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.
|Type:||Research and Analysis Report|
|Publication date:||14 June 1997|