Human Factors Analysis of Naval Aviation Maintenance Related Mishaps

Naval Aviation has redoubled its long-standing efforts to eliminate mishaps, especially those linked to human error. The focus was expanded not only to cover aircrew error, but maintainer error as well. To examine maintainer error, the Naval Safety Center's Human Factors Analysis and Classification System (HFACS) was adapted to analyze reportable Naval Aviation maintenance related mishaps (MRMs). A total of 470 MRMs for Fiscal Years 90–97 were analyzed. The HFACS Maintenance Extension effectively profiled the nature of maintenance errors and depicted the latent supervisory, working, and maintainer conditions that “set the stage” for subsequent maintainer acts that were the proximate factors leading to a MRM. The profile and general findings held true for both major MRMs and less severe, reportable MRMs.