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This paper describes a safety information management system designed to capture maintenance factors that contribute to aircraft mishaps. The Human Factors Analysis and Classification System-Maintenance Extension (HFACS-ME), an effective framework for classifying and analyzing maintenance errors that lead to mishaps, incidents, and personal injuries, is the theoretical foundation. An existing desktop mishap application is updated, a prototype web-based model is developed, and an Asynchronous Distributed Learning (ADL) module is conceptualized. These tools facilitate data collection, organization, query, analysis, and the reporting of maintenance errors that contribute to aviation mishaps. Together they represent a complete, robust system for analyzing aircraft maintenance mishap related factors anywhere at anytime.

In order to address a Naval Fleet Logistics Support (VR) Wing Commander’s request to proactively uncover safety factors in VR maintenance operations, a prototype climate survey was taken by VR Wing maintainers in 13 squadrons. Nearly 800 surveys were tabulated, and the results were analyzed using a model for high reliability organizations. Overall, the preliminary analysis of the survey data pointed out some potential areas in the VR Wing and each of its aircraft communities for intervention.

To study maintainer error, the Naval Safety Center’s Human Factors Accident Classification System (HFACS) was adapted for Maintenance Related Mishaps (MRMs). The HFACS Maintenance Extension (ME) successfully profiled the errors present Naval Aviation Class A MRMs. In order to assess its suitability for studying major and minor airline accidents, a post hoc analysis was conducted on 124 Naval Fleet Logistics Support (VR) Wing maintenance related mishap, hazard, and injury reports. Two judges separately coded the 124 VR Wing incidents; a Cohen’s kappa of .78 was achieved, indicating an “excellent” level of agreement. Generally, HFACS-ME was able to profile maintainer errors found in more minor incidents and the factors that contribute to them. Common factors observed include errors attributed to third party maintenance, inadequate supervision, failed communications, skill-based errors, and procedural violations.

Naval Aviation has expanded its efforts to eliminate mishaps; especially those linked to human error. This focus was expanded to cover not only aircrew error, but maintainer error as well. To examine maintenance error, the Naval Safety Center's Human Factors Accident Classification System (HFACS) was adapted to analyze eight fiscal years of major maintenance mishaps. The HFACS Maintenance Extension effectively profiled the nature of maintenance errors and depicted the latent supervisory and maintainer conditions that “set the stage” for subsequent unsafe maintainer acts.