SAT-099Ground operations & maintenance

Maintenance error

Unintended maintenance action or omission shaped by task design, data, tools, access, handover, pressure, supervision, and verification.

4Focus areas
4FDM connections
3Deep briefs
12Reading links

What this profile covers

Unintended maintenance action or omission shaped by task design, data, tools, access, handover, pressure, supervision, and verification.

Why it matters

Ground and maintenance activities involve many organizations, handovers, vehicles, tools, procedures, and latent conditions before flight begins. For maintenance error, useful analysis connects the immediate event with exposure, defenses, recurrence, and the wider operating system rather than treating one observation as a final conclusion.

Topic familyGround operations & maintenanceSafety Management
Family lens

Ramp movement, servicing, loading, de-icing, maintenance execution, and technical-error control.

Understand the subject before interpreting a signal.

In plain language, this profile examines unintended maintenance action or omission shaped by task design, data, tools, access, handover, pressure, supervision, and verification.

maintenance errorhuman factorshandoverindependent inspection
Evidence to combine

Build a multi-source picture

  • Technical logs, work cards, and handover records
  • Ramp, vehicle, servicing, and loading records
  • CCTV or ground-surveillance evidence where lawful
  • Aircraft data, reports, and physical inspection
What flight data contributes

Timing, relationships, and recurrence

Relevant recorded context may include engine thrust, brake pressure, autopilot status. Use validated mappings and examine signal relationships over the applicable flight phase.

Interpretation boundary

Do not turn an observation into a conclusion

Aircraft-recorded data usually captures only part of a ground or maintenance sequence; organizational interfaces and physical evidence may be more informative.

Decision standard

Keep controlling material visible

Apply the current approved manuals, procedures, authority requirements, investigation evidence, and validated organizational definitions for any operational decision.

From a broad topic to a defensible safety review.

01

Define

State what maintenance error means for the aircraft, operation, authority, and organization in scope.

02

Verify

Confirm the provenance, quality, timing, units, completeness, and limitations of every data source used.

03

Describe

Reconstruct what happened and quantify relevant exposure before discussing causes or corrective action.

04

Corroborate

Compare flight data with reports, operational context, technical evidence, and authoritative source material.

05

Test barriers

Identify which preventive, recovery, and consequence-mitigation controls should have worked and how their performance can be measured.

06

Assure

Assign proportionate action and verify whether the control and safety performance improve without harmful unintended effects.

Questions before conclusions

  1. Q1

    How is maintenance error defined for the aircraft, operation, authority, and organization being reviewed?

  2. Q2

    Which precursors, recorded signals, reports, and external data would confirm the event and describe its context?

  3. Q3

    Which preventive, recovery, and consequence-reduction barriers should work, and where could they weaken?

  4. Q4

    What does recurrence, exposure, severity potential, or change over time show before choosing a safety action?

4 connected event profiles

These are terminology and family connections for exploration—not claims that FDM alone can determine the topic.

Go deeper into the closest ASIP research guides.

12 useful starting points

Original ASIP summaries lead to publisher pages. ASIP does not copy or host the reports.

No copied report filesSearch all related records →
U.S. Federal Aviation AdministrationTerminology match

SAFO 21004 — SAFO 21004, Air Traffic Control (ATC) Notification and Pilot Awareness When Conducting an Instrument Landing System (ILS) Autoland Procedure

Official U.S. Federal Aviation Administration material indexed for approach and landing and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 20014 — SAFO 20014, Boeing 737-8 and 737-9 Airplanes: Pilot Training and Flight Simulation Training Devices ( FSTD ) Updates

Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 18004 — SAFO 18004, Rotorcraft External Load Attaching Means and Quick Release Devices for Human External Cargo ( HEC )

Official U.S. Federal Aviation Administration material indexed for cabin and cargo and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 18013 — SAFO 18013, Updated Rotorcraft External Load Attaching Means and Quick Release Devices for Human External Cargo ( HEC )

Official U.S. Federal Aviation Administration material indexed for cabin and cargo and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 17001 — SAFO 17001, Pilot and Flightcrew Awareness of Class B Airspace Boundaries

Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 15004 — SAFO 15004, Scenario-Based Go-Around Training

Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 11010 — TCAS II Guidance and Training for Title 14 of the Code of Federal Regulations (14 CFR ) Part 135 and Part 125 Certificate Holders, Part 125 Letter of Deviation Authority ( LODA ) holders (125M), Part 91 Subpart K, (91K) Program Managers, Part 91 Operators and Part 142 Training Centers

Official U.S. Federal Aviation Administration material indexed for navigation and surveillance and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 10006 — In-Flight Icing Operations and Training Recommendations

Official U.S. Federal Aviation Administration material indexed for weather and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 09014 — Concepts for Fatigue Countermeasures in Part 121 and 135 Short-Haul Operations

Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 09015 — Training For Maximum Performance Landings on Contaminated Runways

Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 09017 — Training for Bombardier Learjet 60 (Learjet 60) Pilots on Inadvertent Thrust Reverser Stowageon Takeoff and Landing

Official U.S. Federal Aviation Administration material indexed for approach and landing and takeoff. Open the publisher source for the complete document, scope, and current status.

Open official source
U.S. Federal Aviation AdministrationTerminology match

SAFO 09018 — Passenger/Crew DC Power Outlet installations

Official U.S. Federal Aviation Administration material indexed for cabin and cargo and human factors. Open the publisher source for the complete document, scope, and current status.

Open official source
ICAO / CICTT

Common Taxonomy Team

International work on common aviation occurrence categories and definitions for consistent reporting and analysis.

Open reference
EASA

Safety Risk Management

European safety-risk process connecting data, safety issues, risk portfolios, priorities, and safety action.

Open reference
EASA

Annual programmes and reports

Annual safety reviews and risk portfolios used to identify key risk areas, safety issues, and emerging issues.

Open reference
EASA

European Plan for Aviation Safety 2025

A broad evidence-based portfolio showing the scale and connected nature of current aviation safety issues.

Open reference
SKYbrary

Operational issues index

A practical discovery index for operational safety subjects; official authority and manufacturer sources remain controlling where applicable.

Open reference