i

ACKNOWLEDGEMENT

Bismillahirrahmanirahim
First of all, I would use this opportunity to give appreciations to all individuals that
has help me in completing this thesis especially my supervisor, Dr. Wan Mohd Sufian Wan
Husain who main in important role in helping me to complete my thesis and also my
coordinator Mr. Khairul Adha which guide me on my thesis and also other lectures that help
me to do this research. Thanks also to my parent that also support me on doing this thesis my
giving me advise and also help me when I have problem to do this thesis. Last but not least I
would like to thanks to my friends that help me on how to do it step by step and UniKL
MIAT that provide facilities to do this project.













ii

Table of Contents
ACKNOWLEDGEMENT ....................................................................................................................... i
TO STUDY ABOUT ELEMENT INVOLVE IN MAINTENANCE ERROR MANAGEMENT
SYSTEM TOWARDS IMPLEMENTING THE SYSTEM IN AVIATION SCHOOL ........................ vi
DECLARATION PAGE ....................................................................................................................... vii
ABBREVIATIONS AND EXPLAINATIONS ................................................................................... viii
ABSTRACT ........................................................................................................................................... ix
1 INTRODUCTION ............................................................................................................................... 1
1.0 Background ............................................................................................................................. 1
1.1 Maintenance Error .................................................................................................................. 3
1.2 Human Error ........................................................................................................................... 3
1.3 Problem Statement .................................................................................................................. 5
1.4 Objectives ............................................................................................................................... 5
1.5 Aim ......................................................................................................................................... 5
1.6 Scope and Limitation .............................................................................................................. 6
2 LITERATURE REVIEW ............................................................................................................... 7
2.1 Preface..................................................................................................................................... 7
2.2 Tools of Reducing Maintenance Error .................................................................................... 7
2.2.1 Accident System Evaluation Programme (ASEP) .......................................................... 7
2.2.2 Generic Error and Modelling System (GEMS) ............................................................... 7
2.2.3 Human Error Assessment and Reduction Technique (HEART) ..................................... 8
2.2.4 Justification of Human Error Data Information (JHEDI) ............................................... 8
2.2.5 Procedural Event Analysis Tools (PEAT) ...................................................................... 8
2.2.6 Maintenance Error Decision Aid (MEDA) ..................................................................... 8
2.3 Maintenance Error Management System (MEMS) ............................................................... 10
2.4 Maintenance management..................................................................................................... 10
2.4.1 History of Maintenance Error Management System (MEMS) ..................................... 12
2.4.2 Introduction of MEMS .................................................................................................. 12
2.4.3 MEMS concept ............................................................................................................. 14
2.4.4 MEMS Investigation Method ........................................................................................ 16
2.5 Previous Project Vs Proposed Project ................................................................................... 17
2.6 Advantages of MEMS ........................................................................................................... 18
2.7 Disadvantages of MEMS ...................................................................................................... 19
2.8 Problem Statement from Research ........................................................................................ 19
iii

3 METHODOLOGY ....................................................................................................................... 20
3.1 Project Flow .......................................................................................................................... 20
3.2 Implementation of MEMS on Aviation School .................................................................... 22
3.2.1 Investigator ................................................................................................................... 23
3.2.2 Investigation Process..................................................................................................... 23
3.3 List of Budget ....................................................................................................................... 23
4 RESULT & DISCUSSION ........................................................................................................... 24
4.1 Result .................................................................................................................................... 24
4.1.1 Questionnaire Result: Section A: General Questions ................................................... 26
4.1.2 Maintenance Error Management System Questions ..................................................... 31
4.1.3 Section B: Yes/No/Maybe Question ............................................................................. 38
4.1.4 Section C: Opinion Question ........................................................................................ 44
4.2 Discussion ............................................................................................................................. 45
5 CONCLUSION ............................................................................................................................. 48
5.1 Suggestion to implementation of MEMS in Aviation School .............................................. 48
5.1.1 Person Involve In Mems In Aviation School ................................................................ 49
5.1.2 The Flow Of The System .............................................................................................. 50
5.1.3 Limitation Of The System ............................................................................................. 51
REFERENCES ..................................................................................................................................... 52
APPENDIX ........................................................................................................................................... 53











iv

List of Figures
Figure 2-1 Shows the arrangement of data collection on MEDA. (15th Annual Symposium - Human
Factors in Maintenance and Inspection, 2001) ....................................................................................... 9
Figure 2-2 Specific issues that related to maintenance performance. (HID, 2005) ............................. 11
Figure 2-3 A decision tree that determines the faulty of decision acts. (Reason, 1997) ....................... 16
Figure 3-1 Flow of Methodology .......................................................................................................... 20
Figure 4-1 Percentage of occupation among respondent. ..................................................................... 25
Figure 4-2Percentage of male respondent and their age. ...................................................................... 25
Figure 4-3Percentage of female respondent and their age. ................................................................... 26
Figure 4-4 I clearly understand what maintenance error is ................................................................... 27
Figure 4-5 As an instructor/student, I think that human error always occurs. ...................................... 28
Figure 4-6 I aware of human error ........................................................................................................ 28
Figure 4-7 Human error is the main root of maintenance error. ........................................................... 29
Figure 4-8 Maintenance error can be managed properly with the cooperation between student and
instructor. .............................................................................................................................................. 30
Figure 4-9 Error investigation will be conduct if maintenance error occurs. ....................................... 31
Figure 4-10 I understand the important of MEMS................................................................................ 32
Figure 4-11 There would be strong acceptance if error investigation such as MEMS implemented in
Aviation School .................................................................................................................................... 33
Figure 4-12 There would be strong acceptance if error investigation such as MEMS implemented in
management of Aviation School ........................................................................................................... 34
Figure 4-13 I believe that it is important for the University to share their error investigation system
with other University ............................................................................................................................ 35
Figure 4-14 There will be less error once MEMS is implemented in Aviation School. ....................... 36
Figure 4-15 Error investigation system such as MEMS would be useful for discussing probability that
can cause incident. ................................................................................................................................ 37
Figure 4-16 By using tools to reduce maintenance error such as MEMS will reduce work to me. ...... 38
Figure 4-17 Did you ever know about Maintenance Error Management System? ............................... 39
Figure 4-18 Aviation School did not need error preventing system such as MEMS? .......................... 40
Figure 4-19 Did you think it is necessary in Aviation School? ............................................................ 41
Figure 4-20 Do you think it can improve student discipline toward maintenance error? ..................... 42
Figure 4-21A new culture of safety can be practiced in aviation school if MEMS is implemented..... 43
Figure 5-1 Flowchart of implementation system .................................................................................. 50







v

List of tables
Table 1-1 Maintenance task and types of defence to avoid maintenance error. (HSE, 2005) ................. 4
Table 2-1 Comparison of others maintenance error tools (Marx, 1998) ............................................... 10
Table 3-1 List of Budget ....................................................................................................................... 23
Table 4-1 Respondent feedback of the questions .................................................................................. 26
Table 4-2 Respondent feedback of the question section A part 2 ......................................................... 31
Table 4-3 Respondent feedback on section B ....................................................................................... 38
Table 4-4 Result on majority section A ................................................................................................ 45
Table 4-5 Result on majority MEMS section. ...................................................................................... 46
Table 4-6 Result on majority Section B ................................................................................................ 47



















vi

TO STUDY ABOUT ELEMENT INVOLVE IN MAINTENANCE ERROR
MANAGEMENT SYSTEM TOWARDS IMPLEMENTING THE SYSTEM IN
AVIATION SCHOOL







MUHAMMAD YAZID BIN ITHNIN
53259209165







Report Submitted to Fulfil the Partial Requirements
For the Bachelor of Aircraft Engineering Technology
University Kuala Lumpur



JULY 2012




vii

DECLARATION PAGE





I declare that this report is my original work and all references have been cited adequately as
required by the University.












