An Overview of Human Factor in Aviation Maintenanc

ATSBTRANSPORTSAFETYREPORTAviationResearchandAnalysisReport–AR-2008-055AnOverviewofHumanFactorsinAviationMaintenanceAlanHobbsPh.D.December2008AnOverviewofHumanFactorsinAviationMaintenanceOverviewofhumanFactorsinAviationmaintenance.indd117/12/089:55:59AMATSBTRANSPORTSAFETYREPORTAviationResearchandAnalysisReportAR-2008-055FinalAnOverviewofHumanFactorsinAviationMaintenanceAlanHobbsPh.D.-iii-Publishedby:AustralianTransportSafetyBureauPostaladdress:POBox967,CivicSquareACT2608Officelocation:62NorthbourneAve,CanberraCity,AustralianCapitalTerritoryTelephone:1800020616;fromoverseas+61262746440Accidentandincidentnotification:1800011034(24hours)Facsimile:0262473117;fromoverseas+61262473117E-mail:[e-mail]:©CommonwealthofAustralia2008.Thisworkiscopyright.Intheinterestsofenhancingthevalueoftheinformationcontainedinthispublicationyoumaycopy,download,display,print,reproduceanddistributethismaterialinunalteredform(retainingthisnotice).However,copyrightinthematerialobtainedfromotheragencies,privateindividualsororganisations,belongstothoseagencies,individualsororganisations.Whereyouwanttousetheirmaterialyouwillneedtocontactthemdirectly.SubjecttotheprovisionsoftheCopyrightAct1968,youmustnotmakeanyotheruseofthematerialinthispublicationunlessyouhavethepermissionoftheAustralianTransportSafetyBureau.Pleasedirectrequestsforfurtherinformationorauthorisationto:CommonwealthCopyrightAdministration,CopyrightLawBranchAttorney-General’sDepartment,RobertGarranOffices,NationalCircuit,BartonACT2600:see‘Documentretrievalinformation’onpagevii.-iv-CONTENTSTHEAUSTRALIANTRANSPORTSAFETYBUREAU...............................viii Introduction............................................................................................................1 Thecostofmaintenanceerror...........................................................................1 Uniquehumanfactorsissuesinaviationmaintenance.....................................2 ExamplesofAccidentsRelatedtoMaintenance...............................................3 JapanAirlinesBoeing747,1985..........................................................3 EasternAirlinesL-1011,1983.............................................................4 AlohaAirlinesBoeing737,1988.........................................................6 BritishAirwaysBAC-111,1990..........................................................7 AirMidwest,Beech1900D,2003........................................................7 Amodelofaccidentandincidentcausation.........................................................9 Individualactions..............................................................................................9 Physicaldescriptionsoferrors............................................................10 Psychologicaldescriptionsoferrors...................................................10 LocalConditions.............................................................................................17 Timepressure.....................................................................................17 Maintenanceproceduresanddocumentation.....................................17 Teamwork...........................................................................................18 Shifthandover....................................................................................20 Groupnorms.......................................................................................22 Fatigue................................................................................................22 Lackofsystemknowledge.................................................................24 Equipmentdeficiencies......................................................................24 Designformaintainability..................................................................24 Riskcontrols...................................................................................................26 Organisationalinfluencesonmaintenanceerror.............................................27 Managingtheriskofmaintenanceerror............................................................29 Errormanagementsystems.............................................................................29 Incidentreportingprogramsinmaintenance......................................29 HumanFactorsTraining.....................................................................30 Learningfromincidents.....................................................................31 IncidentInvestigationSystems...........................................................31 -v-Conclusion.............................................................................................................33 Resourcesandfurtherreading............................................................................34 References.............................................................................................................35 -vi-DOCUMENTRETRI