Analyzing Human Error in Aircraft Ground Damage Incidents Caren A
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International Journal of Industrial Ergonomics 26 (2000) 177}199 Analyzing human error in aircraft ground damage incidents Caren A. Wenner, Colin G. Drury* State University of New York at Buwalo, Department of Industrial Engineering, 342 Bell Hall, PO Box 606050, Buwalo, NY 14260, USA Received 10 June 1997; accepted 18 February 1998 Abstract Ground damage incidents (incidents in which airline personnel cause damage to an aircraft on the ground) occur as airline personnel are working on, or around, an aircraft on the ground, either on the ramp or at a maintenance facility. Each incident can be quite costly to the airline, with costs both tangible (repair costs and lost revenue) and intangible (passenger inconvenience, increased maintenance workload). Thus, airlines have a "nancial incentive to reduce the number of ground damage incidents that occur. One of the airline's most di$cult tasks has been to utilize the information collected in their existing error reporting systems to determine the common latent failures which contribute to typical ground damage incidents. In this study, 130 ground damage incidents from a major airline were reviewed to determine the active and latent failures. Twelve distinct hazard patterns (representing the active failures) were identi"ed, with three hazard patterns accounting for 81% of all ground damage incidents. Nine major latent failures were identi"ed, and the relationships between the hazard patterns and latent failures were examined in depth. This type of analysis allows the latent failures common to di!erent hazard patterns to be identi"ed, and provides a means for developing focused intervention strategies to prevent future ground damage. Relevance to industry Airlines have generally had a di$cult time analyzing reports of human error to make improvements in their maintenance systems. This study provides a methodology that allows reports of human error to be analyzed, and interventions developed based on the results of the analysis. The methodology would also be applicable to, and useful in, other industries. ( 2000 Elsevier Science B.V. All rights reserved. Keywords: Aircraft ground damage; Human error analysis 1. Introduction besides #ight operations, that have a serious impact on aviation safety. Errors in maintenance opera- Since the Aloha Airlines accident in 1988, tions, especially, have the potential to result in in which the failure of airline inspectors to de- serious safety problems, and/or cause an accident. tect cracks in the fuselage resulted in the aircraft However, most e!ort (by airline personnel, industry splitting apart in #ight, the aviation community consultants, and human factors researchers) on re- has recognized that there are other departments, ducing errors was concentrated on improvements to the #ight deck, and on pilot training. McDonald and Fuller (1996a) point out that human factors * Corresponding author. Fax: #1-716-645-3302. e!orts on the #ight deck has been a recognized E-mail address: drury@bu!alo.edu (C.G. Drury). research "eld for 25 yr, while e!orts on aviation 0169-8141/00/$ - see front matter ( 2000 Elsevier Science B.V. All rights reserved. PII: S 0 1 6 9 - 8 1 4 1 ( 9 9 ) 0 0 0 6 5 - 7 178 C.A. Wenner, C.G. Drury / International Journal of Industrial Ergonomics 26 (2000) 177}199 maintenance have only just begun. Recognizing One example, documented in Airline Equipment this shortcoming, the FAA'sO$ce of Aviation Maintenance (Chandler, 1995), describes a typical Medicine established a program in 1988 to fund American Airlines ground damage incident in a broad range of human factors research in the which the cost of repairing a damaged aircraft was airline maintenance domain. $39,300. However, the total cost of the incident was Many projects within this program have focused calculated to be $367,500 due to passenger and on human errors in the maintenance environment, cargo revenue lost. In addition, there are non- and on how to prevent similar errors from reoccur- tangible costs to the airline including: passenger ring. It is widely recognized that although a large inconvenience, a!ected #ight schedules throughout number of errors may occur on a regular basis, it is the entire airline system, and increased mainten- very rare that a situation is elevated into a serious ance workload. A typical airline may have 100}200 incident a!ecting #ight safety. In most situations, reportable GDIs each year, resulting in signi"cant an error is either caught immediately or the de- "nancial losses that could be prevented. fenses of the maintenance system act to prevent the Thus, it is obvious that airlines have a signi"cant error from becoming an incident. Thus, the error is "nancial incentive to reduce the number of GDIs prevented from propagating through the system. that occur. However, due to the di$culty that often Mechanics are especially conscious of the impor- accompanies the