Human Factors in Aircraft Maintenance
Human Factors in Aircraft Maintenance
Human Factors in Aircraft Maintenance
SAB/IP/94/02
RP/9 1/02
This report was produced by the Bureau of Air Safety Investigation (BASI), PO Box 967, Civic Square ACT 2608.
The Director of the Bureau authorised the investigation and the publication of this report pursuant to his delegated pow-
ers conferred by Air Navigation Regulations 278 and 283 respectively. Readers are advised that the Bureau investigates for
the sole purpose of enhancing aviation safety. Consequently, Bureau reports are confined to matters of safety significance
and may be misleading if used for any other purpose.
As BASI believes that safety information is of greatest value if it is passed on for the use of others, copyright restric-
tions d o not apply to material printed in this report. Readers are encouraged to copy or reprint for further
distribution, but should acknowledge BASI as the source.
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CONTENTS
Synopsis ........................................................................................................................................................................................................................................................... 1
1. Introduction ........................................................................................................................................................................................................................ 1
1.1 Previous research ..................... :................................................................................................... ................................ 3
1.2 Humanerror .................................................................................................................................................................................................. 3
1.2.1 Studies of error in industry and transport .............................................................................. 3
1.2.2 Latent failures, active failures and accidents ............................................................................. 4
1.2.3 Theoretical issues of active failures .. ............................................................................. 4
1.2.4 Quantification of human error ................................................................................................................ 5
2. Conclusion .............................................................................................................................................................................................................. 6
Appendix Research proposal: Human factors in aircraft maintenance ................................................. 7
References .................................................................................. ........................................................................................................................................................ 9
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1. . INTRODUCTION
Maintenance constitutes a significant and rising cost to the airline industry. In the USA, main-
tenance costs are increasing as a proportion of airline operating costs. In 1989 maintenance
constituted 11-8% of US airline operating costs or greater than US$S billion per year
(Shepherd 1991). The annual cost to the Australian airline industry is likely to be in the order
of A$500 million per year.
The increasing complexity and computerisation of modern aircraft presents particular
challenges to the maintenance workforce, which must come to terms with highly automated
systems. In this regard, advanced aircraft can be described as opaque complex systems. Such
systems are characterised by a complexity which exceeds the comprehension of the people who
maintain and operate them (Perrow 1984).
Maintenance anomalies are serious safety issues for the airline industry. Boeing (1993) has
estimated that in the period 1983-1992, 3.3% of US airline hull loss accidents had a
maintenance discrepancy as the primary cause of the accident. (A hull-loss accident is one in
which the aircraft is destroyed or damaged beyond repair.) However, it has been estimated that
12% of major accidents involved maintenance as a contributing factor, although not
necessarily the sole factor (Marx and Graeber 1994). The UK Civil Aviation Authority recently
reported that 8% of occurrences to large aircraft involved a maintenance discrepancy (BAS1
1992). However, it is possible that both of these figures are underestimations of the true
incidence of maintenance-related accidents.
Some aviation authorities believe that the role of maintenance in airline accidents is increasing.
Ramsden (1992) reports that whereas world airline activity increased by a factor of 20% from
the first half of the 1980s to the second half of that decade, maintenance-related accidents
increased by 40% over the same period. The worlds worst single aircraft disaster, the JAL
Boeing 747 accident of August 1985, in which 520 people were killed, was a maintenance-
related accident.
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In 1991 worldwide, there were at least four major airline accidents where maintenance was a
likely causal factor. These were Lauda 767 over Thailand, United 737 at Colorado Springs,
Nationair Canada DC8 in Saudi Arabia and Continental Express Brasilia in Texas. All four
aircraft and a total of 530 occupants were lost (Ramsden 1992).
On a routine basis, maintenance workers must contend with environmental conditions such as
cold, heat, rain, darkness, noise, heights, difficult-to-access work areas, awkward working
postures, chemical hazards, night-shift work and the presence of heavy vehicles and moving
aircraft. In some situations, such as during an engine run-up, the noise level is such that
workers wearing ear protection are unable to communicate verbally.
For the purposes of this paper, the term maintenance anomaly will refer to any incident in
which maintenance work was carried out in a manner which had the potential to affect the safe 4
or economical operation of an aircraft. This will include instances where anomalous work was
detected and corrected before the aircraft was dispatched. Some examples of maintenance
anomalies may help illustrate the diverse nature of the problem.
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1 .l Previous research into human factors in aircraft maintenance
Human factors in aviation have attracted a considerable amount of research attention; however, it is
apparent that aircraft maintenance has been largely ignored. Extensive studies have been made of flight
crew errors, from early studies such as Fitts and Jones (1947) through to more recent efforts e.g. Ruffel
Smith (1979), Billings and Reynard (1984) and Sarter and Woods (1992). The human factors of Air
Traffic Control have always enjoyed a high profde in the public eye and have been the focus of extensive
research. Hopkin (1988) provides a brief summary. Cabin safety issues such as the behaviour of
passengers during evacuationshave been studied by Muir, Marrison and Evans (1989),among others.
