Judgemental errors in aviation maintenance

Aircraft maintenance is a critical success factor in the aviation sector, and incorrect maintenance actions themselves can be the cause of accidents. Judgemental errors are the top causal factors of maintenance-related aviation accidents. This study asks why judgemental errors occur in maintenance. Referring to six aviation accidents, we show how various biases contributed to those accidents. We first filtered aviation accident reports, looking for accidents linked to errors in maintenance judgements. We analysed the investigation reports, as well as the relevant interview transcriptions. Then we set the characteristics of the actions behind the accidents within the context of the literature and the taxonomy of reasons for judgemental biases. Our results demonstrate how various biases, such as theory-induced blindness, optimistic bias, and substitution bias misled maintenance technicians and eventually become the main cause of a catastrophe. We also find these biases are interrelated, with one causing another to develop. We discuss how these judgemental errors could relate to loss of situation awareness, and suggest interventions to mitigate them.

[1]  T. Wickens.  Elementary Signal Detection Theory , 2001 .

[2]  Frédéric Vanderhaegen,et al.  Can dissonance engineering improve risk analysis of human–machine systems? , 2017, Cognition, Technology & Work.

[3]  A. Tversky,et al.  BELIEF IN THE LAW OF SMALL NUMBERS , 1971, Pediatrics.

[4]  E. Heit,et al.  Assessing the belief bias effect with ROCs: it's a response bias effect. , 2010, Psychological review.

[5]  M. Falkenstein,et al.  Switching of auditory attention in “cocktail-party” listening: ERP evidence of cueing effects in younger and older adults , 2017, Brain and Cognition.

[6]  C. S. Place,et al.  Investigating the investigations: a retrospective study in the aviation maintenance error causation , 2011, Cognition, Technology & Work.

[7]  Sudhir Gupta,et al.  Case Studies , 2013, Journal of Clinical Immunology.

[8]  Frédéric Vanderhaegen,et al.  Towards increased systems resilience: New challenges based on dissonance control for human reliability in Cyber-Physical&Human Systems , 2017, Annu. Rev. Control..

[9]  Nancy L. Leech,et al.  Qualitative Analysis Techniques for the Review of the Literature , 2012 .

[10]  Waldemar Karwowski,et al.  Influence of Cognitive Biases in Distorting Decision Making and Leading to Critical Unfavorable Incidents , 2015 .

[11]  B. Fischhoff,et al.  Judgment under uncertainty: Debiasing , 1982 .

[12]  Mica R. Endsley,et al.  Theoretical Underpinnings of Situation Awareness, A Critical Review , 2000 .

[13]  Pierre Barrouillet,et al.  Heuristic and analytic processes in mental models for conditionals: An integrative developmental theory , 2009 .

[14]  N Moray,et al.  A lattice theory approach to the structure of mental models. , 1990, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[15]  Zhigang Xu,et al.  Machines versus humans: People's biased responses to traffic accidents involving self-driving vehicles. , 2019, Accident; analysis and prevention.

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

[17]  Melissa A. Schoenlein.  Assessing the Relationship Between Change Blindness and the Anchoring Effect , 2017 .

[18]  Msn DHSc Adel F. Almutairi Rn,et al.  Practical guidance for the use of a pattern-matching technique in case-study research: A case presentation , 2013 .

[19]  J. Gerring,et al.  Case-Selection : A Diversity of Methods and Criteria , 2015 .

[20]  D. Kahneman.  Thinking, Fast and Slow , 2011 .

[21]  Gerd Gigerenzer,et al.  Good Judgments Do Not Require Complex Cognition , 2008 .

[22]  Gary Klein,et al.  Naturalistic Decision Making , 2008, Hum. Factors.

[23]  John K. Schmidt,et al.  Human Factors Analysis of Naval Transport Aircraft Maintenance and Flight Line Related Incidents , 1999 .

[24]  R. Yin.  Case Study Research: Design and Methods , 1984 .

[25]  Gordon Wood,et al.  The knew-it-all-along effect. , 1978 .

[26]  Gregory S Nelson,et al.  Bias in Artificial Intelligence , 2019, North Carolina Medical Journal.

[27]  Michael Kinsey,et al.  Cognitive Biases Within Decision Making During Fire Evacuations , 2019 .

[28]  Wing Lam,et al.  Diary of a domain analyst: a domain analysis case-study from avionics , 1996 .

[29]  L. Festinger.  Cognitive dissonance. , 1962, Scientific American.

[30]  Uday Kumar,et al.  Identifying Significance of Human Cognition in Future Maintenance Operations , 2018, IHSI.

[31]  M. Baddeley.  Herding, social influences and behavioural bias in scientific research , 2015, EMBO reports.

[32]  J. G. Hollands,et al.  Engineering Psychology and Human Performance , 1984 .

[33]  Tina Chen.  Not Just Noise: Individual Differences in Cognitive Ability and Response Bias , 2017 .

[34]  M. Guha.  The Sage Encyclopedia of Social Science Research Methods , 2005 .

[35]  Mica R. Endsley,et al.  Designing for Situation Awareness : An Approach to User-Centered Design , 2003 .

