Aircraft maintenance errors are estimated to be involved in 12% of airline accidents worldwide. Records maintained by the Australian Transport Safety Bureau (ATSB) indicate that 4.5% of Australian aircraft accidents involve maintenance deficiencies. Human error in aircraft maintenance is poorly understood and has not been the subject of previous studies in Australia. In late 1998 the Bureau of Air Safety Investigation (now ATSB) distributed a survey to Licensed Aircraft Maintenance Engineers (LAMEs) in Australia. The survey was designed to identify safety issues in maintenance, with a particular emphasis on the human, or nontechnical aspects of the job.
The survey provided LAMEs with the opportunity to describe occurrences that had the potential to threaten the safety of an aircraft, or the safety of maintenance workers. Six hundred and ten occurrence reports were reported via the survey. In most cases the reported events resulted in relatively minor consequences. The most common form of occurrence was one in which an aircraft system was activated in an unsafe manner during maintenance. The next most common form of occurrence involved the incomplete installation of components. Over 95% of the occurrences involved the actions of people. The most common forms of human error contributing to the events were memory lapses and procedure shortcuts. The contributing factors most frequently listed by survey respondents were time pressure, equipment deficiencies, inadequate training, coordination difficulties and fatigue. There was evidence that the frequency of safety occurrences fluctuated throughout the 24 hour day and that the early hours of the morning were times of particular risk for maintenance occurrences.
Several safety deficiencies were identified in the course of this study. These included: a current lack of programs to limit the extent of fatigue experienced by maintenance workers; a lack of recurrent training for licenced aircraft maintenance engineers; a need for maintenance personnel to be trained in crew resource management skills such as communication and the management of production pressures; a widespread blame culture in aircraft maintenance which discourages personnel from officially reporting incidents; and the simultaneous maintenance of critical multiple redundant systems, which can make the consequences of errors more serious. The report concludes with recommendations directed at these issues.
|Type:||Research and Analysis Report|
|Publication date:||26 February 2001|
|ISBN:||0 642 27473 8|