Module 1: Maintenance Error Decision Aid
(MEDA)
What is MEDA?
• A structured process that is used to
investigate events caused by maintenance
technician and/or inspector performance.
• From error model to event model
o Reason: because not all events are
caused by errors.
• “ERROR” investigation process -> “EVENT”
investigation process
• Events - errors/violations that are committed
by the technician
• Purpose: gather the information that is
needed to carry out a MEDA event
investigation
• How: interview with the maintenance
technician and/or inspector whose
performance led to the event to find out:
o What errors and violations occurred?
o The contributing factors to the errors
and violations
Contributing Factors
• Anything that contributes to committing
events
• Contributing factors of maintenance
performance
• Some factors may not be seen, or it is not a
variable
• Can negatively affect how a maintenance
technician and/or inspector does his/her job
• Ranges from the smallest of things to critical
decision making
• Contributing Factors to Maintenance
Performance:
The MEDA Event Model
• Cause-in-fact: if “A” exists (occurred), then
“B” will occur.
• Probabilistic: if “A” exists (occurred), then
the probability of “B” occurring increases.
• In the maintenance technician/inspector’s
world.
o There are relatively few “cause-in-
fact” occurrences.
o Especially about contributing factors
causing errors.
• For the “contributing factors -> error”
relationship.
o Almost all causes are “probabilistic”.
• For the “error -> event”.
o It is possible to have some “cause-
in-fact”
• Figure 3: there is a probabilistic relationship:
o Between contributing factors and an
error and
o Between an error and an event.
• It can be 2 or more factors that can
contribute that may lead to an event.
• Figure 4: there are 3 to 5 contributing
factors to each error.
o It can be 2 or more factors that can
contribute that may lead to an event.
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• Figure 5: there are contributing factors to
the contributing factors.
o Ask why after previous answer for 5
times.
o Why were you fatigued? I only slept
for 5 hours. Why did you only sleep
for 5 hours? And so on.
o “Lead to” = causation arrows.
• Figure 7: another way that a violation can
contribute to an event.
o Failure to carry out an operational
check (a violation) at the end of a
procedure that would catch an error.

• Figure 8: if the technician failed and then

the inspector failed the system will fail and
• Figure 6: first way that a violation can an event will occur
contribute to an event. o Figures 6 and 7 can contribute to a
o The maintenance technician does single event.
not use a torque wrench when called
out in the maintenance manual to
torque a bolt (this is a violation)
o Because he does not use a torque
wrench, he under torques the bolt
(this is a system failure)
o Because the bolt is under torqued,
an event occurs, like an air turn back
o But there is a reason (contributing • Figure 9: summarization of causational
factor) for why the maintenance events
technician did not use the torque o Interprets the theoretical bases of
wrench (maybe there was no torque MEDA
wrench available to do the task or o Final event causation model that
maybe the work group norm was not includes errors and violations.
to use a torque wrench).
• There may be contributing factors to the
contributing factors.
• In some cases, the violation itself leads
directly to the event rather that to an error
that leads to an event.

