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At least 55 records · Page 3

Predicting Human Error in Air Traffic Control Decision Support Tools and Free Flight Concepts

The document is a set of briefing slides summarizing the work the Advanced Air Transportation Technologies (AATT) Project is doing on predicting air traffic controller and airline pilot human error when using new decision support software tools and when involved in testing new air traffic control concepts. Previous work in this area is reviewed as well as research being done jointly with the FAA. Plans for error prediction work in the AATT Project are discussed. The audience is human factors researchers and aviation psychologists from government and industry.

Mogford, Richard↗

Human error in aviation operations

This report is a brief description of research being undertaken by the National Aeronautics and Space Administration. The project is designed to seek out factors in the aviation system which contribute to human error, and to search for ways of minimizing the potential threat posed by these factors. The philosophy and assumptions underlying the study are discussed, together with an outline of the research plan.

Billings, C. E.↗

Resilience, ASRS, and the Narrative about Human Error

We present a study of weather-related incident reports submitted to NASA’s Aviation Safety Reporting System (ASRS) by air carrier pilots in the US. Using specific examples, we examine the relevant aspects of human performance and resilience management exhibited during these incidents. We describe the common narrative about human error and how ASRS data can be used to change it.

resilience↗

'Systemic Failures' and 'Human Error' in Canadian TSB Aviation Reports Between 1996 and 2002

This paper describes the results of an independent analysis of the primary and contributory causes of aviation accidents in Canada between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of these adverse events. Our results suggest that the majority of these high consequence accidents were attributed to human error. A large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗

Incident reporting: Its role in aviation safety and the acquisition of human error data

The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

Reynard, W. D.↗

Addressing Human Error in International Space Station Flight Control Teams: Advances in Ground Training for Science Operators

In flight control, as with any human in the loop system, operator error is an inevitable reality. On the International Space Station (ISS) where crew time and physical resources are precious and often irreplaceable, operator errors can result in significant, irreversible consequences. Flight controllers at the Payload Operations Integration Center (POIC) located at NASA's Marshall Space Flight Center (MSFC) in Huntsville, Alabama know this reality well. At the POIC, operator errors can be caused by a variety of factors, from poor hardware or software design to environmental factors such as time pressure or fatigue. The most difficult errors to address, however, are those which result from ineffective teamwork. To address these teamwork errors, trainers at the POIC have drawn best practices from high reliability industries as well as from our sister ISS control center at the Johnson Space Center (JSC) in Houston, Texas, to develop and implement a new training program focused specifically on teamwork skills. This training program, called Team Skills Training, is inspired by modern and historical training programs developed by NASA and is specifically tailored to the needs of the payload operations flight control team at the POIC. The program consists of training for both certified and trainee flight controllers, and covers team skills topics such as situational awareness, leadership, and communication skills. To maximize effectiveness, the program uses novel instructional techniques which extend beyond the classroom to encourage students to apply what they have learned to their day to day work. Minimizing operator errors in flight control is an endeavor which requires constant vigilance and continuous improvement. At the POIC, Team Skills Training is an important step in this journey.

Harris, Samantha S.↗

Addressing Human Error in International Space Station Flight Control Teams: Advances in Ground Training for Science Operators

In flight control, as with any human in the loop system, operator error is an inevitable reality. On the International Space Station (ISS) where crew time and physical resources are precious and often irreplaceable, operator errors can result in significant, irreversible consequences. Flight controllers at the Payload Operations Integration Center (POIC) located at NASA’s Marshall Space Flight Center (MSFC) in Huntsville, Alabama know this reality well. At the POIC, operator errors can be caused by a variety of factors, from poor hardware or software design to environmental factors such as time pressure or fatigue. The most difficult errors to address, however, are those which result from ineffective teamwork.Academic research in teamwork has resulted in the identification of many factors which make cross-functional teaming difficult, including leadership, trust building, and communication challenges. These factors, especially when combined with the challenging environmental factors flight control teams must contend with daily, make the goal of minimizing operator errors in payload operations challenging to achieve. To address such teamwork errors, trainers at the POIC have drawn best practices from high reliability industries such as commercial aviation, healthcare, and nuclear power plants, as well as from our sister ISS control center in Houston, Texas, to develop and institute a new training program focused specifically on teamwork skills.This training program, called the Team Skills Curriculum, is based on the concept of Crew Resource Management (CRM) which was developed by NASA in the 1970s for the commercial aviation industry in response to a series of aviation disasters resulting from ineffective teamwork. CRM was later tailored by the Johnson Space Center (JSC) for use in astronaut and flight control training. The result, called Space Flight Resource Management (SFRM) was formally introduced into manned spaceflight training in the late 90s. SFRM has evolved over the years, but the focus has remained on helping operators develop the skills needed to work as part of an effective team. Using these concepts as well as the latest research in cross-functional teaming and data on specific errors occurring at the POIC, trainers in the integrated flight control training branch created a custom training program for both new and certified payload operations specialists.

