Considering the Human Factor Impact of Maintenance Documentation

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Steve Bentley MD of SAS ( discusses the various areas where the Maintenance Planning Process was able to become a precursor contributing to potential maintenance.

EASA commissioned a “Study on the need of a common worksheet/work card system” to evaluate the impact of maintenance documentation on the Human Factor concern.

(Specifications N°: EASA/2006/OP/25 On demand of the European Aviation Safety Agency (EASA), BUREAU VERITAS conducted a “Study on the need of a common worksheet/work card system” from January to November 2007. The present document presents the results of this study.)

The study aimed at providing further insights on the use of documentation, the common practices in place between operators and maintenance organisations and to assess whether current rules and practices may still contribute to incidents/accidents.

Among other results, the study produced a list of incidents/accidents related to the use of maintenance documentation.

Some outstanding events where detailed where it is proven that the documentation was directly or indirectly a contributing factor to the incident/accident.

To evaluate the lessons learned in relation with post event analysis to assess whether contributing factors of such events, in terms of impact of the maintenance documentation, are still at risk.

Factors which raise the exposure to Human Factor Incidents include:

a) Manpower issues
b) Guidance is essential regarding the minimum technical staff quality and qualification for both the operator (or a CAMO) and the MRO to appropriately manage maintenance documentation and contracts (writing, signature, follow up)
c) Contracts’ specifications. It is important to ensure that information is correctly understood by all parties – note that this applies for internal as well as external organisations – see information on Service Level Agreements
d) Amendment to the instructions about maintenance documentation. Required to be managed so that appropriate controls and distribution mechanisms are in place
e) An estimation of “how long in advance” documentation should be agreed, adding last minute tasks to a maintenance check can add uncertainty and potential issues leading to shortage of manpower and associated stress factors
f) All staff should receive necessary training on the documentation and the need to ensure a safe completion of the work card/sheet system
g) An understanding of the best process for managing the maintenance documentation and controlling the human factor elements when carrying out maintenance
h) Additional actions to be taken to enhance safety?

Sofema Aviation Services and our sister site offer classroom and online Human Factor Training. For information please email or

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