Signature:...

Date:

Full Name:.

ID No:









viii

ABBREVIATIONS AND EXPLAINATIONS

AMMS Aurora Mishap Management System
ASEP Accident System Evaluation Program
ASRS Aviation Safety Reporting System
ATC Air Traffic Control
BASIS British Airways Safety Information System
CAA Civil Aviation Authority
CAA AWN 71 Civil Aviation Authority Airworthiness Notices 71
CHIRP Confidential Human Factor Incident Reporting Programme
GEMS Generic Error And Modelling System
HEART Human Error Assessment And Reduction Technique
HMRS Human Reliability Management System
HRA Human Reliability Assessment
JAR-145 Joint Aviation Requirement
JHEDI Justification Of Human Error Data Information
MEDA Maintenance Error Decision Aid
MEI Maintenance Error Investigation
MEMS Maintenance Error Management System
MESH Managing Safety Engineering Health
MORS Mandatory Occurrence Reporting Scheme
MRO Maintenance, Repair and Operation
PEAT Procedural Event Analysis Tools
TEAM Tools for Error Analysis and Maintenance
VDP Voluntary Disclosure Programme


ix

ABSTRACT

Maintenance is referring to the word maintain that is to maintain the states of aircraft
on safety aspect. It is one of the important things in aviation industry and cannot be ignored.
Day by day, many peoples try to create something that can maintain the aircraft in proper
ways. Maintenance error is an error that occurs from the maintenance, it is usually related to
human error which is the misbehaviour of human themselves. To control human error, it is
not an easy task; proper guideline must be done to improve the uncontrolled human error.
One of the systems to reduce it is by the system called Maintenance Error Management
System. It is a system that manages the maintenance error, so it can be reduce and avoid it to
occur again. It should be applied on every place that can be related to the aviation industry so
peoples will be aware to do the maintenance error.


















1


CHAPTER 1
1 INTRODUCTION
1.0 Background

In aviation industry, safety and profit is the most important thing to achieve. If one of it is
neglected, it can cause a big loss of money and also hundreds to thousands of lives. Every
little thing on aircraft should not be neglected to ensure the safety of an aircraft. As be
mentioned about safety, it is a thing that should be put on first place whenever to do
everything on this industry. Once it is neglected it can causes serious damage to an aircraft
and can make the airlines company to lost millions of dollars especially to maintaining the
aircraft. There are many factors that can affect the loss of profit and ignored safety. This error
is related to human factor. Human factor is an individual behaviour which contributes to
safety of an aircraft. On example of human factor is maintenance error. For the maintenance
human factor, about 20-30% of in-flight engine shutdown and 50% of delays are caused by
human error reported by Boeing on 1997 (Byrd, 2007). This situation can lead to millions
of cost to be fixed. For examples, average cost of in-flight engine shutdown are about USD
500,000 and for flight cancelation, the average cost is USD 50,000.

For the types of maintenance error, about 39% of maintenance error is from installation
error, 16% are inattention or damage and only 1% for misinterpretation application data.
CHIRP is a programme which is aim to contribute to improvement of aviation safety in UK.
It has been operate since 1982 and restructured on 1996 to make it more effective to solving
safety-related issues. It accept reports of safety-related issues from everyone in aviation
industry such as air traffic control (ATC) officers, flight crew, licensed aircraft engineers, and
others. After received the report, the reports must be ensure of it validated and reviewed the
objective of the information to maintain the confidential of the sources. If it is appropriate,
the information of the report is discussed with relevant agencies to find a solution. Then,
CHIRP is all about the safety that must take precedence.


2

One of the examples of neglecting the safety is maintenance error. Maintenance error is a
failure that are not expected when to conduct a maintenance task with the requirement and
not working according to their task. It is important to ensure the safety of the aircraft and to
avoid serious damages on aircraft. Examples of maintenance error are such as installation
error, access panel not close, loosen object left on aircraft, wrong part fitting, insufficient
lubrication, unsecured of fairing, access panel and cowling. Many airlines company has taken
several steps to maintain the safety of the aircraft then can lead to reduction of the
maintenance cost.

One of the systems that have been made to maintain the safety of the aircraft is
Maintenance Error Management System (MEMS). It is a system to manage the maintenance
error that has been introduced to UKs maintenance organization; CAA also supports this
system by declared their policy on Airworthiness Notice 71. It is function when an error is
identified and it can consider critical, some investigation should be made to discover the root
of the error. MEMS are function after the error has been investigated and try to eliminate the
error. MEMS should create an environment where errors and problems are easily to be
reported and investigated with no fear of not suitable of disciplinary action to individuals and
organization, create a mechanism for reporting and recording the problems or error,
investigate problems to identify the root of the problem, provide an appropriate information
for managers to help them to carry out appropriate action solve or reduce the issues.

MEMS are the continuation system of Maintenance Error Decision Aid or known as
MEDA. MEDA has been introduced by Boeing Company on early 1990s (Allen, 2009) to
the industries in order to improve the maintenance sector. MEDA is a system that is being
used to investigate an error that lead to problems to the aircraft. By investigating the problem,
improvement can be done to ensure same kinds of problems are not recurring in the future.
The system is being assist by MEMS in order to manage the problem that has been
investigated by MEDA to reduce or eliminate the maintenance error.





3

1.1 Maintenance Error

A maintenance error is considered to have occurred when the maintenance system, which
includes the human element, fails to perform in the manner expected in order to achieve its
safety objectives. (Source: UK CAA AWN 71), March 2000. Maintenance error is
something that airlines cannot avoided to be happens. It can occur due to many reasons such
as human factor, system error, design error and also part error. Human error is a task that is
not success due to lack of knowledge or experience. System error is an error when the
equipment is being return without having proper testing method on it. While design error can
be described as the parts that are needed is not as expected to be achieve. Lastly is part error
is incorrect part that has been installed. From all of the error, human error are the mostly error
that happens on maintenance error, it is because it is depends on behaviour of human
themself in working and their achievement.

1.2 Human Error

It is one of the causes of maintenance error that occur from misbehaviour of humans. MEMS
will investigate the causes of the maintenance error. For human error, it is not an easy task
because it related to discipline or the management of the work. The table below shows
analysis of human error related to general maintenance task and shows physical defence to
avoid human error to avoid major accidents. The table that shows maintenance task and types
of defence to avoid maintenance error is show as the table below:












4

Table 1-1 Maintenance task and types of defence to avoid maintenance error. (HSE, 2005)


In order to ensure human error to be reduce, there are many ways that need to be used to
improve human behaviour such as, the maintenance personnel should be highly trained with
high understanding and full of knowledge so that, they can aware to the factors that can lead
them to human error. The other way is by forcing people and scaring them by give the
instruction but not in violent way.





5

1.3 Problem Statement

Safety are the most important thing in aviation industry, once it is ignore it can bring to
lost millions of money on life. The backbone of the safety of the aircraft are the maintenance,
it should be minimize to avoid an error that will affect the aviation industry since MEMS
have been introduced to manage the maintenance error to be reduced. But is this system can
manage maintenance error systematically, it is the question mark that should be answered.
Maintenance error is errors that are not easy to control, because most of it related to human
error. To control human error, it needs to be control from the root. The implementation of this
system in aviation school needs to be suggested to develop a generation that aware of human
factor.
1.4 Objectives

1. To study the system purpose and element involve.
2. To identify the advantages and disadvantages of the systems.
3. To identify either this system can be implemented on aviation school.
There are 3 main objectives of my study which is about MEMS. Firstly is to study the
system purpose and element involve in MEMS. Author will get the information of the MEMS
purpose and element involve in it on the internet and also book or articles. Next is to find
advantages and disadvantages of this system. From the research that has been made, this
research will find out the advantages and disadvantages of this system, this will help easy
decision to use MEMS on the industry and can let peoples know about MEMS. Lastly, this
research will implement MEMS on aviation school and try to purpose this project to aviation
school in Malaysia to let student applied MEMS as the real situation on the industry.
1.5 Aim

The aim of this study is to identify element that related to Maintenance Error Management
System by using the existing data and implement it on aviation school.



