In recent years, cognitive error models have yielded insights into the unsafe acts that lead to many accidents in safety critical environments. However, there is a lack of information in the literature on possible links between specific errors and contributing factors. In this research, 619 safety occurrences involving aircraft maintenance were reported by self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research are described.
Samenvatting