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IATA Maintenance Error Survey68/93

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IATA Maintenance Error Survey

Introduction
Prepared for: IATA

The following survey is designed to assist IATA in better understanding maintenance errors or why individuals fail to follow
operational procedures and/or policies. This survey is designed to investigate maintenance errors across various maintenance
activities and operational scenarios such as during: 1) Installation; 2) Servicing; 3) Repair; 4) Inspection; and 4) Airplane /
Equipment Damage. A random sample of respondents will be asked to respond to the aforementioned scenarios from the
perspective of complying with the company's SOP. In reflecting on the questions in the survey, please use your company's
operational procedures unless instructed otherwise.

The initial question of the survey will ask you to check off as many of these operational scenarios as you have experienced.
Depending on how you respond to this question, you will be randomly assigned to a specific operational scenario to complete. You
may answer as many of these scenarios as you wish. In fact, we encourage all participants to complete at least 2 scenarios. On
average, each survey will take 10 to 12 minutes to complete. Some of you will be asked to complete any one of the aforementioned
scenarios from the perspective of complying with the company's SOPs for that operational scenario. Please note: you can save a
partially completed survey and come back to it at a later time and date. Re-engagement with the survey will require web access.

It is very important that you be as complete in your answers as possible; please only leave a question blank if you have
absolutely no recollection of it, or if you do not feel it applies.

Remember you can save your answers and come back to the survey as many times as required to complete it.

We sincerely thank you in advance for your expert assistance in this important safety initiative.

Your anonymity and confidentiality will be protected at all times.

Recalling past experiences

2.1

Please indicate which of the following maintenance scenarios you have experienced (please check as many as apply):

1 Installation
2 Servicing
3 Repair
4 Inspection
5 Airplane / Equipment Damage
6 Modification
7 Other

2.2

Have you experienced a maintenance error or not correctly followed the maintenance operational procedures in any of these
scenarios above? If you have experienced more than one event it is recommended that you choose the most vivid event that you
had experienced.

1 Yes
2 No

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You will now be asked a set of questions related to a recent maintenance scenario where you were compliant to the maintenance
operational procedures.

2.6

Please name the activity in question.

2.8

Please indicate the work setting and/or environment wherein the event occurred:

1 Hanger / Base Maintenance

2 Line Maintenance
3 Support Shop (i.e., component shops, etc.)
4 Other

2.9

What type of document delivery system (i.e., manuals and procedures) were you working with at the time of the event?

1 Paper
2 Electronic / tablet
3 Other

2.10

At the time of the event who were you employed with?

1 International Airline
2 National Airline
3 Regional Airline
4 Airline Technical Subsidiary
5 MRO
6 Cargo Airline
7 Charter Operator
8 Other

2.11

At what hub or location did the event take place?

2.12

At which airport did the event occur? (Please enter the 3 letter airport code).

Recalling the contextual factors associated with this event

To answer the following questions we would like you to recall your experience. Take a few moments now to recall this event and to
remember it clearly before answering. Really try to put yourself back in that situation, recalling the sequence from prior to the
event to the conclusion of the event. Consider: what you were thinking or talking about, what you were feeling, etc.

3.2

When did the event you are recalling happen?

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1 0 - 6 months ago
2 7 - 12 months ago
3 1 to 2 years ago
4 more than 2 years, and up to 5 years ago
5 more than 5 years ago

3.3

Your position held at time of this event?

1 Mechanic
2 Supervisor
3 Manager
4 Apprentice Mechanic
5 Other

3.4

Approximate total years of experience when event occurred?

1 Less than 1 year

2 1 to 2 years
3 3 to 4 years
4 5 to 6 years
5 7 to 8 years
6 9 to 10 years
7 Greater than 10 years

3.5

When the event took place.

1 Shift work
2 Weekends

3.6

How many days in a row had you worked prior to this event?

11
22
33
44
55
66
7 Other

3.7

How long were you into this particular activity before an error occurred?

1 30 minutes
2 1 hour
3 2 hours
4 3 hours
5 4 hours
6 5 hours
7 6 hours
8 More than 6 hours

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3.8

To the best of your recollection how much time past before detecting the maintenance error?

3.9

At the time of the event were you working alone?

1 Yes
2 No

3.10

Please name the aircraft type were you operating at the time of this event?

3.12

How alert or fatigued were you during this maintenance activity?

