Memorandum as Corrective Action

[Abhishek Jain]

This is my first post here, hope everything goes well!

I work in a maintenance -145 and -CAMO organization. We also have other ISO and CAR approvals.
I am part of the compliance monitoring team here, and a recurring issue here is that our use of HFACS and MEDA model seems to provide the auditees with an easy way out with some of the NC types.

RCA: "RCA revealed that some employees were not aware of the procedure"
MEDA H6 - Work Process/ Procedure
CA: "All relevant employees shall be made aware of the procedure and importance of following the procedures in place via Technical Memorandum"

Now, this is the same for 60% of the NCs raised for "ineffective implementation" of any process. This is there heavily for stores based processes.
My question here is that given enough time the Memo repository would parallel the existing SOPs and Manuals, and the same non-awareness issue will arise again.
I feel an "ineffective monitoring of x, y, z processes" combined level 1 NC would be the way to set things in the right direction? Not in a punitive way, just to get the correct RCCA and to resolve future repetition of the NCs.
Is there any other way to go about it? Or is a memo the right way, combining the correction and corrective action for such findings?

Added by Moderator

• 145 - Aircraft Maintenance Organization
• CAMO - Continuing Airworthiness Management Organization
• HFACS - Human Factor Analysis and Classification System
• MEDA - Maintenance Event Decision Aid

 

[QuinnM]

Hi Abhishek,
Welcome to the Cove. I'll focus on one point. If many RCAs are "RCA revealed that some employees were not aware of the procedure" then there is an issue with the training program. The RCA s not going far enough. As far as the memo, I would need to better understand the companies nonconformance / CAPA process. Is there a person who reviews the NCs for final approval, for maybe the could help?

 

[Abhishek Jain]

Hi Abhishek,
Welcome to the Cove. I'll focus on one point. If many RCAs are "RCA revealed that some employees were not aware of the procedure" then there is an issue with the training program. The RCA s not going far enough. As far as the memo, I would need to better understand the companies nonconformance / CAPA process. Is there a person who reviews the NCs for final approval, for maybe the could help?

We are the ones who review the NCs for final approval, raising and RCCA acceptance, so the question is how do we change our approach here?
As for the training program, the "ineffective implementation" is of the SOPs that are not trained against, but more-like receive on-the-job training for.
The memos would be something along the lines of "...advising all employees to refer SOP-xyz for carrying out abc tasks."

 

[gakiss2]

Based on your description, mainly the repeated use of 'review the procedure' I feel that I can say that the CA has not been effective, especially when you start reviewing the same procedure with the same team members. So, first order of business is a deeper investigation to find the true root cause. I've seen training mentioned above and that makes some sense but be sure to talk with the folks who have 'forgotten' the procedure and ask then where they are struggling.

On the 'detection' side of things, I would recommend looking into a Layered Process Audit in which a quick check that the folks on the line understand the procedure and are doing it correctly. You can look in more detail on LPA. The basics are that you have different layers of the organization (meaning mgmt, supv., technician) use a check list to verify that things are set up and done correctly. the auditor immediately corrects anything they find wrrong that they can so the member who is not doing the procedure properly gets a quick reminder and the auditor verifies they get it right. Some items can't be fixed immediately, they get put on an action list to run those down.

This LPA won't fix the root cause but it does do a better job of monitoring and correcting

 

[Bev D]

Hey @Randy - do you think a technical memo to tell operators to be more aware of procedures is sufficient for aircraft maintenance?

Aircraft maintenance? Time for some tough love:

Memos and retraining and “awareness” are NEVER sufficient. Do you have any evidence that these pieces of paper are effective at preventing recurrence? Knowing what I know about ‘operator awareness’ I can say that you don’t have any evidence. WHY are the operators not aware of procedures? And what do you mean by ‘not aware’? I suppose that it means that they aren’t following the procedures…since they unaware of them…In which case how the heck can untrained operators be allowed to work on aircraft maintenance?

The only way out of this black hole to hell is that the operators do in fact know what they are doing, are doing it correctly and are not creating any quality/safety problems; but the auditors are focusing on whether or not the operators know where the silly pieces of paper are, what they say and what they are called. Most likely because they are silly and incorrect and supercilious.

This difference is critically important and is why so called ROOT CAUSE ANALYSIS is supposed to get at the root or the problem in order to prevent recurrence.

So which is it?

Otherwise, you have a serious systematic problem and your so called corrective actions to prevent recurrence are lazy, wasteful and ignorant. How’s that for an answer?

You are correct to suspect that this is the wrong thing to do - but are far too casual and surface in your concern…I get that it is probably tough to buck the management trend but this is a disgrace especially as it affects human life in an industry that used to pride itself in it’s dedication to safety.