Identifying contributory factors to aviation maintenance error events, commercial air transport maintenance, and the effective and ineffective elements of verbal communication

Abstract

The effect of maintenance error in the commercial air transport maintenance domain can lead to loss of life of crew, passengers and bystanders. The key step to reduce such errors requires the identification of contributory factors which lead to error. This thesis is constructed of three studies which identified and explored contributory factors to commercial air transport maintenance error in post and pre accident environments.The first study examined accidents and incidents caused by maintenance error. Boeing’s Maintenance Error Decision Aid (MEDA) taxonomy was used to categorise the contributory factors to error from 138 maintenance error report narratives. Analyses of these factors using Pearson’s Chi-Square, Lambda and Odds Ratio tests revealed that a modest frequency of communication categorisations was significantly associated with leadership and supervision, individual factors and technical knowledge contributory factors in maintenance error events.The second study identified which contributory factors to error were considered most salient by commercial air transport maintainers. Semi-structured interviews of 40 aircraft maintainers elicited 746 emergent contributory factors and undesired outcome descriptions. These were grouped into industry recognisable categories using the ‘Dirty Dozen’ taxonomy (Dupont, 1997). Of the 746 factors, communication factors were the most frequently described (147), of which 99 were verbal, 34 were written and 14 were general. Of these, 22 verbal and 10 writtentask miscommunication examples were accompanied by undesired outcomes. The key finding was that verbal communication is perceived to be more important to maintenance task performance than other contributory factors in the commercial air transport maintenance environment.The third study examined verbal communication by using the Critical Incident Technique to interview 23 licensed aircraft maintainers. This method extracted 140 effective and ineffective verbal communication incidents which were sorted into 27 descriptive codes within send, receive, pre-feedback and feedback themes using template analysis. The resultant template was then used to adapt Eunson’s 2006 communication model (Eunson, 2007) into two versions depicting elements of effective and ineffective verbal communication.This thesis has contributed new knowledge by identifying that verbal communication is a more important contributory factor to maintenance error than previously considered. Moreover, the thesis has identified what maintainers consider to constitute effective and ineffective verbal communication. These findings have the potential to be developed into tools which can categorise, train and assess verbal communication in the commercial air transport maintenance domain.

Date of Award	Mar 2025
Original language	English
Awarding Institution	Coventry University
Supervisor	Steve Scott (Supervisor) & Don Harris (Supervisor)