In airline company maintenance and engineering department

This work arises from the increasing need of systems to manage risks associated with aircraft operations in order to improve the culture of Safety by the Aircraft Operators, particularly in the case of the Department of Engineering and Maintenance of these operators. The motivation for this study began with the partnership with a company dedicated to operate heavy aircraft worldwide. It was studied the case of risk management associated with the Department of Maintenance and Engineering airworthiness and created a program (or more specifically a set of procedures, connected by a database) to assist the members of this department controlling situations that threaten the safety, airworthiness and profitability of their fleet. The analysis of applicable legislation in the case of Maintenance and Engineering Department was made, as well as studied programs for risk management in different contexts. After that, we have outlined the general procedure as well as the various components that complete the analysis and mitigation of adverse events associated with the activities of this department. The implementation of this program was followed for one year in this study being presented here the results obtained from the analysis of the collected information. This work increased the safety culture of this department, as well as assisted in the implementation of mandatory legislation, introduced by the various authorities that regulate the operation of this operator.Este trabalho surge aquando da necessidade crescente de criar sistemas de gestão de risco em operações com aeronaves, de forma a melhorar a cultura de segurança por parte dos Operadores Aéreos. A motivação surgiu da parceria com uma empresa dedicada a operar aeronaves pesadas por todo o mundo. Foi estudado o caso particular da gestão de riscos associados ao Departamento de Manutenção e Engenharia e criado um programa (ou mais concretamente um conjunto de procedimentos, unidos por uma base de dados) para auxiliar os membros deste departmento a controlar situações que ameacem a segurança, aeronavegabilidade e rentabilidade da sua frota. Foi feita a análise da legislação aplicável ao caso concreto da Manutenção e Engenharia, assim como estudados programas aplicados em diversas áreas para gestão de riscos. Posto isto, foi delineado o procedimento geral assim como os diversos componentes que completam a análise e mitigação de eventos negativos associados com as actividades deste departamento. A implementação deste programa foi acompanhada durante um ano no âmbito deste estudo, sendo aqui apresentados os resultados obtidos da análise da informação recolhida. Este trabalho veio assim aumentar a cultura de segurança deste departamento, assim como ajudar na implementação da legislação mandatória, introduzida pelas diversas autoridades que regulam o sector no âmbito da operação deste operador

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Application of Systems Engineering Science to the Healthcare Environment

This Doctoral dissertation consists of a research portfolio examining the application of systems engineering techniques to the healthcare environment. The portfolio consists of three final publishable articles submitted to meet the program requirements for the, Doctor of Philosophy in Nursing degree from the University of San Diego, Hahn school of Nursing and Health Sciences. Article one is titled; Use of a bed projection tool to predict ICU bed needs. This article describes the dissertation research study in which a bed projection tool was piloted on an ICU unit to determine the tool\u27s ability to predict inpatient bed requirements. Article 2 is titled; Reducing Disruptive Communication in the Health Care Setting: Use of the Crew Resource Model (CRM). Crew resource is a human factor-engineering model that creates uniform team roles and communication structure. This article advocates the use of this model to assist in dealing with disruptive behaviors by healthcare team professionals. The article advocates the use of the CRM model for meeting the Joint Commission on Hospital Accreditation requirement for organization\u27s in which a plan is implemented for dealing with disruptive communication in the health care environment (by health care team professionals). Article 3 is titled; Application of systems engineering to the hospital environment; has the time for a Nurse Engineer role arrived? This article describes the evolution of systems engineering as a discipline and its historical application. The article stresses the need for Nurses to acquire an engineering skill set in order to participate in the redesign of clinical health systems, which will ensure efficiency and patient safety

Improving Perinatal Team Communication to Decrease Patient Harm With Team Strategies and Tools to Enhance Performance and Patient Safety Training

