Aeronautics Study - Safety Threats Term Paper

Length: 12 pages Sources: 12 Subject: Transportation Type: Term Paper Paper: #71826789 Related Topics: Aircraft Maintenance, Drunk Driving, Root Cause Analysis, Accident Investigation
Excerpt from Term Paper :

Percentage (a)

System operated unsafely during maintenance 80 13

Incomplete installation 48 8

Maintenance worker contacted hazard 45 7

Incorrect assembly or location 44 7

Towing event 44 7

Vehicle or equipment contacted aircraft 31 5

Material left in aircraft 27 4

Wrong equipment or part installed 23 4

Part not installed 22 4

Part damaged during repair 21 3

Panel or system not closed 21 3

Required service not performed 20 3

Failure of component or tool 15 2

Fault not found 15 2

Falls and trips 14 2

System not made safe before maintenance 12 2

System not reactivated 10 2

Pin or tie left in place 9 1

Documentation error 9 1

Note. For an additional 14 occurrences, the outcome could not be determined.

A a) Figures are rounded to nearest percentage.


Perceptual error

Example: After being on duty for 18 hr on a long overtime shift, the worker was carrying out a general inspection on an engine at around 22:00. He missed obvious damage to the internals of the cold stream duct area. The damage was found later, when another defect was being investigated.

Memory lapse

Example: Just prior to the departure of the aircraft, I remembered I had left a blanking plug within the engine inlet area. I advised the pilot that I needed to check that area again and retrieved the blank.


Example: Without thinking, I moved to wipe oil with a rag. The rag was ingested in the engine intake causing FOD [Foreign Object Damage].

Rule-based error

Example: A mechanic did not check the


When the pump started, the flaps began to retract automatically. This could have caused damage to the aircraft or injured other workers.


Example: At the end of a shift we realized that an engine hadn't been run to check for oil leaks when the aircraft was to be placed online. Under pressure to avoid a delay due to this oversight, the run was carried out too quickly and the engine was not un-cowled properly to check for oil leaks and consequently after departure that particular engine ran out of oil as the result of a damaged seal.

Knowledge-based error

Example: I wanted to turn the radio master on but could not find it, as the switches were poorly marked or unreadable. I was unfamiliar with the aircraft, so I asked an airframe tradesman who was working on the aircraft and he pointed to a red rocker switch. I queried him and he said that must be it. I pushed the switch and the right engine turned over, with the propeller narrowly missing a tradesman who was inspecting the engine. There is no radio master in this aircraft. I immediately marked the "start" and some other switches and learned a valuable lesson.


Example: A service procedure was carried out in accordance with the aircraft maintenance manual. The manual however, contained an error, which resulted in an aircraft system failing to operate correctly during a functional test at the end of the maintenance procedure.

Factor n or Fatigue 1-0.2

Pressure 8-1.9

Coordination 6-1.4

Training 1-0.2

Supervision 5-1.9

Procedure 16 9.0 **

Equipment 1-0.3 deviation 4-4.3 *

Environment 1-0.8 chi square](9, N = 805) 46.68

Wald test significant at p

Sources Used in Documents:


Bruggink, Gerard M. (2000, August). "Remembering Tenerife." Retrieved November 23, 2007, at

Dismukes, Key, Berman, Benjamin a. And Loukopoulos, Loukia D. (2007). The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline.... Ashgate Publishing, Ltd. Retrieved November 23, 2007, at

Fadden, S., Ververs, P.M., & Wickens, C.D. (2001). Pathway HUDs: Are They Viable?. Human Factors, 43(2), 173. Retrieved November 19, 2007, from Questia database:

Hobbs, a., & Williamson, a. (2003). Associations between Errors and Contributing Factors in Aircraft Maintenance. Human Factors, 45(2), 186+. Retrieved November 23, 2007, from: Questia database:
Jentsch, F., Barnett, J., Bowers, C.A., & Salas, E. (1999). Who Is Flying This Plane Anyway? What Mishaps Tell Us about Crew Member Role Assignment and Air Crew Situation Awareness. Human Factors, 41(1), 1. Retrieved November 20, 2007, from Questia database:
Johnson, Chris W. And Palanque, Philippe. (2004). Human Error, Safety and Systems Development. Springer. Retrieved November 23, 2007, at
Kirwan, Barry, Rodgers, Mark and Sch fer, Dirk. (2005). Human Factors Impacts in Air Traffic Management. Retrieved November, 22, 2007, at
Krieger, J.L. (2005). Shared Mindfulness in Cockpit Crisis Situations: An Exploratory Analysis. The Journal of Business Communication, 42(2), 135+. Retrieved November 23, 2007, from Questia database:
Mcfadden, K.L. (2002). DWI Convictions Linked to a Higher Risk of Alcohol-Related Aircraft Accidents. Human Factors, 44(4), 522+. Retrieved November 23, 2007, from Questia database:
NTSB Warns of Runway Collision Risk; Encouraged by Potential for Technology to Improve Road Safety. (2007, November 8, 2007). NTSB News. Retrieved November 22, 2007, at
Olson, W.A., & Sarter, N.B. (2001). Management by Consent in Human-Machine Systems: When and Why it Breaks Down. Human Factors, 43(2), 255. Retrieved November 19, 2007, from Questia database:
Runway Safety. (2007, October 10). Federal Aviation Administration. Retrieved November 23, 2007, at
Runway Safety Data and Statistics. (2007, July 11). Retrieved November 23, 2007, at
Runway Safety the Human Element. (2007). Retrieved November 23, 2007, at
Scarborough, M.P.H., Pounds, Ph.D., and Bailey, Ph.D. (N.d). "Human Factors Classification of Runway Incursions Associated with Vehicle and Pedestrian Deviations." FAA Civil Aeromedical Institute. Retrieved November 22, 2007, at

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