Harris, Samantha S.↗

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.↗

A Comparison of Human Error Probabilities Collected from HuREX and SHEEP Frameworks

This paper discusses how different are the HEPs collected from HuREX and SHEEP frameworks. This study is a preceding research to infer full-scope HRA data based on the data collected from the SHEEP framework. For the comparison, we used HEPs in the HuREX database published in KAERI-TR-6649 [6]. The HEPs have been collected from actual licensed operators when manipulating MCR simulators of Westinghouse type and Optimized Power Reactor (OPR1000) type in South Korea. For the HEPs based on the SHEEP framework, these have been collected from actual licensed operators and students when using a simplified simulator, i.e., Rancor Microworld.

99 GENERAL AND MISCELLANEOUS↗

How Systems Engineering and Risk Management Defend Against Murphy's Law and Human Error

Systems Engineering and Risk Management processes can work synergistically to defend against the causes of many mission ending failures. Defending against mission ending failures is facilitated by fostering a team that has a healthy respect for Murphy's Law and a team with a of curiosity for how things work, how they can fail, and what they need to know. This curiosity is channeled into making the unknowns known or what is uncertain more certain. Efforts to assure mission success require the expenditure of energy in the following areas: 1. Understanding what defines Mission Success as guided by the customer's needs, objectives and constraints. 2. Understanding how the system is supposed to work and how the system is to be produced, fueled by the curiosity of how the system should work and how it should be produced. 3. Understanding how the system can fail and how the system might not be produced on time and within cost, fueled by the curiosity of how the system might fail and how production might be difficult. 4. Understanding what we need to know and what we need learn for proper completion of the above three items, fueled by the curiosity of what we might not know in order to make the best decisions.

Bay, Michael↗

Classification and reduction of pilot error

Human error is a primary or contributing factor in about two-thirds of commercial aviation accidents worldwide. With the ultimate goal of reducing pilot error accidents, this contract effort is aimed at understanding the factors underlying error events and reducing the probability of certain types of errors by modifying underlying factors such as flight deck design and procedures. A review of the literature relevant to error classification was conducted. Classification includes categorizing types of errors, the information processing mechanisms and factors underlying them, and identifying factor-mechanism-error relationships. The classification scheme developed by Jens Rasmussen was adopted because it provided a comprehensive yet basic error classification shell or structure that could easily accommodate addition of details on domain-specific factors. For these purposes, factors specific to the aviation environment were incorporated. Hypotheses concerning the relationship of a small number of underlying factors, information processing mechanisms, and error types types identified in the classification scheme were formulated. ASRS data were reviewed and a simulation experiment was performed to evaluate and quantify the hypotheses.

Rogers, W. H.↗

Application of Artificial Intelligence in Detection and Mitigation of Human Factor Errors in Nuclear Power Plants: A Review

Human factors and ergonomics have played an essential role in increasing the safety and performance of operators in the nuclear energy industry. In this critical review, we examine how artificial intelligence (AI) technologies can be leveraged to mitigate human errors, thereby improving the safety and performance of operators in nuclear power plants (NPPs). First, we discuss the various causes of human errors in NPPs. Next, we examine the ways in which AI has been introduced to and incorporated into different types of operator support systems to mitigate these human errors. We specifically examine (1) operator support systems, including decision support systems, (2) sensor fault detection systems, (3) operation validation systems, (4) operator monitoring systems, (5) autonomous control systems, (6) predictive maintenance systems, (7) automated text analysis systems, and (8) safety assessment systems. Finally, we provide some of the shortcomings of the existing AI technologies and discuss the challenges still ahead for their further adoption and implementation to provide future research directions.