During childbirth, multiple providers deliver care at the bedside that requires optimal teamwork and communication to prevent patient harm. The complexity of caring for obstetrical patient demands a well-coordinated team to relay information and respond to conditions that can change quickly during childbirth. A patient safety strategy to prevent perinatal harm is Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training. TeamSTEPPS is an evidence-based program based on crew resource management (CRM) principles developed in the aviation and military industries. This process improvement project used the Plan-Do-Study-Act framework and Kotter\u27s change theory to implement TeamSTEPPS training after an increase in patient safety events from 2014 to 2016. A convenience sample of 200 physicians, nurses, respiratory therapists, scrub techs, and patient care techs from perinatal units completed the training in a community hospital setting. The Teamwork Perceptions Questionnaire administered pre- and posttraining show a statistical improvement in teamwork, communication, and situational awareness among nursing staff that correlated with a decrease in safety events. Project limitations include lack of a control group for comparison and lack of physician involvement with training. The positive social impact of TeamSTEPPS training is the decrease in maternal and newborn adverse events surrounding childbirth due to perinatal teams using CRM principles. Over the long term, TeamSTEPPs training may become the standard team training method to improve birth outcomes and support the establishment of a patient safety culture, which may be replicated in perinatal centers around the world

Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents

Minor safety incidents on the railways cause disruption, and may be indicators of more serious safety risks. The following paper aimed to gain an understanding of the relationship between active and latent factors, and particular causal paths for these types of incidents by using the Human Factors Analysis and Classification System (HFACS) to examine rail industry incident reports investigating such events. 78 reports across 5 types of incident were reviewed by two authors and cross-referenced for interrater reliability using the index of concordance. The results indicate that the reports were strongly focused on active failures, particularly those associated with work-related distraction and environmental factors. Few latent factors were presented in the reports. Different causal pathways emerged for memory failures for events such a failure to call at stations, and attentional failures which were more often associated with signals passed at danger. The study highlights a need for the rail industry to look more closely at latent factors at the supervisory and organisational levels when nvestigating minor safety of the line incidents. The results also strongly suggest the importance of a new factor – operational environment – that captures unexpected and non-routine operating conditions which have a risk of distracting the driver. Finally, the study is further demonstration of the utility of HFACS to the rail industry, and of the usefulness of the index of concordance measure of interrater reliability

Intelligent CRM on the cloud

This paper presents a new conceptual framework and practical solution for Customer Relationship Management(CRM) and E-Loyalty programs for cutting edge M-Commerce. CRM has come to the world of technology to help companies maximise technology usage. CRM means disciplined business strategy to create and sustain long-term, profitable customer relationships. To this aim, it must concentrate on customer. This paper introduces the notion of Intelligence CRM (i-CRM), and will define and develop i-CRM, E-Loyalty for the M-Commerce environment including Cloud services. The conceptual framework will include solutions for customer complaints and evaluation of the solution through perceived value, interactivity, and acceptance of i-CRM, perceived ease of use, perceived usefulness, loyalty and E-Loyalty. This paper shows how i-CRMcan foresee the threshold of customer feedback creating an innovative solution to minimize negative customer feedback and increase the loyalty and E-Loyalty of an organization

An Assessment of Reduced Crew and Single Pilot Operations in Commercial Transport Aircraft Operations

Future reduced crew operations or even single pilot operations for commercial airline and on-demand mobility applications are an active area of research. These changes would reduce the human element and thus, threaten the precept that "a well-trained and well-qualified pilot is the critical center point of aircraft systems safety and an integral safety component of the entire commercial aviation system." NASA recently completed a pilot-in-the-loop high fidelity motion simulation study in partnership with the Federal Aviation Administration (FAA) attempting to quantify the pilot's contribution to flight safety during normal flight and in response to aircraft system failures. Crew complement was used as the experiment independent variable in a between-subjects design. These data show significant increases in workload for single pilot operations, compared to two-crew, with subjective assessments of safety and performance being significantly degraded as well. Nonetheless, in all cases, the pilots were able to overcome the failure mode effects in all crew configurations. These data reflect current-day flight deck equipage and help identify the technologies that may improve two-crew operations and/or possibly enable future reduced crew and/or single pilot operations

A legacy handbook for business support

Legacy Handbook reviewing emda's experience of business support activity. Identifies key achievements and draws out lessons learned that may be relevant to successor bodies active in this area