Factors Leading to Human Error in Commercial Aviation Line Maintenance

Since World War II, commercial aviation, in partnership with aircraft manufacturers and regulatory agencies, has endeavored to promote safety by increasing system reliability. This effort has fostered a learning culture in the industry, moving many carriers toward becoming a high reliability organization (HRO). A core HRO characteristic is a preoccupation with detecting conditions leading to system failure. The Federal Aviation Administration, in partnership with the National Aeronautics and Space Administration, established the Aviation Safety Reporting System (ASRS) to provide a vehicle for personnel to self-report safety concerns. This study examined 361 ASRS cases voluntarily reported by maintainers from 2002 to 2007. The Human Factors Analysis Classification System-Maintenance Extension (HFACS-ME) was used to code conditions that can precipitate failures in pre- and postflight servicing, planned maintenance, and unplanned maintenance. The findings identified 4 specific latent conditions, or 15% of those provided by HFACS-ME, that can affect maintenance: adverse mental state, inadequate training or preparation, inadequate communication, and inadequate assertiveness. The results showed how these four conditions make up 66% of the factors influencing error on the flight line. These results may be used for commercial aviation maintenance to increase maintainer awareness of conditions leading to maintenance error. This awareness can promote the safety refinement of specific human intervention patterns through self-realization by line maintenance personnel. Implications for positive social change include improving workforce awareness of latent conditions that could lead to improved commercial aviation safety.