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Unsafe acts and unsafe outcomes in aircraft maintenance

Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.

Maintenance/manpower/methods

On-Orbit Maintenance Operations Strategy for the International Space Station - Concept and Implementation

The International Space Station (ISS) has an operational mission and profile that makes it a Logistics and Maintenance (L&M) support challenge different from previous programs. It is permanently manned, assembled on orbit, and multi-national. With this technical and operational challenge, a unique approach is needed to support the hardware and crew. The key is the integration of on-orbit and ground analysis, supply, maintenance, and crew training into a coherent functional process that supports ISS goals and objectives. To integrate all the necessary aspects of hardware and personnel to support on-orbit maintenance, a myriad of products and processes must be created and coordinated, such that the right resources are in the right place at the right time to ensure continued ISS functionality. This paper will familiarize the audience with ISS On-Orbit Maintenance (OOM) concepts and capabilities for different maintenance tasks and discuss some of the logic behind their selection. It will also identify the operational maintenance support responsibility split between the U.S. and the various International Partners (IPs).

Patterson, Linda P.

A survey on degradation modeling, prognosis, and prognostics-driven maintenance in wind energy systems

Wind energy generation proliferated over the past decades, introducing unique challenges and opportunities for failure prediction, operation and maintenance. Decision-makers are continuously looking into new methods to infer failure mechanisms and behaviors of wind turbine components to detect and intervene in the failures before they happen. Evidently, degradation modeling and prognosis become engaging topics for researchers and practitioners to prevent catastrophic failures. Prognostics-driven approaches predict the time of failure for the components (e.g., predicting remaining useful life), which provides significant insights for scheduling of operations and maintenance activities. Integrating these prognostics-driven insights into wind farm operations and maintenance presents a substantial challenge, demanding careful consideration of numerous factors such as accessibility, crew routing, and spare part logistics. This study provides state-of-the-art review for degradation modeling, prognosis, and prognostics-driven maintenance techniques for wind energy systems. The discussed techniques align with the United Nations' sustainable development goals, in particular Goal 7 (Affordable and Clean Energy), by enhancing effectiveness and sustainability of wind energy operations. This work also showcases open research questions related to degradation modeling, prognosis, and prognostics-driven maintenance.

Altinpulluk, Nur Banu

DOE EV Data Collection - Maintenance Data

Maintenance data includes information on maintenance performed on the electric vehicles, including preventive maintenance, service calls, and availability of the vehicles. The parameters collected, and their definitions, will vary due to the differences in maintenance tracking systems that exist between fleets. Parameter definitions are detailed in the data dictionary, and specific vehicle information is available in the vehicle attributes table. Vehicle ID can be used as a key between maintenance data and vehicle attribute tables. Data is being uploaded quarterly through 2023 and subject to change until the conclusion of the project.

32 ENERGY CONSERVATION, CONSUMPTION, AND UTILIZATI

Crew interface specifications development for inflight maintenance and stowage functions

Findings and data products developed during crew specification study for inflight maintenance and stowage functions are reported. From this information base, a family of data concepts to support crew inflight troubleshooting and corrective maintenance activities was developed and specified. Recommendations are made for the improvement of inflight maintenance planning, preparations and operations in future space flight programs through the establishment of an inflight maintenance organization and specific suggestions for techniques to improve the management of the inflight maintenance function.

Carl, J. G.

General aviation avionics equipment maintenance

Maintenance of general aviation avionics equipment was investigated with emphasis on single engine and light twin engine general aviation aircraft. Factors considered include the regulatory agencies, avionics manufacturers, avionics repair stations, the statistical character of the general aviation community, and owners and operators. The maintenance, environment, and performance, repair costs, and reliability of avionics were defined. It is concluded that a significant economic stratification is reflected in the maintenance problems encountered, that careful attention to installations and use practices can have a very positive impact on maintenance problems, and that new technologies and a general growth in general aviation will impact maintenance.

Parker, C. D.

