Engineering Papers⌕ Search

SEARCH · Engineering Papers

Results for “human error”

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.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 109 records · Page 6
All sourcesNASA NTRSDOE OSTI
NASA NTRS1998

Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation

Advances in technology and new levels of automation on commercial jet transports has had many effects. There have been positive effects from both an economic and a safety point of view. The technology changes on the flight deck also have had reverberating effects on many other aspects of the aviation system and different aspects of human performance. Operational experience, research investigations, incidents, and occasionally accidents have shown that new and sometimes surprising problems have arisen as well. What are these problems with cockpit automation, and what should we learn from them? Do they represent over-automation or human error? Or instead perhaps there is a third possibility - they represent coordination breakdowns between operators and the automation? Are the problems just a series of small independent glitches revealed by specific accidents or near misses? Do these glitches represent a few small areas where there are cracks to be patched in what is otherwise a record of outstanding designs and systems? Or do these problems provide us with evidence about deeper factors that we need to address if we are to maintain and improve aviation safety in a changing world? How do the reverberations of technology change on the flight deck provide insight into generic issues about developing human-centered technologies and systems (Winograd and Woods, 1997)? Based on a series of investigations of pilot interaction with cockpit automation (Sarter and Woods, 1992; 1994; 1995; 1997a, 1997 b), supplemented by surveys, operational experience and incident data from other studies (e.g., Degani et al., 1995; Eldredge et al., 1991; Tenney et al., 1995; Wiener, 1989), we too have found that the problems that surround crew interaction with automation are more than a series of individual glitches. These difficulties are symptoms that indicate deeper patterns and phenomena concerning human-machine cooperation and paths towards disaster. In addition, we find the same kinds of patterns behind results from studies of physician interaction with computer-based systems in critical care medicine (e.g., Moll van Charante et al., 1993; Obradovich and Woods, 1996; Cook and Woods, 1996). Many of the results and implications of this kind of research are synthesized and discussed in two comprehensive volumes, Billings (1996) and Woods et al. (1994). This paper summarizes the pattern that has emerged from our research, related research, incident reports, and accident investigations. It uses this new understanding of why problems arise to point to new investment strategies that can help us deal with the perceived "human error" problem, make automation more of a team player, and maintain and improve safety.

Woods, David D.↗
NASA NTRS1986

Towards automatic Markov reliability modeling of computer architectures

The analysis and evaluation of reliability measures using time-varying Markov models is required for Processor-Memory-Switch (PMS) structures that have competing processes such as standby redundancy and repair, or renewal processes such as transient or intermittent faults. The task of generating these models is tedious and prone to human error due to the large number of states and transitions involved in any reasonable system. Therefore model formulation is a major analysis bottleneck, and model verification is a major validation problem. The general unfamiliarity of computer architects with Markov modeling techniques further increases the necessity of automating the model formulation. This paper presents an overview of the Automated Reliability Modeling (ARM) program, under development at NASA Langley Research Center. ARM will accept as input a description of the PMS interconnection graph, the behavior of the PMS components, the fault-tolerant strategies, and the operational requirements. The output of ARM will be the reliability of availability Markov model formulated for direct use by evaluation programs. The advantages of such an approach are (a) utility to a large class of users, not necessarily expert in reliability analysis, and (b) a lower probability of human error in the computation.

Liceaga, C. A.↗
NASA NTRS1997

Designing to Control Flight Crew Errors

It is widely accepted that human error is a major contributing factor in aircraft accidents. There has been a significant amount of research in why these errors occurred, and many reports state that the design of flight deck can actually dispose humans to err. This research has led to the call for changes in design according to human factors and human-centered principles. The National Aeronautics and Space Administration's (NASA) Langley Research Center has initiated an effort to design a human-centered flight deck from a clean slate (i.e., without constraints of existing designs.) The effort will be based on recent research in human-centered design philosophy and mission management categories. This design will match the human's model of the mission and function of the aircraft to reduce unnatural or non-intuitive interfaces. The product of this effort will be a flight deck design description, including training and procedures, and a cross reference or paper trail back to design hypotheses, and an evaluation of the design. The present paper will discuss the philosophy, process, and status of this design effort.

