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Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

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At least 37 records · Page 2
All sourcesNASA NTRSDOE OSTI
NASA NTRS2006

What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports

The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.

Maille, Nicolas P.↗
DOE OSTI2022

Multi-area parameter error identification for large power systems

Power grid model parameters may contain errors due to various reasons. Detecting and correcting parameter errors typically requires significant computational effort due to the size and complexity of the parameter database. While the normalized Lagrange multiplier (NLM) method can effectively detect, identify and correct parameter errors, its computational burden could rapidly grow with increasing system size. This paper addresses this issue by proposing a multi-area parameter error identification method. Each area has its own outlier detection tool for detecting the incorrect parameters and measurements within the area. On the other hand, due to the reduced redundancy at area boundaries, parameter errors on branches incident to boundary buses may not be detected. Such errors are subsequently detected by a coordination level estimator completing the system-wide parameter detection procedure. In conclusion, performance of the developed method is demonstrated using the IEEE 118-bus and 2000-bus Texas synthetic systems.

24 POWER TRANSMISSION AND DISTRIBUTION↗
NASA NTRS1997

Identification of Error Patterns in Terminal-Area ATC Communications

Advancing air traffic management technologies have enabled a greater number of aircraft to use the same airspace more effectively. As aircraft separations are reduced and final approaches are more finely timed, there is less room for error. The present study examined 122 terminal-area, loss-of-separation and procedure violation incidents reported to the Aviation Safety Reporting System (ASRS) by air traffic controllers. Narrative description codes were used for the incidents for type of violation, contributing factors, recovery strategies, and consequences. Usually multiple errors occurred prior to the violation. Error sequences were analyzed and common patterns of errors were identified. In half of the incidents, errors were noticed in time to correct mistakes. Of these, almost 43% committed additional errors during the recovery attempt. This analysis shows that redundancies in the present air traffic control system may not be sufficient to support large increases in traffic density. Error prevention and design considerations for air traffic management systems are discussed.

Quinn, Cheryl↗
NASA NTRS2010

Wavefront Sensing of X-Ray Telescopes

Phase Retrieval analysis of off-axis or defocused focal-plane data from telescope optics has been proven effective in understanding misalignments and optical aberrations in normal incidence telescopes. The approach is used, e.g., in commissioning of the James Webb Space Telescope (JWST) segmented primary mirror. There is a similar need for evaluating low-order figure errors of grazing incidence mirrors and nested telescope assemblies. When implemented in these systems, phase retrieval does not depend on normal incidence access to each mirror (shell) surface and, therefore, provides an effective means for evaluating nested x-ray telescopes during integration and test. We have applied a well-known phase retrieval algorithm to grazing incidence telescopes. The algorithm uses the Levenberg-Marquardt optimization procedure to perform a non-linear least-squares fit of the telescope Point Spread Function (PSF). The algorithm can also retrieve low order figure errors at visible wavelengths where optical diffraction is the dominant defect in the PSF. In this paper we will present the analytical approach and its implementation for grazing incidence mirrors of the International X-Ray Observatory (IXO). We analyze the effects of low order axial surface errors individually, and in combination on the system PSF at 633 nanometers. We demonstrate via modeling that the wavefront sensing algorithm can recover axial errors (of the grazing incidence mirrors) to a small fraction of the known axial figure errors using simulated PSFs as input data to the algorithm.

Saha, Timo↗
NASA NTRS1995

Safety in the operating theatre--part 1: interpersonal relationships and team performance

The authors examine the application of interpersonal human factors training on operating room (OR) personnel. Mortality studies of OR deaths and critical incident studies of anesthesia are examined to determine the role of human error in OR incidents. Theoretical models of system vulnerability to accidents are presented with emphasis on a systems approach to OR performance. Input, process, and outcome factors are discussed in detail.

Non-NASA Center↗
NASA NTRS2006

What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports

The objective of the Aviation System Monitoring and Modeling project of NASA's Aviation Safety and Security Program was to develop technologies to enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. Information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. In Volume I, the concept of the Scenario was introduced as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. In this Volume II, that study continues into the analyses of the free narratives to gain understanding as to why the incident occurred from the reporter s perspective. While this is just the first experiment, the results of our approach are encouraging and indicate that it will be possible to design an automated analysis process guided by the structure of the Scenario that can achieve the level of consistency and reliability of human analysis of narrative reports.