Space Telescope maintenance and refurbishment

The Space Telescope (ST) represents a new concept regarding spaceborne astronomical observatories. Maintenance crews will be brought to the orbital worksite to make repairs and replace scientific instruments. For major overhauls the telescope can be temporarily returned to earth with the aid of the Shuttle. It will, thus, be possible to conduct astronomical studies with the ST for two decades or more. The five first-generation scientific instruments used with the ST include a wide field/planetary camera, a faint object camera, a faint object spectrograph, a high resolution spectrograph, and a high speed photometer. Attention is given to the optical telescope assembly, the support systems module, aspects of mission and science operations, unscheduled maintenance, contingency orbital maintenance, planned on-orbit maintenance, ground maintenance, ground refurbishment, and ground logistics.

Trucks, H. F.

Design metrics for maintenance +

Results of a study to develop maintenance metrics based on structural software design characteristics are described. A characteristic metric set suited to explain and predict software maintenance behavior is defined. The maintenance aspects investigated are stability and modifiability. While stability addresses the average number of modules affected per change cause, modifiability characterizes the ease with which changes can be made within each of these modules. Additional interest is dedicated to the difference between characteristic design and implementation metric sets, and to the difference between change behavior during development and maintenance. The development of six software systems and controlled maintenance experiments using these system is examined.

Rombach, H. D.

Hubble Space Telescope maintenance and refurbishment planning analysis

This paper presents an updated analytical approach toward the identification of Hubble Space Telescope system failures and downstates, maintenance requirements, and overall support to maintenance mission planning. Different sparing options of Orbital Replacement Units are evaluated, and the optimum spares complement that satisfies the expected servicing requirements is identified. Specific Space Telescope Reliability and maintenance Simulation Computer Program (SPATEL) updates and refinements are reported, and input data updates relevant to failure rates, downstate ground rules, and maintenance policy are addressed. A summary of the latest SPATEL outputs is provided along with maintenance analysis results.

Pizzano, F.

Time maintenance system for the BMDO MSX spacecraft

The Johns Hopkins University Applied Physics Laboratory (APL) is responsible for designing and implementing a clock maintenance system for the Ballistic Missile Defense Organizations (BMDO) Midcourse Space Experiment (MSX) spacecraft. The MSX spacecraft has an on-board clock that will be used to control execution of time-dependent commands and to time tag all science and housekeeping data received from the spacecraft. MSX mission objectives have dictated that this spacecraft time, UTC(MSX), maintain a required accuracy with respect to UTC(USNO) of +/- 10 ms with a +/- 1 ms desired accuracy. APL's atomic time standards and the downlinked spacecraft time were used to develop a time maintenance system that will estimate the current MSX clock time offset during an APL pass and make estimates of the clock's drift and aging using the offset estimates from many passes. Using this information, the clock's accuracy will be maintained by uplinking periodic clock correction commands. The resulting time maintenance system is a combination of offset measurement, command/telemetry, and mission planning hardware and computing assets. All assets provide necessary inputs for deciding when corrections to the MSX spacecraft clock must be made to maintain its required accuracy without inhibiting other mission objectives. The MSX time maintenance system is described as a whole and the clock offset measurement subsystem, a unique combination of precision time maintenance and measurement hardware controlled by a Macintosh computer, is detailed. Simulations show that the system estimates the MSX clock offset to less than+/- 33 microseconds.

Hermes, Martin J.

The development and application of composite complexity models and a relative complexity metric in a software maintenance environment

A great deal of effort is now being devoted to the study, analysis, prediction, and minimization of software maintenance expected cost, long before software is delivered to users or customers. It has been estimated that, on the average, the effort spent on software maintenance is as costly as the effort spent on all other software costs. Software design methods should be the starting point to aid in alleviating the problems of software maintenance complexity and high costs. Two aspects of maintenance deserve attention: (1) protocols for locating and rectifying defects, and for ensuring that noe new defects are introduced in the development phase of the software process; and (2) protocols for modification, enhancement, and upgrading. This article focuses primarily on the second aspect, the development of protocols to help increase the quality and reduce the costs associated with modifications, enhancements, and upgrades of existing software. This study developed parsimonious models and a relative complexity metric for complexity measurement of software that were used to rank the modules in the system relative to one another. Some success was achieved in using the models and the relative metric to identify maintenance-prone modules.

Hops, J. M.

