A Human Error Analysis and Model of Naval Aviation Maintenance Related Mishaps

by Dylan D. Schmorrow

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 A599553. The abstract provided by the Pentagon Naval Aviation is in the midst of a major transformation as it attempts to come to terms with the demands of maintaining operational readiness in the face of diminishing budgets and reduced manning. Diminishing operating and procurement budgets mean that Naval Aviation is for the most part "making do" with existing aircraft. Over the past decade, one in four Naval Aviation mishaps were partially attributable to maintenance error. The present operating environment underscores the need to address maintenance error and its causes. The current study accomplishes three things. First, it evaluates 470 Naval Aviation mishaps with distinct maintenance error correlates. Second, it categorizes those errors using a taxonomy based upon current organizational and psychological theories of human error. Third, it mathematically models the consequences of these errors and uses the models to (a) predict the frequency with which maintenance-based mishaps will occur in the future and (b) approximate the potential cost savings from the reduction of each error type.

147 pages, Spiral-bound

Published January 1, 1998