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31 July 2011 C1 CIVIL AVIATION DEPARTMENT HONG KONG ...

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• Feedback of results to workforce• Analysis of the collective data showing contributing factor trends andfrequencies2.3 The aim of the scheme is to identify the factors contributing to incidents, andto make the system resistant to similar errors. Whilst not essential to thesuccess of a MEMS, it is recommended that for large organisations acomputerised database be used for storage and analysis of MEMS data. Thiswould enable the full potential of such a system to be utilised in managingerrors.2.4 For the purpose of this Notice a maintenance error is considered to haveoccurred when the maintenance system, including the human element, fails toperform in the manner expected in order to achieve its safety objectives. Thehuman element includes technicians, engineers, planners, managers, storekeepersinfact any person contributing to the maintenance process. Theforegoing definition differs from that of a human error as it demandsconsideration of the system failings (e.g. inadequate staffing, organisationalfactors, tooling availability, ambiguous manuals etc.) as well as the errorcommitted by a person.3 The Director-General's Assurances3.1 It is recognised that the success of a MEMS programme is dependent on fulland free investigation without fear of action by the Director-General.Accordingly, the Director-General gives the following assurances:3.1.1 The Director-General will be checking, as part of CAD approval auditprocess, that the organisation's internal occurrence reporting andinvestigation process is functioning as described in the proceduresapproved by the Director-General and in line with the objectives of theprogramme as explained in UKCAA CAP 716 Issue 2. The CADaudit may involve the review of dis-identified MEMS investigationssuch that the foregoing can be satisfied. However, the Director-General makes the following assurances:(a)(b)The Director-General will, subject to sub-paragraph (b) below,not disclose the name of the person submitting the MEMSreport, nor of a person to whom it relates, nor pass on a MEMSreport to a third party, unless required to do so by law or unlessthe persons(s) concerned authorises such disclosure.The Director-General will take all reasonable steps possible toavoid disclosing the identity of the reporter or of thoseindividuals involved in the occurrence, should any follow-upaction arising from a MEMS report be taken.AN-71 P.330 September 2006

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