Information Management System Development for the Characterization and Analysis of Human Error in Naval Aviation Maintenance Related Mishaps

This is a NAVAL POSTGRADUATE SCHOOL MONTEREY CA report procured by the Pentagon and made available for public release. It has been reproduced in the best form available to the Pentagon. It is not spiral-bound, but rather assembled with Velobinding in a soft, white linen cover. The Storming Media report number is A526483. The abstract provided by the Pentagon follows: The purpose of this thesis is to develop a prototype safety information management tool to capture human error in Naval Aviation maintenance mishaps. The Human Factors Analysis and Classification System-Maintenance Extension taxonomy, an effective framework for classifying and analyzing the presence of maintenance errors that lead to mishaps, incidents, and personal injuries, is the foundation of this management tool. The target audience for this information management system tool includes safety personnel, mishap investigators, Aircraft Mishap Board (AMB) members, and analysts. A review of three areas is needed to produce the prototype: 1. the collection, use, and management of accident information, 2. human error theories as related to aviation mishaps, and 3. the design of an effective mishap database tool. A usability study was conducted using potential end-users (Naval Aviation Safety Officers). The participants are given both written procedures to navigate through the prototype and an exit survey. The results of the survey, including objective and subjective responses about the prototype are gathered. The resulting data indicates an improved version of the prototype could directly lead to a decreased mishap rate and overall increased mission readiness due to the training and analysis opportunity it provides.