Results for “corrective action management” — Page 7

NASA NTRS2008

Integrated Software Systems for Crew Management During Extravehicular Activity in Planetary Terrain Exploration

Initial planetary explorations with the Apollo program had a veritable ground support army monitoring the safety and health of the 12 astronauts who performed lunar surface extravehicular activities (EVAs). Given the distances involved, this will not be possible on Mars. A spacesuit for Mars must be smart enough to replace that army. The next generation suits can do so using 2 software systems serving as virtual companions, LEGACI (Life support, Exploration Guidance Algorithm and Consumable Interrogator) and VIOLET (Voice Initiated Operator for Life support and Exploration Tracking). The system presented in this study integrates data inputs from a suite of sensors into the MIII suit s communications, avionics and informatics hardware for distribution to remote managers and data analysis. If successful, the system has application not only for Mars but for nearer term missions to the Moon, and the next generation suits used on ISS as well. Field tests are conducted to assess capabilities for next generation spacesuits at Johnson Space Center (JSC) as well as the Mars and Lunar analog (Devon Island, Canada). LEGACI integrates data inputs from a suite of noninvasive biosensors in the suit and the astronaut (heart rate, suit inlet/outlet lcg temperature and flowrate, suit outlet gas and dewpoint temperature, pCO2, suit O2 pressure, state vector (accelerometry) and others). In the Integrated Walkback Suit Tests held at NASA-JSC and the HMP tests at Devon Island, communication and informatics capabilities were tested (including routing by satellite from the suit at Devon Island to JSC in Houston via secure servers at VCU in Richmond, VA). Results. The input from all the sensors enable LEGACI to compute multiple independent assessments of metabolic rate, from which a "best" met rate is chosen based on statistical methods. This rate can compute detailed information about the suit, crew and EVA performance using test-derived algorithms. VIOLET gives LEGACI voice activation capability, allowing the crew to query the suit, and receive feedback and alerts that will lead to corrective action. LEGACI and VIOLET can also automatically control the astronaut's cooling and consumable use rate without crew input if desired. These findings suggest that non-invasive physiological and environmental sensors supported with data analysis can allow for more effective management of mission task performance during EVA. Integrated remote and local view of data metrics allow crewmember to receive real time feedback in synch with mission control in preventing performance shortcomings for EVA in exploration missions.

Kuznetz, Lawrence↗

NASA NTRS1975

Apollo experience report: Flight anomaly resolution

The identification of flight anomalies, the determination of their causes, and the approaches taken for corrective action are described. Interrelationships of the broad range of disciplines involved with the complex systems and the team concept employed to ensure timely and accurate resolution of anomalies are discussed. The documentation techniques and the techniques for management of anomaly resolution are included. Examples of specific anomalies are presented in the original form of their progressive documentation. Flight anomaly resolution functioned as a part of the real-time mission support and postflight testing, and results were included in the postflight documentation.

Lobb, J. D.↗

DOE OSTI2023

Performance Assessment for the Disposal of Low-Level Waste in the 200 West Area Burial Grounds (Annual Status Report FY 2022)