calculation of the total cost of tance and seriousness of their work, and typically each GDI, airlines have not been able to quantify expend considerable e!ort to prevent, or at least the magnitude of the losses with any accuracy. recognize and correct, errors that could lead In addition, airlines have had a di$cult time con- to safety concerns for personnel, passengers, and trolling these costs, since they have been equipment. unable to pinpoint the causes of recurrent incidents Fortunately, airlines report few maintenance- (McDonald and Fuller, 1996b). induced incidents that a!ect the safety of personnel and passengers. However, ground damage, or dam- 1.2. Error reporting systems age to an aircraft caused by airline personnel while the aircraft is on the ground, remains a serious Problems in identifying causes of recurrent inci- problem for most airlines, with costs in the tens of dents are at least partially the result of inadequate millions of dollars per year. Ground damage can methods of collecting information about errors. In occur while ramp personnel are servicing an air- a typical airline, errors (above a certain threshold of craft, and/or while maintenance personnel are per- severity) are strictly monitored and recorded. For forming maintenance work. In fact, ground damage example, airline management may maintain strin- incidents (GDIs) can occur at any time personnel gent records of on-time #ight departures/arrivals, are working on, or around, an aircraft that is on the turnaround time for aircraft requiring mainten- ground. This category of incident only includes ance, injuries to personnel, damage to aircraft and damage that is inherently preventable by airline other ground equipment, and other measures that personnel on the ground: damage caused by hail, document the airline's overall performance. In ad- bird strikes, part failures, or even by foreign object dition, many errors (below the threshold of severity damage is not considered to be ground damage, for reporting) may be detected and corrected and some of these categories even have their own routinely as part of the system with no records separate prevention programs. kept. Most of the error-reporting systems in use at 1.1. Why is ground damage important to airlines? a typical airline are maintained and utilized by di!erent departments, and are rarely used together Ground damage incidents are extremely costly to to analyze the system as a whole. But, there are an airline; the total cost of an incident includes the many inherent problems that may a!ect more than cost of repairing the damage, as well as the less one of these performance measures, and similar tangible costs of keeping an aircraft out of service. errors may lead to an incident to be recorded in C.A. Wenner, C.G. Drury / International Journal of Industrial Ergonomics 26 (2000) 177}199 179 di!erent error reporting systems. For example, if the factors leading up to the incident, or the other a mechanic drops a wrench on his foot, the incident system factors that may have contributed to the would be recorded as an OJI (on-the-job injury). If incident. However, these type of reporting systems a mechanic drops a wrench on an aircraft, damag- do provide for quantitative tracking of error data, ing it severely, the incident would be recorded as including such information as the number of inci- Technical Operations Ground Damage. If the dents per month at each station, number of inci- wrench were dropped on the aircraft, causing no dents occurring on each type of aircraft, etc. They damage, the incident would not be recorded at all! also allow the particular individuals responsible for Finally, if a ground operations employee drops the incident to be identi"ed, and for blame to be a wrench on an aircraft, the incident would be assigned. Generally, these reporting systems are recorded as Ground Operations Ground Damage. useful to monitor trends in performance, but In each of these scenarios, the error was exactly the little use is made of this information to redesign the same, only the "nal consequences di!ered, in turn systems that generated the errors in the "rst place. a!ecting the way in which each of these incidents is In recent years, other error reporting systems recorded. Without compiling information from all with explicit human factors components have been of these error-reporting systems, it is quite di$cult introduced which provide investigators with tools to get a full picture of the types, and frequencies, of to help identify latent failures that may have con- recurrent errors. tributed to an error. Boeing's Maintenance Error The current project, as is typical of FAA O$ce Decision Aid (MEDA) system, and Aurora Safety of Aviation Medicine projects, was a joint e!ort and Information Systems Inc.'s Aurora Mishap between researchers and a partner airline. In Management System are examples of current error our partner airline, ground damage incidents are reporting systems which are being used by airlines recorded in narrative reports.