21 SPECIFIC NUCLEAR REACTORS AND ASSOCIATED PLANTS↗

Human Performance Analysis Depending on Operator Expertise (Student vs. Operator) and Simulator Complexity (Rancor Microworld vs. Compact Nuclear Simulator)

Human reliability analysis (HRA) evaluates human errors and provides human error probabilities (HEPs) for application in probabilistic safety assessment (PSA), which is a comprehensive safety assessment method for nuclear power plants (NPPs). Generally, HRA methods estimate HEPs based on human reliability data collected from actual historical measurement, simulator experiments, or expert judgement. Most recent HRA data collection studies focus on collecting data via full-scope main control room (MCR) simulators with actual licensed reactor operators. Contrary to this, Idaho National Laboratory (INL) has adopted a different approach, which attempts to collect HRA data based on experiment using simplified simulators and student participants by following the Simplified Human Error Experimental Program (SHEEP). This approach has a couple of advantages compared to full-scope data collection. Representatively, it has relatively low entry point for collecting HRA data, and secures large sample sizes with reasonable cost and labor. In the previous studies, we developed the SHEEP framework, then verified whether the data collected through the framework could support a representative full-scope data collection study, i.e., the Human Reliability Data Extraction (HuREX) study. Also, we analyzed human performance measurements depending on participant type (i.e., student vs. operator). In this paper, we analyze human performance data collected from an experiment comparing operator expertise and simulator complexity when using the more simplified simulator developed by INL, i.e., Rancor Microworld and the less simplified simulator, i.e., Compact Nuclear Simulator (CNS) developed by Korea Atomic Energy Research Institute (KAERI). Analysis of variance (ANOVA) tests and correlation analysis are used for analyzing the experimental data.

99 GENERAL AND MISCELLANEOUS↗

Formative vs. Summative Dependence in Human Reliability Analysis

Dependence in human reliability analysis (HRA) is the concept that once an initial human error has occurred, subsequent human errors are more likely. The approach almost universally adopted in HRA was first introduced in the Technique for Human Error Rate Prediction (THERP). In THERP, calculated human error probabilities (HEPs) are adjusted for dependence in the final step of quantification. This final adjustment for dependence involves anchoring the HEP to a set of values corresponding to low through complete dependence. The effect is to increase the HEP. In this paper, we propose formative dependence, which occurs at the onset of quantification. We demonstrate that dependence should be considered earlier in the calculation process, because it is not actually necessary to calculate the HEP when it is subsequently overridden by the dependence anchors. By applying dependence first in the calculation, processing steps can be eliminated, making for more efficient analysis.

99 GENERAL AND MISCELLANEOUS↗

A Framework to Integrate Human Reliability Data Obtained from Different Sources Based on the Complexity Scores of Proceduralized Tasks

For many decades, PSA (Probabilistic Safety Assessment) or PRA (Probabilistic Risk Assessment) techniques have been used to enhance the operational safety of nuclear power plants (NPPs) based on the consideration of potential hazards that could result in an unexpected consequence. As human error is one of the potential hazards, diverse human reliability analysis (HRA) methods have been proposed to provide a systematic way to estimate the likelihood of human errors (i.e., human error probability, HEP) in specific task contexts. Accordingly, it is evident that the quality of HRA results strongly depends on the credibility of HEP estimations. This implies that, in terms of enhancing this credibility, the collection of raw information (HRA data) that is helpful for understating when and why human errors occur is a crucial issue. In order to address this issue, in this study, the feasibility of a framework to integrate HRA data obtained from different sources is investigated based on the complexity of proceduralized tasks.

99 GENERAL AND MISCELLANEOUS↗

Human factors process failure modes and effects analysis (HF PFMEA) software tool

Methods, computer-readable media, and systems for automatically performing Human Factors Process Failure Modes and Effects Analysis for a process are provided. At least one task involved in a process is identified, where the task includes at least one human activity. The human activity is described using at least one verb. A human error potentially resulting from the human activity is automatically identified, the human error is related to the verb used in describing the task. A likelihood of occurrence, detection, and correction of the human error is identified. The severity of the effect of the human error is identified. The likelihood of occurrence, and the severity of the risk of potential harm is identified. The risk of potential harm is compared with a risk threshold to identify the appropriateness of corrective measures.

Chandler, Faith T.↗