Ferryman, Thomas A.↗
NASA NTRS1980

Proton upsets in LSI memories in space

Two types of large scale integrated dynamic random access memory devices were tested and found to be subject to soft errors when exposed to protons incident at energies between 18 and 130 MeV. These errors are shown to differ significantly from those induced in the same devices by alphas from an Am-241 source. There is considerable variation among devices in their sensitivity to proton-induced soft errors, even among devices of the same type. For protons incident at 130 MeV, the soft error cross sections measured in these experiments varied from 10 to the -8th to 10 to the -6th sq cm/proton. For individual devices, however, the soft error cross section consistently increased with beam energy from 18-130 MeV. Analysis indicates that the soft errors induced by energetic protons result from spallation interactions between the incident protons and the nuclei of the atoms comprising the device. Because energetic protons are the most numerous of both the galactic and solar cosmic rays and form the inner radiation belt, proton-induced soft errors have potentially serious implications for many electronic systems flown in space.

Mcnulty, P. J.↗
NASA NTRS2003

Improved Conflict Detection for Reducing Operational Errors in Air Traffic Control

An operational error is an incident in which an air traffic controller allows the separation between two aircraft to fall below the minimum separation standard. The rates of such errors in the US have increased significantly over the past few years. This paper proposes new detection methods that can help correct this trend by improving on the performance of Conflict Alert, the existing software in the Host Computer System that is intended to detect and warn controllers of imminent conflicts. In addition to the usual trajectory based on the flight plan, a "dead-reckoning" trajectory (current velocity projection) is also generated for each aircraft and checked for conflicts. Filters for reducing common types of false alerts were implemented. The new detection methods were tested in three different ways. First, a simple flightpath command language was developed t o generate precisely controlled encounters for the purpose of testing the detection software. Second, written reports and tracking data were obtained for actual operational errors that occurred in the field, and these were "replayed" to test the new detection algorithms. Finally, the detection methods were used to shadow live traffic, and performance was analysed, particularly with regard to the false-alert rate. The results indicate that the new detection methods can provide timely warnings of imminent conflicts more consistently than Conflict Alert.

Paielli, Russell A.↗
NASA NTRS2011

Automatic Facial Expression Recognition and Operator Functional State

The prevalence of human error in safety-critical occupations remains a major challenge to mission success despite increasing automation in control processes. Although various methods have been proposed to prevent incidences of human error, none of these have been developed to employ the detection and regulation of Operator Functional State (OFS), or the optimal condition of the operator while performing a task, in work environments due to drawbacks such as obtrusiveness and impracticality. A video-based system with the ability to infer an individual's emotional state from facial feature patterning mitigates some of the problems associated with other methods of detecting OFS, like obtrusiveness and impracticality in integration with the mission environment. This paper explores the utility of facial expression recognition as a technology for inferring OFS by first expounding on the intricacies of OFS and the scientific background behind emotion and its relationship with an individual's state. Then, descriptions of the feedback loop and the emotion protocols proposed for the facial recognition program are explained. A basic version of the facial expression recognition program uses Haar classifiers and OpenCV libraries to automatically locate key facial landmarks during a live video stream. Various methods of creating facial expression recognition software are reviewed to guide future extensions of the program. The paper concludes with an examination of the steps necessary in the research of emotion and recommendations for the creation of an automatic facial expression recognition program for use in real-time, safety-critical missions.

Blanson, Nina↗
NASA NTRS2012

Automatic Facial Expression Recognition and Operator Functional State

The prevalence of human error in safety-critical occupations remains a major challenge to mission success despite increasing automation in control processes. Although various methods have been proposed to prevent incidences of human error, none of these have been developed to employ the detection and regulation of Operator Functional State (OFS), or the optimal condition of the operator while performing a task, in work environments due to drawbacks such as obtrusiveness and impracticality. A video-based system with the ability to infer an individual's emotional state from facial feature patterning mitigates some of the problems associated with other methods of detecting OFS, like obtrusiveness and impracticality in integration with the mission environment. This paper explores the utility of facial expression recognition as a technology for inferring OFS by first expounding on the intricacies of OFS and the scientific background behind emotion and its relationship with an individual's state. Then, descriptions of the feedback loop and the emotion protocols proposed for the facial recognition program are explained. A basic version of the facial expression recognition program uses Haar classifiers and OpenCV libraries to automatically locate key facial landmarks during a live video stream. Various methods of creating facial expression recognition software are reviewed to guide future extensions of the program. The paper concludes with an examination of the steps necessary in the research of emotion and recommendations for the creation of an automatic facial expression recognition program for use in real-time, safety-critical missions

