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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.
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.
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.
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.
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.
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.
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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.
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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.
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.
Aerospace electrical systems are required to withstand and adequately operate in extremely harsh environments that include, for example, high radiation exposure, temperature extremes, intense vibrational stress and drastic temperature cycling. The nature of aerospace electronics also demands high reliability since, with very few exceptions, there is no chance for hardware servicing or repairs. Common risk mitigation techniques for this type of situation are to perform a Reliability Analysis of the system throughout the development cycle, and to use electrical components that are regarded as “high reliability” because of additional controls and requirements applied in their design, manufacturing and testing. Unfortunately, studies have shown that even though these techniques are used, many systems fail to meet mission requirements well before the predicted lifetimes. This paper presents the analysis of failures of electrical parts, experienced during various stages of system development, at NASA Goddard Space Flight Center, Greenbelt MD, between the years 2001 and 2013. These components were subjected to qualification, screening and testing in which the goal was to ensure that the components would survive the stresses of the mission. The analysis categorizes failures by part type and failure mechanisms. One of the results of the analysis was the realization that a surprising proportion of failures experienced during system integration and testing were caused by human error (i.e. human induced defect). Further analysis included the determination of root failure mechanisms and any influencing factors contributing to these failures. The major causes of these defects were attributed to electrostatic damage (ESD), electrical overstress (EOS), mechanical overstress (MOS), and thermal overstress (TOS). Finally, the study proposes a risk analysis tool which incorporates these major causes for the failures, termed error-producing conditions (EPCs), and a proportionality factor representing the number of each type of failure that has occurred at the facility under study. These factors are quantified and used to communicate the risk of human induced defects for the assembly, integration and testing of space hardware based on the system’s electrical parts list. The new risk identification can trigger risk-mitigating actions more effectively, based on the presence of component categories or other hazardous conditions that have a history of failure due to human error.
Abstract This study addressed the cognitive impacts of providing correct and incorrect machine learning (ML) outputs in support of an object detection task. The study consisted of five experiments that manipulated the accuracy and importance of mock ML outputs. In each of the experiments, participants were given the T and L task with T-shaped targets and L-shaped distractors. They were tasked with categorizing each image as target present or target absent. In Experiment 1, they performed this task without the aid of ML outputs. In Experiments 2–5, they were shown images with bounding boxes, representing the output of an ML model. The outputs could be correct (hits and correct rejections), or they could be erroneous (false alarms and misses). Experiment 2 manipulated the overall accuracy of these mock ML outputs. Experiment 3 manipulated the proportion of different types of errors. Experiments 4 and 5 manipulated the importance of specific types of stimuli or model errors, as well as the framing of the task in terms of human or model performance. These experiments showed that model misses were consistently harder for participants to detect than model false alarms. In general, as the model’s performance increased, human performance increased as well, but in many cases the participants were more likely to overlook model errors when the model had high accuracy overall. Warning participants to be on the lookout for specific types of model errors had very little impact on their performance. Overall, our results emphasize the importance of considering human cognition when determining what level of model performance and types of model errors are acceptable for a given task.
Human error is a major contributor to accidents and performance losses in complex engineered systems. If one examines these human error caused failures further, a specific cause, the lack of situation awareness, has dominated as a major cause of human errors that instigate latent or catastrophic failures in complex systems. Studies of aviation accidents involving major air carriers revealed that situation awareness was the root cause of around 90% of accidents involving pilot error. Another study explored offshore drilling accidents involving human error and found that 40% of accidents were directly attributed to the loss of situation awareness. Studies of human errors in other domains such as nuclear power, air traffic control, process industry, and advanced driving show that loss of SA was a root cause in a majority of the events. Situation awareness-related failures are not only common but also costly and fatal (e.g., Bhopal Gas Leak, Air France 447 Flight Crash). Thus, the concept of situation awareness has emerged as an important construct in human factors, resulting in numerous models and measurement methods to aid in promoting appropriate levels of situation awareness.
Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%‐80% of failures, accidents and incidents in high‐risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.
This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.
Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (~12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.
Efforts to improve operational safety often focus on preventing human error. But humans don't just make mistakes. They do, in fact, make a tremendous contribution to operational safety, and there is much to learn from what goes right. To support people in their role, the operation should be human-centered. To make the operation human-centered, the framework of the 4Ps can be used to create a clear, coherent, consistent and comprehensive guidance.