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
Naval Aviation Flight Mishap Rate Naval Aviation Flight Mishap Rate 776 aircraft destroyed in FY50-99 FY50-99 1954 Angled Carrier Decks Class A Flight Mishaps /100,000 Flight Hours 60 Aviation Safety Center Naval Aviation Maintenance Program 50 FRS Concept Initiated 40 30 Squadron Safety Program 20 Designated Aircraft 10 23 aircraft destroyed in 1999 0 Fiscal Year 0 5 0 5 5 6 8 9
Engineering & Administrative Controls have Impacted Hardware Reliability, but…. 16 Class A, B,& C Mishaps/100,000 Flight Hours 14 12 Human Error 10 8 22 Class A FMs in 1999 6 17 Had Human Error 4 Involvement! Material Failure 2 0 90’s 90’s 70’s 70’s 80’s 80’s
Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix Personnel Engineering Administrative Control Control Control Most Mishap Recommendations Error Fall into Just Two Prevention Categories!!!!!!! Performance Enhancement
Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix Personnel Engineering Administrative Control Control Control X X Error Prevention Performance Enhancement
Human Factors Human Factors Intervention Strategy Matrix Intervention Strategy Matrix Personnel Engineering Administrative Control Control Control Most Mishap Recommendations X X Error Fall into Just Two Fall into Just Two Prevention Categories!!!!!!! Categories!!!!!!! Performance Enhancement “We Need to Start Thinking Out of the Box”
Human Factors Quality Management Board Watershed Event Wa Watershed Event Wa
Human Factors Quality Management Board Watershed Event Wa Watershed Event Wa
Mishap Data Analysis in Naval Aviation = 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: Reason’s “Swiss Cheese” Model HFACS- Organizational Human Factors Analysis Factors & Classification System Unsafe Unsafe Supervision Supervision Unsafe Act Unsafe Act Preconditions Preconditions Failed or Failed or Absent Defenses Absent Defenses Mishap
Mishap Data Analysis: Reason’s “Swiss Cheese” Model HFACS- Organizational Human Factors Analysis Factors & Classification System Unsafe Unsafe Supervision Supervision Unsafe Act Unsafe Act Preconditions Preconditions Unsafe Active Failure Acts Failed or Failed or Absent Defenses Absent Defenses Mishap
Mishap Data Analysis: Reason’s “Swiss Cheese” Model HFACS- Organizational Latent Condition Human Factors Analysis Factors & Classification System Unsafe Unsafe Latent Condition Supervision Supervision Unsafe Act Unsafe Act Latent Condition Preconditions Preconditions Unsafe Active Failure Acts Failed or Failed or Absent Defenses Absent Defenses Mishap
Mishap Data Analysis Focus: Naval Aviation Class A FM Causal Factors Initial emphasis on “Pilot Error”; but to reach goal of cutting human 70% 62% factors mishaps in half the focus 56% 60% 50% 39% maintenance maintenance 40% 30% 17% 20% 5% 10% 0% y w l e s a r c e e i o r n i r t s e c i a l t i r i n v a c i A r M e a e t F n p i u a S M Determined Causal Factor
HFACS-ME Model ORGANIZATIONAL CLIMATE ORGANIZATIONAL CLIMATE Supervisory Maintainer Working Conditions Conditions 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
HFACS- Maintenance Extension Supervisory Conditions Supervisory Conditions Working Conditions Working Conditions Maintainer Conditions Maintainer Conditions Maintainer Acts Maintainer Acts 3 ORDERS
Human Error in Maintenance Human Error in Maintenance Related Mishaps (FY 90-97) Related Mishaps (FY 90-97) = 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
HFACS-Maintenance Extension Profile: Class A vs. B/C MRMs Supervisory Maintainer Conditions 90 Acts Errors % Class A& B/C MRMs 80 70 60 Violations r e 50 s n n i a o 40 t i t n s g i n i d n a o 30 n i M i k o t i C r d 20 o n W o C 10 0
General Findings 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.
HFACS-ME Implementation = 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)
Supporting Agencies/Sponsors Medical Specialties Division FAA Office of Aviation Medicine Dr. Barbara Kanki Crew Factors System Safety Branch NASA Ames Research Center Moffett Field, CA CAPT Jim Frazier MC USN Aeromedical Division Naval Safety Center
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