Understanding Human Error in Naval Aviation Mishaps.

OBJECTIVE: To better understand the external factors that influence the performance and decisions of aviators involved in Naval aviation mishaps.

BACKGROUND: Mishaps in complex activities, ranging from aviation to nuclear power operations, are often the result of interactions between multiple components within an organization. The Naval aviation mishap database contains relevant information, both in quantitative statistics and qualitative reports, that permits analysis of such interactions to identify how the working atmosphere influences aviator performance and judgment.

METHOD: Results from 95 severe Naval aviation mishaps that occurred from 2011 through 2016 were analyzed using Bayes' theorem probability formula. Then a content analysis was performed on a subset of relevant mishap reports.

RESULTS: Out of the 14 latent factors analyzed, the Bayes' application identified 6 that impacted specific aspects of aviator behavior during mishaps. Technological environment, misperceptions, and mental awareness impacted basic aviation skills. The remaining 3 factors were used to inform a content analysis of the contextual information within mishap reports. Teamwork failures were the result of plan continuation aggravated by diffused responsibility. Resource limitations and risk management deficiencies impacted judgments made by squadron commanders.

CONCLUSION: The application of Bayes' theorem to historical mishap data revealed the role of latent factors within Naval aviation mishaps. Teamwork failures were seen to be considerably damaging to both aviator skill and judgment.

APPLICATION: Both the methods and findings have direct application for organizations interested in understanding the relationships between external factors and human error. It presents real-world evidence to promote effective safety decisions.