Carrier Air Wing Mishap Reduction Using a Human Factors Classification System and Risk Management
http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA531422&Location=U2&doc=GetTRDoc.pdf
Carrier Air Wing Mishap Reduction Using a Human Factors
Classification System and Risk Management
Aviat Spac e Envir on Med 2010; 81: 1028 – 32 .
Kris M. Belland , Cara Olsen , and Russell Lawry
Introduction: In 1998, the Navy’s center of excellence for advanced air wing combat operations, namely the Naval Strike and Air Warfare Center (NSAWC), had a spike in Class A fl ight mishaps. The spike triggered an intense review of prior mishaps and current mishap-reduction
practices using the Human Factors Analysis and Classifi cation System (HFACS). The review resulted in NSAWC instituting a comprehensive multifactorial mishap reduction plan applying Operational Risk Management (ORM) precepts. Methods: This is a nonrandomized investigational study with use of a historical comparison population. The Class A mishap rate per fl ight hour covering 10 yr prior to the mishap reduction efforts was estimated and compared to the Class A mishap rate per fl ight hour for the 10 yr after implementation using Poisson regression. Results: Combined Fleet and NSAWC data shows a 27% reduction in mishap rate, but the 21% reduction in the Fleet alone was not statistically signifi cant. The mishap reduction at NSAWC was statistically signifi cant with an 84% reduction. Fallon carrier air wing mishap rates post-ORM mishap reduction efforts are approaching those seen in the Fleet, but are still elevated overall (3.7 vs. 2.4). Conclusion: The incidence rate ratio was 80% lower at Fallon than the rest of the Fleet, indicating a significantly greater reduction in NSAWC air wing mishaps and suggests focused aviation mishap reduction efforts in similar circumstances could result in similar reductions.
Labels: flight mishaps, HFACS, Human Factors Classification System, patient safety

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