This annual review provides the projected dose estimates of radionuclide inventories disposed in the active 200 West Area Low-Level Waste Burial Grounds (LLBGs) since September 26, 1988. These estimates are calculated using the original dose methodology developed in the performance assessment (PA) analysis (WHC-EP-0645). The estimates are compared with the performance objectives defined in U.S. Department of Energy requirements (DOE O 435.1 and its companion documents DOE M 435.1-1 and DOE-STD-5002-2017). All performance objectives are currently satisfied, and operational waste acceptance criteria (HNF-EP-0063) and waste acceptance practices continue to be sufficient to maintain compliance with performance objectives. Inventory estimates and associated dose estimates from future waste disposal actions are unchanged from previous years’ evaluations that indicate potential impacts well below performance objectives; therefore, future compliance with DOE O 435.1 is expected. Within the active burial grounds, low-level and mixed low-level waste currently may be disposed only in two lined trenches in the 218-W-5 Burial Ground (Trenches 31 and 34) until they are either filled or a decision is made to close these trenches. Some mixed low-level waste is also disposed at the Environmental Restoration Disposal Facility in the 200 West Area (which is covered under a separate PA). During this (fiscal year 2022) reporting period (October 1, 2021, through September 30, 2022), waste was disposed to the 200 West Area LLBGs. Continued groundwater monitoring of the 200 West Area LLBGs indicates no groundwater contamination due to LLBG waste. Current assumptions about future land use at the Hanford Site are consistent with PA analysis assumptions of a postclosure facility that will not be degraded by human activity. The LLBGs are in an area identified for waste management and containment of residual contamination (DOE/EIS-0391). The current closure plan for the LLBGs (DOE/RL-2000-70) estimates that the 200 West LLBGs will be closed in the 2050 timeframe. The Disposal Authorization Statement, other technical basis documents, and the radioactive waste management basis are of continued adequacy to meet the performance objectives of DOE O 435.1. Overall, there are no substantive changes to primary PA assumptions and no changes to the PA analysis conclusion; therefore, compliance with DOE O 435.1 and the Disposal Authorization Statement is maintained. A new PA to evaluate the long-term impacts of three disposal trenches that are currently active within the 200 East and 200 West Areas (Trench 94 in the 200 East Area and Trenches 31 and 34 in the 200 West Area) was initiated in fiscal year 2019 and completed in fiscal year 2022. Corrective actions addressing 3 key issues and 31 secondary issues identified during the review process were developed and submitted to the Low-Level Waste Disposal Facility Federal Review Group Co-Chairs for review and approval. This PA provides additional technical basis for the continued adequacy of the existing Operating Disposal Authorization Statement.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

NASA NTRS2026

Spacecraft Water Impurity Monitor, a System for Water Quality Analysis on Exploration Missions Beyond Low Earth Orbit

Exploration missions beyond low-earth-orbit (LEO) will require advanced instrumentation to monitor water quality. Traveling beyond LEO means the transfer of water samples to an Earth-based laboratory for detailed analysis is not feasible. Detailed analysis of water composition during exploration is still necessary, because having the capability to determine the specific organic chemical causing a change in total organic carbon (TOC) or the specific metal or ionic species causing a change in conductivity has the potential to inform the crew health and system management decisions. On a new vehicle such as a lunar or Mars surface habitat or a Mars transit vehicle, finding “new” impurities not seen on ISS should be expected. The key is to identify the impurity so the correct action can be taken. On ISS we can measure TOC, conductivity, and other physical properties but do not have the capability for detailed analysis using vehicle instrumentation. This is acceptable because ISS can send samples down to Earth for further analysis and obtain the detailed composition. The Spacecraft Water Impurity Monitor (SWIM) will provide detailed water quality analysis for missions in which sample down mass is not available. SWIM is a system comprising organic and inorganic analysis modules. For organic chemicals, a gas chromatograph mass spectrometer (GCMS) detects and identifies organic impurities. For inorganic species, a capillary electrophoresis capacitively coupled contactless conductivity detection (CE-C4D) system as well as ion specific electrodes detect and identify metal ions and other inorganic salts / acids. The SWIM technology demonstration project has completed a System Requirements Review (SRR) to finalize detection requirements and is currently working to refine vehicle interface requirements for a future technology demonstration. The project also has begun preliminary flight design activities for the core analyzers in the instrument suite.

Water Monitoring↗

NASA NTRS2026

Spacecraft Water Impurity Monitor, a System for Water Quality Analysis on Exploration Missions Beyond Low Earth Orbit

Exploration missions beyond low-earth-orbit (LEO) will require advanced instrumentation to monitor water quality. Traveling beyond LEO means the transfer of water samples to an Earth-based laboratory for detailed analysis is not feasible. Detailed analysis of water composition during exploration is still necessary, because having the capability to determine the specific organic chemical causing a change in total organic carbon (TOC) or the specific metal or ionic species causing a change in conductivity has the potential to inform the crew health and system management decisions. On a new vehicle such as a lunar or Mars surface habitat or a Mars transit vehicle, finding “new” impurities not seen on ISS should be expected. The key is to identify the impurity so the correct action can be taken. On ISS we can measure TOC, conductivity, and other physical properties but do not have the capability for detailed analysis using vehicle instrumentation. This is acceptable because ISS can send samples down to Earth for further analysis and obtain the detailed composition. The Spacecraft Water Impurity Monitor (SWIM) will provide detailed water quality analysis for missions in which sample down mass is not available. SWIM is a system comprising organic and inorganic analysis modules. For organic chemicals, a gas chromatograph mass spectrometer (GCMS) detects and identifies organic impurities. For inorganic species, a capillary electrophoresis capacitively coupled contactless conductivity detection (CE-C4D) system as well as ion specific electrodes detect and identify metal ions and other inorganic salts / acids. The SWIM technology demonstration project has completed a System Requirements Review (SRR) to finalize detection requirements and is currently working to refine vehicle interface requirements for a future technology demonstration. The project also has begun preliminary flight design activities for the core analyzers in the instrument suite.

