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Human error in maintenance: a review


B.S. Dhillon and Y. Liu
Department of Mechanical Engineering, University of Ottawa, Ottawa, Canada
Abstract
Purpose The aim of the paper is to present the impact of human errors in maintenance as found in the literature in order for practitioners to be aware of their impact and develop actions to mitigate their effect. Design/methodology/approach The paper systematically categorizes the published literature and then analyzes and reviews it methodically. Findings Human error in maintenance is a pressing problem. Practical implications A maintenance person plays an important role in the reliability of equipment. It is also a well-known fact that a signicantly large proportion of total human errors occur during the maintenance phase. Human error in maintenance is a subject which in the past has not been given the amount of attention that it deserves. This paper will be useful to people working in the area of maintenance engineering, as it presents a general review of literature published on maintenance errors in various sectors of industry. Originality/value The paper contains a comprehensive listing of publications on the eld in question and their classication according to industry. The paper will be useful to researchers, maintenance professionals and others concerned with maintenance to understand the importance of human error in maintenance. Keywords Error analysis, Human failure, Maintenance, Maintenance reliability, Inspection Paper type Literature review

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1. Introduction In the nature of things, nothing man-made is indestructible, but performing repairs at intervals by an activity known as maintenance can extend useful life. Maintenance can be dened as those activities required to keep a facility in as-built condition and therefore continuing to have its original productive capacity (Reason, 2000). Maintenance is usually categorized into the following three types (Dhillon, 2002): (1) preventive maintenance all actions carried out on a planned, periodic, and specic schedule to keep an item/equipment in stated working condition through the process of checking and reconditioning; (2) corrective maintenance unscheduled maintenance or repair to return items/equipment to a dened state, carried out because maintenance persons or users perceived deciencies or failures; and (3) predictive maintenance the use of modern measurement and signal-processing methods to accurately diagnose items/equipment condition during operation. It is only since Second World War that there have been profound advances in engineering and scientic technology that have highlighted the need for more attention

Journal of Quality in Maintenance Engineering Vol. 12 No. 1, 2006 pp. 21-36 q Emerald Group Publishing Limited 1355-2511 DOI 10.1108/13552510610654510

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to be paid to maintenance of engineering systems. Each year over $300 billion is spent on plant maintenance and operation by US industry, and about 80 percent of this is spent to correct the chronic failures of machines, systems, and people. Humans play an important role during the design, installation, production, and maintenance phases of a product. Human error may be dened as the failure to perform a specied task (or the performance of a forbidden action) that could lead to disruption of scheduled operations or result in damage to property and equipment. While human error has existed since the beginning of mankind, only in the last 50 years has it been the subject of scientic inquiry. There are various reasons for the occurrence of human errors, including inadequate lighting in the work area, inadequate training or skill of the manpower involved, poor equipment design, high noise levels, an inadequate work layout, improper tools, and poorly written equipment maintenance and operating procedures. Human error may be classied into six categories: (1) operating errors; (2) assembly errors; (3) design errors; (4) inspection errors; (5) installation errors; and (6) maintenance errors (Dhillon, 1986). Maintenance error occurs due to incorrect repair or preventive actions. Two typical examples are the incorrect calibration of equipment and application of the wrong grease at appropriate points of the equipment. The occurrence of maintenance errors increases due to the increase in maintenance frequency as the equipment becomes older (Dhillon, 2002). A comprehensive review of the published literature during the period 1981-2003 is presented below. Figure 1 presents a histogram of publications on human error in maintenance for the period 1981-2003. Sources of reviewed journals and conference papers are given in Tables I and II, respectively. Table III presents the classication of the reviewed publications according to industry. A pie chart depicting the corresponding publication percentages of Table III industry classications is shown in Figure 2. A detailed review of Table III publications is presented below.

Figure 1. A histogram of published literature on maintenance error

Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Source Acta Astronautica Aircraft Engineering and Aerospace Technology Aviation Week and Space Technology Chemical Processing Cognition, Technology & Work Cognitive Engineering in Aviation Domain Computers and Operations Research Dongli Gongcheng/Nuclear Power Engineering European Journal of Engineering Education Expert Systems with Applications Human Factors and Ergonomics in Manufacturing Information and Software Technology International Civil Aviation Organization Journal International Journal of Human-Computer Studies International Journal of Industrial Ergonomics International Journal of Pressure Vessels & Piping International Journal of Systems Science Journal of Quality in Maintenance Engineering Journal of the Operational Research Society Journal of Safety Research Kerntechnik Maintenance Management International Microelectronics and Reliability Mining Technology Naval Engineers Journal Reliability Engineering & System Safety Safety Engineering and Risk Analysis

