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Author Catherine Drury Barnes, Colin G. Drury |
| Abstract Procedure following is used in many safety-critical enterprises to help ensure that technically correct methods are used for many tasks. Despite this, Failure to Follow Procedures is cited as one of the prime causal or contributing factors in many incidents and accidents. This paper follows an earlier study of failure to follow procedures in aviation maintenance, by going beyond the literature and pre-existing accident/incident data bases to collect data from system participants in eight different maintenance sites. Interviews were conducted with 63 users of procedures, mainly aviation mechanics, who had experience with such incidents, and with 92 managers, supervisors and procedure writes whose job is to control the maintenance process. The users provided details of an incident, then noted whether each of 90 contributing factors played a part. The managers rated the 15 “good practices” from the literature and provided detailed narrative comments. Analysis of the data confirmed the earlier analyses, although with some dissociation. Based on the data a set of interventions was developed, with training programs and audit procedures for each human function within the maintenance system. While the interventions are specific to aviation maintenance, the general good practices and contributing factors validated here have obvious application in other domains. |
