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Assessing Naval Aviation Maintenance Safety:Error Reporting, Data Management, and Trend Analysis
CDR John Schmidt USNLtCol Bob Figlock USMC (ret.)LCDR Dylan Schmorrow USN
School Of Aviation SafetyNaval Postgraduate School
Monterey CA
Naval Aviation Flight Mishap RateNaval Aviation Flight Mishap Rate
Fiscal Year
776 aircraftdestroyed in
1954 FY50-99FY50-99
0
10
20
30
40
50
60
50 65 80 95
Angled Carrier Decks Aviation Safety Center
Naval Aviation Maintenance Program
FRS Concept Initiated
Squadron Safety Program
Designated Aircraft
23 aircraftdestroyed in
1999Cla
ss A
Flig
ht M
isha
ps /1
00,0
00 F
light
Hou
rs
Cla
ss A
, B,&
C M
isha
ps/1
00,0
00 F
light
Hou
rs
0
2
4
6
8
10
12
14
16
Material Failure
Human Error
70’s70’s 80’s80’s 90’s90’s
Engineering & Administrative Controls have Impacted Hardware Reliability, but….
22 Class A FMs in 199917 Had Human Error
Involvement!
Human FactorsHuman FactorsIntervention Strategy MatrixIntervention Strategy Matrix
EngineeringControl
AdministrativeControl
PersonnelControl
ErrorPrevention
PerformanceEnhancement
Most Mishap RecommendationsFall into Just Two Categories!!!!!!!
Human FactorsHuman FactorsIntervention Strategy MatrixIntervention Strategy Matrix
EngineeringControl
AdministrativeControl
PersonnelControl
ErrorPrevention
PerformanceEnhancement
X XMost Mishap RecommendationsFall into Just Two Categories!!!!!!!
Human FactorsHuman FactorsIntervention Strategy MatrixIntervention Strategy Matrix
EngineeringControl
AdministrativeControl
PersonnelControl
ErrorPrevention
PerformanceEnhancement
X X
“We Need to Start Thinking Out of the Box”
Fall into Just Two Categories!!!!!!!
Most Mishap RecommendationsFall into Just Two Categories!!!!!!!
Human Factors Quality Management Board
Watershed EventWatershed EventWatershed EventWatershed EventMishap DataAnalysis
B r a i n s t o r m i n g
Best PracticesBenchmarking
CommandSafety
Assessment
Recommendationsfor Intervention
Human Factors Quality Management Board
Watershed EventWatershed EventWatershed EventWatershed EventMishap DataAnalysis
B r a i n s t o r m i n g
Best PracticesBenchmarking
CommandSafety
Assessment
Recommendationsfor Intervention
bb Naval Aviation Safety Program (OPNAV 3750)Naval Aviation Safety Program (OPNAV 3750)•• Specifies Reporting Requirements (3 W’s)Specifies Reporting Requirements (3 W’s)•• Covers Major Mishaps to Minor Hazards:Covers Major Mishaps to Minor Hazards:
Supervisory, Aircrew, Maintenance, Material, &Supervisory, Aircrew, Maintenance, Material, &Facility (Focus ENG & ADM, touches HF Issues)Facility (Focus ENG & ADM, touches HF Issues)
bb Naval Safety Center Safety Information Naval Safety Center Safety Information Management System (SIMS)Management System (SIMS)•• Relational Database Structured IAW 3750.6QRelational Database Structured IAW 3750.6Q•• Permits Structured Reports & On-line QueriesPermits Structured Reports & On-line Queries
Mishap Data Analysis in Naval Aviation
Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Mishap
Unsafe ActPreconditions
UnsafeSupervision
Unsafe ActPreconditions
OrganizationalFactors
UnsafeSupervision
Failed orAbsent Defenses
Failed orAbsent Defenses
HFACS-Human Factors Analysis& Classification System
Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Active FailureUnsafe
Acts
Mishap
Unsafe ActPreconditions
UnsafeSupervision
Unsafe ActPreconditions
OrganizationalFactors
UnsafeSupervision
Failed orAbsent Defenses
Failed orAbsent Defenses
HFACS-Human Factors Analysis& Classification System
Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Active FailureUnsafe
Acts
Latent Condition
Latent Condition
Latent Condition
Mishap
Unsafe ActPreconditions
UnsafeSupervision
Unsafe ActPreconditions
OrganizationalFactors
UnsafeSupervision
Failed orAbsent Defenses
Failed orAbsent Defenses
HFACS-Human Factors Analysis& Classification System
Mishap Data Analysis Focus:Naval Aviation Class A FM Causal Factors
62%56%
39%
17%
5%
0%
10%
20%
30%
40%
50%
60%
70%
Supervi
sory
Aircre
w
Mat
eria
l
Mai
ntenan
ce
Facili
ties
Determined Causal Factor
Initial emphasis on “Pilot Error”;
but to reach goal of cutting human
factors mishaps in half the focus
maintenancemaintenance
SupervisoryConditions
MaintainerConditions
WorkingConditions
MaintainerActions
MaintenanceConditions
AircrewActions
M I S H A P / I N J U R YM I S H A P / I N J U R YM I S H A P / I N J U R YM I S H A P / I N J U R Y
ORGANIZATIONAL CLIMATEORGANIZATIONAL CLIMATE
HFACS-ME Model
HFACS- Maintenance Extension
Maintainer ActsMaintainer Acts
Working ConditionsWorking Conditions
Supervisory ConditionsSupervisory Conditions
Maintainer Conditions Maintainer Conditions
3 ORDERS
bb 470 Maintenance Related470 Maintenance RelatedMishaps Were AnalyzedMishaps Were AnalyzedFor Human ErrorsFor Human Errors
bb Classification ProcessClassification ProcessPerformed by NavalPerformed by NavalMaintenance PersonnelMaintenance Personnel
Human Error in MaintenanceHuman Error in MaintenanceRelated Mishaps (FY 90-97)Related Mishaps (FY 90-97)
0
10
20
30
40
50
60
70
80
90
Mai
ntai
ner
Con
diti
ons
Violations
Supe
rvis
ory
Con
diti
ons
Mai
ntai
ner
Act
s
Errors
% C
lass
A&
B/C
MR
Ms
Wor
king
Con
diti
ons
HFACS-Maintenance Extension Profile:Class A vs. B/C MRMs
Poor/Non - existent maintenance proceduresInadequate/Poor Supervision of Maintenance EvolutionsMiscommunication - supervisor to subordinate, pass-down, or shift turnoverNot using, lack of, or outdated
Violations - not following policy, procedures, checklists, etc.
General Findings
bb HFACS-ME Adopted for Inclusion in 3750.6RHFACS-ME Adopted for Inclusion in 3750.6Rbb Results Influencing the Naval AviationResults Influencing the Naval Aviation
Maintenance Program Policies (4790.2G)Maintenance Program Policies (4790.2G)bb Tailored Training Materials for UsersTailored Training Materials for Usersbb Data Collection/Analysis Tool DevelopmentData Collection/Analysis Tool Developmentbb Interim Construction of HFACS-ME DatabaseInterim Construction of HFACS-ME Database
(training, intervention, & ROI)(training, intervention, & ROI)
HFACS-ME Implementation
Supporting Agencies/Sponsors
Dr. Barbara KankiCrew Factors System Safety BranchNASA Ames Research CenterMoffett Field, CA
Medical Specialties DivisionFAA Office of Aviation Medicine
CAPT Jim Frazier MC USNAeromedical DivisionNaval Safety Center
Questions?