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Table I. Sources of journal articles reviewed

2. Literature review 2.1 Aviation An aviation maintenance and inspection task is a complex undertaking in which individuals perform varied tasks in an environment with time pressures, minimal feedback, and sometimes-difcult ambient conditions. These situational characteristics, in combination with generic human erring tendencies, result in varied forms of errors. Latorell and Prabhu (2000) reviewed current approaches to identifying, reporting, and managing human error in aviation maintenance and inspection. They focused on both reactive and proactive methods of error detection and intervention strategies for controlling human error in aviation maintenance. Graeber and Marxs (1993) article was focused on aircraft safety, and showed that maintenance error has signicant economic implications. Maintenance resource management (MRM) was the theme of Taylors (2000a) article. In this article, he discussed systems thinking and culture change as current subjects in aviation human factors. In another paper, Taylor (2000b) described the test of the effectiveness of the MRM/TOQ (Maintenance Resource Management/Technical Operation Questionnaire) for its intended purpose as an evaluative measure. Allen and Rankin (1995) in their article discussed the Maintenance Error Decision Aid (MEDA) Tool and eld test evaluation. In another article, Hibit and Marx (1994) anticipated that, by improving the analysis of individual events through tools such as MEDA,

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Source Proceedings of the International Air Safety Seminar Proceedings of the IEEE Cement Industry Technical Conference Proceedings of the Australian Aviation Psychology Symposium Proceedings of the Flight Safety Foundation Conference Proceedings of the IEEE Conference on Human Factors and Power Plants Proceedings of the IEEE Annual Human Factors Meeting Proceedings of the International Mechanical Engineering Congress and Exhibition Proceedings of the SPIE The International Society for Optical Engineering Conference Proceedings of the FAA Meeting on Human Factors in Aircraft Proceedings of the 1991 International Conference on Aging Aircraft Proceedings of the Annual Reliability and Maintainability Symposium Proceedings of the Aviation Safety Conference and Exposition Proceedings of the International Conference on Health, Safety Environment in Oil and Gas Exploration and Production Proceedings of the Human Factors and Ergonomics Society Conference Proceedings of the International Aviation Safety Conference Proceedings of the International Ergonomics Association World Conference Proceedings of the International Symposium on Aviation Psychology Proceedings of the Symposium on Corporate Culture and Transportation Safety FAA/AAM Human Factors in Aviation Maintenance and Inspection Research Phase Reports Proceedings of the International Air Safety Seminar & International Federation of Airworthiness International Conference Proceedings of the International Aviation Safety Conference

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Table II. Sources of conference articles reviewed

20 21

people can begin to better understand those factors underlying human error in maintenance so that future system performance can be methodically improved in better safety, greater maintenance system reliability, and economic efciencies gained through error reduction. Nelson et al. (1998) presented structured methods of human error analysis developed and applied at Idhao National Engineering and Environmental Laboratory (INEEL) to identify potential human errors, assess their effect on system performance, and develop strategies to prevent the occurrences of errors or mitigate their consequences. Maintenance is considered an essential component of the air transportation system and an accident factor contributing to the loss of human lives. Masson and Koning (2001) in their publication tried to capture the philosophy and method behind JAR66 (Joint Aviation Requirements) and presented an overview of the error management concepts. Kania (1997) conducted research into the causal factors that result in human error and additional maintenance paperwork. Ford (1997) discussed three different aspects of aerospace safety accidents, regulation and human factors in airline maintenance, and what is required to lessen the safety inadequacies in each of these two aspects. Manwaring et al.s (1998) study showed that by adhering to existing regulations and manufacturer recommendations, and by implementing improved training and frequent maintenance, helicopter external load operations become safer. Shepherd (1997) presented a discussion of factors such as evaluation of simplied English, technician teaming and advanced technology, which inuence the

