since then, the DAEMS Project Team in the MAA and Baines Simmons, and the project officers nominated in NCHQ, HQ JHC and Royal Air Force (RAF) Flight Safety have been working on the progressive implementation of EMS at units in the respective ODHs’ areas of responsibility. This note provides a summary of progress as at June 2012.
The lessons drawn from an early Field Development Phase (FDP) of the DAEMS Project, held at RNAS Culdrose in 2011, and from the RAF’s Aviation Error Management System (AEMS) work, have informed the design of a flexible model for the application of implementation and training at units, supported by tailored training material that will maximize skills transfer. A full package of courses has been developed to provide foundation HF and EM training for personnel at junior, middle and senior levels on units, and training in the specialist investigation, review and system management roles in an EMS. This training material has been produced in formats consistent with the Defence Systems Approach to Training (DSAT), with accompanying Training Objectives (TOs), Enabling Objectives (EOs) and Instructional Specifications (ISpecs). These will be provided to training schools through the appropriate Training Requirements Authorities (TRAs) for Services, branches and trades once suitable long-term in-house training arrangements for each course or role have been identified. JPA competences have been created for each course and role to enable training to be recorded and tracked.
An initial scoping visit with 9 Regiment Army Air Corp at Dishforth was carried out in May. L-R WO1 Ade Pickering, Maj Keith Armstrong (JHC), Maj Steve Binning, Baines Simmons Principal Consultant Steve Harriss and Capt Jamz Cunningham
An overall implementation project plan has been developed in conjunction with Service and ODH project officers, with units placed in accordance with the priorities set by their ODH and taking account of their operational, training and other commitments and constraints. The process of engagement for each unit begins with a Training and Learning Needs Analysis (TLNA) to define the scope of work and training needed and to assess existing levels of HF and EM understanding so that training can be tailored accordingly. Once this analysis is complete, Baines Simmons staff work with unit project officers to brief senior management, design and implement the local systems, orders and procedures needed, and start training those who play key parts in running the unit EMS. Once the necessary orders and processes are in place, the EMS is ready to use and training begins for those unit personnel across all of the ‘4 worlds’.
Following senior level engagement and training at HQ Air Command, the first unit in the DAEMS Project implementation programme was RAF Leuchars, which hosted its training courses in January and February 2012, and ‘switched on’ its EMS at the end of February 2012. The benefits were quickly apparent, with a number of potential hazards and error-provoking conditions highlighted and addressed in the first few weeks. In launching his EMS the Station Commander and Air Officer Scotland said:
"At RAF Leuchars we are rightly proud of our achievements and our reputation for excellence in all that we do. In order to preserve and continuously improve our standards and working practices we must adopt an open and honest reporting culture: we need to know what’s wrong so that we can fix it. That means that we must admit and report our mistakes. In a Just Culture honest and well-intentioned mistakes are not punished, they are learned from. If you have the courage to admit your mistakes, submit an EMS report, and so play your part in preventing the same mistake being made again, you will have nothing but my thanks and admiration."
By the end of March one of his warrant officers said:
"Apart from the obvious benefits we have experienced from the introduction of an EMS across the Station, which usually manifest themselves as an increase in the number of reports submitted, there is another less tangible indicator which is probably far more significant. For some time now there has appeared to be a perception that it was not a good idea to admit that you had made a mistake, almost as though admitting that an aircraft engineer had made a mistake somehow de-valued the aircraft engineer cadre. So admitting that a mistake had been made was not the 'done thing', and people were reluctant to do so. Since we have rolled out the EMS across the whole station this 'credibility' issue seems to have gone away: all of a sudden the whole station is able to admit to making errors, without fear of losing credibility. It is no longer seen as 'uncompetitive' to hold your hands-up and admit that you have made a mistake. I believe with the Service-wide introduction of EMS we have removed the perception that admitting to making an error makes you a less capable tradesmen. I firmly believe that there is now a genuine acceptance of EMS as a Service-wide vehicle to make things better and because it is across the whole station, my guys are more willing to use it. This may well be an intangible aspect of what we have sought to achieve, but it is a far better indication of the effectiveness of the system than just the number of reports raised."
So far the DAEMS Project has provided HF and EM training to the HQ staff of all five ODHs, and implemented error management systems for the DDHs’ organizations at five units, with a further three in progress. A total of 3,011 people have received HF and EM training in the course 136 training-days; results that indicate that the project is some 20 per cent of the way through the total target of five ODHs and 27 DDHs, and has expended some 20 per cent of the planned resource in the first 10 months of a 42-month contract. The implementation programme will continue into 2013 and 2014 for the remaining 19 DDH units, and for DE&S project teams who are being involved in the project in parallel with the aircraft types that they support.
During this time a great deal has been learned. It is now clear that the ‘population’ of the 4 worlds is greater than first estimated, and that more effort is needed at the start of each unit engagement with the TLNA to analyse numbers and HF/EM knowledge levels in greater depth. The MAA will be providing unit project officers with more detailed guidance on how to prepare for this, and it is conducting a parallel higher-level analysis so that it can continue to maintain a proportionate allocation of resources through the remainder of the project. The MAA recognizes the need to target future training programmes more effectively, and to develop other training solutions in addition to the Baines Simmons courses. These might include facilitated workplace discussions of how to get the best from EMS, making use of local training capabilities, and accelerating the work with in-house training schools to ensure that those arriving from training reach their new units fully HF and EM ‘capable’. The MAA is developing a better model for implementation and training at unit level, with a focus on those activities that most effectively transfer EM skills to the unit. Finally, with the arrival of long-awaited DAEMS Project management staff in both the MAA and Baines Simmons more will be done to monitor and assure the results of EMS implementation work at the unit level, and to communicate the results across Defence Aviation.
1The 4 worlds of Defence Aviation are the aircrew, engineers, air traffic management personnel, and other support elements such as logistics, movements and ground-handling staff, bowser drivers, and anyone else whose work bring them into contact with aviation activities.