Only in recent years however, have maintenance issues been examined by the human-factors
community. One of the earliest studies in this field was carried out in the UK in the early 1980s (Lock
and Strutt 1990). This study concentrated on aircraft inspection tasks. Data was collected via a
questionnairewhich was circulated to aircraft operators and by face-to-face discussions with inspection
personnel. Lock and Strutt considered such practical issues as inspector eyesight, training, lighting,
noise stands and access. The authors also identified potential problems with the workcard system, an
area which has attracted further attention in the 1990s.
Much of the recent research into maintenance-related human factors has been sponsored by the US
Federal Aviation Administration (FAA) Office of Aviation Medicine. At the time of writing, research
has been directed at a wide variety of issues including the organisational structure of maintenance
organisations (Taylor 1990), visual inspection issues (Drury and Gramopadhye 1990, Latorella and
Drury 1992),advanced technology as an aid to maintenance training (Johnson 1990),employment of
women and minorities in military aviation maintenance (Eitelberg 1991),illumination in maintenance
workplaces (Reynolds and others 1992), the design of work control cards (Pate1 and others 1992),
future availabilityof aircraft maintenance personnel (Shepherd and Parker 1991) and the introduction
of crew resource management to maintenance training (Taggert 1990, Stelly and Taylor 1992).
European interest in maintenance-related human factors is also becoming evident. A one-day
conference organised by the Royal Aeronautical Society (1991) addressed issues such as training,
aircraft design and the implications of new technology. However, no research results were presented at
the conference.
Jim Reason of the University of Manchester has developed a computer-based system (known as MESH)
to help managers monitor the safety health of maintenance organisations. However, at the time of
writing, no evaluations of the system were available.
While the research outlined above has undoubtedly contributed to airline safety, to date, researchers
have focused on highly specific maintenance issues. It might be expected that before specific human-
factors issues of maintenance anomalies were addressed, the general nature of the problem would first
be examined. Surprisingly, a broad examination of anomalies in aircraft maintenance has not been
conducted.
Such an examination could be achieved by cataloguingthe anomalies which occur when airline aircraft
are being maintained. The information obtained would be central to the design of intervention
strategies.
It is highly likely that human error will feature significantly in maintenance anomalies and hence the
concept of human error must be considered. The terms error and human error are widely used in
the literature and do not imply that operators are blamed for workplace incidents.
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the field have examined the errors which occur in situations such as nuclear power plants (e.g.
Rasmussen 1980, Wu and Hwang 1989), railway accidents (e.g. Quist 1988), road accidents
(e.g. Hale, Stoop and Hommels 1990, Groeger 1990) and operating theatres (Runciman and
others 1993). Southcombe (1991) describes some of the precautions which aircraft designers
take to minimise maintenance error.
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be a useful framework for the analysis of errors in a wide variety of industrial and domestic
situations.
Other research in the field has complemented the SRK framework. Reason and Norman have
divided errors into slips and mistakes. The term slips encompasses the group of errors which
occur at the skill-based level of performance. Mistakes are errors at the rule- or knowledge-
based level of cognitive control.
Reason (1990) makes an important further distinction between two forms of unsafe acts-
errors and violations. Violations, in contrast to errors, are intentional unsafe acts.
Other authors such as Rasmussen and Vicente ( 1989) have proposed additional categorisation
systems which can be applied in conjunction with the SRK framework.
Aircraft maintenance is a crucial element of the aviation system, yet until recently, maintenance
has been largely ignored by human-factors researchers.
Recent years have seen a growing interest in maintenance-related human factors, yet much of
the published information has focused on specific problems or particular solutions. To date,
there has been no broad examination of the human factor in maintenance.
An examination of maintenance anomalies could employ models of error and system
breakdown which have proved useful in other areas of aviation and industry.
Following on from this information paper, BAS1 has commenced a wide-ranging examination
of maintenance anomalies and the human factors which lead to them. Preliminary results will
be available in the second half of 1994. The research plan is described in the appendix
Appendix
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3.1.2 Data collection
Maintenance workers assembled in focus groups will be asked to provide examples of times when things
went wrong in the maintenance of an aircraft, following the critical incidents technique developed by
Flanagan (1954). Interviews will follow a standard structure and all reports will be treated confidentially.
All incidents will have involved the reporter, either as a participant or observer. Workers will be free to
nominate any incidents from the past. It is likely that there will be systematic biases in recall related to
when the incident occurred. The time elapsed since the incident occurred will be recorded to enable such
biases to be studied. The incident anecdotes will be recorded, transcribed and coded onto a database. It is
hoped that at least 50 critical-incident reports will be gathered.
3.1.3 Data analysis
Events and factors which preceded the anomaly will be coded using the Williamson and Feyer (1990)
classification system and the Reason model.
With the assistance of experienced maintenance personnel, the severity of potential consequences of the
anomaly will be assessed and the maintenance task at the time of the anomaly will be categorised
according to Air Transport Association (ATA) chapter. (The internationally recognised ATA system assigns
a chapter number to each major part of an aircraft.) Unsafe acts will be categorised according to:
the violation/error distinction;
the omission/commission/substitutiondistinction; and
the level of cognitive control (SRK) framework.
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