Number 1

Industry Aviation

References Allen and Marx (1999); Allen and Rankin (1995); Amalberti and Wioland (1997); Bacchi at al. (1997); Braithwaite (1997); Ciavarelli (1997); Drury (1991); Endsley and Robertson (2000); Ford (1997); Fotos (1991); Graeber and Marx (1993); Havard (1995); Hibit and Marx (1994); Hobbs and Robertson (1995); Hobbs and Williamson (1995); Ivaturi et al. (1995); Kania (1997); Koli et al. (1998); Latorell and Prabhu (2000); McGrath (1999); Manwaring et al. (1998); Marksteiner (1999); Masson and Koning (2001); Nelson et al. (1998); Nunn and Witts (1997); OConnor and Bacchi (1997); OLeary and Chappell (1996); Rankin et al. (2000); Reason (1997a, b, 2000); Shepherd (1991, 1997); Shepherd and Johnson (1995); Shepherd and Kraus (1997); Strauch and Sandler (1984); Taylor (2000a, b); Walter (2000); Wanders (1985); Wenner and Drury (2000) Gertman (1992); Huang and Zhang (1998); Jacobsson and Svensson (1991); Kim (1997); Lee et al. (1997); Nakatani et al. (1997); Pekka et al. (1997); Pyy et al. (1997); Rowekamp and Berg (2000); Seminara and Parson (1985); Sola et al. (1997); Toriizuka (2001) Balkey (1996); Eves (1985); Nelson (1996); Pekkarinen et al. (1993); Raman et al. (1991); Underwood (1991) Lee et al. (2001) Mason (1996); Morgan (1998) Agnihotri et al. (1992); Anderson et al. (1998); Bradley (1995); Carr and Christer (2003); Chung (1987); Dhillon (1986, 2002); Dhillon and Rayapati (1988a, b); Dhillon and Yang (1993, 1995); Dodson and Nolan (1999); Gramopadhye and Drury (2000); Gupta et al. (1991)); Jacob et al. (1997); Maillart and Pollock (1999); McRoy (1998); Nakashima et al. (1999); Narmada and Jacob (1996); Park and Jung (1996); Ramalhoto (1999); Reason (1990); Salvendy (1986); Sanders and McCormick (1993); Sridharan and Mohanavadivu (1997); Su et al. (2000); Sur and Sarkar (1996); Vaurio (1995, 2001); Wang and Sheu (2003); Yang and Dhillon (1995)

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Nuclear power

3 4 5 6

Chemical processing Medical devices Mining Miscellaneous

Table III. Classications of reviewed publications according to industry

Figure 2. A pie chart of publication percentages of Table III corresponding to industry classications

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performance of inspectors and maintainers. Rankin et al. (2000) evaluated the development and implementation of an airline industry process (MEDA) for determining the factors that contribute to maintenance errors and making corrective actions to eliminate the occurrence of similar errors in future. Fotos (1991) in his paper presented a cockpit resource management (CRM) technique that is widely used by major US airlines to encourage teamwork and effective problem solving by maintenance personnel or pilots. Manwaring et al. (1998) presented a descriptive analysis of National Transportation Safety Board (NTSB) accident briefs indicating that mechanical failure, pilot error, and maintenance errors are the most common probable causes of accidents. Koli et al. (1998) discussed two human factor audits inspection audit and maintenance audit which can provide aircraft maintenance and inspection personnel with rapid means of locating the human-system mismatches that can lead to errors. McGrath (1999) discussed aviation maintenance management imperatives in the hope of enhancing the professionalism of the eld personnels culture with regard to airworthiness and safety. Ivaturi et al. (1995) reviewed task analysis of aircraft inspection/maintenance operations, which is the rst effort to examine team training and effort within the aircraft inspection/maintenance environment. In Ciavarellis (1997) article, the purpose of his study was to develop, validate, and apply a questionnaire survey methodology for assessing the effectiveness of naval units in managing risks associated with ight operations. Allen and Marx (1999) discussed the leading causes of major aircraft accidents and maintenance error analysis with the MEDA tool. Bacchi et al. (1997) reviewed major systems used in the aviation maintenance eld for accident analysis and safety assessment. Walter (2000) discussed major elements of a model that includes needs identication, outlining targeted jobs, writing and verifying training procedures, and evaluating and establishing a maintenance/audit plan. Hobbs and Williamson (1995) conducted research in cooperation with an air carrier in the Asia-Pacic region with the aim of identifying the types of errors made by aircraft maintenance technicians. Endsley and Robertson (2000) presented recommendations for developing a training program to improve situation awareness in aircraft maintenance at the individual and team levels. Wenner and Drury (2000) developed a methodology that allows analysis of reports of human error. Reason (1997a) argued that maintenance-related errors rather than fallibility on the ight deck constitute the largest single human factors problem facing modern aircraft systems. In another paper (Reason, 1997b), he discussed safety culture and its important four elements: (1) reporting culture; (2) just culture; (3) exible culture; and (4) learning culture. OConnor and Bacchi (1997) described an error taxonomy with respect to providing a structured framework for identifying and classifying human error in maintenance and dispatch operations. Reason (2000) discussed a cognitive engineering perspective on maintenance errors and an activity-oriented approach to identify the human performance problem in aviation. Wanders (1985), in his case study, described the

