Human error is recognised as an important issue in fields as
diverse as medicine, mining and shipping, and to some extent
aviation.
Although the human element has long been recognised as important
in the cockpit, its role in aircraft maintenance has been largely
overlooked.
According to Boeing figures 12% of major aircraft accidents
involve maintenance, and 50% of flight delays in the US are caused
by maintenance errors.
In response to a worldwide lack of information on the issue, in
late 1998 the Bureau distributed a safety survey to all licensed
aircraft maintenance engineers in Australia.
This survey was the first such study undertaken anywhere in the
world.
In addition to collecting incident reports, part of the survey
used a technique pioneered by road safety researchers in the UK,
where recipients were asked to report minor errors and
shortcuts.
The focus was on learning how common these events are relative
to one another, rather than obtaining precise event frequency
information. In that regard there was no specific time frame
specified in the survey form in which the event could have
occurred.
Most of the errors reported by the respondents constitute 'near
misses'. However, it is possible to anticipate how more serious
events could occur by gathering this information.
The ATSB considers that the issues identified in the survey are
not specific to Australia but will be of use to safety agencies
around the world.
Based on early information from the survey the Bureau previously
published in Asia-Pacific Air Safety articles that
identified a number of recommendations:
- the need for refresher training for aircraft maintenance
engineers - the need to remove barriers which discourage aircraft
maintenance engineers from reporting incidents - the need for fatigue management programs
- human factors training for management and engineers, and
- minimisation of the simultaneous disturbance of multiple or
parallel systems, such as both engines on twin-engine
aircraft.
The recent article on the survey on the ATSB Supplement to
Flight Safety Australia March-April 2000 also included
advice directed to aircraft maintenance engineers concerning memory
lapses, pressure, fatigue and coordination difficulties.
The survey is part of a broader study of aircraft maintenance
operations, which is anticipated, will lead to identification of
targeted safety measures.