Water Monitoring↗

NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗

NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗

NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗

NASA NTRS1995

A fuzzy logic intelligent diagnostic system for spacecraft integrated vehicle health management

Due to the complexity of future space missions and the large amount of data involved, greater autonomy in data processing is demanded for mission operations, training, and vehicle health management. In this paper, we develop a fuzzy logic intelligent diagnostic system to perform data reduction, data analysis, and fault diagnosis for spacecraft vehicle health management applications. The diagnostic system contains a data filter and an inference engine. The data filter is designed to intelligently select only the necessary data for analysis, while the inference engine is designed for failure detection, warning, and decision on corrective actions using fuzzy logic synthesis. Due to its adaptive nature and on-line learning ability, the diagnostic system is capable of dealing with environmental noise, uncertainties, conflict information, and sensor faults.

Wu, G. Gordon↗

NASA NTRS2019

Human Performance Contributions to Safety in Commercial Aviation

Every day in aviation, pilots, air traffic controllers, and other front-line personnel perform countless correct judgments and actions in a variety of operational environments. These judgments and actions are often the difference between an accident and a non-event. Ironically, data on these behaviors are rarely collected or analyzed. Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence how decision makers characterize problems and identify solutions. Large volumes of data are collected on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that result in routine successful outcomes, safety management and system design decisions are based on a small sample of nonrepresentative safety data. This assessment aimed to find and document “safety successes” made possible by human operators. With many Aeronautics Research Mission Directorate (ARMD) Programs and Projects focusing on increased automation and autonomy and decreased human involvement, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant risk — a risk that has not been recognized to date. Without understanding how humans contribute to safety, any estimate of predicted safety of autonomous capabilities is incomplete and inherently suspect. Furthermore, understanding the ways in which humans contribute to safety can promote strategic interactions among safety technologies, functions, procedures and the people using them. Without this understanding, the full benefits of an integrated, optimized human/technology or autonomous system will not be realized. Historically, safety has been consistently defined in terms of the occurrence of accidents or recognized risks (i.e., in terms of things that go wrong). These adverse outcomes are explained by identifying their causes, and safety is restored by eliminating or mitigating these causes. An alternative to this approach is to focus on what goes right and identify how to replicate that process. Focusing on the rare cases of failures attributed to “human error” provides little information about why human performance routinely prevents adverse events. Hollnagel has proposed that things go right because people continuously adjust their work to match their operating conditions. These adjustments become increasingly important as systems continue to grow in complexity. Thus, the definition of safety should reflect not only “avoiding things that go wrong” but “ensuring that things go right.” The basis for safety management requires developing an understanding of everyday activities. However, few mechanisms to monitor everyday work exist in the aviation domain, which limits opportunities to learn how designs function in reality. This concept of safety thinking and safety management is reflected in the emerging field of resilience engineering. According to Hollnagel, a system is resilient if it can sustain required operations under expected and unexpected conditions by adjusting its functioning prior to, during, or following changes, disturbances, and opportunities. To explore “positive” behaviors that contribute to resilient performance in commercial aviation, the assessment team examined a range of existing sources of data about pilot and air traffic control (ATC) tower controller performance, including subjective interviews with domain experts and objective aircraft flight data records. These data were used to identify strategies that support resilient performance, methods for exploring and refining those strategies in existing data, and proposed methods for capturing and analyzing new data.