1 1 - Very alert
22
3 3 - Alert
44
5 5 - Moderately tired
66
7 7 - Sleepy, but no difficulty remaining awake
88
9 9 - Very sleepy, fighting sleep

3.13

How often had you performed this maintenance activity previously?

1 Never
2 Rarely
3 Sometimes
4 Fairly often
5 Very often
6 Always

Now we would like you to spend a few minutes thinking again about this specific event, namely those few minutes immediately
preceding the event you are recalling. Take a few moments now to focus in on thoroughly remembering the details of that period,
what the conditions were, what was said or communicated if anything, what you were noticing and thinking, and how you were
feeling about the activity you were performing, etc. Please note that the following series of questions are to be related to the event
you are recalling and if none of the responses apply, please leave it blank.

Please indicate your awareness/consideration of the following factors that may have contributed to this event.

3.18

Feeling rushed or a sense of urgency.

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

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3.19

Being interrupted by an external factor (i.e., co-worker or supervisor).

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

3.20

Distracted by situational activities (i.e., noises, co-workers interacting, etc.).

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

3.21

Environmental conditions, such as weather conditions (i.e., freezing rain, snow, strong winds, sunlight, etc.).

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

3.22

Fatigue.

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

3.23

Concerned about having the correct tools and equipment to work with.

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

3.24

Feeling unfamiliar with the task at hand.

1 Not present
2 Present but unaware of at the time
3 Present and aware of, but not actively considered or discussed
4 Present and aware of, actively considered but NOT discussed
5 Present and aware of, actively considered and discussed

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Not present Present but unaware of at the time Present and aware of, but not actively considered or discussed Present and aware of,
actively considered but NOT discussed Present and aware of, actively considered and discussed

Now, please describe your experiences further during this same event, by recording your agreement or disagreement with each of
the following aspects of the situation as you experienced it in those moments just prior to the error or non-compliance event
occurring. Consider what you were feeling, thinking and the conditions and people around you at the time. If a question does not
apply to the event that you are recalling, please leave it blank.

3.29

On the occasion of this event I recall being mindful of the risks associated with not correctly following the maintenance procedures.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.30

On the occasion of this event I recall being mindful of the risks associated being distracted or interrupted.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.31

The operational context for this event was routine and as such I expected the same or typical outcomes to occur.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.32

As a result of higher than normal maintenance (workload) demands, I anticipated that an error was a possibility.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.33

As a result of time pressures, I anticipated that a maintenance error was a possibility.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree

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4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.36

I was in listening to my "gut" feeling to signal to me the importance of correctly following the maintenance procedures.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.38

I was feeling distracted by other operational demands (i.e., noises, co-workers, weather, etc.).

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.40

I was aware that given the complexity of the task at hand, I had anticipated that not correctly following the maintenance procedures
was a very real possibility.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.41

I was effectively managing any effects of "fatigue".

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.42

I was effectively managing the risks associated with routine and repetitive activities.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

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3.43

During or just prior to this event I was distracted by interruptions but felt confident the distraction had not compromised my
attention to my present activity.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.44

It is typical for me to use memory tricks or aids to ensure that I properly monitor the maintenance procedural compliance
requirements.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.45

I recall telling myself to be extremely vigilant (focused) on the maintenance activity I was carrying out.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.46

I recall thinking that the procedures are written poorly.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.47

I recall knowing how to correctly use the tools I was working with to perform this specific maintenance task.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.48

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I recall thinking that the maintenance procedural manuals were difficult to follow and confusing.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.49

I recall being well aware of the limits of the tools and systems I was working on for this activity.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.50

My experience tells me that my co-workers do not fully respect or see the true value in some of our maintenance procedural
requirements.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.51

For this event, although it was required for me to continuously refer to the maintenance manuals and procedures, I felt the task did
not require it, as I had memorized the procedures.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.52

With respect to the preceding question, it was typical for our maintenance shop and/or group to work from memory versus
continuously referring to the manuals and procedures.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.53

Before beginning this maintenance activity I recall mapping out or thinking through all of the tools and support materials I would

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need to correctly complete this task.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.54

I was aware from my own experience in similar situations that a maintenance error was a possibility.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.55

My experience in performing this task previously positively influenced my ability to remain compliant to the maintenance
operational procedures.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.56

Our maintenance procedures and manuals served me well on this day.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.57

As a company I feel we dedicate enough training to help us deal with errors associated with routine or the lack of vigilance and/or
attention to the task at hand.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.58

Our pre-shift briefings for work activities did not serve me well on this occasion.

