On initial introduction it would appear to be a rebadged Murphy report.
Also like anything new it needs to be driven from the top to ensure it works.
At Lossie it works very well and the management love it. At Brize they are just starting to catch up.!
MEMS is not a rebadged Murphy. It should be used for any incident were suspect or actual maintenance error is found, but not causing a major accident/incident where a formal BOI is madatory.. It is there to stop such incidents being lost as brushed under the carpet..
As an investigator, it is difficult to make people realise that I am not out to stitch them up but simply find out what did/did not happen. Management have to stress that blame is NOT the reason for investigation, working in 'partnership' is about the only thing they seem to have got right!
In Civvy street, the form is known as an Internal Occurance Report (IOR) in company use and if the incident is serious enough to have to go up to the CAA, it will become a Mandatory Occurance Report (MOR). MOR's are in the main flight related, but serious ground incidents also come under the CAA remit for reporting as well. Anybody can raise an IOR in a company for for any incident or problem found during an inspection/function check that looks like it is due to an maintenance error (of any shape form or description). It is then up to the Quality department to investigate everything surrounding the initial report on work done, personnel involved, situation, conditions and equipment/tooling using MEDA techniques (developed by Boeing, but free for ANY organisation to use). The interviews are never a "blame you for doing that" or under oath like a BOI, because the investigators just want to know what happened. When they make a judgement on the case, then they will make a proper report with recommendations. If it is due to a willful neglegence, well that goes further up the company management chain to decide, however laspes and mistakes will be looked at with any underlying reasons for such decisions. Reports come out as Quality Notices, that are placed on the main notice board. Also,Continuation training of the Licenced Technicians will included reviewing the reports produced in the period previous to their last training, so they are made aware of these incidents and the reasons behind them. Mechanics are also made aware of these during their refreshers. True, there are some things my company will not do in regards of such reports, such as printing as many copies as the Quality boys would like, but..
Take a couple of RAF incidents I know of that fits the bill, although one came very close to being a BOI. A pilot comes back from an post maintenance airtest and complains that yaw trim is awful and has been getting worse. On the afterflight, on application of standby Hyd power, the rudder travels uncommanded to full deflection. On investigation an input rod is found disconnected from the Rudder Actuator as the bolt was not fitted with a nut and locked. This bolt was removed as part of a check of the yaw control system that was called up as a F2988 in the work pack to be done IAW the AMM. The task itself was not in the form of a MMP with all the details of the task. The tradesman that did the task did not record the disconnect on any F707B (naughty) , so no reconnect/indie paperwork was raised. why the experienced SNCO didn't check the entire run as most others usually did, is neither here or there, but the whole incident was brushed under the carpet apart from rumours of the one way conversation the relevent parties got from their empire.. A leason that everybody else should have heard about officially.
The second was another Rudder incident, this time on a line squadron. A lifed item was being replaced and the dayshift ran out of time to finish it. A top table was going on, so all of the day SNCOs were unavailable. The Cpl running Recs told the Rigger Cpl running the job to ensure that the paperwork was up to the stage of the AMM proceedure that they had reached, so nights would have a clear indication where they were taking over (as well as the "progress" entry in the handover diary). The next day, the oncoming shift found that the rudder was damaged as the nightshift had finished the job, The day shift Cpl had put no entries on the 707B for what his team had done, Nights had signed the whole replacement off and found during the function test that days had ommited to set up the item to the correct position and during the functional, it had ripped out its attachment to the rudder. The Newbie Cpl on Nights took the hit for signing up for work he hadn't been involved in and the incident was hushed up by a rudder change.. However, no incident report ever was raise and the educational elements that would be useful to everybody else working on the type was lost apart from rumours..
MEMS cases indeed.. How many error have E-goaters seen and been brushed under the carpet, so nobody else can avoid the same mistakes?? Many thousands of pounds and manhours wasted, because people are not told of possible mistakes, so make the same one? Shortfalls in tooling and manuals not highlighted, especially when modern PDF manual are easily updated? An incident that is a carbon copy of a previous ends up as a lost airframe and lost lives?
However the Just Culture behind such systems has to be taken on board by Management and not given lip service as the system will not work..
That is my Rigga view on the subject..cup of corrrfeee
