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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!!!!!!!


EngineeringControl


PersonnelControl

ErrorPrevention


X XMost Mishap RecommendationsFall into Just Two Categories!!!!!!!


EngineeringControl


PersonnelControl

ErrorPrevention


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

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


OrganizationalFactors

UnsafeSupervision

Failed orAbsent Defenses


HFACS-Human Factors Analysis& Classification System


Active FailureUnsafe

Acts

Mishap


UnsafeSupervision



UnsafeSupervision





Active FailureUnsafe

Acts

Latent Condition

Latent Condition

Latent Condition

Mishap


UnsafeSupervision



UnsafeSupervision




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?

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