Null, Cynthia H.↗

NASA NTRS1987

Environmental projects. Volume 3: Environmental compliance audit

The Goldstone Deep Space Communications Complex is part of NASA's Deep Space Network, one of the world's largest and most sensitive scientific telecommunications and radio navigation networks. Activities at Goldstone are carried out in support of six large parabolic dish antennas. In support of the national goal of the preservation of the environment and the protection of human health and safety, NASA, JPL and Goldstone have adopted a position that their operating installations shall maintain a high level of compliance with Federal, state, and local laws governing the management of hazardous substances, abestos, and underground storage tanks. A JPL version of a document prepared as an environmental audit of Goldstone operations is presented. Both general and specific items of noncompliance at Goldstone are identified and recommendations are provided for corrective actions.

Source record↗

DOE OSTI2025

Fostering Nuclear Security Culture through Effective Leadership: An Operational Perspective

Security culture plays a critical role in determining the effectiveness of an organization's security performance, making its significance impossible to overemphasize. It encompasses the collective values, shared perceptions, and habitual actions embraced by all individuals within a nuclear organization—from leadership to frontline staff. When the entire workforce recognizes the reality of potential threats, accepts that security is a shared duty, and integrates security-minded behavior into everyday routines, it fosters an environment where strong security practices are the norm. In such a setting, everyone can take pride and feel reassured in being part of an organization where a strong security culture is deeply embedded. Security culture is based on the broader concept of organizational culture. All organizations—whether families, social clubs, religious institutions, businesses, non-governmental organizations, or governments—possess an underlying culture shaped by core values and beliefs. These values and beliefs influence attitudes and drive behavior throughout the organization. While multiple factors contribute to the development of a strong security culture, leadership plays a particularly pivotal role. In organizations where security culture is well-established, leaders go beyond rhetoric; they demonstrate a genuine commitment to security through their actions. They implement policies and procedures that actively engage all employees, foster open dialogue around security concerns, and encourage teamwork in resolving issues. Furthermore, they reward proactive behavior and ensure that corrective actions are taken promptly. Regular assessments of the organization's security culture allow such leaders to gauge its effectiveness and take strategic steps to strengthen it when necessary. This paper leverages practical, real-world experience to guide leadership and senior management within nuclear organizations through the foundational steps of cultivating a robust, organization-wide culture of nuclear security. It emphasizes the critical importance of early leadership engagement in shaping this culture and outlines a comprehensive approach that includes strategic, tactical, and operational measures. Additionally, it explores methods for fostering a unified vision across all levels of the organization to ensure alignment, commitment, and continuous improvement in nuclear security practices.

Zineddin, Dr. Z. [ORNL] (ORCID:0009000848740725)↗

DOE OSTI2024

Continuous thermostat setpoint monitoring and correction (Thermostat setpoint correction) v1.0

The Continuous Thermostat Setpoint Monitoring and Correction software is a set of fault detection and correction algorithms that can be implemented in thermostats with two-way OpenAPIs. It is written in the Python language. The algorithms aim to detect the most common and impactful efficiency problems associated with thermostat setpoints - overly aggressive heating or cooling setpoints, incorrect schedules/setbacks, and overly narrow deadbands. These algorithms can automatically detect faults, and implement associated corrective actions to bring the system back to a state of efficient operation. The algorithms can run remotely in the cloud, and directly implemented by connected thermostat manufacturers, or by third party service providers. The software enables a lightweight cost-effective energy management strategy for HVAC systems. The solution is specially viable for small and medium sized commercial buildings, where a full scale building automation system and fault detection and diagnostic tools are often unavailable.

Granderson, Jessica↗

NASA NTRS2015

Risk of Performance and Behavioral Health Decrements Due to Inadequate Cooperation, Coordination, Communication, and Psychosocial Adaptation within a Team

A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).

Landon, Lauren Blackwell↗

DOE OSTI2025

Calendar Year 2024 Underground Test Area Annual Sampling Letter Report, Nevada National Security Site, Nevada, Rev. 1

The Underground Test Area (UGTA) Sampling Plan for Corrective Action Units (CAUs) 101 and 102: Central and Western Pahute Mesa, Nevada National Security Site (NNSS), Nevada (referred to herein as “the Plan”) (DOE/EMNV, 2025) describes the approach for collecting and analyzing groundwater samples to meet the objectives of the U.S. Department of Energy (DOE), Environmental Management (EM) Nevada Program’s UGTA Activity. The Plan is designed to ensure compliance with the UGTA Quality Assurance Plan (QAP) (DOE/EMNV, 2024), and the Federal Facility Agreement and Consent Order (FFACO) (1996, as amended).

