In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.
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Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.
Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.
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