When Paperwork Misleads: Myths in Aircraft Maintenance

By Florin Necula, PhD | Maintenance Manager & Licensed Aircraft Engineer
Nov 16th, 2025

Abstract

Despite aviation’s good safety record, maintenance organisations still operate under intense production pressure and persistent misconceptions. This article examines seven recurring myths about human error, compliance, documentation, staffing and competence, the shortage of certifying staff, the misuse of accident reports and the supposed conflict between “safety first” and business goals, drawing on established research and current evidence.

Myth 1: “Human error is the root cause.”

Treating “human error” as the cause stops learning at the point where it should begin. Classic safety science positions error as a symptom of how systems are designed and controlled – procedures, tools, access, time pressure, handovers and organisational priorities (Reason, 1990; Rasmussen, 1997). A contemporary reminder came with the Alaska Airlines 737-9 door-plug event: the NTSB concluded that undocumented factory work and missing fasteners (systemic control failure) not an individual’s isolated lapse, precipitated the in-flight separation (NTSB, 2025).

Investigations in maintenance should search for error-enabling conditions and redesign the work environment (task access, documentation usability, tooling, oversight) rather than stopping at the last human who touched the job.

Myth 2: “Compliance equals safety (we’re covered in papers).”

Compliance is necessary, but it’s not the same thing as being safe. “Safety clutter” research shows that activities performed in the name of safety (extra forms, signatures, reviews) can accumulate without reducing operational risk and may even create cynicism and surface compliance (people comply with the ritual rather than with the risk) (Rae, Provan, Weber & Dekker, 2018). ICAO’s Safety Management Manual (Doc 9859) is explicit that organisations must manage safety performance with objectives, SPIs/targets and monitoring, not just the existence of processes (ICAO, 2018). EASA’s rules echo this, expecting operators and maintenance organisations to demonstrate performance, not paperwork alone. In other words: you can be fully compliant and still be drifting toward risk. The broader governance literature calls this “audit ritual” – verification activities that look rigorous but can crowd out attention to real work (Power, 1997).

Myth 3: “A documented task card means the job was done properly.”

A signed task card demonstrates that documentation occurred; it does not, by itself, validate that the work was performed correctly. Decades of human-factors research show that technical documentation can itself be a source of maintenance risk (through ambiguous steps, weak effectivity control and missing visuals) contributing to rework, delays, and latent errors (Avers, Johnson, Banks, & Wenzel, 2012; Drury, 2013). In other words, poor procedure design can coexist with immaculate signatures.

The Alaska Airlines Flight 1282 investigation made this painfully clear. The NTSB found that four bolts securing the 737-9 mid-exit door plug were missing and that key production work was undocumented, underscoring how documentation artefacts can fail to reflect the true state of the aircraft (NTSB, 2025). The airplane, not the paperwork, revealed the discrepancy.

In many audits, attention clusters around what is easiest to verify – forms, signatures and check boxes. That focus is understandable: documents are accessible; hardware and configuration evidence are harder to sample. But when assurance effort concentrates on artefacts rather than work as done, organisations risk protecting the binder instead of the aircraft.

Myth 4: “Enough staff on manpower plan means competent staff.”

Headcount is not competence. Regulations require maintenance organisations to establish and control personnel competence (defined across knowledge, skills and behaviours for the specific tasks performed) rather than merely filling rosters. Competence must be assessed, recorded and maintained through appropriate supervision, authorisations and corrective actions when gaps are found.  In short, an organisation may be fully staffed and still be under-competent for the work actually planned.

This distinction matters operationally. “Competence” in EASA’s framework is dynamic: it includes type-specific knowledge, task method proficiency (e.g., EWIS, FTS, composites), recency of experience and behaviours under real constraints (e.g., handovers, tool control, independent inspection culture).

Industry human-factors guidance (e.g. CAP 716) likewise warns about skill-fade and the limits of generic classroom training, emphasising observed performance in context and the role of supervision. Counting FTEs without ensuring the right mix of licences, type ratings, recent experience and supervision ratios yields the appearance of capacity while silently increasing rework and risk. A robust manpower plan is a competence plan. Staff numbers must be backed by evidence of assessed, current, task-relevant competence, clear authorisation scopes and supervision strong enough to catch competence drift. Anything less is staffing the schedule, not assuring the aircraft.

Myth 5: “The lack of certifying staff is a temporary blip.”

It isn’t. The shortage of certifying staff is structural, driven by demographics, constrained training capacity, long time-to-licence and type ratings and cross-sector wage competition. Independent outlooks since 2023 consistently project persistent gaps and skills mismatches through this decade, even as pipelines improve: Oliver Wyman’s 2025 ten-year forecast highlights labour constraints alongside rapid fleet growth, while an ARSA/Oliver Wyman executive summary puts a worker gap in the North American maintenance.

