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Quality and Safety are 2 Sides of the Same Coin

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This report is presented towards analyzing the statement "Quality and Safety are 2 Sides of the Same Coin" in the Aviation Industry,

This report is presented towards analyzing the statement "Quality and Safety are 2 Sides of the Same Coin" in the Aviation Industry,

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  • 1. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDONTable of Contents1 Introduction........................................................................................................................................... 22 Aviation ................................................................................................................................................. 23 Definition ............................................................................................................................................... 2 3.1 Quality ........................................................................................................................................... 2 3.2 Safety ............................................................................................................................................. 34 Relationship ........................................................................................................................................... 45 Case Studies........................................................................................................................................... 5 5.1 Case Study 1 BA5390 ..................................................................................................................... 5 5.1.1 Background............................................................................................................................ 5 5.1.2 Analysis .................................................................................................................................. 5 5.2 Case Study 2 CAL 1611 .................................................................................................................. 5 5.2.1 Background............................................................................................................................ 5 5.2.2 Analysis .................................................................................................................................. 6 5.3 Summary of Analysis ..................................................................................................................... 66 Systems.................................................................................................................................................. 77 Conclusion ............................................................................................................................................. 71|Page Prepared by: Rohit Tomar
  • 2. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDONQuality and Safety are 2 sides of thesame coin.1 IntroductionThis report is presented towards analyzing the statement “Quality and Safety are 2 sides of the samecoin”. For the analysis, this report focuses on the Aviation Industry in which quality and safety share acomplex relationship. The report also analyses 2 case studies of accidents in the aviation history inretrospect to differentiate the Quality and Safety objectives in the processes employed within theaviation industry. The report also briefly introduces the 2 Systems Quality System and Safety Systemthat have been introduced in the aviation industry.2 AviationAviation is a strongly regulated industry and among one of the industries where Quality and Safety arecomplexly interrelated. The regulators of aviation have a single prime focus of achieving safetransportation of passengers. With this focus regulators across the world have developed variousmandatory requirements that an Airline has to meet in order to operate. To ensure safe operations ofAirlines the regulators under OPS 1.035 defined the requirement of a Quality System. It should be notedthat QMS (Quality Management System) must be implemented achieve Safe Operational Practices i.e. toachieve the Safety requirements for Aviation Transport.3 Definition3.1 QualityISO 9000 defines Quality as “Degree to which a set of inherent characteristics fulfils requirements”1.With reference to the Airline Industry taken as an example in this report, the requirements mentioned inthe above definition can be divided as 1) Customer’s Requirements a. The requirements of Customers in an Airline can be Fares, On-Time Performance (OTP), Safety, Customer Service and Care, In Flight Food and Drinks, Seat Comfort and more. These requirements can either be Stated, Implied or Obligatory. E.g.: On-Time Performance with regards to ensuring the airline meets its departure time and arrival time as printed in the ticket is a stated requirement, safety is an implied requirement and In Flight Food and Drinks will be an Obligatory requirement for a full service airline.1 http://www.praxiom.com/iso-definition.htm#Quality2|Page Prepared by: Rohit Tomar
