Auremar stock photo Auremar

Human Factors Training For MRO Personnel Makes NTSB Hit List

NTSB advocates greater attention to addressing human factors issues, such as fatigue, for MRO workers.

Printed headline: Most Wanted 


Fatigue-related issues in aviation maintenance once again are highlighted in the National Transportation Safety Board’s (NTSB) “Most Wanted” list. The biennial publication serves as an advocacy tool for the board to spur action on recommendations.

This year’s list of top priorities was released in February after a month-long delay due to the U.S. government shutdown. There are 1,200 outstanding NTSB safety recommendations; 267 of those fall into a “most-wanted” category. In its 2019-20 publication, the board focuses on 46 recommendations, with a goal of implementing all of them by 2021.

“We at the NTSB can speak on these issues. We board members can testify by invitation to legislatures and to Congress, but we have no power of our own to act,” says NTSB Chairman Robert Sumwalt. “We are counting on industry, advocates and government to act on our recommendations. We are counting on the help of the broader safety community to implement these recommendations.”


The publication notes several overarching safety issues and cites specific proposed actions for each, to include eliminating distractions, ending drug and alcohol impairment, improving the safety of Part 135 operations, reducing fatigue-related accidents and strengthening occupant protection.

Among the aviation-specific prioritized recommendations is A-07-018, directing the FAA to require initial and recurrent human-factors training for personnel performing maintenance under Parts 121, 135, 145 and 91 Subpart K.

The recommendation was issued in 2013 in response to a Sundance Helicopter tour crash that killed a pilot and four passengers. Probable cause was determined to be inadequate maintenance, stemming in part from maintenance personnel fatigue.

The FAA’s most recent response to the human-factors training recommendation pointed to the Safety Assurance System, which encourages repair stations and Part 121 operators to implement comprehensive human-factors training and fatigue-management programs. The NTSB acknowledged the evaluation process as an acceptable alternative to formal rulemaking, but declined to close the recommendation without more detail on human-factors training components in Part 135 and 91 training programs.

The Sundance accident spurred an NTSB recommendation for maintenance personnel duty-time limitations, which was included in previous NTSB most-wanted lists. The recommendation was closed after the NTSB received what it deemed an “unacceptable response” from the FAA administrator last April. The agency maintained there was not enough justification to proceed with formal rulemaking and that no further action was planned to implement the maintenance duty-time recommendation. 

Hide comments


  • Allowed HTML tags: <em> <strong> <blockquote> <br> <p>

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.