6

1.6 Scope and Limitation

This project is limited to management on maintenance error under maintenance scope. To
ensure this project is under limit, this project will focus on Unikl MIAT students, lecturers
and technicians to get the feedback either Maintenance Error Management System can be
implemented in Aviation School.


















7

CHAPTER 2
2 LITERATURE REVIEW

2.1 Preface

Maintenance error should be avoided to make sure the safety of the aircraft. It is because it
can cause a big loss of the system on the aircraft such as the flight control surface system.
Maintenance error may be from human factor or problem from the system itself. Maintenance
error decision aid (MEDA) is one of the system that has been use to minimize this error. It
will identify the error and to reduce it, theres a process that is Maintenance Error
Management System (MEMS). There are several tools that have been produce to minimize
the error that occur on the aircraft.

2.2 Tools of Reducing Maintenance Error
2.2.1 Accident System Evaluation Programme (ASEP)

It consists of pre-accident screening with nominal human reliability analysis and post-
accident screening and nominal human reliability analysis facilities. It provide a short way for
the human reliability analysis by requiring less training to use the tools, less expertise for
screening estimates, and less time to complete the analysis.

2.2.2 Generic Error and Modelling System (GEMS)

It is an error classification that has been developed by Reason and focuses on cognitive
GEMS is an error classification scheme developed by Reason that focuses on cognitive
factors in human error compare to environmental or other factors. It is based on Rasmussen
that has classified three major categories of errors such as skill-based slips and lapses, rule-
based mistakes, and knowledge-based mistakes. GEMS can be describe as black box that
can be used to identify the mechanism of slips and mistakes.

8

2.2.3 Human Error Assessment and Reduction Technique (HEART)

It is a technique that uses human reliability assessment (HRA) to evaluate the probability of
human error through task completion. From the research that has been done to reduce the
error, there are 3 main reasons to conduct HRA, which are identification error, quantification
error and reduction error. This method is based on when the task there always has error.
2.2.4 Justification of Human Error Data Information (JHEDI)

JHEDI is derived from the Human Reliability Management System (HMRS) and it is a tools
for human reliability analysis that dont need too many training. This tool consist of a
scenario description, task analysis, human error identification, a quantification process, and
performance shaping factors and assumptions. It is suitable to use for human reliability
analysis due to their properties which are moderate, flexible and auditable tool.

2.2.5 Procedural Event Analysis Tools (PEAT)

It is a tools that the operators to do investigation on incidents and create ways to prevent the
same event to occur again in the future. It is use after the incident of an aircraft. It will create
the cooperative between airlines, pilot and Boeing human factor specialists. PEAT is
originally from an extensive effort to find a way to ensure the incident not occur again in the
future.

2.2.6 Maintenance Error Decision Aid (MEDA)

To reduce maintenance error, it will go through a process step by step. For the first process, it
will identify the maintenance error through Maintenance Error Decision Aid (MEDA).
MEDA is a tool of identifying maintenance error. It will collect more information about
maintenance error. It will help maintenance personnel to be blaming for making errors by
investigating and understanding the causes. Operators for MEDA will be provided with five
basic steps to follow such as event, decision, investigation, prevention strategies and
feedback.

9

For the event, if an event occurs, the maintenance organization will be responsible to select
the error causes to be investigated. In a decision, after the problem has been fixed and the
aircraft will return to service, the operators will make a decision either the event related to
maintenance, if it is related then they will perform MEDA. The operators will investigating
use MEDA result by record general information about the aircraft with the specification of
the maintenance and the event occur, the causes of the event error and list of possible
strategies to prevent it. Then prevention strategies are to ensure the error not occurs again.
The operators will provide feedback to maintenance personnel so technicians know the
changes that have been made from MEDA.




Figure 2-1 Shows the arrangement of data collection on MEDA. (15th Annual Symposium -
Human Factors in Maintenance and Inspection, 2001)

In MEDA process during investigation, it is necessary to identify whether the event is from
human behaviour and find the individuals involved. Instead of give punishment, the
maintenance personnel were interviewed to get more understanding on the factors and get
their ideas for possible improvements that can be added up to database. The central part of
this process is to make improvement to avoid the factors of the event to occur again. The
form of MEDA will be given on the appendices.

However there are other methods to that related to maintenance error system such as Round
Tables, ASRS, TEAM, BASIS/MEI, MESH, and AMMS. These principle systems bring new
techniques for the investigation of maintenance error. A few programs from the flight
operations domain will be reviewed along with the typical mechanical reliability program of
10

today. The comparison of this system are summarize as Table 2-1 Comparison of others
maintenance error tools below:

Table 2-1 Comparison of others maintenance error tools (Marx, 1998)

2.3 Maintenance Error Management System (MEMS)
2.4 Maintenance management

Every maintenance system should be managed properly to avoid maintenance error, if not it
will give problem to the whole system. Maintenance management can be defined as:

All the activities of the management that determine the maintenance objectives or priorities
(defined as targets assigned and accepted by the management and maintenance department),
11

strategies (defined as a management method in order to achieve maintenance objectives),
and responsibilities and implement them by means such as maintenance planning,
maintenance control and supervision, and several improving methods including economical
aspects in the organization. (Mrquez, 2007).

For maintenance management, it can be divided into 2 processes which are:

1. The definition of the strategy.

It requires the maintenance objective definition as an input, and then derived it from the
business plan. The first part of maintenance management process will give successful of
maintenance in an organization and can determines the effectiveness of the maintenance
plans, schedules, controls and improvements.

2. The strategy implementation.

This process is related to efficiency of the management. Efficiency can be produce with
expense, minimum waste or unnecessary effort. It will measure the performances of doing the
task not whether if the task is correct. Efficiency can be related to improvement of the
maintenance with same amount of cost.




Figure 2-2 Specific issues that related to maintenance performance. (HID, 2005)

12

2.4.1 History of Maintenance Error Management System (MEMS)

Error is something that naturally occurs and cannot be avoided on any system. The causes of
an error must be identified, so it will easy to manage the error. Managing an error will
provide better good return in investment. About 70% of error that occurs are responsible by
the management and not the maintenance personnel. So, data collection must be done to find
the types of error occurs and understanding their causes. CAA has introduce many ways to
eliminate maintenance error by managing the error, the history of Error Management in
United Kingdom are shown as below:
History of Error Management in UK:
1992 - Boeing MEDA group (British Airways)
1996 - CAA promotion of error management principles
2000 - CAA policy stated in airworthiness AWN71
2000 - JAR-145 NPA 12 proposals included error management
2004 - JAR-145 Amendment 5 requires occurrence management systems


2.4.2 Introduction of MEMS

To overcome maintenance error, Boeing has create MEDA which help to identify
maintenance error then, MEMS will support MEDA to reduce maintenance error by
investigate the error, the causes of the error and try to find a way to reduce it because of the
nature flow that always happens. It is actually to achieve MRO standard for part 145. There
are several aim for the MEMS to achieve that consist of:
Clearly identified aims and objectives
Demonstrable corporate commitment with responsibilities for the MEMS clearly
defined
Corporate encouragement of uninhibited reporting and participation by individuals
Disciplinary policies and boundaries identified and published
An event investigation process
The events that will trigger error investigations identified and published
Investigators selected and trained
MEMS education for staff, and training where necessary
13

Appropriate action based on investigation findings
Feedback of results to workforce
Analysis of the collective data showing contributing factor trends and frequencies.

MEMS is responsibly to identify the factor that contributes to incidents and must find ways to
reduce the error. For large organisations, a storage and analysis of MEMS data should be
computerised. This will make this system systematic to managing an error.