The effects of Crew Resource Mangement (CRM) training in airline maintenance: Results following three years' experience

This report describes three years' evaluation of the effects of one airline's Crew Resources Management (CRM) training operation for maintenance. This evaluation focuses on the post-training attitudes of maintenance managers' and technical support professionals, their reported behaviors, and the safety, efficiency and dependable maintenance performance of their units. The results reveal a strong positive effect of the training. The overall program represents the use of CRM training as a long-term commitment to improving performance through effective communication at all levels in airline maintenance operations. The initial findings described in our previous progress reports are reinforced and elaborated here. The current results benefit from the entire pre-post training survey, which now represents total attendance of all managers and staff professionals. Additionally there are now full results from the two-month, six-month, and 12-month follow-up questionnaires, together with as many as 33 months of post-training performance data, using several indicators. In this present report, we examine participants' attitudes, their reported behaviors following the training, the performance of their work units, and the relationships among these variables. Attitudes include those measured immediately before and after the training as well as participants' attitudes months after their training. Performance includes measures, by work units, of on-time flight departures, on-schedule maintenance releases, occupational and aircraft safety, and efficient labor costs. We report changes in these performance measures following training, as well their relationships with the training participants' attitudes. Highlights of results from this training program include increased safety and improved costs associated with positive attitudes about the use of more assertive communication, and the improved management of stress. Improved on-time performance is also related to those improved attitudes, as well as favorable attitudes about participative management.

Taylor, J. C.

Qualitative Analysis for Maintenance Process Assessment

In order to improve software maintenance processes, we first need to be able to characterize and assess them. These tasks must be performed in depth and with objectivity since the problems are complex. One approach is to set up a measurement-based software process improvement program specifically aimed at maintenance. However, establishing a measurement program requires that one understands the problems to be addressed by the measurement program and is able to characterize the maintenance environment and processes in order to collect suitable and cost-effective data. Also, enacting such a program and getting usable data sets takes time. A short term substitute is therefore needed. We propose in this paper a characterization process aimed specifically at maintenance and based on a general qualitative analysis methodology. This process is rigorously defined in order to be repeatable and usable by people who are not acquainted with such analysis procedures. A basic feature of our approach is that actual implemented software changes are analyzed in order to understand the flaws in the maintenance process. Guidelines are provided and a case study is shown that demonstrates the usefulness of the approach.

Brand, Lionel

Evaluation of Hands-Free Devices for the Display of Maintenance Procedures

Over the past year, NASA's focus has turned to crewed long duration and exploration missions. On these journeys, crewmembers will be required to execute thousands of procedures to maintain life support systems, check out space suits, conduct science experiments, and perform medical exams. To support the many complex tasks crewmembers undertake in microgravity, NASA is interested in providing crewmembers a hands-free work environment to promote more efficient operations. The overarching objective is to allow crewmembers to use both of their hands for tasks related to their mission, versus holding a paper manual or interacting with a display. The use of advanced, hands-free tools will undoubtedly make the crewmembers task easier, but they can also add to overall task complexity if not properly designed. A leading candidate technology for supporting a hands-free environment is the Head-Mounted Display (HMD). A more recent technology (e-book reader) that could be easily temp-stowed near the work area is also a potential hands-free solution. Previous work at NASA involved the evaluation of several commercially available HMDs for visual quality, comfort, and fit, as well as suitability for use in microgravity. Based on results from this work, three HMDs were selected for further evaluation (along with an e-book reader), using International Space Station (ISS)-like maintenance procedures. Two evaluations were conducted in the Space Station Mockup and Trainer Facility (SSMTF) located at the NASA Johnson Space Center (building 9). The SSMTF is a full scale, medium fidelity replica of the pressurized portions of the ISS. It supports crew training such as ingress and egress, habitability, and emergency procedures. In each of the two evaluations, the participants performed two maintenance procedures. One maintenance procedure involved inspecting air filters in a life support system and replacing them with a clean filter if one were found to be contaminated. The second maintenance procedure focused on working in a confined space; specifically, pulling down a rack to inspect wiring configurations, and rewiring in a different pattern. The maintenance procedures were selected to assess mobility, tool use, and access to multiple document sources during task performance. That is, the participant had to move from rack to rack, use a wrench, a camera, etc., replace components, and refer to diagrams to complete tasks. A constraint was imposed that the ISS-like format of the procedures was to be retained, and not modified or optimized for the electronic device ("plug and play" approach). This was based on future plans to test with real procedures on ISS.