54 ENVIRONMENTAL SCIENCES↗

NASA NTRS2014

Application of Fault Management Theory to the Quantitative Selection of a Launch Vehicle Abort Trigger Suite

The theory of System Health Management (SHM) and of its operational subset Fault Management (FM) states that FM is implemented as a "meta" control loop, known as an FM Control Loop (FMCL). The FMCL detects that all or part of a system is now failed, or in the future will fail (that is, cannot be controlled within acceptable limits to achieve its objectives), and takes a control action (a response) to return the system to a controllable state. In terms of control theory, the effectiveness of each FMCL is estimated based on its ability to correctly estimate the system state, and on the speed of its response to the current or impending failure effects. This paper describes how this theory has been successfully applied on the National Aeronautics and Space Administration's (NASA) Space Launch System (SLS) Program to quantitatively estimate the effectiveness of proposed abort triggers so as to select the most effective suite to protect the astronauts from catastrophic failure of the SLS. The premise behind this process is to be able to quantitatively provide the value versus risk trade‐off for any given abort trigger, allowing decision makers to make more informed decisions. All current and planned crewed launch vehicles have some form of vehicle health management system integrated with an emergency launch abort system to ensure crew safety. While the design can vary, the underlying principle is the same: detect imminent catastrophic vehicle failure, initiate launch abort, and extract the crew to safety. Abort triggers are the detection mechanisms that identify that a catastrophic launch vehicle failure is occurring or is imminent and cause the initiation of a notification to the crew vehicle that the escape system must be activated. While ensuring that the abort triggers provide this function, designers must also ensure that the abort triggers do not signal that a catastrophic failure is imminent when in fact the launch vehicle can successfully achieve orbit. That is, the abort triggers must have low false negative rates to be sure that real crew‐threatening failures are detected, and also low false positive rates to ensure that the crew does not abort from non‐crew‐threatening launch vehicle behaviors. The analysis process described in this paper is a compilation of over six years of lessons learned and refinements from experiences developing abort triggers for NASA's Constellation Program (Ares I Project) and the SLS Program, as well as the simultaneous development of SHM/FM theory. The paper will describe the abort analysis concepts and process, developed in conjunction with SLS Safety and Mission Assurance (S&MA) to define a common set of mission phase, failure scenario, and Loss of Mission Environment (LOME) combinations upon which the SLS Loss of Mission (LOM) Probabilistic Risk Assessment (PRA) models are built. This abort analysis also requires strong coordination with the Multi‐Purpose Crew Vehicle (MPCV) and SLS Structures and Environments (STE) to formulate a series of abortability tables that encapsulate explosion dynamics over the ascent mission phase. The design and assessment of abort conditions and triggers to estimate their Loss of Crew (LOC) Benefits also requires in‐depth integration with other groups, including Avionics, Guidance, Navigation and Control(GN&C), the Crew Office, Mission Operations, and Ground Systems. The outputs of this analysis are a critical input to SLS S&MA's LOC PRA models. The process described here may well be the first full quantitative application of SHM/FM theory to the selection of a sensor suite for any aerospace system.

Lo, Yunnhon↗

NASA NTRS2011

NASA Accident Precursor Analysis Handbook, Version 1.0

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.

Groen, Frank↗

NASA NTRS2024

False Cape Data Collection Annex, Solid Waste Management Unit 113, Limited Resource Conservation and Recovery Act Facility Investigation Report, Kennedy Space Center, Florida

This Resource Conservation and Recovery Act (RCRA) Facility Investigation (RFI) Report summarizes groundwater investigation activities performed between July 2020 and October 2023 at the False Cape Data Collection Annex (FCDC) (Solid Waste Management Unit [SWMU] 113) located at Kennedy Space Center, Florida. The purpose of the RFI is to characterize the nature and extent of volatile organic compound (VOC)-contaminated groundwater at FCDC; evaluate the fate and transport of VOC contamination; collect sufficient data to evaluate potential future requirements for the site, such as corrective measures, long term monitoring, or No Further Action; and conduct a human health preliminary risk evaluation (PRE) based on the groundwater data.

False Cape Data Collection Annex↗