3 CAA Assurances

The successful of MEMS is dependent on freedom of investigation without fear of action that
has been taken by CAA. CAA gives this assurance to follow such as CAA will be checking
the organisations internal occurrence investigating and reporting process is follow the
procedure and approved by CAA as part of audit process as described in CAP 716 Issue 2.
CAA audit will identified the misused of MEMS, however, they will make this following
assurance such as:

1) Not to show the name of person that make the MEMS report, not to a related person,
not pas the MEMS report to other party, unless need to do so by the law and unless
the person give a permission.
2) Take responsible step in order to avoid exposing the identity of the reporter.
3) Not as a base to start the criminal proceeding by unpremeditated and inadvertent
breaches of the law which comes to its attention only because of they have been
reported under MEMS, except if in case involving dereliction of duty amounting to
lack of carefulness and recklessness.

As what the CAA required, the organisation that has working on MEMS programme in
accordance with Part 145.6.60(b), a surveyor may ask to see the following documents and
evidence, and to satisfy them, they may wish to speak individually to the members of staff at
any level in the organisation:
a) A copy of the companys disciplinary and safety policy shows that the staff are aware of
the policy, believe it will be and has been conduct fairly.

14

b) The procedure that describe the companys process of reporting and investigating errors
and incidents and occurrences types that would be investigated normally.

c) Evidence that occurrences meet the criteria detailed above have been reported, and to
assure himself that occurrences are not frequently going unreported.

d) Within a large company, it is evidence that MEMS investigators had received appropriate
training.

e) Evidence of workforce feedback on occurrences and investigation and feedback to the
workforce, on both occurrences and their investigation, and corrective action taken must be
expected.

For the small organisation, the surveyor would accept evidence as describe as above but on a
small structured basic. If the organisation not gives evidence to the surveyor, the surveyor
may see directly to the staff.

2.4.3 MEMS concept

A Maintenance Error Management System (MEMS) must be:
provide an environment where there are freely action to reporting and investigating, without
having fear of inappropriate disciplinary action to the individual or organisation
create a mechanism for recording and reporting errors and problems
investigate problems to identify the main causes
provide correct information to managers to help them to do take proper action for the
problem to be solved and control the causes.

In MEMS process it should cover all incidents, occurrences and many problem part of the
causes which are not necessarily known when the incident or problem report first comes to
light. The causes of the incident should not be assume as the human error. By applying the
MEMS process, all incident should be know the root causes whether environmentally,
technically or human error.

15

Most organization know use the concept of blame and train to identify the culprit and
discipline or fire them. It will help to avoid the problem to occur again. Most people are
generally do not making mistakes but there is always a person that will break up the rules and
not have discipline. For this situation, disciplinary action should be done to that person but in
a professional way. In an organization, there should be a policy that states an individuals will
be getting disciplinary action in specific circumstances. The circumstances may vary depends
on company but must be following the guideline that given in CAA AWN 71 as follows:

In the context of error management it is considered that an unpremeditated or inadvertent
lapse should not incur any punitive action, but a breach of professionalism may do so. As a
guideline, individuals should not attract punitive action unless:
(a) The act was intended to cause deliberate harm or damage .
(b) The person concerned does not have a constructive attitude towards complying with safe
operating procedures.
(c) The person concerned knowingly violated procedures that were readily available,
workable, intelligible and correct.
(d) The person concerned has been involved previously in similar lapses.
(e) The person concerned has attempted to hide their lapse or part in a mishap.
(f) The act was the result of a substantial disregard for safety.
Substantial disregard, for this purpose, means:
-In the case of a certification authorisation holder (eg. licensed engineer or Certifying Staff)
the act or failure to act was a substantial deviation from the degree of care, judgement and
responsibility reasonably expected of such a person.
-In the case of a person holding no maintenance certification responsibility, the act or
failure to act was a substantial deviation for the degree of care and diligence expected of a
reasonable person in those circumstances.(source: CAA AWN 71).


From the book of James Reason that is Managing The Risk of Organizational Accident, he
has create a flow chart as a guide to take and appropriate action to the suitable problem. The
flow can be refer as below:


16


Figure 2-3 A decision tree that determines the faulty of decision acts. (Reason, 1997)

2.4.4 MEMS Investigation Method

There are several methods on MEMS investigation process that can be described as table
below:
Table 3: MEMS method of investigation
Method Description
Round-table group discussion 1.Same as meeting that will held every 3 months
2. Involve Safety Manager, Quality Manager and
Departmental Manager.
3. Consider Successful if all the meeting members knows
the causes of the incident.

Paper-based tools Same as Maintenance Error Decision Aid (MEDA).
PC based tools 1. Computerise system of MEDA such as software.
2. Examples are Tools for Error Analysis in Maintenance
(TEST), BASIS Maintenance Error Investigation (BASIS
MEI) and Aurora Mishap Management System (AMMS).
Proactive tools Involved engineers to put data into a computer at regular
intervals, as opposed to after an incident.
Self-reporting Schemes 1. System that are externally from the company such as
Aviation Safety Reporting System (ASRS) and CHIRP.
2. They provide voluntary reporting work, the reporter
17

details will be deleted after all the details is obtained to
protect subscriber.

Other that this, there are several method of MEMS such as Mandatory Occurrence Reporting
Scheme (MORS) which is the schemes that tend to not incorporate all the elements of MEMS
tool, but with similar principles, Air Carrier Voluntary Disclosure Programme (VDP) that
provide an immunity to organization that are acting to prevent the problem and Aviation
Safety Action Programme (ASAP) that same like round-table method but must include of
FAA, Airlines and Unions.

2.5 Previous Project Vs Proposed Project

From the paper work that has been found, from the research on Baines Simmons (Simmons,
2012) that found on their website the details of their research are as follow:
Table 4: Comparison from previous project
Aspect Previous project Proposed project
Project Title Provision of a bespoke error
management program for the
Attack Helicopter Depth Servicing
Unit (AHDSU).
To study the effectiveness of
MEMS and implement it on aviation
school.
Aim To provide the AHDSU
Management team with a practical
understanding of Error
Management Systems in a
maintenance environment,
empowering a targeted solution to
the unique structure of their
organisation.
The aim of this study is to study
about Maintenance Error
Management System to implement
it on aviation school.

Objective 1.To develop and deliver a rapid
suite of training packages, aimed at
management, key staff, staff,
nominated Maintenance Error
1.To study the system purpose and
element involve.
2.To identify the advantages and
disadvantages of the systems.
18

Investigators and Error committee
staff.
2. To develop suites of protocols
this complimented the current
procedures within the organisation.
3.To implement Maintenance Error
Management System (MEMS) on
aviation school.

Project
Outcomes
The project delivered a fully
functioning error management
programme, generate more reports
and follow up actions that will help
manage the organisation more
effectively. The measurements of
error management before and after
illustrated demonstrable
improvement benefits.
This project is expected to achieve
useful feedback from an aviation
school to implemented MEMS. The
feedback will be used to produce
several information to implement it
on aviation school.

From the study that has been made there are several advantages and disadvantages of MEMS
that has been identified. The advantages and disadvantages are shown as below:
2.6 Advantages of MEMS

1. The safety of the reporter is safe and not lead to other party because in this system, the
investigator need to ensure the information of the reporter are safe and cannot let the
information spread to peoples.
2. This system works with professional authority such as CAA. To done this system, it
must works with the approval personnel in aviation industry to ensure there is no
problem on the investigation process including third party
3. Help to reduce maintenance error with managing the error. The main objective in this
system is to reduce maintenance error, by investigate the error and discuss several
ways to reduce it, it will help the error to be reduce.