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1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.59

Although available to me I did not review or have at my side the procedural manual for how to complete the task I was performing.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.60

I felt confident in the design and detail of the operational procedures I was following in order to complete the task.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.61

On the occasion of this event I was going through the motions of my activities without full attention or commitment to confirming
my own actions.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.62

On this occasion I felt the task I was performing was pushing my knowledge and ability to there limits.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.63

Our company's SOPs for monitoring and validating our work are not realistic.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree

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4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.64

I strictly followed company procedures for the work I was conducting.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.65

On the occasion of this event if I needed my supervisor's support or input I had confidence I could consult with them.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.66

I was feeling no inhibition or hesitation to challenge my co-worker in the manner in which he/she was supporting the maintenance
activity I was performing.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.67

I was feeling pressure from my co-workers, supervisor and/or flight crew to hurry up.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.68

I was feeling very confident in my knowledge of the performance limits of the tools and equipment I was using for this activity.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

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3.69

Prior to commencing my work activity I did a thorough assessment of the operational hazards and/or risks within the context of my
work activity.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.70

The team I was working with had good communication through this work activity.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.71

The team I was working with for this activity had good team coordination and collaboration.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.72

The quality of supervisor on the day of this event was poor (i.e., unavailable and/or uninterested).

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.73

When I have a safety concern, or safety suggestion I know that my reports are considered and drive improvement.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

Strongly Disagree Moderately Disagree Slightly Disagree Slightly Agree Moderately Agree Strongly Agree
3.75

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The most important thing I learned from this experience was:

1 Always follow the procedures

2 Need for continuous training
3 Need to anticipate threats (i.e., rushing, interruptions and/or distractions) while working
4 Better document / manual management (i.e., paper or i-pads)
5 Ask for help or assistance
6 Other

Looking back on it now, what do you think were the main factors that influenced your experience? Please rate each of the following
in terms of how big a factor you think it was in contributing to the outcome.

3.79

The weather.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.80

Being interrupted from the task at hand.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.81

Poor supervision and/or management oversight.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.82

Incorrect tools for the task.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.83

Fatigue.

1 Not a factor at all

2 A minor factor
3 A moderate factor

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4 A main factor
5 The single biggest factor

3.84

Poor training.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.85

Being distracted from the task at hand.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.86

Co-worker coordination.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.87

Co-worker communication.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.88

Experience.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.89

Co-worker competency.

1 Not a factor at all

2 A minor factor
3 A moderate factor

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4 A main factor
5 The single biggest factor

3.90

Company pressure to complete the task.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.91

Passenger pressure.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.92

The task was very routine.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.93

I did not have the correct equipment.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

3.94

Flight crew pressure to complete the task.

1 Not a factor at all

2 A minor factor
3 A moderate factor
4 A main factor
5 The single biggest factor

Not a factor at all A minor factor A moderate factor A main factor The single biggest factor
3.96

Other, please specify.

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The following questions are designed to assess tendencies or habits in your behaviour while managing operational procedures.

3.100

I will knowingly "not" sign off on work completed.

1 Never
2 Rarely
3 Sometimes
4 Fairly often
5 Very often
6 Always

3.101

It is common in our maintenance department to take short cuts.

1 Never
2 Rarely
3 Sometimes
4 Fairly often
5 Very often
6 Always

Never Rarely Sometimes Fairly often Very often Always

3.103

It is difficult for me to approach others and ask for assistance.

1 Strongly Disagree
2 Moderately Disagree
3 Slightly Disagree
4 Slightly Agree
5 Moderately Agree
6 Strongly Agree

3.104

What other information or ideas, if any, would you like to add to your description of this event that we asked you to recall? Please
type any other thoughts you have, or details we did not ask about that you feel were important, in the space provided.

Respondent Demographics
4.1

Current position

4.2

Which company are you currently employed with?

4.3

Gender

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1 Male
2 Female

4.4

Is English your first language?

1 Yes
2 No

Acknowledgement of your participation

On behalf of IATA we genuinely appreciate your support and participation in this survey. Upon saving your survey responses here
you will be taken to a thank-you page wherein you can offer further comments and insights. Once you close this page you will have
the opportunity to complete another survey if applicable from the original landing page.

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