SLIDE 1 Assessing Naval Aviation Maintenance Safety:
Error Reporting, Data Management, and Trend Analysis
CDR John Schmidt USN LtCol Bob Figlock USMC (ret.) LCDR Dylan Schmorrow USN School Of Aviation Safety Naval Postgraduate School Monterey CA
SLIDE 2 Naval Aviation Flight Mishap Rate Naval Aviation Flight Mishap Rate
Fiscal Year
776 aircraft destroyed in 1954
FY50-99 FY50-99
10 20 30 40 50 60
5 6 5 8 9 5
Angled Carrier Decks Aviation Safety Center Naval Aviation Maintenance Program FRS Concept Initiated Squadron Safety Program Designated Aircraft
23 aircraft destroyed in 1999
Class A Flight Mishaps /100,000 Flight Hours
SLIDE 3 Class A, B,& C Mishaps/100,000 Flight Hours 2 4 6 8 10 12 14 16
Material Failure Human Error
70’s 70’s 80’s 80’s 90’s 90’s Engineering & Administrative Controls have Impacted Hardware Reliability, but….
22 Class A FMs in 1999 17 Had Human Error Involvement!
SLIDE 4 Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix
Engineering Control Administrative Control Personnel Control Error Prevention Performance Enhancement
Most Mishap Recommendations Fall into Just Two Categories!!!!!!!
SLIDE 5 Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix
Engineering Control Administrative Control Personnel Control Error Prevention Performance Enhancement
X X
SLIDE 6 Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix
Engineering Control Administrative Control Personnel Control Error Prevention Performance Enhancement
X X
“We Need to Start Thinking Out of the Box”
Fall into Just Two Categories!!!!!!! Most Mishap Recommendations Fall into Just Two Categories!!!!!!!
SLIDE 7
Human Factors Quality Management Board
Watershed Event Watershed Event Wa Wa
SLIDE 8
Human Factors Quality Management Board
Watershed Event Watershed Event Wa Wa
SLIDE 9 = = 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)
= = Naval Safety Center Safety Information
Naval Safety Center Safety Information Management System (SIMS) Management System (SIMS)
- Relational Database Structured IAW 3750.6Q
Relational Database Structured IAW 3750.6Q
- Permits Structured Reports & On-line Queries
Permits Structured Reports & On-line Queries
Mishap Data Analysis in Naval Aviation
SLIDE 10 Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Mishap
Unsafe Act Preconditions Unsafe Supervision Unsafe Act Preconditions Organizational Factors Unsafe Supervision
Failed or Absent Defenses Failed or Absent Defenses
HFACS-
Human Factors Analysis & Classification System
SLIDE 11 Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Active Failure
Unsafe Acts
Mishap
Unsafe Act Preconditions Unsafe Supervision Unsafe Act Preconditions Organizational Factors Unsafe Supervision
Failed or Absent Defenses Failed or Absent Defenses
HFACS-
Human Factors Analysis & Classification System
SLIDE 12 Mishap Data Analysis: Reason’s “Swiss Cheese” Model
Active Failure
Unsafe Acts
Latent Condition Latent Condition Latent Condition Mishap
Unsafe Act Preconditions Unsafe Supervision Unsafe Act Preconditions Organizational Factors Unsafe Supervision
Failed or Absent Defenses Failed or Absent Defenses
HFACS-
Human Factors Analysis & Classification System
SLIDE 13 Mishap Data Analysis Focus:
Naval Aviation Class A FM Causal Factors
62% 56% 39% 17% 5% 0% 10% 20% 30% 40% 50% 60% 70%
S u p e r v i s
y A i r c r e w M a t e r i a l M a i n t e n a n c e F a c i l i t i e s
Determined Causal Factor Initial emphasis on “Pilot Error”; but to reach goal of cutting human factors mishaps in half the focus
maintenance
maintenance
SLIDE 14 Supervisory Conditions Maintainer Conditions Working Conditions Maintainer Actions Maintenance Conditions Aircrew Actions
M I S H A P / I N J U R Y M I S H A P / I N J U R Y M I S H A P / I N J U R Y M I S H A P / I N J U R Y
ORGANIZATIONAL CLIMATE ORGANIZATIONAL CLIMATE
HFACS-ME Model
SLIDE 15
HFACS- Maintenance Extension
Maintainer Acts Maintainer Acts Working Conditions Working Conditions Supervisory Conditions Supervisory Conditions Maintainer Conditions Maintainer Conditions
3 ORDERS
SLIDE 16
SLIDE 17
= = 470 Maintenance Related
470 Maintenance Related Mishaps Were Analyzed Mishaps Were Analyzed For Human Errors For Human Errors
= = Classification Process
Classification Process Performed by Naval Performed by Naval Maintenance Personnel Maintenance Personnel
Human Error in Maintenance Human Error in Maintenance Related Mishaps (FY 90-97) Related Mishaps (FY 90-97)
SLIDE 18 10 20 30 40 50 60 70 80 90 M a i n t a i n e r C
d i t i
s Violations Supervisory Conditions Maintainer Acts Errors % Class A& B/C MRMs W
k i n g C
d i t i
s
HFACS-Maintenance Extension Profile: Class A vs. B/C MRMs
SLIDE 19
Poor/Non - existent maintenance procedures Inadequate/Poor Supervision of Maintenance Evolutions Miscommunication - supervisor to subordinate, pass-down, or shift turnover Not using, lack of, or outdated Violations - not following policy, procedures, checklists, etc.
General Findings
SLIDE 20
= = HFACS-ME Adopted for Inclusion in 3750.6R
HFACS-ME Adopted for Inclusion in 3750.6R
= = Results Influencing the Naval Aviation
Results Influencing the Naval Aviation Maintenance Program Policies (4790.2G) Maintenance Program Policies (4790.2G)
= = Tailored Training Materials for Users
Tailored Training Materials for Users
= = Data Collection/Analysis Tool Development
Data Collection/Analysis Tool Development
= = Interim Construction of HFACS-ME Database
Interim Construction of HFACS-ME Database (training, intervention, & ROI) (training, intervention, & ROI)
HFACS-ME Implementation
SLIDE 21 Supporting Agencies/Sponsors
Crew Factors System Safety Branch NASA Ames Research Center Moffett Field, CA Medical Specialties Division FAA Office of Aviation Medicine CAPT Jim Frazier MC USN Aeromedical Division Naval Safety Center
SLIDE 22
Questions?
