A prospective study of maintenance deviations using HFACS-ME

Document identifier: oai:DiVA.org:ltu-76338
Access full text here:10.1016/j.ergon.2019.102852
Keyword: Engineering and Technology, Annan samhällsbyggnadsteknik, Drift och underhållsteknik, Situation awareness, Latent condition, Active error, Incidents, Aviation maintenance, Samhällsbyggnadsteknik, Mechanical Engineering, Other Civil Engineering, Civil Engineering, Produktionsteknik, arbetsvetenskap och ergonomi, Maskinteknik, Teknik och teknologier, Production Engineering, Human Work Science and Ergonomics, Operation and Maintenance
Publication year: 2019

The factors initiating aviation accidents are usually hidden behind various steps, systems, and tasks, and systematic root-cause analysis is required to uncover the initial factor(s). To reduce the risk of unfavourable events, it is more appropriate to study their causal factors. We argue that an in-depth study on maintenance process deviations could assist in uncovering hidden causal factors. We therefore analyse reported maintenance deviations from an aviation organisation using the Human Factor Analysis and Classification System-Maintenance Extension (HFACS-ME) taxonomy to aggregate and map hidden causal factors. We find attention and memory errors and inadequacy of processes and documentation are major causal factors. We argue a well-run organisation can capture hidden causal factors and reduce the risk of incidents and accidents. More specifically, we show how situation awareness (SA) interventions can assist in the mitigation of maintenance deviations and capture hidden causal factors.


Prasanna Illankoon

Luleå tekniska universitet; Drift, underhåll och akustik; Human Factors
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Phillip Tretten

Luleå tekniska universitet; Drift, underhåll och akustik
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Uday Kumar

Luleå tekniska universitet; Drift, underhåll och akustik
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