Learning from our Mistakes: A Review of Maintenance Error Investigation and Analysis Systems

Since the ALOHA accident in 1988, the FAA, labor unions, aircraft and engine manufacturers, and the U.S. air carrier industry have been working together in a new endeavor called maintenance human factors. With the growing recognition that many accidents may involve maintenance error, the industry has turned to the science of human factors to provide answers to why a technician, ground crew agent, or storeroom clerk could have made an unthinkable accident-causing error. Through human factors, we were to take a new look at technician performance, a look that would lead us to error-provoking factors that, if properly managed, would result in a large reduction in maintenance error.