A prospective study of maintenance deviations using HFACS-ME

Illankoon, Prasanna; Tretten, Phillip; Kumar, Uday

doi:10.1016/j.ergon.2019.102852

Cited by 19 publications

(10 citation statements)

References 27 publications

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“…The study revealed that supervisory, maintainer, and working latent conditions are present that can impact maintainers in the performance of their jobs. Illankoon, Tretten, and Kumar [8] analyzed data acquired from a fighter aircraft fleet looking for reported maintenance deviations over a period of 38 months beginning from January 2013, using HFAC-ME (Maintenance Extension) taxonomy to find and mark hidden causal factors. The study identifies attention, memory errors, inadequacy of processes, and documentation as key causal factors.…”

Section: Aircraft Maintenance Related Safety Occurrences In Military mentioning

confidence: 99%

“…Aircraft maintenance is a critical task that is essential for warranting aviation safety in relation to the life-cycle of an aircraft [4][5][6]. Even though maintenance is regarded as one of aviation's many high-risk areas due to its direct impact on aviation safety, it still has a considerable contribution in aircraft maintenance accident and incident occurrences [7][8][9][10]. Hobbs and Williamson [11] and Floyd [12] highlight the importance of understanding maintenance errors along with promoting a culture of identifying, reporting, and learning from maintenance errors for improving work quality and safety.…”

Section: Introductionmentioning

confidence: 99%

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A Preliminary Investigation of Maintenance Contributions to Commercial Air Transport Accidents

et al. 2020

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Aircraft maintenance includes all the tasks needed to ensure an aircraft’s continuing airworthiness. Accidents that result from these maintenance activities can be used to assess safety. This research seeks to undertake a preliminary investigation of accidents that have maintenance contributions. An exploratory design was utilized, which commenced with a content analysis of the accidents with maintenance contributions (n = 35) in the official ICAO accident data set (N = 1277), followed by a quantitative ex-post facto study. Results showed that maintenance contributions are involved in 2.8 ± 0.9% of ICAO official accidents. Maintenance accidents were also found to be more likely to have one or more fatalities (20%), compared to all ICAO official accidents (14.7%). The number of accidents with maintenance contributions per year was also found to have reduced over the period of the study; this rate was statistically significantly greater than for all accidents (5%/year, relative to 2%/year). Results showed that aircraft between 10 and 20 years old were most commonly involved in accidents with maintenance contributions, while aircraft older than 18 years were more likely to result in a hull loss, and aircraft older than 34 years were more likely to result in a fatality.

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Section: Aircraft Maintenance Related Safety Occurrences In Military mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

A Preliminary Investigation of Maintenance Contributions to Commercial Air Transport Accidents

et al. 2020

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“…Schemata guide our attention to what is informative in a situation, rather than what is self-evident; they also guide our inference at the time of recall (Plant and Stanton 2013). Based on schemata and mental models, SA acknowledges a wide range of cognitive mechanisms (see Illankoon et al 2019b) including deliberate thinking and autonomous thinking (Endsley 1995(Endsley , 2015; therefore, decisions with SA may not be perfectly rational. While yet, SA demands explicit awareness for active information seeking (Endsley 2000), integrating and comprehending their meanings to project the future (Endsley 1988).…”

Section: Interventions For Judgemental Biasesmentioning

confidence: 99%

Judgemental errors in aviation maintenance

Illankoon

Tretten

2019

Cogn Tech Work

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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.

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“…To obtain the systematic risk factors of the unsafe acts of ATCers and construct a comprehensive risk early warning indicator system of the unsafe acts of the controllers, it is necessary to adopt systematic thinking and related methods. Human Factors Analysis and Classification System (HFACS) has significant advantages in the systematic analysis of human factors in accidents, and has been applied in the field of aviation safety (Daramola, 2014; Illankoon et al, 2019; Pratama et al, 2018; Zhou et al, 2018). Organizational and managerial defects are found to be the most important potential cause behind most human errors leading to catastrophic accidents (Rostamabadi et al, 2019).…”

Section: Introductionmentioning

confidence: 99%

Risk early warning indicators for air traffic controllers' unsafe acts

Luo

Zhou³

et al. 2022

Hum Ftrs & Erg Mfg Svc

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The establishment of an early warning indicator system is the foundation and the key to prevent the unsafe acts of air traffic controllers (ATCers). Therefore, the objective of this study is to determine the early warning indicators for controllers' unsafe acts.Data were encoded through grounded theory and HFACS, and the early warning indicator system was designed. The parameter values were calculated by using the data collected from the expert questionnaire survey. Combining the existing safety performance indicators and expert opinions, the measurement and judgment of indicators were clarified. The results show that the early warning indicator system includes four levels: environment, organization, supervision and ATCers. Among the indicators, the mean values of "degree of job skills mastered," "intensity of working load," "lack of safety awareness and responsibility" rank the first three. Based on the findings of this study, the unsafe acts of ATCers can be effectively alerted.

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A prospective study of maintenance deviations using HFACS-ME

Cited by 19 publications

References 27 publications

A Preliminary Investigation of Maintenance Contributions to Commercial Air Transport Accidents

A Preliminary Investigation of Maintenance Contributions to Commercial Air Transport Accidents

Judgemental errors in aviation maintenance

Risk early warning indicators for air traffic controllers' unsafe acts

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