ENGINEERING & MAINTNANCE
Edited by: Salahuddin Azhar salahuddin.azhar@piac.aero
Maintenance Error example from Distinguishing Aviation and Occupational Health,
our experience: Safety & Environment (OSHE) Hazards
Reference investigation report B777/BGY/01-
3/15 dated 11/08/2015 AP-BGY
Flight # PK-783 was on schedule flight from
th
Karachi (KHI) to Toronto on 29 March, 2015.
Aircraft diverted to Karachi while operating
PK783 (KHI-YYZ) due following EICAS
message HYD QTY LOW C appears with
quantity showing 0.28 units. Also EICAS
message RESERVE BRAKES/STRG (Steering) indirectly) on the operational
appears.
The aircraft diverted to Karachi and made safe
landing.
During investigation, lock wire on Differential
Pressure Indicator (DPI) for pressure filter found having purely OSHE
broken and O-ring seal was also damaged. The
centre Hydraulic system fluid depleted after
escaping through damaged seal.
The maintenance records did not indicate pop out by the organization‘s OSHE
of DPI and its reset which involves opening of
DPI.
Apparently the mechanic carrying out the
maintenance activity and reuse the O-ring seal
and did not record the maintenance .
As per AMM O-ring seal do not reuse. During
inspection O-ring seal replaced and discard
old seal.
Maintenance Error Reporting Policy
MOE 2.25
As policy, management functions must
encourage maintenance error reporting by
personnel in the Organization. Chief Engineer
(QA) shall ensure that no punitive action shall be
initiated against person reporting such errors.
Issue August 2015
Understanding whether a
hazard is pertinent to aviation
safety or Occupational Safety,
Health & Environment (OSHE)
would depend on its potential
or foreseeable consequence or
risk. Any hazard that can have
an impact (whether directly or
safety of aircraft or aviation
safety related equipment,
products and services should
be deemed to be pertinent to
an aviation SMS. A hazard
consequences only (i.e. without
any aviation safety impact),
should be separately addressed
system / procedures in
accordance with its relevant
national or organizational
OSHE requirements as
appropriate. OSHE hazards and
consequences with no impact
on aviation safety are not
pertinent to an aviation SMS.
Safety risks associated with compound hazards that simultaneously
impact aviation safety as well as OSHE, may be managed through
separate (parallel) risk mitigation processes to address the
separate aviation and OSHE consequences respectively.
Alternatively, an integrated aviation & OSHE risk mitigation system
may be used to address such compounded hazards. An example of
a compounded hazard is ―lightning strike on an aircraft‖ (at an airport
transit gate). This hazard may be deemed by an OSHE inspector as a
Workplace hazard‖ (ground personnel/ workplace safety).
To an aviation SMS inspector it is also an aviation hazard with risk of
damage to aircraft and passenger safety. Since OSHE and aviation safety
consequences of such compounded hazards are not the same, due
consideration should be taken to manage them separately. The purpose
and focus of preventive controls for OSHE and aviation safety
consequences would be different.
Ref: ICAO SMM Doc 9859 Ed:3
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ENGINEERING & MAINTNANCE

Edited by: Salahuddin Azhar salahuddin.azhar@piac.aero Issue August 2015

Understanding Hazards and Consequences

A hazard is generically defined by safety practitioners as a condition or an object with the potential to cause death, injuries to
personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function. For the
purpose of aviation safety risk management, hazard should be focused on those conditions that could cause or contribute to
unsafe operation of aircraft or aviation safety related equipment, product and services. (Guidance on distinguishing hazards
which are directly pertinent to aviation safety from other general/industrial hazards is addressed in ICAO SMM Doc 9859 1.12.4.
Consider, for example, a fifteen-knot wind, which is not necessarily a hazardous condition. In fact, a fifteen-knot wind blowing
directly down the runway improves aircraft takeoff and landing performance. However, a fifteen-knot wind blowing in a direction
ninety degrees across a runway of intended take-off or landing creates a crosswind condition that may be hazardous due to its
potential to contribute to an aircraft operational occurrence, such as lateral runway excursion. Hazards are an inevitable part of
aviation activities. However, their manifestation and possible consequences can be addressed through various mitigation
strategies to contain the hazard‘s potential from resulting in unsafe aircraft or aviation equipment operations. There is a common
tendency to confuse hazards with their consequences or outcomes. A consequence is an outcome that could be triggered by a
hazard. For example, a runway excursion (overrun) is a projected consequence in relation to the hazard of a contaminated
runway. By first defining the hazard clearly, one can then project the proper consequence or outcome. It may be noted that
consequences can be multi-layered, including such as an intermediate unsafe event, before an ultimate consequence (accident).
In the crosswind example above, an immediate outcome of the hazard could be loss of lateral control followed by a consequent
runway excursion. The ultimate consequence could be an accident. The damaging potential of a hazard materializes through one
or many consequences. It is therefore important for safety assessments to include a comprehensive account of all likely
consequences described accurately and in practical terms. The most extreme consequence, loss of human life, should be
differentiated from those that involve the potential for lesser consequences such as increased flight crew workload, passenger
discomfort or reduction in safety margins. The description of consequences according to their plausible outcomes will facilitate the
development and implementation of effective mitigation strategies through proper prioritization and allocation of limited resources.
Proper hazard identification leads to appropriate evaluation of their potential outcomes.
Other example are Bird strike, Non compliance with mandatory requirement, and Inadequate recording of maintenance .
Hazards should be differentiated from error, a normal and unavoidable component of human performance, which must be
managed.
Hazard Identification Methodologies
The three methodologies for identifying hazards are:
1. Reactive – Through analysis of past outcomes or events. Hazards are identified through investigation of safety occurrences. Incidents
and accidents are clear indicators of systems‘ deficiencies and therefore can be used to determine the hazards that were both
contributing to the event or are latent.
2. Proactive – Through analysis of existing or real time situations. This is the primary job of the safety assurance function with its audits,
evaluations, employee reporting, and the associated analysis and assessment processes. This involves actively seeking hazards in the
existing processes.
3Predictive – . Through data gathering in order to identify possible negative future outcomes or events. Analyzing system processes
and the environment to identify potential future hazards and initiating mitigating actions.

Confidential & Voluntary Safety Reporting through (SAMS)

Reporter registration and activation on SAMS
New user (reporter) will go to the PIAC web page, click corporate icon and
then SMS, new page will display with SAMS login page. Existing user can
just login, whereas, new user can click the option “create account”
Subsequently, a new page with new fields for potential user will open. After
filling the required information, the register button can be pressed. E-mail
notification will be sent at given email address.
In parallel, an email notification is also received by the Administrator.
Administrator will send the reply email.
For activation you send a email to pkfdm@piac.aero with following
information , Name, P No. , Section/Division/Department , Station of duty
and Name of Manager /Incharge. After receiving the response
about above information, administrator will activate the new user as
registered reporter. The primary function of reporter is to submit reports of potential safety hazards observed during work.

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