The Nimrod Review - Official Documents

The Nimrod Review
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Commander Jeanne Paul (XO Programmes, COS SPP) and the support of Air Commodore Julian Young
(ACOS A4). The great advantage of HF M(EMS) is that it encourages a pro-active reporting and trend analysis
culture. Using the ‘Iceberg Analogy’, HF (M)EMS focuses attention on the ‘below the waterline’ near-misses,
which, if openly and honestly reported in sufficient numbers, provide valuable information and visibility of
potential issues before an incident or accident occurs. This changes fundamentally the approach of hazard
management from reactive to pro-active. (See Heinrich’s Triangle, CHAPTER 18).
Following a rise in the RAF’s HF-related maintenance incidents in 2007, early in 2008 Jeanne Paul analysed
the last two years’ Flight Safety Investigations (RAF F765Bs) in accordance with current Error Management
theory. 39 Her review showed three things. First, an increase in repeat incidents, indicating that the root
causes of the maintenance errors were not being addressed effectively in the first place. Second, the RAF had
particular HF-related maintenance issues which stemmed from motivation-based, ‘can do’ cultural errors in
the maintenance arena. Third, these problems resulted in part from the cumulative effect of recent significant
‘change initiatives’ (some of which were undertaken to meet Defence efficiency targets) compounded by
an increase in operational tempo. Jeanne Paul then attended a Confidential Human Incident Reporting
Programme (CHIRP) meeting where the civil community share best practice, at which she learnt of the
work of Baines Simmons Ltd. (Baines Simmons) who have proven expertise in project-managing HF (M)
EMS in the civil sphere and had recently had successfully helped the Army introduce HF (M)EMS in a military
support environment at the Apache Helicopter Depth Support Unit at Wattisham. Jeanne Paul briefed Air
Commodore Young and proposed the introduction and implementation of an RAF-wide HF (M)EMS using
Baines Simmons. Julian Young supported the proposal, lobbied for the funding necessary and sponsored
the Business Case for a four-year contract to introduce HF (M)EMS in the Forward environment on 12 of the
RAF’s Main Operating Bases (MOBs). Between April and October 2008, Jeanne Paul visited the majority of the
MOBs and gained the support of all the Officer Commanding Forward Support Wings (OC FSWs – the senior
Engineer Officer at an MOB). DE&S committed to supporting Air Command by ensuring that the PTs would
be able to act intelligently on HF (M)EMS data as it flowed from Forward into the Support environment. A
paper on HF (M)EMS implementation was submitted to HQ Air Command’s 2-star Command Delivery Group
in January 2009 and was endorsed. The Air Command HF (M)EMS programme is set to roll out in four phases
over 42 months:
(1) Phase 1 – Understanding: assessing the current position using Error Management Diagnostic
(EMD) and Safety Culture Surveys at the MOBs.
(2) Phase 2 – Enabling: developing ‘Just Culture’ policy, Fatigue Management policy, Shift/Task
Handover defences, Roles and Responsibilities, Training Needs Analysis on MOBs. 40
(3) Phase 3 – Reporting: training Maintenance Error Investigators (MEI) as part of a three-month
trial for the civil industry standard investigative/reporting tool, Maintenance Error Decision Aid
(MEDA), with the aim of training approximately 15-20 MEIs on each MOB.
(4) Phase 4 – Learning: continue skills and MEI training, quality assurance and sharing of best practice
with industry.
The (M)EMS initiative is already paying substantial dividends in the RAF: to date five investigations have
been carried out using the new techniques and there is a radical improvement in both (a) the quality of
investigation, and (b) the effectiveness of the interventions and solutions recommended.
In early 2009, DE&S asked Jeanne Paul to brief both Joint Helicopter Command and Fleet (RN) about the Air
Command project; both Commands have expressed significant interest in adopting HF (M)EMS, tailored to
their own specific operating environments. This has led to a proposal that Air Command should take the lead
for implementing HF (M)EMS across all four Top Level Budgets (TLBs) (Air Command, Land Command, Fleet
and DE&S) to ensure consistency of approach and common processes across the Joint Defence environment.
Funding to achieve this aim has, however, not been identified, and is expected to be an issue.
39 Reason, J and Hobbs, A. (2003). MANAGING MAINTENANCE ERROR A Practical Guide. Aldershot: Ashgate.
40 Baines Simmons Ltd Flowchart Analysis of Investigation Results (FAIR) System developed in April 2009, and adapted by Air Commodore Young,
specifically to support the RAF HF (M)EMS introduction.