Errors in Aviation Maintenance: Taxonomy and Control

Abstract

Maintenance errors account for a small, but highly visible, portion of aviation-related accidents and fatalities. To measure, and hence eventually control, errors in any field requires a taxonomy which enumerates and classifies the errors. This taxonomy can come from reported errors, but a pro-active system is needed to cover potential errors, as well as those which happen to have been committed and recorded so far. A standard starting point for human and system errors is the description and analysis of those tasks necessary to complete the maintenance-inspection requirements of aircraft in an approved manner. As each step of this Task Description is listed, the failure modes associated with that step can be logically deduced. Following an extensive Task Description and Analysis of aircraft maintenance, an error taxonomy was developed from the failure modes of each task. From current theoretical approaches to human error come ways of extending this classification, and of relating potential errors to levels of human functioning within the system.

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References

Ashby

W.R.

(1956). An Introduction to Cybernatics, New York: Wiley.

Brown

I.D.

Groeger

(Eds.) (1990). Errors in the operation of transport systems. Special Issue of Ergonomics, 33, 11, pp. 1183–1430.

Drury

C.G.

(1990). Designing ergonomic studies and experiments. In Wilson

J.R.

Corlett

E.N.

(Eds.). Evaluation of Human Work, London: Taylor & Francis, pp. 101–129.

Drury

S.G.

Prabhu

Gramopadhye

(1990). Task analysis of aircraft inspection activities: Methods and Findings. In Proceedings of the Human Factors Society 34^th Annual Meeting, Volume 2, pp. 1181–1185.

Hollnagel

(1989). The phenotype of erroneous actions: Implications for HCI Design. In Weir

G.R.S.

Alty

J.L.

(Eds.), Human-computer Interaction and Complex Systems. London: Academic Press.

Meister

(1971). Human Factors: Theory and Practice. New York: Wiley.

Norman

D.A.

(1981). Categorization of action slips. Psychological Review, 88(1), pp. 1–15.

Rassmussen

(1982). Human errors, a taxonomy for describing human malfunctions in industrial installations. Journal of Occupational Accidents. 4, pp. 311–333.

Reach

(1990). A framework for classifying errors. In Rasmussen

Duncan

Leplat

(Eds.), New Technology and Human Error. London: John Wiley.

10.

Reason

(1979). Actions not as planned: The price of automatization. In Underwood

Stevens

(Eds.), Aspects of Consciousness, Volume 1, Psychological Issues. London: Academic Press.

11.

Reason

(1987). Generic error-modelling system (GEMS): A cognitive framework for locating human error forms. In Rasmussen

Duncan

Leplat

(Eds.), New Technology and Human Error. London: John Wiley.

12.

Rouse

W.B.

Rouse

S.H.

(1983). Anaylsis and classification of human error. IEEE Transactions Systems, Man & Cybernetics, Vol. SMC-13, pp. 539–549.

13.

Shepherd

W.T.

(1990). Human factors in the maintenance and inspection of aircraft. In Proceedings of the Human Factors Society 34^th Annual Meeting, Volume 2, pp. 1167–1170.

14.

Taylor

J.C.

(1990). Organizational context for aircraft maintenance and inspection. In Proceedings of the Human Factors Society 34^th Annual Meeting, Volume 2, pp. 1176–1180.