Schutte, Paul C.↗
NASA NTRS2000

Safety Metrics for Human-Computer Controlled Systems

The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems.This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

Leveson, Nancy G↗
NASA NTRS2000

A Model-based Framework for Risk Assessment in Human-Computer Controlled Systems

The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems. This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions. Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

Hatanaka, Iwao↗
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.↗
NASA NTRSDate not supplied

How Humans Contribute to Safety

We have all heard, and much too often, how human error is the leading cause of accidents. What we haven’t been hearing is how humans produce safety far more often than reduce safety. Before we embark on developing technologies to replace the error-prone human, it behooves us to understand how humans produce safety lest we lose that primary source of resilience in our aviation system.

safety↗
NASA NTRS2004

Error-associated behaviors and error rates for robotic geology

This study explores human error as a function of the decision-making process. One of many models for human decision-making is Rasmussen's decision ladder [9]. The decision ladder identifies the multiple tasks and states of knowledge involved in decision-making. The tasks and states of knowledge can be classified by the level of cognitive effort required to make the decision, leading to the skill, rule, and knowledge taxonomy (Rasmussen, 1987). Skill based decisions require the least cognitive effort and knowledge based decisions require the greatest cognitive effort. Errors can occur at any of the cognitive levels.

error rates↗
NASA NTRS2017

Accounting for the Speed-Accuracy Trade-Off in Quantifying Human-In-The-Loop Error Probabilities

Human-in-the-loop (HITL) simulations cannot collect enough data from human operators to validate estimates of error probabilities for task components. Error rates for tasks have been estimated by using laboratory data for error rates depending on variables such as the cognitive complexity of the task. The limited channel capacity of human operators compels error rates to be strongly related to the time available for the task, the speed-accuracy trade-off. HITL simulations can provide valuable data on the time available for the operator's tasks. We propose that the response times be used in conjunction with measured speed-accuracy curves to estimate the operator error rates contributing to mission failure. Such analyses should be especially important in the estimation of error rates in off-nominal situations.

probability↗
NASA NTRSDate not supplied

Can Resilience Assessments Inform Early Design Human Factors Decision-making?

There is a growing call among researchers for tighter coupling between human factors and human reliability assessments. In this research, we explore if early design stage resilience assessments can help bridge some of the gaps between human factors and human reliability assessments. Resilience in systems is their ability to recover reasonably and operate within acceptable bounds during failures and unexpected events. The fmdtools toolkit allows designers to assess the resilience of a system by modeling the human error and machine-related failure propagation in both nominal and faulty scenarios during the early design stages. As a result, the fmdtools toolkit has a low-fidelity dynamic human reliability assessment component built into it. In this paper, we study if the results from the fmdtools simulations can help inform and prioritize human factors design decision-making, resulting in tighter coupling between human factors and human reliability assessments during the design process. Specifically, we explore the results from a rover design example to understand the types of information that can help guide human factor-related decision-making.

Resilience-based Design↗
NASA NTRS2013

HRA Aerospace Challenges

Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.

DeMott, Diana↗
NASA NTRS2016

Why Do People Make Mistakes?

Multitasking is endemic in modern life and work: drivers talk on cell phones, office workers type while answering phone calls, students do homework while text messaging, nurses prepare injections while responding to doctors calls, and air traffic controllers direct aircraft in one sector while handling additional traffic in another. Whether in daily life or at work, we are constantly bombarded with multiple, concurrent interruptions and demands and we have all somehow come to believe in the myth that we can, and in fact are expected to, easily address them all - without any repercussions. However, accumulating scientific evidence is now suggesting that multitasking increases the probability of human error. This talk presents a set of NASA studies that characterize concurrent demands in one work domain, routine airline cockpit operations, in order to illustrate the ways operational task demands together with the proclivity to manage them all concurrently make human performance in this and in any domain vulnerable to potentially serious errors and to accidents.

multitasking↗
NASA NTRSDate not supplied

Establishing Trust in NASA’s Artemis Campaign Computer-Human Interface (CHI) Implementation