19

2.7 Disadvantages of MEMS

1. Take longer time to process because it need to do investigation properly. In the
investigation process, the process needs to be done carefully without any disruption
from other side. So it will take longer time to make sure the process can be done
smoothly.
2. Required other personnel to conduct this process rather than maintenance personnel
itself. Because of this system regarding the management of the error, it doesnt
require any of maintenance personnel.
3. More cost is needed to pay the operator to do investigation of MEMS. Because of this
system need approval personnel to do investigation and not required any maintenance
personal, the cost to operate this system will be higher because it need to pay to the
approval personnel.

2.8 Problem Statement from Research

From the research that has been made, author have identified several problem statements
which are:

1. MEMS should be create to make the system more efficient and use short time but this
system take a long period to be done because of the investigation process that need to
collect all the data manually by the operators.
2. The aim of MEMS is to reduce in operational cost of Airlines, but actually it required not
really because of it pays different operator rather than maintenance personnel to conduct
the management error.









20

CHAPTER 3
3 METHODOLOGY

3.1 Project Flow

This project is to identify the element involve in maintenance error management system
(MEMS) and identify either this system can be implemented in aviation school, new
methodology can be made to ensure this system is really can be use on the aviation school.
The initial process flow of this project is shown as below:














Figure 3-1 Flow of Methodology



RESEARCH
(COLLECT DATA)
DISTRIBUTE
QUESTIONNAIRE
STATISTIC
IDENTIFY
PROBLEM
FIND SOLUTION
START
CONCLUSION
21

To start this project it will begin with collecting data or do some research. Data collection
must be done through the internet by searching on the website or e-book that gives
information about MEMS.
After the data are collected, the data is then being compiling by the objective. Problem
statement then should being made to identify the problem of this system that should be
improved.
Questionnaire is then will be create to get feedback from the airlines that use this system. The
questionnaire will be given to Unikl Miat students, lecturers and technicians to get their
feedback either this system should be implemented in Aviation School. This questionnaire is
aim to maintenance personal or management person. This questionnaire will consist of 18
questions on scale from totally disagree to totally agree and 2 subjective.
Data was collected from a total of 50 respondents from a questionnaire that was designed to
gather information about the implementation of Maintenance Error Management System
(MEMS) in Aviation School. The questionnaire consists of 4 sections:
Personal information
General Section
MEMS question
Suggestion question

1. Personal information
In this section, the respondent need to fill in about their age and sex, so, it will easy to know
the respondent background from the feedback.

2. General Section
For this section, respondent will be asked about their general knowledge on maintenance
error, the factor related to maintenance error and also human error. In this section, respondent
needs to tick their choice from totally disagree to totally agree.




22

3. MEMS questions
In this section, respondent will be asked about question related Maintenance Error
Management System (MEMS). In the first page of the questionnaire, there are description
about MEMS and respondent can answer the question on this section from their
understanding on the description.

4. Suggestion questions
This section will need respondent to give suggestion on how to improve this system either in
organization or in aviation school.

.The questionnaire will be given to within 2 weeks to the target then after the questionnaire
has been collected, the data will be collected and statistic should be made in the form of:
1) Pie Chart
2) Column
3) Table
After the statistic has been shown, the problem of this system in the industry will be
identified and the ways to improve should be made by create a new flow or designing the
system so that, it can be use on airlines industry or implement it to any aviation college in the
world to make people alert on maintenance error.
The improvement of this system is very important to ensure the system can be done
systematically on the future. Other than that this system also can be implementing on the
aviation school without having any problem and efficient enough to be control to avoid
maintenance error.

3.2 Implementation of MEMS on Aviation School

After the feedback has been receive, the result will be compile and from the result, this
research will use the feedback to improve MEMS system and try to implement it on aviation
school. It will include the investigation process to identify the root causes of the incident.

23

3.2.1 Investigator

For the investigation process on the maintenance error, the investigator will be among the
lecturers that have an experience on doing MEMS or among the Quality Assurance
Department. The investigator must be free from bribe and must do an investigation according
to MEMS policy. The action on the culprit also must suitable to the offense.
3.2.2 Investigation Process

The investigation process must be done fairly and according to policy. The information of the
reporter must be hiding properly to ensure their safety unless it is required by the dean of the
aviation school.
The implementation on aviation school must base from the feedback that has given to the
airlines industry, so it will done systematically on the aviation school and provide proper
MEMS real situation in aviation school. So, after student has been working, they will know
how to manage well the maintenance error.
3.3 List of Budget

Below is the list of budget that needs to be use in this research:
Table 3-1 List of Budget
List of Budget Amount (RM)
Transportation Fuel 50
Photocopy of questionnaire 20
Free give for respondent 100
Total 170





24


CHAPTER 4
4 RESULT & DISCUSSION
4.1 Result
As per methodology before, this research were made to identify either this system is suitable
to implemented it on Aviation School. To identify it, questionnaire were created and given at
the Aviation School. The questionnaires were distributed at University of Kuala Lumpur
Malaysian Institute of Aviation Technology. The targets of the respondent are 50 persons
which divided into lecturers, students and technician. But unfortunately, only 41
questionnaires were received back. The questionnaire consist of 3 sections which are Section
A which included general questions about maintenance error and human factor and general
questions about Maintenance Error Management System (MEMS). Section B and C are
questions that more to the opinions of respondent to the implemented MEMS. The
questionnaire can be referring to Appendix B. The result of the questionnaire can refer as
below:
From Figure 4-1 Percentage of occupation among respondent. below shows the percentage of
respondent status of occupation, because of this survey has been made at Aviation School, so
the respondent consists of student, lecturers and technicians only. Majority of the respondent
are student with 49%, lecturers with 36% and technicians with 15%. This research is to
identify either MEMS system can be implemented in Aviation School to be use among them.
Most of the lectures familiar with this system and had experience on this system so it help to
do this research by given some ideas to the way of implementing this project.
25


Figure 4-1 Percentage of occupation among respondent.

In Figure 4-2Percentage of male respondent and their age. and Figure 4-3Percentage of female
respondent and their age. below, it shows the sex and the age of the respondent. The respondent
are consist of 85% male and the rest are female and the majority of the age are 20-29 for male
and 30-39 for female. Because of this questionnaire were distributed in Aviation School, so
majority of the respondent are male and only a few of them are female among lecturers and
students.

Figure 4-2Percentage of male respondent and their age.
49%
36%
15%
OCCUPATION
STUDENTS LECTURERS TECHNICIANS
58%
19%
15%
4%
4%
MALE
20-29 30-39 40-49 50-59 60+
26



Figure 4-3Percentage of female respondent and their age.


4.1.1 Questionnaire Result: Section A: General Questions

Table 4-1 Respondent feedback of the questions
Question Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
Total
1 0 1 11 16 13 41
2 0 2 1 18 20 41
3 0 0 10 19 12 41
4 1 1 12 18 9 41
5 0 0 5 18 18 41
6 0 0 4 21 16 41
TOTAL 1 4 43 110 88 246

Table 4-1 Respondent feedback of the questions above shows that the result of the questionnaire
that has been done by respondent in section A questions. In this section, respondent need to
tick from strongly agrees to strongly disagree. Then the result was collected and the data of the
result can been shown as the table 1. In this section, majority of the respondent are agreed
with the statement as in the questionnaire while secondly is strongly agree, neutral, disagree
and lastly strongly agreed. This section in the questionnaire consists of question that related to
general question of human error and maintenance error. Hence, it shows that majority of the
respondent are family with maintenance error and human error. On question, 1,3,5,6 the
respondent answers it with agree which is the majority, while on the questions 2 and 5,
33%
67%
FEMALE
20-29 30-39 40-49 50-59 60+
27

majority of the respondent strongly agreed with the statement. Only on questions 4 which is
human error is the main root of maintenance error, only one respondent strongly disagreed
with the statement and it is the only statement that strongly disagreed has been chosen.


