Maintenance error reduction

Citation

(2001), "Maintenance error reduction", Aircraft Engineering and Aerospace Technology, Vol. 73 No. 5. https://doi.org/10.1108/aeat.2001.12773eac.003

Maintenance error reduction

Maintenance error reduction

This paper was presented by Mr Mike Thompson, Course Director, Cranfield University, who headlined certain issues, including the fact that large transport accident rates have fallen over the last 30 years. However if, as predicted, air traffic doubles over the next ten to 15 years this low accident rate could yield double the number of accidents. Incorrect installation contributed to 60 percent of 200 maintenance occurrences, and Boeing statistics identified maintenance error as the primary cause of 6 percent of aircraft losses and a contributory cause in approximately 17 percent. The introduction of initiatives aimed at establishing awareness in the workplace of the conditions that provoke error, and the adoption of appropriate maintenance error management systems, will improve the situation

A few accident reports were mentioned, identifying human error as the contributory cause. These include windscreen accident – in which a BAC 1-11 was climbing through 17,300ft on departure when the left windscreen was blown out under the effects of cabin pressure. The windscreen had been replaced just prior to the flight and it was discovered that 84 of the 90 securing bolts were smaller than the specified diameter. Another incident involved a Jetstream 41 on post-maintenance air test. When aileron trim was applied to eliminate a roll, it was found to be operating in reverse. Trim was applied in the opposite sense and the aircraft returned to balanced flight. These instances demonstrate how human failings contribute to serious consequences. The UK CAA has formally addressed the subject and must continue to maintain the momentum.

Creating and implementing a maintenance error management system is a vital need and it is crucial to get everyone involved. In conclusion, an AAIB analysis of three incidents involving maintenance error showed that in all cases the engineers involved were considered by their companies to have been well qualified and competent. Furthermore, all occurred at night, there were staff shortages, time pressures, hands-on supervisors, they involved handovers, a can-do attitude was prevalent, interruptions had occurred, there was failure to use company or approved procedures, manuals were confusing and inadequate pre-planning and equipment was the rule.