SUMMARY OF STUDIES ON COMMUNICATION ERRORS IN AIRCRAFT MAINTENANCE ORGANIZATION

Researchers Study Methods Results Recommendation

Alan Hobbs Maintenance Interview & Incident Over 80% of the unsafe acts of Functional checks and
(1999) Mistakes and reports maintenance mechanics fell into one independent inspections are
Systems Solution of five types; examples of safeguards designed
to capture errors before they
cause harm.
Memory lapse 24%, when a person
is interrupted to go and do something
else.

Work-arounds 23% involves

performing a task without all the
necessary equipment or according to
approved procedures.

Situational awareness 18%, errors

occur when a mechanic starts work
without first gaining a accurate
picture of the situation being dealt
with.

Expertise 10%, errors of expertise

happen when someone doesn’t have
the knowledge, skills or experience to
do all aspects of their job.
Action Slips 9%, occur when
someone accidentally does
something unintentionally on routine,
highly familiar tasks.

The BASI analysis of maintenance

incident reports found that for
incidents which had airworthiness
implications, the most common
factors in the work area at the time of
the incident were:

Confusion

misunderstandings or difference of
opinions about procedures,

communication breakdowns between

people

pressure or haste,

lack of tools or spares.

 In terms of organizational factors,
errors occur due to:

lack of refresher training

lack of learning from incidents.

Fatigue

James C. The Evolution and Focus group interview Increase two way AMT-management NIL
Taylor (2000). effectiveness of - asked about causes communication,
Maintenance of paperwork errors
Resource
Management Install newer film

Involve AMT in revising the logbook

form and to rewrite the FMM

Provide AMTs review and feedback

to engineers before engineering
orders are issued.

Reduce number of maintenance

 checks

provide AMT training in paperwork.

Installed telephone hotline for AMT to

address any non-emergency and
non-grievances issues.

MRM second year, another focus

group were interviewed about
problems and solutions – same as
previous results.

Later union and management agreed

to implement pre-shift meeting and
had the line station to redesign
company’s aircraft log book.

Results proved quality of paperwork

and documentation
Chervak & Effects of Job Simplified Technical 1. Simplified English is effective NIL
Drury (2002) Instruction on English (STE) but only for the total error
Maintenance Task
Performance measure and only contrasted
Fleish-Kincaid reading with a hybrid version of work
 Focusing on score card.
Vocabulary pattern
across procedural 2. 6 Hollnagel’s list of error
text vocabulary Video Taped task on a phenotypes for procedural
pattern to determine gasoline engine from a
reduction of error rotary lawnmower to task was used for example
rate in maintenance measure maintenance repetition, omission, delay
task task performance
premature action,
replacement, and insertion.
Other 6 categories were
added (slip, wrong tool, wrong
oil amount, experimenter
intervention and
uncertainties).

3. The performance measure

using only the original and
Simplified English versions
showed no significant effects
of language version.

Parke et al Shift turnover related Voluntary report by Communication issues was NIL
(2003) errors in ASRS Airframe and contributing factor
reports Powerplant technicians
in Aviation Safety
Report System (ASRS) 7% communication between crew
and lead
 8% between departments (between
flights and maintenance)

involved installation

incomplete installation (36%)

wrong equipment (17%)

system or equipment not activated or

deactivated (17%)

improper fault isolation and

documentation
Munro, Kanki Logbook Survey and interview 1. Logistical factors structured feedback on the entries,
& Jordan communication include the mechanic in CRM
(2008) between pilots and  time factor due to short turn- training, logbook entry training for
mechanics pilots and more structured forms
around times of aircraft and
for reporting discrepancies like
mechanics’ schedule, checklist or electronic menus.

 pilots’ general description in

the logbook compared to
 mechanic entries.

 pilots claimed lack of training

in logbook writing

 mechanics have little chance

to follow up with pilot to
explain a logbook entry once
the pilot left the aircraft.

2. Organization factors:

 company policy in
stating the level of
detail in logbook
entries.

Lattanzio, maintenance Exploratory Contributing Factors that cause a Document Deficiencies are best
Patankar & procedure incident methodologies: technician to err: served by document improvement
Kanki (2008) reports strategies and User Error
Modified MEDA coding Documentation deficiencies:
scenarios are best served by
Perilog  infomation not training, process or policy
understandable changes. The frequency of non
Content analysis compliance as an operational
 information incorrect event suggests that a more
focused look at policies and
 information not enough organizational culture might be
needed.
 information not used
  Information unavailable

User Errors:
mechanic did not read/ follow
documents
Chen et al Identification of Analytical hierarchy ERRORS OF FLIGHT CREW NIL
(2009) significant threats Process
1. Intentional non-compliance
and errors affecting
error
aviation safety in
2. Procedural error
Taiwan 3. Communication error
4. Proficiency error
5. Operational decision error

ERRORS OF AIRCRAFT
MAINTENANCE STAFF

1. Incorrect installation of
components
2. Fitting of wrong parts
3. Electrical wiring discrepancies
incld. Cross connection
4. Loose object left in a/c
5. Landing gear ground lock
pins not removed before
departure
6. Cowling access panels and
fairing not secured
7. Inadequate lubrication
 ERRORS OF ATC PERSONNEL

1. Stress
2. Boredom
3. Conceit n over confidence
4. Ability to prevent error

Ma, Drury & Language errors in Survey: Study 1: better communication design in
Marin (2010) aviation documentation, standard protocol,
60% of Asian respondents stated as
maintenance: job-related English training to
Quantifying the To assess the having misperceived ability to speak reduce language error
issues and incidence of 7 English
interventions in 4 language error
world regions scenarios and factors
leading to such errors
more than 50% of them also
misunderstood the translated
documents

more than 70% respondents from

European region misunderstood
English documents followed by Latin
America respondents as the second
 highest.

Language errors result from

inadequate ability of AMTs, low
familiarity of task, task complex
instructions and time pressure.

Study 2:
The accuracy performance was
generally good and only translation
was proved to be an effective
intervention. Time pressure on AMT
and inspector was reported as major
cause of language errors

Computational
Linguist to quantify
the effectiveness of Language Errors (Verbal)
language error
intervention by using 2
Task Cards; easy and 1. AMT/inspectors not able to
difficult communicate verbally to the
(comprehension test) level required for adequate
performance.
 2. AMT/inspector and the
person to whom they were
speaking did not realize the
other had limited English
ability
3. Native English speakers with
different regional accents did
not understand each others
communications
4. AMT/ inspector did not
understand a safety
announcement over the
public address system

Language Errors (written)

1. AMT/ inspector did not fully

understand a safety placard
2. AMT/inspector did not fully
understand documentation in
English-manual
3. AMT/inspector did not fully
understand a document
translated from another
language into their native
language.