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MEDA Philosophy
Explained using the final MEDA event model.
• A maintenance-related event can be caused
by an error, by a violation, or by an
error/violation combination
• Maintenance errors are not made on
purpose
• Maintenance errors are caused by a series
of contributing factors
• Violations, while intentional, are also caused
by contributing factors
• Most of these errors or violations
contributing factors are under the control of
management, therefore, can be improved
so that they do not contribute to future,
similar events.
The MEDA Investigation Process
• MEDA - developed by Boeing in 1992
To help address errors and eventually even
violations
1. Event occurs
2. Investigation finds that event was caused by
technician/inspector performance
3. Find the maintenance technician or
inspector who did the work
4. Interview the person
1. Find error/violations
2. Find contributing factors
3. Get ideas for process improvement
5. Carry out follow-up interview to get all
relevant contributing factors information
6. Add the result from investigation information
to a maintenance event data base
7. Make process improvements
a. Based on this event
b. Based on data from multiple events
8. Provide feedback to all employees affected
by the process improvements
Module 2: Safety Reporting and Safety Culture
Safety Reporting
Safety Reporting
• Accidents are obvious and fortunately rare
in the industry but near misses as well as
minor incidents are very common
• Many incidents in this industry would go
unnoticed if no one reported them.
• The reporting of incidents enables the
industry to learn from them and make the
system safer.
• The chain of events that lead to a near miss
are the same chain of events that led up to
an accident.
• Accurate and timely reporting of relevant
information related to hazards, incidents, or
accidents is a fundamental activity of safety
management. (Accurate safety reporting)
• The data used to support safety analyses
are reported by multiple sources.
• One of the best sources of data is direct
reporting by front-line personnel since they
observe hazards as part of their daily
activities.
• A workplace in which personnel have been
trained and are constantly encouraged to
report their errors and experiences is a pre-
requisite for effective safety reporting.
• Hazard - things, situations, activities, or
conditions can bring harm and can cause
lives.
• Identifying hazard is one way to prevent
accidents
• Safety management is caused by safety
hazard reporting
• Through safety hazard reporting the
management will be able to identify the
hazard and will be able to improve safety.
• To prevent hazards - reporting hazards
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Five Basic Characteristics of Effective Safety
Reporting
Willingness
• People are willing to report their errors and
experiences.
• Management should be a culture of
willingness
• Related to communication and trust
between the employees and the
management.
Information
• People are knowledgeable about the
human, technical, and organizational factors
that determine the safety of the system.
• Trained to report the proper risks.
• Knowledgeable enough to know if a certain
event is already a hazard.
• Because you have a realistic view of the
hazard you know the damage.
Flexibility
• People can adapt reporting when facing
unusual circumstances, shifting from the
established mode to a direct mode thus
allowing information to quickly reach the
appropriate decision-making level.
Learning
• People have the competence to draw
conclusions from safety information systems
and the will to implement major reforms.
Accountability
• People are encouraged and rewarded for
providing essential safety-related
information. However, there is a clear line
that differentiates between acceptable and
unacceptable behavior.
Types of Reporting
1. Online reporting
2. Hotline reporting
3. Verbal reporting
4. Hard copy reporting
Westrum Organizational Culture
Organizational literature proposes three
characterizations of organizations, depending on
how they respond to information on hazards and
safety information management. (Ron Westrum
invention)
a. Pathological - hide the information
▪ Power-oriented
b. Bureaucratic - restrain the information
▪ Rule-oriented
▪ Many factors must be considered
that’s why the process is slow
phased.
c. Generative - value the information
▪ Goal-oriented
Safety Culture
• Culture is characterized by the beliefs,
values, biases, and their resultant behavior
that are shared among members of safety,
group, or organization.
• Culture - set of values, behaviors, and
attitude.
• Encouraging or giving confidence to the
employees to report hazards.
• Safety culture is one of those nebulous
things, like safety management.
• Behavior and performance of employees
when no one is watching.
• You cannot see it or touch it.
• You can only see evidence or absence of its
existence.
• A safety culture is not something you get or
buy; it develops over time and must be
maintained – like your professional
reputation.
• A positive safety culture relies on a high
degree of trust and respect between
personnel and management and must
therefore be created and supported at the
senior management level.
• Like trust, positive safety culture takes time
and effort to establish and can be easily
lost.
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Safety Culture Maturity Model Generative
• Patrick Hudson • Generate High Reliability Organization
• Developed back in 2000 (2003) (HRO), Health, Safety, and Environment
• Specifies at which level the hazard is. (HSE)
• Increasingly informed • Is how we do business around here.
• Increasing trust and accountability • They use failure to improve, not to blame.
Pathological • Never think that their system is never
• Who cares as long as we’re not caught? enough.
• No care safety culture, “who cares” • Despite all their efforts they believe that
approach accidents may and will occur.
• Business is top priority • Safety environment is top priority. (Core
• Emerging Value)
Reactive • Safety is not driven by numbers, but by a
• Safety is important, we do a lot every time core value that safety is an integral part of
we have an accident. the operation.
• Safety is regarded as a burden. • Safety improvement is investment not a cost
• Fix to blame approach • They have outstanding communication with
• They see accidents are caused by their work force.
employees • Continually improving
• Managing
Calculative
• We have systems in place to manage all
hazards.
• Many audits are collective which will be
used to improve the system.
• The mindset of the management is the
system they have is already enough.
• Complacency
• Everything is caused by what happened in
the past.
• Safety is not the core value
• Involving
Proactive
• Safety leadership and values drive
continuous improvement.
• They aim to anticipate the problems before
it happens.
• They consider factors that might go wrong
in the future
• They act before future mistakes may
happen.
• Safety is top priority
• They welcome bad news – they use it to
further improve the system.
• Safety is the core value
• Cooperating

