People error!

“If some evil genius were given the job of creating an activity guaranteed to produce an abundance of errors, he or she would probably come up with something that involved the frequent removal and replacement of large numbers of varied components, often carried out in cramped and poorly lit spaces with less-than-adequate tools, and usually under severe time pressure.
There could also be some additional refinements.
Thus, it could be arranged that the people who wrote the manuals and procedures rarely if ever carried out the activity under real-life conditions.
It could also be decreed that those who started the job need not necessarily be the ones required to finish it. A further twist might be that a number of different groups work on the same item of equipment either simultaneously or sequentially or both together.
Small wonder then, that maintenance-related /engineering build activity
attracts far more than their fair share of human performance problems.”

Reason and Hobbs Managing Maintenance Error

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