Figure 4-4 I clearly understand what maintenance error is

Refer to Figure 4-4 I clearly understand what maintenance error is above, from the first
question which I clearly understand what maintenance error is, majority of the respondent
agree with the statement while 13 from 41 respondent strongly agree, 11 neutral,1 disagree
and none strongly disagree. Majority of the respondent agree maybe due to that had heard
about the maintenance error and some of the have learn about it or have experience about the
maintenance error. Because of the respondent are all from the aviation school so, none of the
strongly disagree of understanding the maintenance error.




0
2
4
6
8
10
12
14
16
18
Strongly
Disagree
Disagree Neutral Agree Strongly Agree
Number of
respondent
Question 1 : I clearly understand what
maintenance error is
28


Figure 4-5 As an instructor/student, I think that human error always occurs.

Based on Figure 4-5 As an instructor/student, I think that human error always occurs.,
majority of the respondent strongly agree that human error always occur and 18 respondents
agree while the rest are neutral and disagree and none strongly disagree. It is because maybe
that have learn about human factor and have experience regarding the human error that
maybe had occur to them while working or practical for student. None of respondent strongly
disagree with the statement because as human are not perfect, they always do mistakes.


Figure 4-6 I aware of human error

On Figure 4-6 I aware of human error above, for the statement of I aware of human error,
majority 19 of total respondent agree while 12 respondent totally agree, 10 respondent neutral
and none disagree and totally disagree. From the result, majority of the respondent are agree
0
5
10
15
20
25
Strongly
Disagree
Disagree Neutral Agree Strongly Agree
Number of
respondent
Question 2 : As an instructor/student, I
think that human error always occur.
0
5
10
15
20
Strongly
Disagree
Disagree Neutral Agree Strongly Agree
Number of
Respondent
Question 3 : I aware of human error
29

and not strongly agree are maybe because of they think that human error are normally
happens, so they give full commitment of awareness of human error. As human, the
awareness of the human error are important because humans are not perfect, they always do
mistakes every time and everywhere.


Figure 4-7 Human error is the main root of maintenance error.

Based on Figure 4-7 Human error is the main root of maintenance error., majority of respondent
agree with the statement which human error is the main root of maintenance error, the rest are
neutral with 12 respondents, totally agree 9 and disagree and totally disagree with only 1
respondent. In aviation industry, as a fact, human error is the main root of the maintenance
error with 60%-70% of the error. But there are other cause of maintenance error such as
machines, tools and equipment.




0
5
10
15
20
Strongly
Disagree
Disagree Neutral Agree Strongly Agree
Number of
Respondent
Question 4 : Human error is the main root
of maintenance error.
30


Figure 4-8 Maintenance error can be managed properly with the cooperation between student
and instructor.

Based on Figure 4-8 Maintenance error can be managed properly with the cooperation
between student and instructor. in the question of maintenance error can be managed properly
with the cooperation between student and instructor. Because of this questionnaire were
given to the student and instructor in aviation school, so, this question related to them. Total
majority of 36 of respondent agree and totally agree with the statement, 5 of them neutral and
none disagree and strongly disagree. This is maybe they think that cooperation is important
especially between student and instructor to work together in managing maintenance error
that occur.

0
2
4
6
8
10
12
14
16
18
20
Strongly
Disagree
Disagree Neutral Agree Strongly Agree
Number of
Respondent
Question 5 : Maintenance error can be
managed properly with the cooperation
between student and instructor
31


Figure 4-9 Error investigation will be conduct if maintenance error occurs.

On Figure 4-9 Error investigation will be conduct if maintenance error occurs., in the
statement of error investigation will be conduct if maintenance error occurs, 21 of the
respondent agree with the statement, 16 of respondent strongly agree while the rest are
neutral and no disagree and strongly disagree. This is maybe due to maintenance error is
important and they need to overcome this error. To overcome the error, the investigation
should be done to know the real causes of the error. None of the respondent disagrees and
strongly disagree the statement because they know the important of error investigation in
reduce maintenance error.

4.1.2 Maintenance Error Management System Questions

Table 4-2 Respondent feedback of the question section A part 2
Question Totally
Disagree
Disagree Neutral Agree Totally
Agree
Total
1 0 1 15 19 6 41
2 0 1 12 22 6 41
3 0 2 14 17 8 41
4 2 1 12 20 6 41
5 1 3 7 24 6 41
6 0 0 9 22 10 41
7 0 2 10 22 7 41
TOTAL 3 10 79 146 49 287


0
5
10
15
20
25
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
Number of
Respondent
Question 6 : Error investigation will be
conduct if maintenance error occurs.
32

Based on Table 4-2 Respondent feedback of the question section A part 2, it shows the results of
respondent feedback on section A question part 2. The result shows that majority of
respondent tick agreed to the statement given, followed by neutral, totally agrees, disagreed
and totally disagreed. As what the author can summarize from the results, majority agreed
with the statement that related to Maintenance Error Management System (MEMS) that
means they understand of this system or maybe there have experience on this system. Only
few of the respondents totally disagreed with some statement of the questionnaire. The details
of the summary of each question as per written below.


Figure 4-10 I understand the important of MEMS

From Figure 4-10 I understand the important of MEMS which is I understand the important of
Maintenance Error Management System, Majority of respondent agree with the statement, 15
of them neutral, 6 totally agree and 1 disagree. From the first page of the questionnaire,
respondent were given an introduction about MEMS, so, mostly answer based on their
understanding of the MEMS and 6 of the respondent totally agree maybe because of they
have heard about it before.

0
5
10
15
20
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 1: I understand the important of
MEMS
33


Figure 4-11 There would be strong acceptance if error investigation such as MEMS
implemented in Aviation School

In the statement of there would be strong acceptance if error investigation system such as
MEMS implemented in Aviation School ,by referring to Figure 4-11 There would be strong
acceptance if error investigation such as MEMS implemented in Aviation School 22 of 41
respondent agree, 12 of respondent neutral, 6 totally agree and the other 1 respondent
disagree. This result may be due to they think that the error investigation system are
important in Aviation School because it can help student alert about it when theyre going to
the reality aviation industry.


0
5
10
15
20
25
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 2: There would be strong
acceptance if error investigation such as
MEMS implemented in Aviation School.
34


Figure 4-12 There would be strong acceptance if error investigation such as MEMS
implemented in management of Aviation School

Based on Figure 4-12 There would be strong acceptance if error investigation such as MEMS
implemented in management of Aviation School 16 out of 41 respondents agree that there would be
strong acceptance if error investigation such as MEMS implemented in management of Aviation
School, while 14 of them neutral, 8 respondents totally agree and 2 respondents disagree. Majority of
the respondent agree because they think that MEMS should be conducted in Aviation School under
the management of the school, so that, the flow of the system will be smooth under the management.


0
2
4
6
8
10
12
14
16
18
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 3 : There would be strong
acceptance if error investigation such as
MEMS implemented in management of
Aviation School.
35


Figure 4-13 I believe that it is important for the University to share their error investigation
system with other University

For the statement I believe that it is important for University to share their error investigation
system with other university, by referring on figure 4-13 majority of the respondent agree
with the statement, 12 of them neutral, 6 of respondent totally agree and the rest disagree and
totally disagree. From the result, I can conclude that the majority of the respondent accepts
that sharing is important for the error investigation system among universities so that, the
graduate student can learn on how to control the error because that has applied it before.

0
5
10
15
20
25
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 4 : I believe that it is important for
the University to share their error investigation
system with other University
36


Figure 4-14 There will be less error once MEMS is implemented in Aviation School.

On Figure 4-14 There will be less error once MEMS is implemented in Aviation School., the
majority of 41 respondent agree that there will be less error once MEMS is implemented in
Aviation School, 7 of them neutral, 6 others totally agree and the rest are disagree and totally
disagree. The majority of them agree maybe because of if MEMS is implemented in Aviation
School, so, the culture of human error can be reduce, so automatically it will make the error
decrease. Only the minority of them totally disagree and disagree maybe because they dont
know clearly about this system.