  • 3. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDON 2) Regulatory Requirements a. These requirements are very strongly stated by the regulators when issuing an Air Operator Certificate (AOC) to an Airline as along with Continuing Airworthiness Requirements stated by regulators that an Airline has to continuously comply with and which is further overseen by an Audit (internal and regulatory). 3) Airline’s Requirements a. These requirements are stated within the Airline’s manuals. These requirements are the processes, procedures, accountabilities, responsibilities that are supposed to be followed and acknowledge by its employee’s.3.2 SafetyOxford dictionary defines Safety as “the condition of being protected from or unlikely to cause danger,risk or injury”2. Another definition which most aptly suits the Aviation industry can be found inWikipedia as “the control of recognized hazards to achieve an acceptable level of risk”3. Since Safety isrelated towards the control of risk, it can be measured by determining the degree of risk an organizationis subjected to. The “risk” as mentioned in the above definition would differ from organization toorganization and in the presented report, the “risk” associated with an Airline can be as follows, 1) Operational a. Risks associated with operational procedures. 2) Resources a. Risks associated with inadequate resources. 3) Personnel a. Risks associated with inadequate training of personnel, negligence of personnel while performing work, risks related to human factor errors. 4) Airworthiness a. Risks associated with improper procedures of maintaining airworthiness.It is worthwhile to note that in practicality there can never be a Zero Risk organization; however thelevel of control over the exposed risk is an indicator for Safety. It would be worthwhile to note thatICAO Doc 9859 released a Safety Management Manual in 2006 revised in 2009 which superseded theICAO Doc 9422 Accident Prevention Manual.2 http://oxforddictionaries.com/definition/safety?q=Safety3 http://en.wikipedia.org/wiki/Safety3|Page Prepared by: Rohit Tomar
  • 4. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDON4 RelationshipAs defined above Quality is focused on meeting Requirements, and Safety becomes a key requirementfor an Airline. Safety is the level of existence of a Hazard, where Hazard is an output of proceduredeviations, human errors, inherent gaps, communication a other like factors. andSafety needs to be measured in order to identify the levels of risks; this can be achieved at selectingvarious points in a procedure or at the end of a procedure. The measurement of risks will act as anindication with regards to the procedure or product is in line with meeting the requirements. heOnce the measurement is done, the findings of the measurements will serve as a feedback to theorganization to look at the procedures and processes and take necessary action to decrease the risks toan acceptable level. In summary, safety measurement serves as an indicator control point andfeedback point to the organization towards the Quality of the processes and procedures within the dbackorganization.The PDCA Cycle that forms the basic structural framework for an Organization’s system towardsmonitoring and managing quality within the organization is presented below along with the position ofsafety indicator in the Cycle. • Plan – Procedures are set up in accordance with the Plan requirements nts and documented • Do – Procedures are performed in accordance Act Do with the documented procedures. • Check Checks –Checks are performed to measure the Check degree of conformance with the requirements, Safety Risks and Hazards are Fig. 1 PDCA CYCLE identified here and measured to identify if acceptable. • Act- Based on feedback from Checks, procedures are reviewed in order to incorporate feedbacks4|Page Prepared by: Rohit Tomar
  • 5. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDON5 Case Studies5.1 Case Study 1 BA539045.1.1 Background On 10th June 1990 during a scheduled flight BA 5390 from Birmingham to Malaga (Spain) carrying 81 passengers, the aircraft suffered explosive decompression at 17,300 feet. The commander of the flight had been partially sucked out of his windscreen. The copilot landed the aircraft safely at Southampton Airport. There were no casualties in this accident. The investigation of the accident highlighted that the shift manager who was responsible for performing the maintenance on the aircraft had carried out replacement of the windshield had erroneously used bolts having a smaller diameter as compared to the correct bolts that had to be installed on the windscreen. These bolts could not hold the windscreen at 17,300 feet due to differential pressure and resulted in the windscreen breakage which caused the raid decompression.5.1.2 Analysis The accident of BA5390 is a classic example of Quality complacency in an organization leading to a Quality Lapse which developed a Hazard and lack of hazard identification and measurement from the airline and the manufacturer resulted in an accident. The procedures carried out by the shift manager were not as per the requirements of the Procedures recommended by the