摘要: |
To help prevent maintenance-related aircraft accidents the complex factors behind previous accidents must be understood. Maintenance-related aircraft accidents were studied to determine the effects of maintenance human factors. A taxonomy of causal factors was developed and used to classify the causes of 101 military and civilian accidents and to determine the frequency of occurrence for each factor. The taxonomy identifies elements, such as people and hardware, interfaces between elements (i.e., human factors), and maintenance processes comprised of elements and interfaces. Human factors were found to have a significant effect in the 86 military and 15 civilian maintenance-related accidents studied. Whereas investigation boards were found to focus most heavily on element failures, a majority of the failures were found to occur at the process level. Maintenance instructions and their interfaces with the maintainers and inspectors who use them were the most frequently failed elements and interfaces, respectively. Recommendations are made to guide further research, and ideas are provided for improving process analysis by maintenance units and investigation boards. |