Managing Procedural Error in Maintenance

摘要

It is well established that procedural non-compliance is a common occurrence in maintenance operations. Hobbsrn& Williamson (2000) reported that 80 percent of maintainers surveyed deviated from procedures at least once inrnthe past year; nearly 10 percent reported doing so often or very often. McDonald et al. (2000) reported that 34rnpercent of routine maintenance tasks were performed contrary to procedures. An analysis of NASA Aviation SafetyrnReporting System (ASRS) incident reports from 1998–2001 indicated that a signifi cant proportion (44 percent)rnof maintenance reports pertained to procedural errors and implicated many types of maintenance documents,rnsuch as: maintenance manual, task cards, minimum equipment list and maintenance log.rnThe reasons for making these errors were diverse. Sometimes the procedure itself was defi cient (e.g., incomplete,rnincorrect, unclear), or it was not the current version. Sometimes the source of the problem was the user of thernprocedure who misread or misinterpreted the document, or simply didn’t follow it. Because the causes underlyingrnprocedural errors in maintenance cover a wide variety of problems, simplistic solutions have not provided longlastingrnor systemic solutions. And in spite of useful document design tools, and information technologies thatrnimprove document production, procedural error in maintenance has persisted. However, as we increase ourrnunderstanding of the causes and contexts in which procedural errors occur, the development of comprehensivernsolutions will accomplish far more than the correction of individual procedures and users. Rather, they willrnaddress the full complexity of the problem including issues such as information technology limitations, usabilityrntesting and training, document system standardization, and organizational safety culture.