Blanson, Nina↗
NASA NTRS1997

Operational Interventions to Maintenance Error

A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

Kanki, Barbara G.↗
NASA NTRS1997

Reduction of Maintenance Error Through Focused Interventions

It is well known that a significant proportion of aviation accidents and incidents are tied to human error. In flight operations, research of operational errors has shown that so-called "pilot error" often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the "team" concept for maintenance operations and in tailoring programs to fit the needs of technical operations. Nevertheless, there remains a dual challenge: to develop human factors interventions which are directly supported by reliable human error data, and to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

Kanki, Barbara G.↗
DOE OSTI2024

Uncertainty-Aware and Explainable Human Error Detection in the Operation of Nuclear Power Plants

The timely and accurate identification of incidents, such as human factor error, is important to restore nuclear power plants (NPPs) to a stable state. However, the identification of abnormal operating conditions is difficult because of the existence of multiple scenarios. In addition, to implement mitigation actions rapidly after an incident occurs, operators must accurately identify an incident by monitoring the trends of many variables. The mental burden posed by this can increase human error and cause failure in identifying incidents. Failure to identify incidents directly results in erroneous mitigation measures, which are detrimental to NPPs. In this study, we leverage uncertainty-aware models to identify such errors and thereby increase the chances of mitigating them. We use the data collected from a physical test bed. The goal is to identify both certain and accurate models. For this, the two main aspects of focus in this study are explainable artificial intelligence (XAI) and uncertainty quantification (UQ). While XAI elucidates the decision pathway, UQ evaluates decision reliability. Their integration paints a comprehensive picture, signifying that understanding decisions and their confidence should be interlinked. Thus, in this study we leverage UQ measures (e.g. entropy and mutual information) along with Shapley additive explanations to gain insights into the features contributing to both accuracy and uncertainty in error identification. Furthermore, our results show that uncertainty-aware models combined with XAI tools can explain the artificial intelligence–prescribed decisions, with the potential of better explaining errors for the operators.

21 SPECIFIC NUCLEAR REACTORS AND ASSOCIATED PLANTS↗
NASA NTRS1987

Phase error statistics of a phase-locked loop synchronized direct detection optical PPM communication system

Receiver timing synchronization of an optical Pulse-Position Modulation (PPM) communication system can be achieved using a phased-locked loop (PLL), provided the photodetector output is suitably processed. The magnitude of the PLL phase error is a good indicator of the timing error at the receiver decoder. The statistics of the phase error are investigated while varying several key system parameters such as PPM order, signal and background strengths, and PPL bandwidth. A practical optical communication system utilizing a laser diode transmitter and an avalanche photodiode in the receiver is described, and the sampled phase error data are presented. A linear regression analysis is applied to the data to obtain estimates of the relational constants involving the phase error variance and incident signal power.

Natarajan, Suresh↗
NASA NTRS1987

X-ray optics - A technique for high resolution imaging

Both scattering and figure errors in grazing incidence optics are larger in the plane of incidence than out-of-plane by a factor equal to 1/sin theta, where theta is the graze angle. When the full annular aperture of a grazing incidence telescope is stopped down, the point spread function becomes highly elliptical with a width as much as sin theta times narrower than the full image. In practice, this means that improvements in resolution of up to 100 times can be achieved, and effective resolution can approach the diffraction limit. Laboratory data demonstrating the effect are presented.

Cash, Webster↗
DOE OSTI2021

Errors introduced in fission neutron spectrum measurements using a single reference

Measurements of physical quantities are often made relative to a reference quantity, simplifying the interpretation of the measurement and its uncertainties. However, if applied without careful considerations, this technique can carry with it a significant and complex systematic error that is usually ignored. For example, measurements of continuous neutron spectra relative to a reference spectrum yield a result that does not properly include the important effects of neutron scattering in the experimental environment. These effects act to distort the measured spectrum shape and create notable errors in spectrum-integrated quantities. While this effect is one of a series of known potential sources of systematic error including, but not limited to target impurities, angular distributions, incident beam flux, and others, the error introduced from differences in environmental scattering effects between the reference and desired spectra are frequently overlooked. In this work, we demonstrate the origin of this error using simulated data corresponding to measurements of the neutron-induced prompt fission neutron spectra of 233 U, 235 U, 238 U, and 239 Pu as well as the spontaneous fission neutron spectrum of 252 Cf. Errors in the spectrum shape can be as high as 10%–15% depending on the combination of incident and outgoing neutron energy. The spectrum integral and average spectrum energy also contain errors that change with incident neutron energy and can be as high as ~2%. Although this study is based on simulated data, we also show a method for proving that this error exists in an experimental data set and we show a correction that can be applied to results of this type to obtain a more accurate result, thereby largely removing systematic errors from environmental scattering effects. The potential for these kinds of errors should be considered in measurements producing continuous neutron spectra.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