Judgemental errors in aviation maintenance

Abstract

Aircraft maintenance is a critical success factor in the aviation sector, and incorrect maintenance actions themselves can be the cause of accidents. Judgemental errors are the top causal factors of maintenance-related aviation accidents. This study asks why judgemental errors occur in maintenance. Referring to six aviation accidents, we show how various biases contributed to those accidents. We first filtered aviation accident reports, looking for accidents linked to errors in maintenance judgements. We analysed the investigation reports, as well as the relevant interview transcriptions. Then we set the characteristics of the actions behind the accidents within the context of the literature and the taxonomy of reasons for judgemental biases. Our results demonstrate how various biases, such as theory-induced blindness, optimistic bias, and substitution bias misled maintenance technicians and eventually become the main cause of a catastrophe. We also find these biases are interrelated, with one causing another to develop. We discuss how these judgemental errors could relate to loss of situation awareness, and suggest interventions to mitigate them.

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Acknowledgements

Open access funding provided by Lulea University of Technology. This project is a part of the human factors research at the Division of Operations and Maintenance, Luleå University of Technology, funded by the Luleå Railway Research Centre (JVTC).

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Correspondence to Prasanna Illankoon.

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Illankoon, P., Tretten, P. Judgemental errors in aviation maintenance. Cogn Tech Work 22, 769–786 (2020). https://doi.org/10.1007/s10111-019-00609-9

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Keywords

  • Judgemental error
  • Heuristics
  • Aviation maintenance
  • Situation awareness