Information Management System Development for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

摘要

The purpose of this research is to evaluate and refine a safety information management system that will facilitate data collection, organization, query, analysis and reporting of maintenance errors that contribute to Naval Aviation mishaps, equipment damage and personnel injury using OPNAV 3750.6R, Human Factors Analysis and Classification System Maintenance Extension taxonomy. The target audience for this information management system tool included safety personnel, mishap investigators, Aircraft Mishap Board (AMB) members, and analysts. A review of three areas was needed to refine the prototype tool: (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. Fifteen Naval Aviation Safety Officers and Naval Aviators were given written procedures to navigate through the prototype and an exit survey. The survey responses, including objective and subjective responses about the prototype were gathered. The results indicate, that with proper training, the prototype could provide insight into maintenance errors, which could be used to target hazards and develop intervention strategies to prevent future mishaps.