difculties experienced in connection with the production control system, its adaptation, and the related organizational changes at a major overhaul facility. Hobbs and Williamson (1995) identied the types of errors made by aircraft maintenance technicians and the systemic or organisational failures that set the conditions for such errors. Shepherd and Johnsons (1995) paper discussed some examples of research efforts that are currently promoting safety and efciency in maintenance worldwide. Shepherd and Kraus (1997) presented recent efforts that have been made to develop pre-training job aids and training programs that address human factors issues. Shepherd (1991) described activities concerning aircraft maintenance and inspection human factors. Amalberti and Wioland (1997) discussed the complex relationship between errors and accidents and the systemic and organisational safety approach followed for large socio-technical systems. Havard (1995) presented British Airways current initiatives with respect to human factors. Nunn and Witts (1997) discussed how human factors impact aircraft maintenance in Air UK Engineering. Hobbs and Robertson (1995) discussed an aircraft maintenance workshop report and its objectives. OLeary and Chappell (1996) discussed the aviation safety reporting system (ASRS) and its role in incident reporting. Marksteiner (1999) concluded that some current maintenance practices and philosophies might be causing more problems than they are preventing. Braithwaite (1997) examined cultural issues and the reasons behind Australias apparently good record for airline safety. Strauch and Sandlers (1984) article discussed the role of the aviation maintenance technician (AMT) in the safe operation of an aviation system. Drury (1991) presented a taxonomy and ways and means of controlling maintenance errors. 2.2 Nuclear power Pyy et al. (1997) discussed various aspects of common cause failure mechanisms and safety indicators describing and forecasting the effectiveness of maintenance performance. Jacobsson and Svensson (1991) evaluated psychosocial work demands of a maintenance group during the annual outage for maintenance work in a nuclear plant. Their study was based on a stress paradigm, and it concluded that increased work strain would have a negative effect on performance. Toriizuka (2001) examined industrial plant maintenance tasks and considered the countermeasure for work improvement through PSFs (performance shaping factors) in his study. Kim (1997) described the K-HPES program and the current status of CASHPES (Computer Aiding System for HPES) development. K-HPES is a Korean version of the Human Performance Enhancement System (HPES), which can reduce human errors and enhance human performance in nuclear power plants. Nakatani et al. (1997) presented a new method to evaluate the human interface design of plant equipment from the viewpoint of human error by maintenance personnel. In another paper, Lee et al. (1997) discussed human factors research being performed in the Korea Atomic Energy Research Institute, including the development of a human factors experimental facility and the analysis of human error data. Gertman (1992) presented a mainframe version of a computer code for simulating maintenance crew performance. Sola et al. (1997) provided a summary description of the main activities that have been carried out by CIEMAT (Research Centre for Energy, Environment and Technology) in the human factors arena. The aim of

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Pyy et al.s (1997) study was to identify common cause failure mechanisms and generate numerical safety indicators with respect to human error in nuclear power plant (NPP) maintenance. Seminara and Parsons (1985) paper provided an overview of human factors research conducted by the Lockheed Corporation under the sponsorship of the Electric Power Research Institute (EPRI). The general objective of this study was to identify human factors problem areas and future research needs rather than to attempt to present immediate solutions for deciencies. Rowekamp and Berg (2000) performed probabilistic re safety analysis for nuclear power plants, including the presentation of a set of data for re-related equipment, human actions and human errors. Their analyses were based on the examination of reported results of the regular inspection and maintenance programs. Huang and Zhang (1998) analysed root causes for human error events and discussed protective measures with respect to safety. 2.3 Chemical processing Pekkarinen et al. (1993) surveyed maintenance work during shutdown in a chemical plant to assess risk and collect ergonomic data for developing maintenance policies. Balkey (1996) showed that the risk-based inspection procedure in fossil fuel plants requires a human error procedure, and that the results from the human error procedure must be fed back into the risk-based inspection procedure. Nelson (1996) discussed various devices used for over-speed protection, and pointed out that the number of accidents caused by maintenance activities in industry is a source of concern. Evess (1985) report focused on the chemical manufacturing industry and examined a wide range of incidents that occurred during maintenance in a chemical processing plant. Underwood (1991) examined several case studies to highlight the signicance of safe systems for maintenance in the chemical industry. Raman et al. (1991) provided a framework for applying Hazop techniques to maintenance procedures in offshore oil and gas platforms. 2.4 Medical devices Lee et al. (2001) presented a new scientic accuracy measure for assessing/evaluating the performance of computer medical diagnostic (CMD) systems. This measure can be used for assessing the performance (reliability) level of competency of a CMD system in assisting a physician in his/her diagnosis. Formulae were also given for estimating the uncertainty of the overall human-computer system. They also presented formulas for calculating the CMD system sensitivity and error caused by humans and computer diagnoses. 2.5 Mining For measuring attitudes to improve electricians safety, Mason (1996) described an attitude survey of electricians in a coaleld. Morgan (1988) described a custom-made in-house program devoted to the safety and technical training of mining plant workers. This program was designed to utilize existing plant equipment, supplies, materials and facilities as well as plant talents and expertise.