This risk is under-considered relative to its safety impact. EASA’s European Plan for Aviation Safety explicitly lists “shortage of operational and technical staff … including maintenance staff” as a systemic safety issue, yet most mitigations in the public domain still emphasize procedures over capacity. In short: we are trying to regulate our way through a people shortage and the math doesn’t close.

Regulators’ involvement should go beyond adding rules. They can materially shift the constraint by: expanding and modernising approved training capacity, streamlining, not lowering, the time-to-competence (e.g. modular/on-the-job pathways tied to privileges). Growing competence at scale, not the compliance stack, is the medium to long-term solution.

Myth 6: “Accident/occurrence reports are not for blaming professionals.”

The purpose of safety investigations is prevention, not fault-finding. ICAO Annex 13 states that the sole objective of an accident/incident investigation is to prevent future occurrences; it is not to apportion blame or liability (Annex 13, §3.1). EU frameworks reinforce this: Regulation (EU) 376/2014 embeds Just Culture protections for reporters and restricts the punitive use of occurrence information within the safety system, while Regulation (EU) 996/2010 (Article 14) protects sensitive safety information gathered during investigations. Misusing reports for discipline predictably suppress reporting and weakens the SMS learning loop.

Yet practice doesn’t always match principle. Courts and prosecutors have, at times, used investigation materials or pursued criminal cases after accidents, creating a chilling effect for open reporting. The English Court of Appeal has held that an AAIB accident report may be admissible as evidence in civil litigation (Rogers v. Hoyle), illustrating how investigative outputs can enter courtrooms despite policy aims to shield them. High-profile prosecutions following fatal accidents (e.g. the Helios 522 case) likewise show the tension between preventive investigations and post-event blame, including actions against maintenance personnel. The result is a perceived risk among professionals that candour may be used against them, exactly what Annex 13 and EU law seek to avoid.

Myth 7: “Safety first” is not what is sounds to be.

Aviation is a system where risk management is a control problem under constant goal conflicts (schedule, cost, workload, customer promise). Organisations are founded to create value and remain viable; none exist solely to “produce safety.” In that sense, “safety first” functions as a slogan. Safety is best understood as a means of doing work reliably, a property of how operations are designed and managed, rather than an end in itself.

Theory and evidence show that when safety is declared but not resourced, production pressures drive drift back toward the boundaries of acceptable performance (Rasmussen, 1997; Amalberti, 2001). Conversely, seeking to armour against all risk is economically untenable and can degrade performance elsewhere.

Conclusion

Maintenance safety depends less on perfect people and more on systems that make correct action easy under pressure. Moving beyond these myths – about error, compliance, documentation, staffing and competence, reporting, and the business–safety balance – enables organisations to reduce risk and cost simultaneously through competence, clarity and continuous learning.

References

Avers, K. B., Johnson, W., Banks, J., & Wenzel, B. (2012). Technical Documentation: Challenges in Aviation Maintenance (DOT/FAA/AM-12/16). FAA Office of Aerospace Medicine.

Drury, C. G. (2013). Writing aviation maintenance procedures that people can/will follow. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 57(1), 1227–1231.

European Union. (2014). Regulation (EU) No 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation (incl. Article 16—Protection of the information source).

ICAO. (2022). Annex 13 — Aircraft Accident and Incident Investigation (Ch. 3.1 Objective: prevention, not apportioning blame).

NTSB. (2025). AIR-25-04: In-Flight Separation of Left Mid-Exit Door Plug, Alaska Airlines Flight 1282, Boeing 737-9. National Transportation Safety Board (Final Report, adopted June 24, 2025).

Oliver Wyman. (2023). Not Enough Aviation Mechanics (Workforce analysis).

AAR/Oliver Wyman. (2025). MRO Demand Challenge 2025 (Survey report).

Aviation Week Network. (2025, Sept 18). Mechanic pipeline filling, but not fast enough, report says.

Rae, A. J., Provan, D. J., Weber, D. E., & Dekker, S. W. A. (2018). Safety clutter: The accumulation and persistence of “safety” work that does not contribute to operational safety. Policy and Practice in Health and Safety, 16(2), 194–211.

Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2–3), 183–213.

Reason, J. (1990). Human Error. Cambridge University Press.

EASA. (2024–2025). Easy Access Rules for Continuing Airworthiness — Part-145 (incl. AMC/GM to 145.A.30 on competence). European Union Aviation Safety Agency.

Amalberti, R. (2001). The paradoxes of almost totally safe transportation systems. Safety Science, 37(2–3), 109–126.