Effects of Maintenance Human Factors in Maintenance-Related Aircraft Accidents

Abstract

To help prevent maintenance-related aircraft accidents the complex factors behind previous accidents must be understood. Maintenance-related aircraft accidents were studied to determine the effects of maintenance human factors. A taxonomy of causal factors was developed and used to classify the causes of 101 military and civilian accidents and to determine the frequency of occurrence for each factor. The taxonomy identifies elements, such as people and hardware, interfaces between elements (i.e., human factors), and maintenance processes comprised of elements and interfaces. Human factors were found to have a significant effect in the 86 military and 15 civilian maintenance-related accidents studied. Whereas investigation boards were found to focus most heavily on element failures, a majority of the failures were found to occur at the process level. Maintenance instructions and their interfaces with the maintainers and inspectors who use them were the most frequently failed elements and interfaces, respectively. Recommendations are made to guide further research, and ideas are provided for improving process analysis by maintenance units and investigation boards.

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References

Gryna

F.M.

Production. Juran's Quality Control Handbook. Juran

J.M.

, and Gryna

F.M.

, eds., McGraw-Hill, New York, N.Y. 1974, pp. 172–1731.

Aircraft Accident Report: Aloha Airlines, Flight 243, Boeing 737-200, Near Maui, Hawaii, April 28, 1988. AAR-89-03. National Transportation Safety Board, U.S. Government Printing Office, 1989.

Nagel

D.C.

Human Error in Aviation Operations. Human Factors in Aviation. Wiener

E.L.

, and Nagel

D.C.

eds., Academic Press, San Diego, Calif., 1988, pp. 263–303.

Edwards

Introductory Overview. Human Factors in Aviation. Wiener

E.L.

, and Nagel

D.C.

eds., Academic Press, San Diego, Calif., 1988, pp. 3–25.

Parker

J.F.

Jr. , ed. Federal Aviation Administration Meeting on Human Factors Issues in Aircraft Maintenance and Inspection: Information Exchange and Communications, DTIC No. AD-A230 270. Federal Aviation Administration, 1990.

Drury

C.G.

The Human Operator as an Inspector: Aided and Unaided. Human Factors Issues in Aircraft Maintenance and Inspection. DTIC No. DOT/FAA/AAM-89/9. Shepherd

W.T.

, and Parker

J.F.

Jr. , eds, Federal Aviation Administration, 1990.

Taylor

J.C.

Organizational Context for Aircraft Maintenance and Inspection. In Proceedings of the Human Factors Society 34th Annual Meeting. Human Factors Society, Santa Monica, Calif., 1990, pp. 1176–1180.

Allen

, and Marx

. Maintenance Error Decision Aid Project. In Meeting Proceedings, 8th Meeting on Human Factors Issues in Aircraft Maintenance and Inspection. Federal Aviation Administration, Nov. 1993, pp. 101–115.

Sears

R.L.

A New Look at Accident Contributions and the Implications of Operational and Training Procedures. Unpublished report. Boeing Commercial Airplane Company, Seattle, Wash., 1986.

10.

Thackray

R.I.

Human Factors Evaluation of the Work Environment of Operators Engaged in the Inspection and Repair of Aging Aircraft. Report DOT/FAA/AM-92/3. Federal Aviation Administration, 1992.