Federal Aviation

Event Investigation Administration

William L. (Bill) Rankin, Ph.D.

Boeing Technical Fellow

Introduction of The Operator’s Manual for Human

Factors in Aviation Maintenance

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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

Federal Aviation 2
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Administration
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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

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 1.0 Event Investigation

The Operator’s Manual for Human Factors in Aviation Maintenance

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 Maintenance-Related Events

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 Maintenance/Inspection Error
as a Primary Cause of Accidents
Hull Loss Accidents - U.S. Commercial Jet Fleet
Number of accidents Percentage of total accidents with known causes
Primary factor 10 20 30 40 50 60 70
1959--1992 1993--2002

190 57.1%
Cockpit crew
32 43.2%
65 19.5%
Airplane
14 18.9%
15 4.5%
Maintenance & Inspection 7 9.5%
15 4.5%
Weather 6 8.1%

Airport/ATC 20 6.0%
2 2.7%
Miscellaneous/other 28 8.4%
13 17.6%
Total with known causes 333 74 Excludes: Legend
Unknown or awaiting reports 14 14 • Sabotage 1959 through 1992
Total 88 • Military action 1993 through 2002
347

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 Maintenance-Related Events

The Operator’s Manual for Human Factors in Aviation Maintenance

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 Maintenance-Caused System Failures
as a Contributing Factor to Accidents
• International Air Transport Association
(IATA) Safety Report 2003
• Total of 92 accidents in 2003
• 42 Western-built jets
• 32 Western-built turboprops
• 7 Eastern-built jets
• 11 Eastern-built turboprops
• Found that in 24 accidents (26%) a
maintenance-caused event started the
accident chain.
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 Event Investigation – Why is it Important
• The purpose of an event investigation
Use bullets and pictures
process is to manage the risks from events
caused by mechanic or inspector actions.
• Event investigations help organizations DO NOT READ THEM THE BOOK!
identify and understand multiple contributing
factors to human error and procedural
deviations that cause events.
•Making improvements to these contributing
factors reduces the likelihood of future,
similar events.
• Making improvements based on
investigations of lower level events helps
prevent higher level events.
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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

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 Event Investigation - How to implement
• Select a manager/department to be
responsible for the process.
• Determine whether the
investigations will be carried out in
the context of ASAP (Aviation Safety
Action Program).
• Cooperative endeavor between
labor and management and
regulator.
• Select an investigation process.
• Write policies and procedures
needed to implement process.
• If necessary, implement a “just”
disciplinary policy.

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 Event Investigation - How to implement
• Select the events to be investigated.
• Select and train the event investigators.
• Establish a management team to review the investigation
findings in order to decide what improvements to make.
• Follow up to insure the improvements are being made.
• Inform all personnel about the improvements that are being
made on the basis of the event investigation findings.
• Analyze the findings using risk assessment techniques and
trend analysis.
• Evolve the system so that personnel report “near events.”

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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is

working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

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 Event Investigation - How to know it is working
• Events are being investigated.
• Contributing factors to errors and to
procedural deviations are being
uncovered.
• These contributing factors are
being corrected.
• The number of events caused by
mechanic/inspector performance
decreases over time.
• The operator saves time and
money.
• Mechanics/inspectors begin to self
report “near events.”
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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

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 Event Investigation - Key References
• Aviation Safety Action Plan
(ASAP) AC 120-66B

• Maintenance Error Decision

Aid (MEDA) User’s Guide and
Results Form

• Ramp Error Decision Aid

(REDA) User’s Guide and
Results Form

• Human Factors Analysis and

Classification System—
Maintenance Extension
(HFACS-ME)

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 Agenda

Why is Event Investigation Important

How to Implement a Event Investigation Program

How to know the Event Investigation program is working

Key References

Discussion as Time Permits

The Operator’s Manual for Human Factors in Aviation Maintenance

Federal Aviation 17
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 Summary
• Maintenance-caused events affect
• Safety of flight
• Personal injury
• Equipment damage.
• Event Investigations can be used to understand the
causes (contributing factors) to these events and to
make improvements to prevent future, similar
events.
• M&E organization must implement process by
• Selecting responsible manager/dept.
• Writing policies and procedures
• Implementing “just” discipline policy
• Training staff
• Carrying out investigations
• Making improvements.
• Investigations result in improvements being made, a
reduction in the number of events, time and money
being saved, and voluntary reporting of “near
events.”
The Operator’s Manual for Human Factors in Aviation Maintenance

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