0
5
10
15
20
25
30
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 5 : There will be less error once
MEMS is implemented in Aviation School.
37


Figure 4-15 Error investigation system such as MEMS would be useful for discussing
probability that can cause incident.

In the statement of error investigation system such as MEMS would be useful for discussing
probability that can cause incident, on figure 4-15, it shows the majority of respondent with
total of 32 respondent answer it with agree and totally agree and the rest answer with neutral
and none for totally disagree and disagree. What I can conclude from the result is the
majority of them know the important of MEMS would be useful for discussing that can cause
incident. It is may due to the experience before about the incident that had occurs.


0
5
10
15
20
25
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 6 : Error investigation system such as
MEMS would be useful for discussing
probability that can cause incident.
38


Figure 4-16 By using tools to reduce maintenance error such as MEMS will reduce work to me.

Based on figure 4-16, by using tools to reduce maintenance error such as MEMS, it will
reduce work to me, in this statement, total of 22 out of 41 respondent agree with the
statement, while the other are totally agree, neutral and disagree and none of them totally
disagree. This is maybe because they think that if the MEMS have been use, error can be
reduce so that it is easier for them to do work smoothly.
4.1.3 Section B: Yes/No/Maybe Question

Table 4-3 Respondent feedback on section B
Question Yes No Maybe Total
1 14 21 6 41
2 8 28 5 41
3 35 4 2 41
4 34 3 4 41
5 34 0 7 41
TOTAL 125 56 24 205

In section B, these questions need respondents to tick with yes, no or maybe one each
questions. This section is more about the implementation of MEMS in Aviation School. Most
of the question asks the respondent either this system suitable to be implemented in Aviation
School and either this system can improve the tendency of human error. Majority of the
respondent answer it with yes, it means they think that MEMS are suitable to be implemented
0
5
10
15
20
25
Totally disagree disagree neutral agree Totally agree
N
u
m
b
e
r

o
f

R
e
s
p
o
n
d
e
n
t

Question 7 : By using tools to reduce
maintenance error such as MEMS will reduce
work to me.
39

on Aviation School to improve safety and reduce human error. The result of the feedback on
this section is shown as table 4-3.

Figure 4-17 Did you ever know about Maintenance Error Management System?

From figure 4-17, most of the respondents think that they never know about Maintenance
Error Management System (MEMS) before. About 21 out of 41 respondents tick with no and
only 14 of them only know about MEMS before and there are not sure is there ever know
about this system. This is probably maybe because of most of them are student and they
never learn about it before, maybe some of them that do more research on study have ever
know about this system. Most of the lecturers that were given questionnaire have the
experience on this system so they should know about this system before because they have
experience on it.
0
5
10
15
20
25
yes no maybe
QUESTION 1: Did you ever know about
Maintenance Error Management
System?
40


Figure 4-18 Aviation School did not need error preventing system such as MEMS?

From the figure above, author ask the respondent either Aviation School did need error
preventing system such as MEMS. From the result, 28 respondents tick no, 8 respondents tick
yes and only 5 respondents tick maybe. It is maybe majority of the respondents think that
Aviation School need an error preventing system such as MEMS this is maybe they realize
the important of this error preventing system. Only 8 of the respondents did not agree that
Aviation School need error preventing system. This is maybe because of they are not realize
the important of the system that can lead to improvement of safety. The minority of the
respondent are not sure either error preventing system needed in Aviation School.







0
5
10
15
20
25
30
yes no maybe
QUESTION 2: Aviation School did not
need error preventing system such as
MEMS?
41


Figure 4-19 Did you think it is necessary in Aviation School?


From the figure above, the respondent were wither MEMS is necessary in Aviation School,
and majority of them answer yes with 35 out of 41 respondents, only 6 of the total
respondents answer it no and the rest 2 choose maybe. It shows that most of the respondents
really think that this system is necessary in Aviation School. It is maybe they know this
system can give big impact to aviation industry hence lead in reduce of human error that can
lead to reduce of maintenance error. Only a few of them disagree that this system is necessary
in aviation school maybe because of they never involve in maintenance error.




0
5
10
15
20
25
30
35
40
yes no maybe
QUESTION 3 : Did you think it is
necessary in Aviation School?
42


Figure 4-20 Do you think it can improve student discipline toward maintenance error?

For question 4 in this section, respondents were either they think an error preventing system
can improve student discipline towards maintenance error. As shown in figure 4-20 above,
about 34 out of total respondent think that an error preventing system such as MEMS can
improve discipline toward maintenance error. Only 3 respondent think that this system can
improve student discipline and they rest answer it maybe. As from the result, it shows that
almost every respondent think that an error preventing system can improve student discipline
toward maintenance error. This is because maybe they what are the important of this system
that can improve student discipline because with this system, student will be more alert to
avoid human error and beware of it.


0
5
10
15
20
25
30
35
40
yes no maybe
QUESTION 4 : Do you think it can
improve student discipline toward
maintenance error?
43


Figure 4-21A new culture of safety can be practiced in aviation school if MEMS is implemented.

On the last question on Section B, the question is if MEMS is implemented, a new culture of
safety can be practiced in Aviation School. Based on the result on figure 4-21 above, the big
majority of 34 of respondents think that a new culture of safety can be practiced in aviation
school if MEMS is implemented. None of the respondent answer with no and the rest answer
it maybe. It can be concluded that respondent really think that MEMS can improve safety and
create a new culture of student that always alert of human error and none of them really think
that by implementing MEMS it doesnt give any impact on the culture of safety.











0
5
10
15
20
25
30
35
40
yes no maybe
QUESTION 5 : A new culture of safety can
be practiced in aviation school if MEMS is
implemented.
44

4.1.4 Section C: Opinion Question

On this section, author will ask the respondents opinion about the implementation of this
system in Aviation School. This section has two questions which are:

1. Do you think MEMS should be implementing in Aviation School? Why?
2. Who should handle this system if the system being implemented in Aviation School?

For the first question, author asks the respondent either MEMS should be implemented in
Aviation School and need the reason of the answer. Almost all of the respondent answer it
with yes, it should be implemented in Aviation School and only a few of them said no. From
the review of the questionnaire, most of the reason of this system should be implemented in
Aviation School is because of the safety reason. For them, by improve the safety, a new
safety culture can be created to improve the discipline of the student. As in aviation industry,
safety is the first thing that should be highlighted. If safety is avoided, airlines can reduce in
millions of dollars or lost thousands of life. Other than that, most of the respondent also
thinks that, by implementing MEMS, student can have a real situation in real life situation in
aviation industry, so they are not like a person who should know nothing about the important
of maintenance error.
On the next question, the respondents were asked about the who the person that need to
involve to handle this system if it is implemented in Aviation School. From the questionnaire
feedback, majority of the respondent think that Quality Assurance department should be a
main role to lead this system. This is because only Quality Assurance department can handle
this system because they can monitored the error and can be done smoothly under the
standard that stated by authority. Other than that, some of the respondent think that the
cooperation of students, instructor and lecturers. The cooperation between them are important
to ensure this system can be done smoothly.








