On Sept. 21, 2014, the flight crew commanding a Delta Air Lines Boeing 747-400, reacting quickly to an engine power loss just after liftoff at Atlanta Hartsfield-Jackson International Airport, shut down the aircraft’s No. 4 engine. The pilots then discharged two fire bottles into the laboring Pratt & Whitney PW4056’s nacelle, wiping out an onboard fire warning after about 80 sec. They spent the next 80 min. cruising around and dumping about 280,000 lb. of fuel in preparation for what would be an uneventful return to Hartsfield.
An NTSB report on the incident found that an improper compressor blade overhaul procedure done a year earlier at a repair station half a world away had set the stage for a blade to fracture and choke the engine.
The incident’s only casualty was the core of one high-bypass turbofan, but it serves as a cautionary tale of how easily a single misstep can tarnish a seemingly ever-improving industry safety record.
Macro figures suggest that commercial aviation is in an unprecedented era of safe operations. The latest figures from the International Air Transport Association (IATA) showed a 2015 global jet accident rate—measured in hull losses per 1 million flights—of 0.32, or one major accident for every 3.1 million flights. While slightly up from 2014’s 0.27 rate, it is a 30% improvement on the 0.46 rolling rate of the previous five years. The commercial turboprop hull-loss rate improved to 1.29 hull losses per million flights in 2015 compared to 3.95 in the five years ending in 2014.
While few would dispute that the industry’s safety record is stellar, fewer still would argue that nothing more can be done. In the maintenance arena, major pushes following seminal accidents have led to widespread changes. The 1988 Aloha Airlines accident opened industry’s eyes to the catastrophic consequences of latent metal fatigue. The 1996 inflight explosion of TWA Flight 800 changed design, certification and maintenance procedures around wiring and center fuel tanks. The results of these accidents—such as retrofitting aircraft with fuel tank inerting systems and conducting additional inspections on aging aircraft—are part of many maintenance programs today.
But while the flight operations world continues to be reshaped by lessons learned from more recent accidents—revamped pilot training standards in the aftermath of Colgan Airways Flight 3407 in 2009 is one example—the maintenance arena has no recent accidents driving industry-altering changes. Yet figures show the MRO world has room to improve.
Each spring, IATA releases a report examining the previous year’s accidents. The most recent version, issued in April 2015, listed 73 accidents in 2014 that met IATA criteria for inclusion in its analysis. The most common category, accounting for 23 accidents, was landing gear malfunction. In six of them, maintenance-related issues were cited as contributing factors.
Put another way, maintenance-related deficiencies were a factor in 26% of the most frequent type of IATA-defined commercial aviation accidents two years ago. Statistics like these underscore the push for MROs to improve.
In some cases, changes can be linked to specific incidents. The repair station that worked on the PW4056 parts implicated in the Delta 747 incident, Turbine Overhaul Services (TOS) in Singapore, audited its overhaul process for the blades in question. TOS discovered that its “grit blasting” process, used to prepare the airfoil part of the blade for needed coatings, was exposing blade necks to media that should be applied only to the blades’ outer surface. This left the blades susceptible to fracturing. TOS changed its procedures to ensure blade necks would not be exposed to grit blasting.
Investigating events and implementing findings-based corrective action is nearly as old as flight itself. As incidents become more infrequent, most people recognize that a risk-based approach is needed to keep improving safety.
This realization is why programs such as the FAA-led Aviation Safety Information Analysis and Sharing (Asias) effort, which aggregates flight and operations data from different organizations to help spot trends, have grown so popular. Airlines that feed data into Asias account for about 96% of all U.S. commercial operations. In 2014, the FAA called for MRO providers to join Asias. AAR Corp. and Haeco Americas did. Both organizations expect to reap benefits—in time.
Haeco International has tapped Ideagen and its cloud-based Gael Enlighten incident reporting and analysis software as the foundation of its Asias database, explains Dave Latimer, Haeco Americas vice president of Regulatory Compliance. “We’re moving along, but we really wanted to have a strong, risk-based program to manage the data.”
Haeco Americas is not waiting for Asias to boost its risk-based approach. Prompted by efforts to gain certification from several civil aviation authorities that require safety management systems (SMS), the company six months ago launched its own program.
