Analyses of Organizational and Individual Factors Leading to Maintenance Errors 2001-01-3005

Maintenance errors, as reported in 939 ASRS reports, were analyzed to determine primary and secondary causal factors. The taxonomy of these causal factors was developed by cross-mapping Reason’s General Failure Types, MEDA’s contributing factors, and the “Dirty Dozen.” At the primary level, the taxonomies were classified into either organizational-type factors or individual-type factors. At the secondary level, the organizational-type and individual-type factors were combined into one comprehensive list. At the primary causal level, the leading organizational factor was poor procedures or poor quality of information that is available to the maintenance personnel and the leading individual factor was a lack of awareness. At the secondary causal level, the leading factor was poor procedures or quality of information.