45

4.2 Discussion

From the results, there are several aspect that need to be discuss to achieve the objective of
this research. The discussion can be made from the result that has been compiling as table
below:
Table 4-4 Result on majority section A
Question Majority
1. I clearly understand what maintenance error is Agree
2. As an instructor/student, I think that human error always occurs. Strongly Agree
3. I aware of human error. Agree
4. Human error is the main root of maintenance error. Agree
5. Maintenance error can be managed properly with the cooperation
between student and instructor.
Agree and Strongly
Agree
6. Error investigation will be conduct if maintenance error occurs. Agree

As from the result based on the table 4-4 above, majority of the respondent agree or strongly
agree with the statement given. This trend shows that most of the respondent really knows
about the maintenance error, human factor, the causes of maintenance error and the need to
reduce maintenance error. This is because they have learnt about human error in their study
and for the lecturers and technicians; they have an experience on human error themselves.
From question 1 and 2, they were ask either they have know about maintenance error and has
experience on it. For question number 3, they were asked either they aware of human factor,
and it is clearly, most of them aware of the system. Next question were asked either the
respondent really know about what the main causes of human error. From the fact, about 70%
of maintenance errors are from human error. For the question number 5 and the last question,
they were asked about the way to manage maintenance error and who the person that need to
responsible to ensure the smooth of the process of managing maintenance error.










46

Table 4-5 Result on majority MEMS section.
Question Majority
1. I understand the important of MEMS Agree
2. There would be strong acceptance if error investigation such as
MEMS implemented in Aviation School
Agree
3. There would be strong acceptance if error investigation such as
MEMS implemented in management of Aviation School.
Agree
4. I believe that it is important for the University to share their error
investigation system with other University
Agree
5. There will be less error once MEMS is implemented in Aviation
School.
Agree
6. Error investigation system such as MEMS would be useful for
discussing probability that can cause incident.
Agree
7. By using tools to reduce maintenance error such as MEMS will
reduce work to me.
Agree

For section B as shown in table 4-5, in all questions, majority of the respondent answer the
question with agree to the statement. This section are fully based on Maintenance Error
Management System (MEMS), the description on MEMS were given on the first page of the
questionnaire. In first question, they were asking about their understanding based on the
description. Majority of them agree they understand the important of the MEMS that are
mostly related to the safety in aviation industry. From question 2 until question 5, the
questions are more to the implementation of MEMS in Aviation School. Majority of them
agree that the implementation of this system is important; it is because they know if to root of
the maintenance error could be control, automatically maintenance error also can be control
to reduce it. On question 6 and 7, the questions are related to the efficiency of this if it is
implemented in aviation school. As from the data shows, the majority of them agreed because
before this there is no such system in aviation school that are practically use to create the
culture of safety from the roots. From the respondent feedback, author can roughly said that
majority of the respondent agree that MEMS can be implemented in aviation school to help
in reducing in maintenance error.








47

Table 4-6 Result on majority Section B
Question Majority
1. Did you ever know about Maintenance Error Management System? No
2. Aviation School did not need error preventing system such as MEMS? No
3. Did you think it is necessary in Aviation School?

Yes
4.Do you think it can improve student discipline toward maintenance
error?
Yes
5 .A new culture of safety can be practiced in aviation school if MEMS is
implemented.
Yes

For this section based on table 4-6, author wants to know either when implementing this
system, what are the effects on aviation school or in aviation industry. In the first question,
author want to know if respondent have heard about the system before, and the majority
really never heard about this system before. In question 2, the question is about either
aviation school really need this system to ensure the maintenance error can be reduce and
majority of the respondent really think that it is needed in aviation school due to the need of
safety that must be create from the root. On question 4 and 5, the respondent was asked about
the safety if MEMS be implemented in aviation school. Almost all of the respondent think
that with this system, it can improve student attitude towards safety. Student will be more
alert on maintenance error because they were trained from the beginning of the aviation
world.
















48


CHAPTER 5
5 CONCLUSION

From this research, author can conclude that the objective of this research is successfully
achieved. The main objective of this research is to identify either this system can be
implemented in aviation school. The other objective will follow the main objective to ensure
the main objective is achieved. Through this research, conclusions can be made based on the
objective of this research which is:
1. This system purpose is clearly to reduce the maintenance error based on the element
involve in this system. The element involve in this system include the investigation
process, investigator and the way to discuss to ensure maintenance error can be reduce.
2. Through this research, author has identified several advantages and these
disadvantages as a guide on this system and also the improvement of this system.
3. From this research, the questionnaires were given to find out either this system can be
implemented on aviation school. From the result of the questionnaire, this system
receives full support from the respondent in Unikl MIAT to be implemented to create
a new safety culture.
5.1 Suggestion to implementation of MEMS in Aviation School

From this research, author has create a suggestion regarding the implementation of this
system if this system were implemented in aviation school.To implement it, there are several
discussion based on the result of the questionnaire that can be made. The discussion on
implementation of MEMS in Aviation School can be divided into several parts which are:
1. The person involve in the system
2. The flow of the system
3. Limitation of the system





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5.1.1 Person Involve In Mems In Aviation School

As from the data of the questionnaire, in Section C the respondent were ask who can should
in charge and can involve in this system, majority of the respondent give opinion that Quality
Assurance (QA) Department should take a lead if this system is implemented in Aviation
School. The Quality Assurance can be defining as all those planned and systematic actions
that are established to ensure that the trial is performed and the data are generated,
documented (recorded), and reported in compliance with Good Clinical Practice and the
applicable requirements. (EFGCP, 2008) Hence, Quality Assurance Department is the
department that need to ensure the system flow need to follow the standard.

In the implementation of MEMS, QA department need to ensure that the system follow the
standard and the suitable action need to be taken to make sure this system are smooth and
achieve their target which is to improve safety and create awareness among student. The role
of QA department in this system is to create the flow of this system properly and responsible
for Quality output. QA department should investigate the error properly and must do a
meeting if there is problem they should discuss the best way to reduce the error so that the
error can be reduce.
Students, lecturers and instructors also need to cooperate each other to make sure the
maintenance error can be reduced. Lecturers and instructors should always remind student
especially before they do a practical task about the maintenance error and the effect of
maintenance error in terms of safety and also the real situation in aviation world. Student also
should aware of the effect of maintenance error and practice a good safety environment so
that they will familiar when they are going to the real-life situation when they are working.







50

5.1.2 The Flow Of The System

From the literature review as stated before, author has list out what is the flow of
Maintenance Error Management System (MEMS) in aviation industry. The flow of this
system is as below:




















Figure 5-1 Flowchart of implementation system


An error occur
Make decision what is the
way to reduce the error and
publish it.
A meeting to identify what
is the possible cause to
reduce the error.
MEDA will
identify what is
the root of the
problem
(maintenance
YES
Analyze the data to identify
the method can reduce
maintenance error.
NO
51

From the flowchart on figure 5-1 above, the flow of this system start with if the error has
been found or has occurred. Then, after the error has been found, Maintenance Error Decision
Aid (MEDA) will investigate either the error is maintenance error or not. If it is maintenance
error, MEDA will identify what is the root cause of the error. If it is not maintenance error,
the problem should bring directly to the QA for they identify what is the best way to reduce it.
Next, after the error has been confirm as maintenance error, a meeting should be conduct
what is the best way to ensure this error can be reduce or eliminate. This meeting must be
among the Quality Assurance department. After the meeting, they will publish their final
decision what is the best way for the error, so that it can be reduce. Lastly, QA department
will analyze the data either after the decision to reduce the error, the maintenance error
successfully reduces or not. If not, they will go to meeting again to discuss other way to
reduce the error.

5.1.3 Limitation Of The System

In every system there will always have limitations to ensure the system is smooth. The
limitation that should be followed such as:
1. Limited to maintenance error only
2. The error must be within the student do their practical
3. Analysis of the data should be made within 2 weeks after the way of reduce the error
has been publish.
Firstly the limitation is this system only limited to maintenance error only if not it should not
use this system, but most of the problem in technical part is because of maintenance error that
are mostly human error. Then the error should be only when the student doing their practical,
it they are in class and has some problem to the lamp, it is not considered as maintenance
error. The time also main the important role of this system, the time limitation is needed
when the data has been analyze. To ensure the successful of MEMS, the data must be use but
only after two weeks of the way of reduce maintenance error has published to student.





52

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APPENDIX