A review of human error in aviation maintenance and inspection

Abstract Aviation safety depends on minimizing error in all facets of the system. While the role of flightdeck human error has received much emphasis, recently more attention has been directed toward reducing human error in maintenance and inspection. Aviation maintenance and inspection tasks are part of a complex organization, where individuals perform varied tasks in an environment with time pressures, sparse feedback, and sometimes difficult ambient conditions. These situational characteristics, in combination with generic human erring tendencies, result in varied forms of error. The most severe result in accidents and loss of life. For example, failure to replace horizontal stabilizer screws on a Continental Express aircraft resulted in in-flight leading-edge separation and 14 fatalities. While errors resulting in accidents are most salient, maintenance and inspection errors have other important consequences (e.g., air turn-backs, delays in aircraft availability, gate returns, diversions to alternate airports) which impede productivity and efficiency of airline operations, and inconvenience the flying public. This paper reviews current approaches to identifying, reporting, and managing human error in aviation maintenance and inspection. As foundation for this discussion, we provide an overview of approaches to investigating human error, and a description of aviation maintenance and inspection tasks and environmental characteristics. Relevance to industry Following an introductory description of its tasks and environmental characteristics, this paper reviews methods and tools for identifying, reporting, and managing human error in aviation maintenance and inspection.

[1]  Pluribus Unum,et al.  National Transportation Safety Board , 1996 .

[2]  A. D. Swain,et al.  Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report , 1983 .

[3]  Jens Rasmussen,et al.  Human errors. a taxonomy for describing human malfunction in industrial installations , 1982 .

[4]  Mustapha Mouloua,et al.  Automation and Human Performance : Theory and Applications , 1996 .

[5]  E. Crouch,et al.  Man and Machine , 1991, British Journal of Psychiatry.

[6]  Graham I. Johnson,et al.  Evaluating usability of human computer interfaces: a practical method (west sussex , 1989 .

[7]  Christopher J. Alberts,et al.  Development of an Automated Nondestructive Inspection (ANDI) System for Commercial Aircraft. Phase 1 , 1994 .

[8]  William B. Johnson,et al.  Job Performance Aids for the Flight Standards Service , 1993 .

[9]  M. Alpers,et al.  Research and Development , 1960, Nature.

[10]  James C. Taylor.  Organizational Context for Aircraft Maintenance and Inspection , 1990 .

[11]  John W Ruffner.  A Survey of Human Factors Methodologies and Models for Improving the Maintainability Design of Emerging Army Aviation Systems , 1990 .

[12]  Jakob Nielsen,et al.  Usability engineering , 1997, The Computer Science and Engineering Handbook.

[13]  D. Norman,et al.  New technology and human error , 1989 .

[14]  George R. S. Weir,et al.  Human Computer Interaction and Complex Systems , 1991 .

[15]  Sandra H. Rouse,et al.  Analysis and classification of human error , 1983, IEEE Transactions on Systems, Man, and Cybernetics.

[16]  Colin G. Drury,et al.  Computer-Simulated Aircraft Inspection Tasks for Off-Line Experimentation , 1992 .

[17]  B Kirwan,et al.  Human error identification in human reliability assessment. Part 1: Overview of approaches. , 1992, Applied ergonomics.

[18]  Michelle M. Robertson,et al.  Team Situation Awareness in Aviation Maintenance , 1996 .

[19]  Colin G. Drury,et al.  The Effects of Different forms of Space Restriction on Inspection Performance , 1994 .

[20]  J E Strutt,et al.  RELIABILITY OF IN-SERVICE INSPECTION OF TRANSPORT AIRCRAFT STRUCTURES ARB FELLOWSHIP 1981 FINAL REPORT , 1985 .

[21]  R. R. Batcher.  Maintainability design , 1964 .

[22]  Rebecca Hibit,et al.  Reducing Human Error in Aircraft Maintenance Operations with the Maintenance Error Decision Aid (MEDA) , 1994 .

[23]  Mica R. Endsley,et al.  Design and Evaluation for Situation Awareness Enhancement , 1988 .

[24]  Colin G. Drury,et al.  Design and Usability Evaluation of Work Control Documentation , 1993 .

[25]  William B. Rouse.  Optimal allocation of system development resources to reduce and/or tolerate human error , 1985, IEEE Transactions on Systems, Man, and Cybernetics.

[26]  Kim J. Vicente,et al.  Coping with Human Errors through System Design: Implications for Ecological Interface Design , 1989, Int. J. Man Mach. Stud..

[27]  Oh-Yang Kwon.  Nondestructive Testing of Aging Aircraft , 1999 .

[28]  Anand K. Gramopadhye,et al.  Application of Advanced Technology to Team Training , 1996 .

[29]  Gopinath Meghashyam.  Electronic Ergonomic Audit System for Maintenance and Inspection , 1995 .

[30]  David Woods,et al.  Behind human error : cognitive systems, computers, and hindsight : state-of-the-art report , 1994 .

[31]  Colin G. Drury.  Errors in Aviation Maintenance: Taxonomy and Control , 1991 .

[32]  S Mason.  Improving plant and machinery maintainability. , 1990, Applied ergonomics.

[33]  Curtis E. Sandler,et al.  Human Factors Considerations in Aviation Maintenance , 1984 .

[34]  B Kirwan,et al.  Human error identification in human reliability assessment. Part 2: Detailed comparison of techniques. , 1992, Applied ergonomics.

[35]  J. Shaoul.  Human Error , 1973, Nature.

[36]  Colin G. Drury,et al.  Task Analysis of Aircraft Inspection Activities: Methods and Findings , 1990 .

[37]  Swapnesh C. Patel,et al.  Relative advantage of portable computer-based workcards for aircraft inspection , 2000 .

[38]  Colin G. Drury,et al.  An Evaluation of the Visual Environment in Aircraft Inspection , 1993 .

[39]  Jens Rasmussen,et al.  The role of error in organizing behaviour* , 1990 .

[40]  C G Drury,et al.  Design of workcards for aircraft inspection. , 1994, Applied ergonomics.

[41]  Colin G. Drury,et al.  Classification of temporal errors in CIM systems: Development of a framework for deriving human-centred information requirements , 1992 .

[42]  D. Norman.  Categorization of action slips. , 1981 .

[43]  Donald H. Taylor,et al.  THE HERMENEUTICS OF ACCIDENTS AND SAFETY , 1981 .

[44]  John W. Senders,et al.  Human Error: Cause, Prediction, and Reduction , 1991 .

[45]  Piedmont Airlines,et al.  AIRCRAFT ACCIDENT REPORT , 1969 .

[46]  William T. Shepherd,et al.  Human Factors in Aviation Maintenance. Phase 1 , 1991 .

[47]  Andrea Carpignano,et al.  A Dynamic Reliability Technique for Error Assessment in Man-Machine Systems , 1993, Int. J. Man Mach. Stud..

[48]  Jens Rasmussen,et al.  Trends in human reliability analysis , 1985 .