航空維修錯誤的代價昂貴，這些疏失不一定由維修作業人員所引發。如果採用過去飛航意外事故的致災因素為分析架構，可以找出航空維修作業中具有共通性的錯誤型態，並加以改善預防。因此本研究應用MEDA檢核表分析61件發生於1993至2004年間的航空維修事件報告，蒐集案例資料有維修錯誤、事件簡述、歸因，經過案例編碼後進行分析。分析結果顯示飛機結構有13件，包含機身結構定檢與控管缺失7件，這樣的疏漏可能喪失早期偵測結構損傷的機會，加油面板未蓋妥與空調艙蓋板脫落及損壞共計3件，1件未進行起落架輪艙門調校程序，1件誤用發動機支撐架自鎖墊片，及錯誤客艙玻璃窗安裝導致玻璃裂開與飛機回航等。另外起落架系統有11件，其中5件起飛前起落架安全插銷未移除，1件測試前起落架安全插銷未安裝，2件起落架感測系統安裝錯，1件起落架組合件安裝錯誤等事件造成飛機空中回航或結構受損，1件起落架組合件損壞導致液壓系統失效，1件起落架減震支柱違規維修等。發動機系統有9件，包含1件因維修程序不完整導致發動機馬力不平衡，最後飛機放棄起飛，1件試車衝出意外使飛機受損，2件整流罩扣環未鎖與檢查疏漏，1件燃油噴嘴安裝錯誤使發動機發生火警與警急降落，1件使用不合格之點火電嘴，有潛藏性空中熄火事件，1件維修程序完成後未連接高壓轉子(N2)測速器電器接頭導致參數異常滑回，1件錯誤解除程序導致反推力器失效，1件滑油油箱蓋未安裝與飛行操作誤判使發動機失去潤滑功能導致報廢等。其他所有系統共有16件錯誤或違規事件，廣泛分布於飛機拖動與滑行、保養維修、空調、內艙裝備、飛機操縱面、燃油、液壓、照明與燈光、隨機輔助氣電源與螺旋槳等飛機系統章節。其餘12件無法鑑定飛機之系統或屬於航空法規違規事件，無法加以編碼。另有21的報告事件為為意圖越軌的行為，這些事件沒有造成飛機的問題、裝備受損、人員受傷或重新修理等MEDA研究範疇，也排除進一步之歸因分析。個案中沒有發現保養錯誤、結構與組合件之修理錯誤、異物損傷與人員受傷事件有可能因為多數報告沒有詳細陳述事件發生經過，或適當蒐集與紀錄相關資訊，影響了歸因的準確性與完整性。從40件事件歸因分析，鑑定出23項歸因，每一件案例由一個以上歸因所肇成，因此；累積次數共計136次，分別為19次時間限制、18次沒有使用資訊、15次作業知識、12次工作干擾、10次航空公司作業程序、10次遺忘、8次飛機系統知識、8次語言障礙、6次容易錯誤安裝、5次停機或試車場所、4次沒有使用安全裝備、4次部門之間溝通、3次工作卡不容易了解、3次沒有遵守工作程序，其餘11次廣泛分布於沒有適當裝備、飛機配備多變性、無法獲取器材、管路標示退色、疲勞、缺少人力、工作群體常規、維修人員之間溝通以及飛行與維修人員之溝通等。從上述致災因素的分佈情形以及維修人為因素個案的情境分析可以得出幾個可行的事故改善與預防對策。

Maintenance errors of aircraft have been costly, but they are not inherent in the mechanics or human operators. Maintenance errors primarily reside in latency within task and/or situational factors in a specific context and emerge as consequences of mismanaging compromises between production and safety goals. By analyzing accident/incident reports in terms of those reported causal factors in the past provided a valuable insight into some of the common types of maintenance error. The current study applied MEDA (Maintenance Error Decision Aid) results form to the analysis of 61 incident reports concerning aircraft maintenance disclosed by the CCAA and undisclosed by others between 1993 and 2004. For each incident report, event, maintenance error, contribution factors, were collected and coded for further analysis. The analysis indicated that there are 13 reports related to aircraft structure, including 7 nonconforming scheduled inspection of fuselage structure, 3 unsecured and detached access panels, 1 door rigging and not following standard procedure testing, 1 incorrect part used on pylon self-lock washer, 1 incorrect part installed on cabin window that had led to window cracked and in flight turn back. Another 11 incidents on landing gear incidents out of which 5 safety pins had not being removed before flight, 1 had not being installed before testing, 2 incorrect installations of landing gear sensing components and 1 down lock actuator. Eight out of these 11 incidents had caused aircraft in flight turn back and one caused aircraft damage. One landing gear actuator failure led to a defective hydraulic system and another landing gear shock absorber repair violated the approval maintenance capacity list. There were nine incidents related to aircraft power plan system including one aborted take off due to an unbalance engine thrust by an incomplete maintenance procedure, 1 ground damaged during engine running up, 2 lost engine cowls during flight due to incomplete locking procedure and remained undetected after inspection, 1 engine fire and emergency air turn back by incorrect installation of fuel nozzle, 1 potential flame out caused by using nonconforming ignition plug, 1 aircraft return to gate caused by unconnected engine N2 sensor plug after maintenance, 1 engines thrust reverser failure caused by an incorrect deactivation procedure, 1 seriously damaged engine and scrap caused by an uncovered oil tank after servicing and incorrect decision of the pilot. There were 16 other incident reports widespread in aircraft systems related to towing and taxiing, servicing, air condition, furnish /equipment, flight control, fuel, hydraulic, lights, auxiliary power and propeller. Twelve incident reports cannot be coded since no specific system component can be identified or they were simply violations from regulations.
Twenty-one incident reports were excluded form further MEDA analysis because they were intentionally deviates from the expected action and they had not caused any equipment damage, personal injury, or rework. It is suspected that incidents related to servicing error, repair error, foreign object damage (FOD) and personal injury had not been reported appropriately since no such cases had been found in our analysis. Very few incident reports provided detail description of the incident event. Thus, contributing factors derived from these incident reports cannot be as accurate and complete as expected.
In depth analysis of 40 incident reports identified 23 common contributing factors. Overall 136 causal factors had been attributed for these 40 incidents reports since most incidents had been caused by more than one factor. Frequency distribution of these causal factors indicated that time constraints (19 cases), information not used (18 cases), task knowledge (15 cases), workplace distractions/interruptions during task performance (12 cases), airline process knowledge (10 cases), memory lapse (10 cases), aircraft system knowledge (8 cases), language barrier (8 cases), easy to install incorrectly (6 cases), inadequate apron or specific engine run up place (5 cases), 4 safety equipment not used, (4 cases), communication between departments (4 cases), work cards not understandable (3 cases), work process not followed (3 cases) were the primary contributing factors. Other contributing factors included equipment unavailable, aircraft configuration variability, parts unavailable, part label faded, fatigue, not enough staff, work group normal practice, communication between mechanics or between flight crew and maintenance. Intervene preventive strategies is developed based on the distribution of causal factors and in-depth analysis of incident scenarios.

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