Manufactures and documented by the Airline. This non conformity to the procedure (Lapse of Quality) leads to the Hazard of windshield failure. It can be argued that the accident could have been avoided if a check would have been carried out after the completion of the windshield replacement (Risk Measurement) or the manufacturer of the Aircraft would have included the Windshield replacement process as a part of double inspection task (Risk Measurement).5.2 Case Study 2 CAL 161155.2.1 Background On 25th May 2002, China Airlines (CAL) Flight CI611 crashed into the Taiwan Strait due to midair disintegration and causing death of all 225 occupants in the flight. The investigation revealed various factors causing the crash which included an incorrect permanent repair carried out by the Maintenance team on the aircraft on 23rd May 1980 due to4 Aircraft Accident Report 1/92, Air Accidents Investigation Branch, Report on the Accident to BAC One-Eleven, G-BJRT over Didcot, Oxfordshire on 10 June 1990 http://www.skybrary.aero/bookshelf/books/636.pdf5 Aviation Occurrence Report Volume 1 ASC-AOR-05-02-001 In-Flight Breakup over the Taiwan Strait northeast ofMakung, Pengshu Island, China Airlines Flight CI611 Boeing 747-200, B-18255 May 25, 2002http://www.asc.gov.tw/downfile/CI611_Report_English_VOL_1.pdf5|Page Prepared by: Rohit Tomar
  • 6. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDON a tail strike on 7th Feb 1980. Another revelation was improper documentation and records which resulted in loss of evidence during the investigation.5.2.2 Analysis The accident of China Airlines is an example of continuous Quality lapses and safety lapses at various stages over 20 years that increased the level of risk and resulted in a crash with loss of life. The maintenance work carried out by the Engineers on 23rd May 1980 was not in accordance with the Boeing SRM (Structural Repair Manual) and furthermore the incorrect repair was not noted or highlighted during various quality audits and inspections carried out by the Airline and the Regulatory Authorities did not reveal any non conformance of procedures followed by China Airlines. The visible marks on the area repaired were visible by naked eye indicating a pressure leak through a crack, however no action was taken to correct the same. The incorrect procedure (lapse of quality) of performing the repair resulted in development of a Hazard which resulted in an Accident occurrence (safety lapse). It can again be argued that if the Repairs would have been carried out as per the documented RSM (Quality) it would have eliminated the Hazards. In addition to this if Safety inspections were able to identify the Hazards while performing Aircraft Inspections before release to service it would have resulted in lowering the probability of the accident occurrence.5.3 Summary of AnalysisThe summary from the Analysis in context of this report can be depicted in Fig 2 and Fig 3 Below. AQuality Lapse in the organization led to a Safety implication and at the same time, the safetyimplications were not measured or observed in order to provide a feedback to the organization tomitigate the quality lapse. Fig. 2 as below shows how a procedure deviation developed a hazard which resulted in an accident. Procedure Hazard Accident deviation development occurance Fig.2 Accident Occurrence6|Page Prepared by: Rohit Tomar
  • 7. QUALITY MANAGEMENT SYSTEM COURSEWORKCITY UNIVERSITY LONDONFig. 3 shows below how Quality System using Safety as an indicator would have affected the Accidentoccurrence. Feedback of Hazard Rectify deviation development Quality Check Safety Check Reduced Mitigate Procedure Accident Hazard deviation occurence development probability Fig.3 Quality System involvement6 SystemsQuality system aims at meeting the requirements both intrinsic and extrinsic. An organization trying toachieve Quality needs to ensure that all its processes and procedures are Planned, Executed, Checkedand Corrected. This can also be referred to PDCA Cycle PLAN, DO, CHECK and ACT. A system of Qualityaims at ensuring at the very start of a process that the process will meet the various requirements.Safety system aims at identifying the risks and hazards and minimizing the risk to an acceptable level forthe organization. Safety serves as an indicator for an organization to review its procedures, processesand its Quality system to find the root cause of the hazard buildup and to mitigate the hazards.7 ConclusionFrom the presented report it would be appropriate to conclude that Quality and Safety have distant yetinterlinked objectives. Safety is a benchmark indicator towards Quality of an Airline and to a large extentfor an airline. Regulators across the world have focused Safety as the sole primary objective that needsto be fulfilled and maintained by having Quality and Safety Systems in an organization. Quality cannotbe achieved without having High Safety Standards and vice versa, High Safety Standards cannot beachieved without having Quality within the operations and processes. Thus it would be apt to say that“Quality and Safety are 2 sides of the same coin”.7|Page Prepared by: Rohit Tomar

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