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At least 271 records · Page 15

Extracting Lessons of Human Performance and Resilience Management from a Study of Weather-Related Safety Risks and Incidents Reported to NASA's Aviation Safety Reporting System (ASRS)

We present a study of weather-related incident reports submitted to NASA’s Aviation Safety Reporting System (ASRS) by air carrier pilots and air traffic controllers in the US. Using specific examples, we examine the weather-related risks reported and the relevant aspects of human performance and resilience management exhibited during these incidents. We describe our methods of lesson extraction to maximize learning, including the use of advance algorithms, and we conclude with a review of the weather-related risks encountered and the resilient practices employed to mitigate them.

resilience↗

Some Challenges in the Design of Human-Automation Interaction for Safety-Critical Systems

Increasing amounts of automation are being introduced to safety-critical domains. While the introduction of automation has led to an overall increase in reliability and improved safety, it has also introduced a class of failure modes, and new challenges in risk assessment for the new systems, particularly in the assessment of rare events resulting from complex inter-related factors. Designing successful human-automation systems is challenging, and the challenges go beyond good interface development (e.g., Roth, Malin, & Schreckenghost 1997; Christoffersen & Woods, 2002). Human-automation design is particularly challenging when the underlying automation technology generates behavior that is difficult for the user to anticipate or understand. These challenges have been recognized in several safety-critical domains, and have resulted in increased efforts to develop training, procedures, regulations and guidance material (CAST, 2008, IAEA, 2001, FAA, 2013, ICAO, 2012). This paper points to the continuing need for new methods to describe and characterize the operational environment within which new automation concepts are being presented. We will describe challenges to the successful development and evaluation of human-automation systems in safety-critical domains, and describe some approaches that could be used to address these challenges. We will draw from experience with the aviation, spaceflight and nuclear power domains.

systems engineering↗

An Ontological Approach to Integrate Commercial Space Operations with an In-time Aviation Safety Management System (IASMS)

The emergence of commercial space operations (CSO) is one of many Advanced Air Mobility domains that pose major challenges to in-time safety assurance because of the different architectures used by the operators and other agents. The National Academies recognized the need to improve integration of disparate architectures and recommended that an In-time Aviation Safety Management System(IASMS) be developed to provide seamless connectivity across interacting architectures and enable in-time safety assurance. An ontological approach to integrating CSO with IASMS involves in-time Services, Functions, and Capabilities design to manage operational risks and inform changes to design. The resulting integrated architecture provides a common basis for risk management and in-time safety assurance.

K Ellis↗

Resilient Space Habitat Design Using Safety Controls

Space habitats will involve a complex and tightly coupled combination of hardware, software, and humans, while operating in challenging environments that pose many risks, both known and unknown. It will not be possible to design habitats that are immune to failure, nor will it be possible to foresee all possible failures. Rather than aiming for designs where ―failure is not an option,‖ habitats must be resilient to disruptions. We propose an approach to resilient design for space habitats based on the concept of safety controls from system safety engineering. We model disruptions using a state-and-trigger approach, where the space habitat is in one of three distinct states at each time instance: nominal, hazardous, or accident. We use safety controls as ways of preventing a system from entering or remaining in a hazardous or accident state. We develop a safety control option space for the habitat, from which designers can select the set of safety controls that best meet resilience, performance, and other system goals. The safety control option space is likely to be large, accordingly, we design a database that links safety controls to the applicable states and triggers. We demonstrate our approach on the early design stage of a Martian space habitat.

Safety↗

NASA aviation safety reporting system

The human factors frequency considered a cause of or contributor to hazardous events onboard air carriers are examined with emphasis on distractions. Safety reports that have been analyzed, processed, and entered into the aviation safety reporting system data base are discussed. A sampling of alert bulletins and responses to them is also presented.

Source record↗

Making the Hubble Space Telescope servicing mission safe

The implementation of the HST system safety program is detailed. Numerous safety analyses are conducted through various phases of design, test, and fabrication, and results are presented to NASA management for discussion during dedicated safety reviews. Attention is given to the system safety assessment and risk analysis methodologies used, i.e., hazard analysis, fault tree analysis, and failure modes and effects analysis, and to how they are coupled with engineering and test analysis for a 'synergistic picture' of the system. Some preliminary safety analysis results, showing the relationship between hazard identification, control or abatement, and finally control verification, are presented as examples of this safety process.

