Abstract:
Aviation maintenance errors account for between 13% and 23% of the global
aviation incidents and accidents initiators, which require a wider global use of aviation
maintenance safety improvement activities. The current research applies the Human Error
Risk Management in Engineering Systems (HERMES) methodology that conceptualizes
two main streams of study. These are the retrospective investigation of human errors
within aviation maintenance contexts, and a prospective innovation of new tools that
work to prevent errors occurring. In this research the impact of human reliability on
aviation maintenance safety is investigated. Rotorcraft is taken as a focal case study.
A new model to represent the accumulation of crucial maintenance human errors
causal factors, within aviation maintenance companies, is introduced. A total of 804
recent maintenance-induced helicopter accidents were reviewed, from which 58 fatal
accidents and serious incidents were thoroughly analysed using Human Factors Accident
Classification System - Maintenance Extension (HFACS-ME). A 4th order of analysis is
newly introduced into the HFACS-ME taxonomy under the notion of ‘Specific Failures’
for better analysis resolution and comprehensiveness. Hypothesizing that human factors
errors within aviation maintenance industry can be more effectively managed by applying
proactive monitoring and early error detecting techniques - at both organizational and
individual levels, a proactive Aviation Maintenance Monitoring Process (AMMP) is
formulated. AMMP is a holistic hybrid retrospective / prospective integrated process that
is to be simultaneously and collectively implemented by main industry stake-holders -
regulators, manufacturers and maintenance organisations. The aim is to proactively
monitor the existence of human error causal factors that are initiated during design
practices, manufacturing processes, or at later stages due to workplace conditions. As a
result, such causal factors can be gradually eliminated to reduce the overall risk of
maintenance errors.
This generic AMMP model is based on a Root Cause Existence Scale (RCES) and
a comprehensive sociotechnical user program, coded as ‘ErroDetect’, built applying the
fuzzy Analytic Network Process (fuzzy ANP) theory. A total of 870 different assessment
criteria were designed and then in-built within the software thus mapping the outcomes of
the retrospective error causal factors investigative studies. Full simulation of the process
is conducted, and then it was further validated practically in real world within industry
for both design for maintainability within major rotorcraft manufacturer facilities, and for
MRO’s performance safety enhancement. Validation results were thoroughly discussed.
The AMMP is found to have significantly enhanced aircraft maintenance proactive safety
for both designers and maintainers. The tool can also be adopted for regulation purposes.