2.6 Miscellaneous Dhillon and Yang (1995) presented a newly developed stochastic model for performing reliability and availability analysis of a repairable standby human-machine system with increasing human error rates and arbitrary failed system repair rates. In another paper (Yang and Dhillon, 1995), they developed a mathematical model for performing reliability and availability analyses of a general standby system with constant human error and common-cause failure rates, and arbitrarily distributed system repair times. Agnihotri et al. (1992) developed a stochastic model representing a two-unit warm standby system with human error and a single repair facility. Park and Jung (1996) examined a simple technique of converting the ratio estimates of subjective human error probability (HEP) and proposed an approach to estimate objective HEP from quotients with a linear transformation. Anderson et al. (1998) analysed the impact of reduced manning on system reliability and maintainability, including changing the characteristics of human error associated with system operation and maintenance in a reduced manning environment. McRoy (1998) concluded that it is important to collect samples of the kind of interactions one expects and the kinds of errors one may encounter. Jacob et al. (1997) presented a reliability analysis of a two-unit standby system with repairs common cause failure, and critical human error. The deteriorating effect of the standby unit on the system was also studied. Sur and Sarkar (1996) presented a probabilistic model of a redundant system with common cause failure, logic failure, and human error. Dhillon and Rayapati (1988b) developed four probabilistic models representing two unit parallel and standby redundant systems with human errors. The supplementary variables method was used to develop system availability expressions for all the four models. In another paper (Dhillon and Rayapati, 1988a), they developed three stochastic models representing standby redundant systems with human error. Sridharan and Mohanavadivu (1997) studied three Markov models with common failures and human error of a two non-identical unit parallel system. Dhillon (1989) presented reliability analysis of repairable and non-repairable redundant systems with human errors and common-cause failures. Narmada and Jacob (1996) studied a stochastic model representing a three-unit system with critical human error and common cause failure. The deteriorating effect of the standby unit on the system was also studied. In order to prevent human error in maintenance tasks, Su et al. (2000) proposed a practical framework for analyzing cognitive types and enhancing fault recovery ability through a knowledge-based system. Nakashima et al. (1999) developed software bug analysis and measures to prevent software bugs. Wang and Sheu (2003) presented a mathematical model to determine the production cycle, process inspection intervals, and the level of maintenance to be performed. Maillart and Pollock (1999) examined the problem of determining and evaluating optimal xed-length inspection intervals for a single machine that operates continuously subject to non-obvious random failures. Gupta et al. (1991) studied a multi-component parallel system with the overloading effects and waiting time for repair under critical human error. Chung (1987) presented a mathematical model of a repairable parallel system with standby units involving human error and common-cause failure. Carr and Christer (2003) extended the mathematics of delay-time modelling of inspection maintenance to