Ronald B Hoffman

Patterns of Error in Confidential Maintenance Incident Reports

Confidential reports of maintenance incidents are a valuable source of information on maintenance errors and the contexts within which they occur. NASA's Aviation Safety Reporting System (ASRS) has been receiving an increasing number of maintenance incident reports since a specialized maintenance reporting form was introduced in 1996. In a series of studies, the database of ASRS maintenance incidents was examined using correspondence analysis, a statistical technique that converts complex data tables into a visual form. The analyses revealed patterns within the ASRS data set that would have otherwise been difficult to detect. The results have implications for a range of purposes including human factors training, the design of procedures, and the identification of improvements in aircraft design.

Hobbs, Alan

Preliminary Analysis of ISS Maintenance History and Implications for Supportability of Future Missions

The International Space Station (ISS) enables the study of supportability issues associated with long-duration human spaceflight. The ISS is a large, complex spacecraft that must be maintained by its crew. In contrast to the Space Shuttle Orbiter vehicle, but similar to spacecraft that will be component elements of future missions beyond low-Earth orbit, ISS does not return to the ground for servicing and provisioning of spares is severely constrained by transportation limits. Although significant technical support is provided by ground personnel, all hands-on maintenance tasks are performed by the crew. It is expected that future missions to distant destinations will be further limited by lack of resupply opportunities and will, eventually, become largely independent of ground support. ISS provides an opportunity to begin learning lessons that will enable future missions to be successful. Data accumulated over the first several years of ISS operations have been analyzed to gain a better understanding of maintenance-related workload. This analysis addresses both preventive and corrective maintenance and includes all U.S segment core systems. Systems and tasks that are major contributors to workload are identified. As further experience accrues, lessons will be learned that will influence future system designs so that they require less maintenance and, when maintenance is required, it can be performed more efficiently. By heeding the lessons of ISS it will be possible to identify system designs that should be more robust and point towards advances in both technology and design that will offer the greatest return on investment.

Watson, Kevin J.

Performance of a Water Recirculation Loop Maintenance Device and Process for the Advanced Spacesuit Water Membrane Evaporator

A water loop maintenance device and process to maintain the water quality of the Advanced Spacesuit Water Membrane Evaporation (SWME) water recirculation loop has been undergoing a performance evaluation. The SWME is a heat rejection device under development at the NASA Johnson Space Center to perform thermal control for advanced spacesuits. One advantage to this technology is the potential for a significantly greater degree of tolerance to contamination when compared to the existing Sublimator technology. The driver for the water recirculation maintenance device and process is to further enhance this advantage through the leveraging of fluid loop management lessons-learned from the International Space Station (ISS). A bed design that was developed for a Hamilton Sundstrand military application, and considered for a potential ISS application with the Urine Processor Assembly, provides a low pressure drop means for water maintenance in a recirculation loop. The bed design is coupled with high capacity ion exchange resins, organic adsorbents, and a cyclic methodology developed for the Extravehicular Mobility Unit (EMU) Transport Water loop. The maintenance process further leverages a sorbent developed for ISS that introduces a biocide in a microgravity-compatible manner for the Internal Active Thermal Control System (IATCS). The leveraging of these water maintenance technologies to the SWME recirculation loop is a unique demonstration of applying the valuable lessons learned on the ISS to the next generation of manned spaceflight Environmental Control and Life Support System (ECLSS) hardware. This

Rector, Tony

Maintenance Human Factors and Flight Safety

This chapter will chronicle the journey of the community of operators, regulators, and researchers who embarked upon the task of identifying critical human factors of maintenance and inspection, establishing a database and research tools, developing practical strategies for reducing the risks of maintenance and inspection errors, and understanding its critical role in preserving flight safety. We will take a historical perspective, developing a timeline that is largely driven by key events such as accidents and regulatory/government actions and initiatives. Part 1 focuses on how the field of maintenance human factors was built, beginning in the late 1980’s. Part 2 describes the development of methods and tools for meeting the maintenance human factors challenges identified. Finally, Part 3 updates the original chapter by focusing on issues that have persisted or emerged since 2010.

maintenance