Analyzing human error in aircraft ground damage incidents

Ground damage incidents (incidents in which airline personnel cause damage to an aircraft on the ground) occur as airline personnel are working on, or around, an aircraft on the ground, either on the ramp or at a maintenance facility. Each incident can be quite costly to the airline, with costs both tangible (repair costs and lost revenue) and intangible (passenger inconvenience, increased maintenance workload). Thus, airlines have a financial incentive to reduce the number of ground damage incidents that occur. One of the airline's most difficult tasks has been to utilize the information collected in their existing error reporting systems to determine the common latent failures which contribute to typical ground damage incidents. In this study, 130 ground damage incidents from a major airline were reviewed to determine the active and latent failures. Twelve distinct hazard patterns (representing the active failures) were identified, with three hazard patterns accounting for 81% of all ground damage incidents. Nine major latent failures were identified, and the relationships between the hazard patterns and latent failures were examined in depth. This type of analysis allows the latent failures common to different hazard patterns to be identified, and provides a means for developing focused intervention strategies to prevent future ground damage. Relevance to industry. Airlines have generally had a difficult time analyzing reports of human error to make improvements in their maintenance systems. This study provides a methodology that allows reports of human error to be analyzed, and interventions developed based on the results of the analysis. The methodology would also be applicable to, and useful in, other industries. Copyright (C) 2000 Elsevier Science B.V.