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incorporate the existence of human error in the form of fault injection during the inspection process. Reason (1990) presented a view of the basic error mechanisms and especially those processes that gave recurrent forms to a wide variety of error types. Ramalhoto (1999) studied the training of maintenance personnel and suggested some actions important to safety. Vaurio (1995) presented a general procedure for optimizing the test and maintenance intervals of safety related systems. Human errors and common cause failures were included in his study. In another paper (Vaurio, 2001), he reviewed and generalized some earlier models developed for quantication of human error dependent probabilities. Dhillon and Yang (1993) presented human error analysis of a system with arbitrarily distributed repair times. The supplementary variables method was used to develop the system availability expressions. Sanders and McCormick (1993) presented various areas of human factors directly or indirectly relating to maintenance. Bradley (1995) presented a methodology that can link all failures including human error such as design error or maintenance error. Miller and Swain (1986) discussed how human error can degrade system performance, how the work situation and tasks can be analysed for human error potential, and how the equipment or task characteristics might be modied to reduce the likelihood of human error. Dhillon (1986) presented various aspects of human reliability, human errors, and human factors including human factors in maintenance and maintainability. Also, in another book (Dhillon, 2002), he discussed various aspects of human error in maintenance. Gramopadhye and Drury (2000) provided the rationale for the increasing number of maintenance and inspection errors. Dodson and Nolan (1999) discussed man-machine function allocation, human factors in production, and human factors in eld test.
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Balkey, J.P. (1996), Human factors engineering in risk-based inspections, Safety Engineering and Risk Analysis, Vol. 6, pp. 97-106. Bradley, E.A. (1995), Case studies in disaster a coded approach, International Journal of Pressure Vessels & Piping, Vol. 61 Nos 2/3, pp. 177-97. Braithwaite, G.R. (1997), A safe culture or safety culture?, Proceedings of the Ninth International Symposium on Aviation Psychology, Columbus, OH, April 27-May 1, pp. 1029-31. Carr, M.J. and Christer, A.H. (2003), Incorporating the potential for human error in maintenance models, Journal of the Operational Research Society, Vol. 53, pp. 1249-53. Chung, W.K. (1987), Reliability analysis of a repairable parallel system with standby involving human error and common-cause failure, Microelectronics and Reliability, Vol. 27 No. 2, pp. 269-71. Ciavarelli, A.J. (1997), Organizational factors in aviation accidents, Proceedings of the Ninth International Symposium on Aviation Psychology, Columbus, OH, April 27-May 1, pp. 310-6. Dhillon, B.S. (1986), Human Reliability with Human Factors, Pergamon, New York, NY. Dhillon, B.S. (1989), Modeling human errors in repairable systems, Proceedings of the Annual Reliability and Maintainability Symposium, Atlanta, GA, 24-26 January, pp. 418-24. Dhillon, B.S. (2002), Engineering Maintenance: A Modern Approach, CRC Press, Boca Raton, FL. Dhillon, B.S. and Rayapati, S.N. (1988a), Human error and common-cause failure modelling of standby systems, Maintenance Management International, Vol. 7 No. 2, pp. 93-110. Dhillon, B.S. and Rayapati, S.N. (1988b), Human error modelling of parallel and standby redundant systems, International Journal of Systems Science, Vol. 19 No. 4, pp. 589-611. Dhillon, B.S. and Yang, N.F. (1993), Human error analysis of a standby redundant system with arbitrarily distributed repair times, Microelectronics and Reliability, Vol. 33 No. 3, pp. 431-44. Dhillon, B.S. and Yang, N.F. (1995), Probabilistic analysis of a maintainable system with human error, Journal of Quality in Maintenance Engineering, Vol. 1 No. 2, pp. 50-9. Dodson, B. and Nolan, D. (1999), Reliability Engineering Handbook, Marcel Dekker, New York, NY. Drury, C.G. (1991), Errors in aviation maintenance: taxonomy and control, Proceedings of the Human Factors Society 35th Annual Meeting, San Francisco, CA, September 2-6, Vol. 1, pp. 42-46. Endsley, M.R. and Robertson, M.M. (2000), Situation awareness in aircraft maintenance teams, International Journal of Industrial Ergonomics, Vol. 26, pp. 301-25. Eves, D.C.T. (1985), Deadly Maintenance: A Study of Fatal Accidents at Work, HMSO, London. Ford, T. (1997), Three aspects of aerospace safety human factors in airline maintenance, Aircraft Engineering and Aerospace Technology, Vol. 69 No. 3, pp. 262-4. Fotos, C.P. (1991), Continental applies CRM concepts to technical, maintenance corps, Aviation Week and Space Technology, August 26, pp. 32-5. Gertman, D.I. (1992), Conversion of a mainframe simulation for maintenance performance to a PC environment, Reliability Engineering & System Safety, Vol. 38 No. 3, pp. 211-7. Graeber, R.C. and Marx, D.A. (1993), Reducing human error in aircraft maintenance operations, Proceedings of the 46th Annual International Air Safety Seminar & International

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