Active and Latent Failures in Aircraft Ground Damage Incidents

Abstract

As part of a larger project to identify common human errors and system failures across different reporting systems, a large number of detailed reports of aircraft ground damage reports were analyzed. Such incidents cost major airlines tens of millions of dollars per year in repairs. It was found that consistent repeating patterns of incident emerged from the analysis based upon the final active failure and the resulting damage-causing impact. Behind these final outcomes, however, were numerous latent failures, or resident pathogens, which occurred across many hazard patterns.

When the hazard patterns were expanded as event trees, the latent failures typical of each pattern were seen. For example, when a ground vehicle was driven into an aircraft, poorly maintained or substituted ground vehicles combined with management pressures for on-time departure and inadequate space around the aircraft led to the final or active failure.

From these analyses, strategies for intervention can be derived at all systems levels. System interventions must address latent failures in the system, instead of the “blame and train” philosophy currently in use. The methodology used in this analysis allows the most cost beneficial interventions to be easily determined.