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Module 3: Safety Risk Safety Risk Severity
*“One cannot manage, what one cannot measure.” • After knowing the probability, you must then
• Consequence - the potential outcome of the assess or identify the safety risk severity
hazard • The extent of harm that might reasonably
• Hazard - a potential source of damage occur as a consequence or outcome of the
identified hazard.
Safety Risk • The extent of the damage
• Projected likelihood and severity of the • The extent of the hazard
consequences or outcome from an existing • Environmental impact
hazard or situation. • Can be identified using questions
• While the outcome may be an accident, • Example: bird strike — catastrophic,
intermediate unsafe event/consequences hazardous, or major
may be identified as – the most credible Severity Meaning Value
outcome.
• Risk management - address all risk, - Equipment destroyed
Catastrophic A
analyses and mitigate (reduce the hazard at - Multiple deaths
an acceptable level) - A large reduction is
safety margins,
Safety Risk Probability physical distress, or a
• The likelihood (chance of something might workload such that the
happen) of how often an unsafe event might operators cannot be
occur depends on the hazard and risk Hazardous relied upon to perform B
identified. their tasks accurately
• Example: not wearing bump cap – or completely
occasional - Serious injury
• One way to determine what value a case is - Major equipment
— from records damage
• How many people are likely to get involved
- A significant reduction
with this hazard
in safety margins, a
reduction in the ability
Probability Meaning Value of the operators to
cope with adverse
Likely to occur many times
Frequent 5 operating conditions
(occurred frequently) Major C
because of an increase
Likely to occur sometimes in workload or because
Occasional 4 of condition impairing
(occurred infrequently)
their efficiency
Unlikely to occur, but
Remote 3 - Serious incident
possible (occurred rarely)
- Injury to persons
Very unlikely to occur (not - Nuisance
Improbable 2
known to have occurred) - Operating limitations
Minor - Use of emergency D
Extremely Almost inconceivable that procedures
1
Improbable the event will occur - Minor incident

Negligible - Few consequences E

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Safety Risk Assessment Matrix Tolerable region
• Safety Risk Index • Medium risk
• Risk Index • Acceptable provided that acceptable
• Combination of the result of the probability mitigation strategies are implemented.
and the assessment of the severity of the • A safety risk initially assessed as intolerable
hazard may be mitigated and subsequently moved
• Colors are relevant — where region it falls into the tolerable region provided that such
in Risk TM risks remain controlled by appropriate
Risk Severity mitigation strategies.
Risk • Example: umaangat or basag na tiles
Catastr Hazard Negligi
Probability
ophic ous
Major Minor
ble • Mitigation: cone or barrier around
C D
A B E the damaged area
Acceptable region
Frequent
5
5A 5B 5C 5D 5E • Low risk
• Acceptable as they currently stand.
Occasional • No further mitigation is required
4
4A 4B 4C 4D 4E • Example: cats around the school
• Hazard: it might bite you
Remote
3
3A 3B 3C 3D 3E

Improbable
2
2A 2B 2C 2D 2E

Extremely
Improbable 1A 1B 1C 1D 1D
1

Safety Risk Tolerability Matrix

Intolerable
• High-risk
• Unacceptable under any circumstances
• The probability and/or severity of the
consequences and the damaging potential
of the hazard is a threat to safety.
• Immediate mitigation is required Safety Risk Management
• Example: lighting strike (hazard: lighting • Overall management
strike) • The assessment and mitigation of safety
• Severity - hazardous, major risks
• Probability - occasional • Objectives:
• Tolerability - intolerable region o To assess the risks associated with
• Prevention: to stop identified hazards.
operations or mitigate ways o Develop and implement effective
to lower down the risk and appropriate mitigations.
• Example: engine failure on take-off • A key component of the safety management
• Severity - can total the aircraft process at both the State and
(catastrophic, hazardous, or major) product/service provider level.
• Probability - remote
• Tolerability - Intolerable region HIRA - Hazard Identification Risk Assessment
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