Bahr, N. J.↗

RICIS Symposium 1992: Mission and Safety Critical Systems Research and Applications

This conference deals with computer systems which control systems whose failure to operate correctly could produce the loss of life and or property, mission and safety critical systems. Topics covered are: the work of standards groups, computer systems design and architecture, software reliability, process control systems, knowledge based expert systems, and computer and telecommunication protocols.

Source record↗

Space transportation system payload safety policy

A brief description of the Space Transportation System (STS) is given, and the evolution of a payload safety policy for it is described. The policy adopted in June, 1976, minimizes STS involvement in the payload design process while maintaining the assurance of a safe operation. The payload developer is responsible for assurance of safety and verification of compliance with the requirements. The STS will exercise reviews to ensure that interaction between payloads does not create hazards.

Scheller, J. A.↗

A Predictive Safety Management System Software Package Based on the Continuous Hazard Tracking and Failure Prediction Methodology

The goal of this research was to integrate a previously validated and reliable safety model, called Continuous Hazard Tracking and Failure Prediction Methodology (CHTFPM), into a software application. This led to the development of a safety management information system (PSMIS). This means that the theory or principles of the CHTFPM were incorporated in a software package; hence, the PSMIS is referred to as CHTFPM management information system (CHTFPM MIS). The purpose of the PSMIS is to reduce the time and manpower required to perform predictive studies as well as to facilitate the handling of enormous quantities of information in this type of studies. The CHTFPM theory encompasses the philosophy of looking at the concept of safety engineering from a new perspective: from a proactive, than a reactive, viewpoint. That is, corrective measures are taken before a problem instead of after it happened. That is why the CHTFPM is a predictive safety because it foresees or anticipates accidents, system failures and unacceptable risks; therefore, corrective action can be taken in order to prevent all these unwanted issues. Consequently, safety and reliability of systems or processes can be further improved by taking proactive and timely corrective actions.

Quintana, Rolando↗

Reporter Concerns in 300 Mode-Related Incident Reports from NASA's Aviation Safety Reporting System

A model has been developed which represents prominent reporter concerns expressed in the narratives of 300 mode-related incident reports from NASA's Aviation Safety Reporting System (ASRS). The model objectively quantifies the structure of concerns which persist across situations and reporters. These concerns are described and illustrated using verbatim sentences from the original narratives. Report accession numbers are included with each sentence so that concerns can be traced back to the original reports. The results also include an inventory of mode names mentioned in the narratives, and a comparison of individual and joint concerns. The method is based on a proximity-weighted co-occurrence metric and object-oriented complexity reduction.

McGreevy, Michael W.↗

An In-time Aviation Safety Management System (IASMS) Concept of Operations for Vertiport Design and Operations

The National Airspace System is foreseen to undergo revolutionary change with Urban Air Mobility (UAM) and its use of vertiports to transport passengers and cargo. To assure safety with UAM and more broadly with Advanced Air Mobility (AAM), the National Academies recommended an In-time Aviation Safety Management System (IASMS) that is extensible to the design and operation of vertiports. Vertiport designs will scale in several dimensions including physical size and infrastructure depending upon location and in the Services, Functions, and Capabilities required for assuring safety with increasingly complex vertiport designs and operations. These operations will be enabled by evolving technologies including electric vertical takeoff and landing (eVTOL) aircraft for passenger-and cargo-carrying commercial transportation. Within this construct, safety hazards and risk mitigations involving predictive data analytics and modeling will be used. Use cases and future challenges are examined to guide maturation of the IASMS ConOps for vertiports.

K Ellis↗

The Search for Nonflammable Solvent Alternatives for Cleaning Aerospace Oxygen Systems

Oxygen systems are susceptible to fires caused by particle and nonvolatile residue (NVR) contaminants, therefore cleaning and verification is essential for system safety. . Cleaning solvents used on oxygen system components must be either nonflammable in pure oxygen or complete removal must be assured for system safety. . CFC -113 was the solvent of choice before 1996 because it was effective, least toxic, compatible with most materials of construction, and non ]reactive with oxygen. When CFC -113 was phased out in 1996, HCFC -225 was selected as an interim replacement for cleaning propulsion oxygen systems at NASA. HCFC-225 production phase-out date is 01/01/2015. HCFC ]225 (AK ]225G) is used extensively at Marshall Space Flight Center and Stennis Space Center for cleaning and NVR verification on large propulsion oxygen systems, and propulsion test stands and ground support equipment. . Many components are too large for ultrasonic agitation - necessary for effective aqueous cleaning and NVR sampling. . Test stand equipment must be cleaned prior to installation of test hardware. Many items must be cleaned by wipe or flush in situ where complete removal of a flammable solvent cannot be assured. The search for a replacement solvent for these applications is ongoing.