The NASA Artemis program will return humans to the Moon. This time, with the help of commercial and international partners, the program's objective is a permanent moon base. The moon base infrastructure, including an orbiting moon station and moon surface assets, will be developed for astronauts to stay for the long haul to learn to live and work on another planet in preparation for an eventual Humans-to-Mars mission. As the roundtrip communication delays increase in deep space exploration, the crew will need more onboard systems autonomy and functionality to maintain and control the vehicle or habitat. These mission constraints will change the current Earth-based spacecraft to ground control support approach that will demand more safe, efficient, and effective Computer-Human Interface (CHI) control. For Artemis, CHI is defined as the elements that the crew interfaces with: audio, video, lighting, and crew controls subsystems. Understanding how CHI will need to evolve to support deep space missions will be critical for the Artemis program--especially crew controls, which is the focus of this paper. How does NASA ensure crew controls are reliable enough to control complex systems and prevent a catastrophic event due to human error--especially when the astronauts could be physiologically and/or psychologically impaired? NASA's approach to mitigating catastrophic hazards in human spaceflight system development such as crew controls, is through a holistic system engineering and Human System Integration methodology that focuses on incorporating NASA's Human-Rating Requirements-that ensures human performance characteristics to control/safely recover the crew from hazardous situations within the human interface design are considered. This paper discusses, at a high level, CHI for the Artemis program. Next, a discussion of what it means to human-rate a space system crew controls and how trust in the human-computer interface begins with the NASA human rating requirements. Finally, a discussion on how systems engineering and the human system integration process ensures that crew control implementation incorporates the NASA human-rating requirements.

artemis↗
NASA NTRSDate not supplied

Establishing Trust in NASA’s Artemis Campaign Computer-Human Interface (CHI) Implementation

The NASA Artemis program will return humans to the Moon. This time, with the help of commercial and international partners, the program's objective is a permanent moon base. The moon base infrastructure, including an orbiting moon station and moon surface assets, will be developed for astronauts to stay for the long haul to learn to live and work on another planet in preparation for an eventual Humans-to-Mars mission. As the roundtrip communication delays increase in deep space exploration, the crew will need more onboard systems autonomy and functionality to maintain and control the vehicle or habitat. These mission constraints will change the current Earth-based spacecraft to ground control support approach that will demand more safe, efficient, and effective Computer-Human Interface (CHI) control. For Artemis, CHI is defined as the elements that the crew interfaces with: audio, video, lighting, and crew controls subsystems. Understanding how CHI will need to evolve to support deep space missions will be critical for the Artemis program--especially crew controls, which is the focus of this paper. How does NASA ensure crew controls are reliable enough to control complex systems and prevent a catastrophic event due to human error--especially when the astronauts could be physiologically and/or psychologically impaired? NASA's approach to mitigating catastrophic hazards in human spaceflight system development such as crew controls, is through a holistic system engineering and Human System Integration methodology that focuses on incorporating NASA's Human-Rating Requirements-that ensures human performance characteristics to control/safely recover the crew from hazardous situations within the human interface design are considered. This paper discusses, at a high level, CHI for the Artemis program. Next, a discussion of what it means to human-rate a space system crew controls and how trust in the human-computer interface begins with the NASA human rating requirements. Finally, a discussion on how systems engineering and the human system integration process ensures that crew control implementation incorporates the NASA human-rating requirements.

artemis↗
NASA NTRS1994

Advanced automated glass cockpit certification: Being wary of human factors

This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes.

Amalberti, Rene↗
NASA NTRS1990

National plan to enhance aviation safety through human factors improvements

The purpose of this section of the plan is to establish a development and implementation strategy plan for improving safety and efficiency in the Air Traffic Control (ATC) system. These improvements will be achieved through the proper applications of human factors considerations to the present and future systems. The program will have four basic goals: (1) prepare for the future system through proper hiring and training; (2) develop a controller work station team concept (managing human errors); (3) understand and address the human factors implications of negative system results; and (4) define the proper division of responsibilities and interactions between the human and the machine in ATC systems. This plan addresses six program elements which together address the overall purpose. The six program elements are: (1) determine principles of human-centered automation that will enhance aviation safety and the efficiency of the air traffic controller; (2) provide new and/or enhanced methods and techniques to measure, assess, and improve human performance in the ATC environment; (3) determine system needs and methods for information transfer between and within controller teams and between controller teams and the cockpit; (4) determine how new controller work station technology can optimally be applied and integrated to enhance safety and efficiency; (5) assess training needs and develop improved techniques and strategies for selection, training, and evaluation of controllers; and (6) develop standards, methods, and procedures for the certification and validation of human engineering in the design, testing, and implementation of any hardware or software system element which affects information flow to or from the human.

Foushee, Clay↗
NASA NTRSDate not supplied

Artemis Flight Plan Evolution

Current capabilities and processes are insufficient to confidently meet mission objectives given the complexity of humans on the ground and on-orbit working with different automated vehicles. This research aims to reduce risk of human error by providing a consolidated, human-digestible, source of information that can be used in pre-mission through mission execution by all team members involved in spaceflight.

Mission Control↗