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

causes were unlikely, in isolation or in combination, to result in ahazardous event in the future. A CAD Airworthiness Officer wouldexpect to see evidence of action(s) to prevent root causes, and/or tomitigate the effects of error where appropriate.(g)Evidence of feedback to the workforce, on both occurrences and theirinvestigation, and remedial action taken, would also be expected.3.3 For a small organisation, the CAD Airworthiness Officer would expectevidence as described above, but on a less structured basis.3.4 If an organisation has no evidence to offer in the form of reported andinvestigated occurrences, the CAD Airworthiness Officer may wish to talk tostaff to assure himself that there have been no such occurrences, as opposed tooccurrences going unreported and uninvestigated. The CAD AirworthinessOfficer would respect staff confidences in seeking such evidence.4 MEMS Code of Practice4.1 The Director-General encourages organisations to adopt the following code ofpractice regarding a MEMS:4.1.1 Where an occurrence reported via MEMS indicates an unpremeditatedor inadvertent lapse by an employee, as described below, the Director-General would expect the employer to act reasonably, agreeing thatfree and full reporting is the primary aim in order to establish why theevent happened by studying the contributory factors that led to theincident, and that every effort should be made to avoid action that mayinhibit reporting.4.1.2 In the context of error management it is considered that anunpremeditated or inadvertent lapse should not incur any punitiveaction, but a breach of professionalism may do so. As a guideline,individuals should not attract punitive action unless:(a)(b)(c)(d)the act was intended to cause deliberate harm or damage.the person concerned does not have a constructive attitudetowards complying with safe operating procedures.the person concerned knowingly violated procedures that werereadily available, workable, intelligible and correct.the person concerned has been involved previously in similarlapses.AN-71 P.530 September 2006