Individual Latent Error Detection (I-LED) in UK naval aircraft maintenance

Abstract

System-induced human error is the most significant factor in aircraft accidents; for which errors are both inevitable and a frequent occurrence. Human error is a by-product of performance variability caused by system failures, for which undetected error becomes a latent error that can impact system safety and therefore contribute to a future undesired outcome. The phenomenon of Individual Latent Error Detection (I-LED) is proposed. ILED refers to the detection of workplace latent errors at some point post-task completion through the recollection of past activity by the individual who suffered the error. An extensive literature review shows the phenomenon to be a novel concept, indicating a clear gap in knowledge requiring research to explore the nature and extent of I-LED events. A multi-process theory is developed and combined with the systems perspective to provide a theoretical framework upon which to conduct real-world observations of ILED events in cohorts of naval air engineers. Collected data indicate time, location and other system cues trigger I-LED events, for which the deliberate review of past activity within a time window of two hours of the error occurring and whilst remaining in the same sociotechnical environment to that which the error occurred appears most effective. Several practicable interventions are designed and tested, from which the overall benefit of integrating the I-LED phenomenon as an additional safety control within an organisation’s safety system is assessed.

This thesis contributes to knowledge on workplace safety by applying systems thinking to understand the nature and extent of I-LED and its benefit to safety resilience in naval aircraft maintenance through enhanced operator competence to detect latent errors. I-LED research arguably offers a step-change in safety thinking by offering a level of resilience within the workplace that has not previously been accounted for in organisational safety strategies.

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ORCID for Neville Stanton: orcid.org/0000-0002-8562-3279

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