MAINTENANCE ERROR DECISION AID (MEDA)

• A Structured process
• Used for investigation an event
• Caused by maintenance technician and/or inspector
performance.
 Error

• An error is a human action that unintentionally deviates from the

expected action.
• Types of errors
error of omission
error of commission
lapse
slip
 Violation

• Violation is a human factor that intentionally deviates from the

expected action.
 Contributing Factor

• A contributing factor is anything that affects how a maintenance

technician does his job.

Immediate Organization
Supervision
philosophy
environment • Planning
Maintenance/
• • Policies
Facilities • Organizing
technician/
• • Procedures
Weather • Prioritizing
inspector
• • Processes
Aircraft design • Delegating
• Knowledge • Selection
• Time pressure • Instructing
• Skills • Training
• Teamwork • Feedback
• Abilities • Continuous
• Documentation • Performance
• Other quality
• Communication management
characteristics
• • Improvemen
On the job • Team building
training t
 The MEDA Event Model

Contributing
Factor Error Event

Probability Probability

Leads Leads
Contributing to to
Factor Error Event
Contributing
Factor
Probability Probability

Leads Leads
Contributing to to
Factor Error Event

Contributing
Factor
CF CF CF
Probability Probability

CF CF Event
Error

CF CF
MEDA investigation process
• Event based investigation process
• Maintenance technician fault or technical failure
• Interviewing of the maintenance technician
• Analysis
• implementation
 MEDA Result Form

• Section I- General Information

• Section II-Event
• Section III-Maintenance System Failure
• Section IV- Chronological Summary of Events
• Section V- Summary of Recommendations
• Section VI-Contributing Factors Checklist
 General Information

• Where, when and what the incident occurred

• Aircraft type
• Engine number
• Date of event/ investigation
• Shift of maintenance
• Type of maintenance
• Interviewer details
• Ref of previous related event.
 Event
7 Types of event
• Operation process event (Flight delay/ cancellation/diversion
etc)
• Aircraft damage
• Personal injury
• Rework
• Airworthiness control event.
• System failure after the maintenance was done and signed
off
• System failure that were found during the flight

• It is possible that more than one event is checked on the

form
• Write a small explanation of the event.
 Maintenance System Failure
Eight system failures are listed below
• Installation Failure
• Servicing Failure
• Repair Failure
• Fault Isolation, test or inspection failure
• Foreign Object Damage/ Debris
• Airplane or equipment damage
• Personal injury
• Maintenance control failure

• It is possible that more than one event is checked on the form

• Write a small explanation of the event
 Chronological Summary Of Events

• Provision of space to describe and summarize.

• List the contributing factors in order
• Summary of interviews
 Summary Of Recommendations

• Write recommendation for each contributing factor.

• A recommendation maybe for multiple contributing factors
• Write the proposed improvement
• Error Preventing strategies
Error Reduction/elimination
Error Capturing
Error Tolerance
Audit program
 Contributing Factor Checklist

• Information: any written or computerized information source

that a worker needs to carry out.
• Not understandable
• Unavailable
• Incorrect
• Conflicting information
• Process is long and complicated
• Incorrect modification
• Information not used
• Inadequate
• Uncontrolled
• Ground Support Equipment, tools and safety equipment: Any
equipment use to carry out maintenance such torque wrenches,
screwdriver, work stands etc. safety equipment Includes
Personal Protection Equipment (PPE) and safety devices such
as hazard barriers and safety railings.
• Unsafe
• Unreliable
• Out of calibration
• Unavailable
• Too complicated
• Incorrectly used
• Aircraft design, Configuration, parts, equipment ad
consumables: this refers to aircraft configuration so that parts
are accessible for maintenance, equipment and parts should be
available and accessible.
• Complex
• Inaccessible
• Parts/equipment unavailable
• Easy to install incorrectly
• Consumable unavailable
• Wrong consumable used
• Expired consumable used
• Job and task: a technicians job is a series of tasks, the tasks
performed can be a contributing factor, the technical skills and
knowledge were expected.
• repetitive/monotonous
• Complex/confusing
• New task
• Different from other similar tasks
• Knowledge and skills: the skills that a worker is expected to
preform without referring to information
• Knowledge is understanding of body of information that is
applied to perform a task.
• Technical skills
• Task planning
• Airline process knowledge
• Aircraft system knowledge
• English language proficiency
• Teamwork skills
• Computing skills
• Individual Factor: it can include health, personal event, fatigue,
strength etc.
• Physical strength visual perception

• Fatigue Assertiveness
• Time pressure Stress
• Peer pressure Situational Awareness
• Complacency
• Personal event
• Memory lapse
• Task distraction
• Organizational Factors: the organizational culture can have a
great impact.
• Quality of support from technical organization
• Company policies
• Not enough staff
• Work process procedures
• Work processes not followed
• Work group normal practice
• Team building
• Leadership/supervision
• Planning/organization of task
• Prioritization of task
• Delegation/assignment of task
• Unrealistic attitude/expectations
• Amount of supervision
• Communication: transfer of information (written, verbal, non-
verbal)
• Between departments
• Between mechanics
• Between shifts
• Between maintenance crew and lead
• Between lead and management
• Between flight crew and maintenance
 How To Carry Out the MEDA Investigation Interview.

• Most important part

• One person or at max 2 person should carry out interview
• One person seems less threatening
• In a 2 person team: one can interview one can write
• With 3 or more people the would would feel outnumbered
• Technician does not share information out of fear and
intimidation
 Guidelines

• Cognitive interviewing : a systematic information retrieval strategy.

• Maintain and develop good rapport
• Encourage the interviewee to be actively involved
• Help the interview concentrate
• Use open, simple and unbiased question
• Listen actively
• Use a communication style to suit the interviewee
• Work as a team with other interviewees