inlet guide ring. In fact, he had only attached the ring loosely with a few bolts. The second team didn’t check it, and the engine was sent to test with bolts missing. The latest issue of Human Factors Industry News reported another incident where AMTs had changed the wrong top-deck relay box because of a misunderstanding between the day shift and the night shift that caused a half-day of missed flights. Flight Safety Australia provides another chilling example of what happens when clear communication does not occur in the maintenance environment when it noted that vague words in a maintenance instruction was one of the things that blew the top of the fuselage off an Aloha Airlines Flight 243 Boeing 737 near Maui in 1988. Ineffective communication, especially with regard to inadequate end- of-shift communication, has also been attributed to accidents due to maintenance errors, including the crash of an Embraer 120 and a Jazz Air crash where over a dozen screws that secure the leading-edge section to the bottom of the wing were missing. The ValueJet crash into the Everglades, the Alaska Airlines 261 crash off the coast of California, and the crash of JAL 123 — the worst single aircraft accident in aviation history — have also been attributed to misunderstandings about maintenance repairs.
PILOT-AVIATION MAINTENANCE
TECHNITIAN COMMUNICATION Poor communication between pilots and AMTs also negatively affects airworthiness and aircraft safety. Mattson and her colleagues, communication researchers at Purdue University, found that safety errors might occur during the maintenance discrepancy reporting process because pilots and maintenance technicians
do not effectively interact with or understand one another. Mattson’s research further revealed that a common complaint from AMTs was the lack of detail provided by pilots while describing any defects they encountered, while flight crew often
complained about lack of detail about rectification of problems by AMTs. Mattson’s findings were reinforced
by the recent work of Tahlia Fisher, a Senior Safety Specialist at Air New Zealand, who also found that pilots and AMTs do not always
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