[36]  Ronald A. Rensink,et al.  Change-blindness as a result of ‘mudsplashes’ , 1999, Nature.

[37]  Walanchalee Wattanacharoensil,et al.  A systematic review of cognitive biases in tourist decisions , 2019 .

[38]  David C Krulak,et al.  Human factors in maintenance: impact on aircraft mishap frequency and severity. , 2004, Aviation, space, and environmental medicine.

[39]  R. East.  Bias in the evaluation of research methods , 2016 .

[40]  Dylan D. Schmorrow,et al.  Human Factors Analysis of Naval Aviation Maintenance Related Mishaps , 2000 .

[41]  M. Antelo,et al.  An inclusive taxonomy of behavioral biases , 2017 .

[42]  C. McMahon,et al.  Decision Making in Paediatric Cardiology. Are We Prone to Heuristics, Biases and Traps? , 2017, Pediatric Cardiology.

[43]  Alexander Brem,et al.  Case Studies as Teaching Tools , 2009 .

[44]  Jens Rasmussen,et al.  Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models , 1983, IEEE Transactions on Systems, Man, and Cybernetics.

[45]  I. Rock,et al.  Inattentional Blindness: An Overview By Arien Mack & Irvin Rock , 1999 .

[46]  N. Stanton,et al.  The explanatory power of Schema Theory: theoretical foundations and future applications in Ergonomics , 2013, Ergonomics.

[47]  David Woods,et al.  Situation Awareness: A Critical But Ill-Defined Phenomenon , 1991 .

[48]  A. Tversky,et al.  Judgment under Uncertainty: Heuristics and Biases , 1974, Science.

[49]  Uday Kumar,et al.  A prospective study of maintenance deviations using HFACS-ME , 2019 .

[50]  Simon Bennett.  Managing Maintenance Error: A Practical Guide , 2004 .

[51]  Paul Baybutt,et al.  Cognitive biases in process hazard analysis , 2016 .

[52]  D. Kahneman,et al.  Representativeness revisited: Attribute substitution in intuitive judgment. , 2002 .

[53]  Mica R. Endsley,et al.  Toward a Theory of Situation Awareness in Dynamic Systems , 1995, Hum. Factors.

[54]  Gabrielle Durepos,et al.  Encyclopedia of case study research , 2010 .

[55]  Stephen X. Zhang,et al.  The Study of Bias in Entrepreneurship , 2015 .

[56]  Russell L. Purvis,et al.  Heuristics and Biases in Information Systems Project Management , 2004 .

[57]  G. Gaskell,et al.  Classical Content Analysis: a Review , 2000 .

[58]  Joel L. Schrag,et al.  First Impressions Matter: A Model of Confirmatory Bias , 1999 .

[59]  John Abeysekera,et al.  Ergonomics for enhancing detection of machine abnormalities. , 2016, Work.

[60]  J. Doyle,et al.  Survey of Time Preference, Delay Discounting Models , 2012, Judgment and Decision Making.

[61]  David Arnott,et al.  Cognitive biases and decision support systems development: a design science approach , 2006, Inf. Syst. J..

[62]  P. Todd,et al.  Simple Heuristics That Make Us Smart , 1999 .

[63]  Benjamin Brooks,et al.  Managing cognitive biases during disaster response: the development of an aide memoire , 2019, Cognition, Technology & Work.

[64]  Alexandra McCarthy,et al.  Practical guidance for the use of a pattern-matching technique in case-study research: a case presentation. , 2014, Nursing & health sciences.

[65]  A. Tversky,et al.  The weighing of evidence and the determinants of confidence , 1992, Cognitive Psychology.

[66]  Phillip Tretten,et al.  Modelling human cognition of abnormal machine behaviour , 2019, Human-Intelligent Systems Integration.

[67]  S. Mittal.  Behavior biases and investment decision: theoretical and research framework , 2019, Qualitative Research in Financial Markets.

[68]  John Gerring,et al.  Selecting Cases for Intensive Analysis , 2016 .

[69]  Sarbjeet Singh,et al.  Lockout and Tagout in a Manufacturing Setting from a Situation Awareness Perspective , 2019, Safety.

[70]  G. Gaskell,et al.  Qualitative Researching with Text, Image and Sound , 2000 .

[71]  Gerd Gigerenzer,et al.  Postscript: Fast and frugal heuristics , 2008 .

[72]  J. L. Taylor.  Cognitive biases are bad for business , 2016 .

[73]  A. Tversky,et al.  Loss Aversion in Riskless Choice: A Reference-Dependent Model , 1991 .

[74]  C. Dobler,et al.  Clinicians’ cognitive biases: a potential barrier to implementation of evidence-based clinical practice , 2018, BMJ Evidence-Based Medicine.

[75]  D. Kahneman,et al.  Conditions for intuitive expertise: a failure to disagree. , 2009, The American psychologist.

[76]  Scott A. Shappell,et al.  HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM. , 2001 .

[77]  David Arnott,et al.  A Taxonomy of Decision Biases , 2001 .

[78]  M. Endsley.  Situation Awareness Misconceptions and Misunderstandings , 2015 .