Mitchell, Mark↗

Making the Hubble Space Telescope servicing mission safe

This paper will detail how the Hubble Space Telescope (HST) system safety program is conducted. Numerous safety analyses are conducted through the various phases of design, test, and fabrication, and results are presented to NASA management for discussion during dedicated safety reviews. This paper will then address the system safety assessment and risk analysis methodologies used (i.e. hazard analysis, fault tree analysis, and failure modes and effects analysis), and how they are coupled with enginering and test analyses for a 'synergistic picture' of the system. Some preliminary safety analysis results, showing the relationship between hazard identification, control or abatement, and finally control verification, will be presented as examples of this safety process.

Bahr, N. J.↗

Reports of Resilient Performance: Investigating Operators' Descriptions of Safety-producing Behaviors in the Aviation Safety Reporting System

While many existing taxonomies and frameworks provide a common vocabulary for describing how human operators fail in the context of sociotechnical systems, at present, there is no common vocabulary to describe how humans succeed. Such a framework would facilitate systematically collecting and analyzing data on how human performance can produce safety, not just how it can reduce safety. One potentially rich source of currently available information for exploring desired performance is the reports submitted to NASA’s Aviation Safety Reporting System (ASRS). These de-identified, confidential, and voluntary narrative reports are submitted by pilots, controllers, ground operators, and others within aviation operations. While these reports are primarily submitted to describe safety risks, incidents, and problems, they also often describe how those risks were mitigated, and provide a window into aspects of everyday work in aviation. This paper describes an analysis of ASRS narratives to understand how operators talk about their own resilient behaviors during adverse safety conditions and events. Guided by Erik Hollnagel’s Resilience Assessment Grid framework (i.e., anticipate, monitor, respond, learn), we illustrate our approach and methodology with examples from reports. We also highlight some of the challenges and how further research is needed in developing a taxonomy of operators’ descriptions of resilient performance.

resilient behaviors↗

Reports of Resilient Performance: Investigating Operators' Descriptions of Safety-producing Behaviors in the Aviation Safety Reporting System

While many existing taxonomies and frameworks provide a common vocabulary for describing how human operators fail in the context of sociotechnical systems, at present, there is no common vocabulary to describe how humans succeed. Such a framework would facilitate systematically collecting and analyzing data on how human performance can produce safety, not just how it can reduce safety. One potentially rich source of currently available information for exploring desired performance is the reports submitted to NASA’s Aviation Safety Reporting System (ASRS). These de-identified, confidential, and voluntary narrative reports are submitted by pilots, controllers, ground operators, and others within aviation operations. While these reports are primarily submitted to describe safety risks, incidents, and problems, they also often describe how those risks were mitigated, and provide a window into aspects of everyday work in aviation. These reports can be searched in a variety of ways. This paper describes methods for systematically examining ASRS narratives to understand how operators talk about their own resilient behaviors during adverse safety conditions and events. Guided by Erik Hollnagel’s Resilience Assessment Grid framework (i.e., anticipate, monitor, respond, learn), various approaches and tools for such inquiries are described. The approach, process, challenges, and suggestions to building an operator-based description of resilient performance are discussed, and tools to facilitate data analysis to maximize learning from these reports are described.

ASRS narratives↗

Evaluating Models of Human Performance: Safety-Critical Systems Applications

This presentation is part of panel discussion on Evaluating Models of Human Performance. The purpose of this panel is to discuss the increasing use of models in the world today and specifically focus on how to describe and evaluate models of human performance. My presentation will focus on discussions of generating distributions of performance, and the evaluation of different strategies for humans performing tasks with mixed initiative (Human-Automation) systems. I will also discuss issues with how to provide Human Performance modeling data to support decisions on acceptability and tradeoffs in the design of safety critical systems. I will conclude with challenges for the future.

Feary, Michael S.↗