Haeco has adopted IATA’s SMS template, developed a customized manual and trained senior staff. The last pre-launch step is training SMS working groups at each of its North American sites.
“By the end of [the second quarter] or the beginning of [the third], we’re going to have a full-blown SMS that assesses all aspects of safety—everything from employee health to risks associated with aircraft systems,” Latimer says.
Internally, SMS is expected to deliver myriad benefits, including proactively evaluating proposed changes. “Before we develop a new procedure or even modify an existing one, that program would be assessed by an SMS group to determine whether any of those changes will have a negative impact and ensure they deliver the positive impact we’re looking for,” Latimer says.
External benefits are even more tantalizing. Most of Haeco’s North American customers either have deployed or or are close to deploying SMS, thanks largely to an extensive FAA pilot program that preceded a 2015 mandate calling for SMS at airlines within three years. By connecting with a customer’s SMS up front, MRO providers can feed data into an airline’s system, giving the repair station’s customers unprecedented big-picture insight.
“The hope is I’ll have all this data in my risk management system, and my customers can go in on a quarterly basis and pull everything that Asias pulls,” Latimer says. “It will be ‘de-identified,’ but they will know exactly what Haeco’s issues are and how we’re addressing them.”
Such tight integrations may not be far off. Haeco Americas feeds data directly into one customer’s SMS. Latimer believes that setting up such exchanges will soon become part of the “airworthiness agreement,” or the basis of each contract between an operator and a repair station. “As our customers implement their SMS, instead of corrective action requests, we’re starting to see different forms of communication coming out of the air carriers,” he says. “We address the issues and can feed the information right back into their SMS.”
Spreading internal program benefits beyond hangar doors is what motivated Pemco to hold its first-ever Lean summit for suppliers earlier this year.
“We thought sharing our journey was very important, [and] we wanted to learn from others’ journeys,” explains Pastor Lopez, Pemco World Air Services CEO.
Lopez, who took over at the MRO provider and freighter conversions specialist last May, immediately became the company’s Lean champion. He chose to focus the Lean effort on the MRO side, deploying a “value stream team” to map out the process of performing a check on a customer aircraft.
“Once the process was mapped, it was reviewed for waste,” he says. “As the waste was identified, it was grouped into buckets of similar waste. The buckets were then reviewed for overall impact to the operation, and a year’s worth of rapid improvement events [RIE] were determined.”
Specially trained teams tackle the RIEs in search of improvements to incorporate into existing processes.
Among the focus areas were revamping material delivery processes to better match routine and nonroutine tasks being performed in specific areas of the hangar. Pemco also set up task assignment boards that convey specific assignments to workers before their shift starts. The benefit: Workers spend less time transitioning between tasks, both physically and mentally.
Efforts such as Lean come down to tracking data and enacting changes based on the figures. Pemco has a set of metrics that are reviewed weekly, and a broader set that is scrutinized monthly.
Last year’s metrics underscore Pemco’s progress, Lopez says. The company pushed the all-important on-time delivery metric up 19% over 2014 and boosted revenue per bay by the same figure. Employee turnover fell 29%. Most important, the added efficiency did not compromise safety or quality.
“Our lean efforts had a profound effect on our on-time performance for 2015,” Lopez says. “Likewise, aircraft reliability, employee injuries, and aircraft damages improved over the previous year.”
Pemco’s success shows how proven programs like Lean, which the U.S. Air Force first studied 25 years ago as a tool for aircraft production, can help aviation companies meet emerging initiatives such as risked-based safety programs. Haeco Americas is having similar success with its Aviation Safety Action Program (ASAP).
The FAA set up ASAP, a voluntary system employees can use to disclose safety issues anonymously without fear of retribution, in 1997. Five years ago, Haeco became the first repair station to implement an ASAP program.
“ASAP, if used correctly, is an amazing program,” Latimer says. “We’ve had several reports that had an immediate impact on aviation safety. In one case, we were able to avoid an incident as a result of one of those filings.”
Because ASAP data is fed into Asias programs, such findings will soon have positive ramifications industry-wide.
“Within Asias, what you’re going to see is data that says, ‘These are common events that we’re seeing, and here are some recommended actions to take,’” Latimer says. “That’s where we see the value, and I believe it’s huge value.”