Naval Safety Center, Norfolk, Virginia.
Hum Factors. 2018 Sep;60(6):763-777. doi: 10.1177/0018720818771904. Epub 2018 Apr 26.
To better understand the external factors that influence the performance and decisions of aviators involved in Naval aviation mishaps.
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.
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.
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.
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.
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.
更好地了解影响海军航空兵事故中飞行员表现和决策的外部因素。
从航空到核电运营等复杂活动中的事故往往是组织内部多个组件相互作用的结果。海军航空兵事故数据库包含相关信息，包括定量统计数据和定性报告，这些信息允许分析这些相互作用，以确定工作氛围如何影响飞行员的表现和判断。
使用贝叶斯定理概率公式对 2011 年至 2016 年期间发生的 95 起严重海军航空兵事故的结果进行了分析。然后对相关事故报告的一个子集进行了内容分析。
在分析的 14 个潜在因素中，贝叶斯应用确定了 6 个因素影响了事故中飞行员行为的特定方面。技术环境、误解和心理意识影响了基本的航空技能。其余 3 个因素用于对事故报告中的背景信息进行内容分析。团队合作失败是由于计划继续执行而加剧的责任扩散造成的。资源限制和风险管理缺陷影响了中队指挥官的判断。
贝叶斯定理在历史事故数据中的应用揭示了海军航空兵事故中潜在因素的作用。团队合作失败对飞行员的技能和判断都有很大的影响。
对有兴趣了解外部因素与人为错误之间关系的组织来说，该方法和发现具有直接的应用价值。它提供了现实世界的证据，以促进有效的安全决策。
