Learning from Incidents in Aircraft Maintenance and Continuing Airworthiness Management: A Systematic Review

摘要

The purpose of this systematic review is to highlight the salient elements of learning from incidents in the aircraft maintenance and continuing airworthiness management area. This involved the review of more than 1,000 publications reflecting practice in different domains. The cache was eventually distilled to 18 publications of relevance to learning from incidents. The systematic review of the literature was not intended to be exhaustive, but it was deliberately bound by the parameters of predefined search terms. A robust analysis was performed on the 18 distilled publications with the use of the NVivo software. A critical and systematic examination of this body of literature further supported the development of the five codification themes. The analysis of the literature revealed the benefits of a just culture as an enabler of reporting and learning from incidents. Moreover, it identified limitations inherent in the current body of knowledge. The most evident being a paucity of literature relevant to the featured industry segment. Some impediments to learning from incidents are also highlighted. Central to this is the prevalence of lack of effective focus and practice on satisfactory causation of events. Currently, the efforts applied across many featured domains appear to be based upon ineffective legacy linear practices. However, emerging investigative philosophies that look beyond direct cause and effect contain opportunities for practitioners to consider causation through dawning axioms. This systematic review could be used in the European aviation regulatory activities associated with improving learning from incident in aircraft maintenance and continuing airworthiness management.