incidents. Please tell us about a maintenance incident, which involved
you or someone else. A maintenance incident can be anything, which
could have prevented an aircraft from operating normally or could have
put the safety of a worker at risk.” A series of closed questions then followed.
Reporters were asked to indicate that they had either been
involved in the incident or had witnessed it, were asked how long ago the
incident had happened, the time when the incident occurred, the length
of the shift being worked at the time, the type of aircraft involved, and
the nature of the task (e.g., inspection, component installation, etc.).
Respondents were then presented with the following four open-response
questions:
1 “What happened? Most incidents involve a chain of events. Start with
the first thing that happened and then describe each of the things that
happened next. Try to give as much detail as you can. If people played
a part in the incident, tell us [their job category] but please do not
identify anyone.”
2 “Why do you think the incident happened?”
3 “Was there anything about the way things were done at your company
that contributed to the incident (e.g., something about the equipment,
documentation, procedures)?”
4 “Did the incident occur because of something you or another person
did or did not do? Please describe the most important thing that you
or they did wrong (or did not do).”
If the respondent did not have an incident to report, or chose not to
report one, they were instructed to leave the section blank, and continue
to the next section of the questionnaire. In a separate part of the questionnaire,
respondents were asked to report the start and finish times of
their most recent work shift. The study met the ethical requirements
stated in Portaluppi et al. (2008). Participation was anonymous and
voluntary. No information that could be used to identify respondents or
their employers was collected. Questionnaires were returned in a prepaid
envelope.
The errors described in incident reports were classified using a modified
version of the SRK model, with the addition of “procedure violations”
as a separate class of error, and the inclusion of perceptual errors,
such as inspection failures, in the skill-based category. Although procedure
violations were not the focus of the current study, they were
included for the sake of completeness as such actions are known to
feature in maintenance incidents (McDonald et al., 2000). Two coders
performed the error classification. The main coder (Rater 1) was an aviation
safety investigator with experience in the investigation of human
error in accidents and incidents. Rater 2 was a research psychologist