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At least 163 records · Page 9
All sourcesNASA NTRSDOE OSTI
NASA NTRS1974

An analysis of pilot error-related aircraft accidents

A multidisciplinary team approach to pilot error-related U.S. air carrier jet aircraft accident investigation records successfully reclaimed hidden human error information not shown in statistical studies. New analytic techniques were developed and applied to the data to discover and identify multiple elements of commonality and shared characteristics within this group of accidents. Three techniques of analysis were used: Critical element analysis, which demonstrated the importance of a subjective qualitative approach to raw accident data and surfaced information heretofore unavailable. Cluster analysis, which was an exploratory research tool that will lead to increased understanding and improved organization of facts, the discovery of new meaning in large data sets, and the generation of explanatory hypotheses. Pattern recognition, by which accidents can be categorized by pattern conformity after critical element identification by cluster analysis.

Kowalsky, N. B.↗
NASA NTRS2018

A Prognostic Launch Vehicle Probability of Failure Assessment Methodology for Conceptual Systems Predicated on Human Causal Factors

Create an improved method to calculate reliability of a conceptual launch vehicle system prior to fabrication by using historic data of actual root causes of failures. While failures have unique "proximate causes", there are typically a finite amount of common "root causes". Heretofore launch vehicle reliability evaluation typically hardware-centric statistical analyses, while most root causes of failures are been shown to be human-centric. A method based on human-centric root causes can be used to quantify reliability assessments and focus proposed actions to mitigate problems. Existing methods have been optimistic in their projections of launch vehicle reliability compared to actuals. Hypothesis: reliability of a conceptual launch vehicle can be more accurately evaluated based on a rational, probabilistic approach using past failure assessment teams' findings predicated on human-centric causes."Human Reliability Analysis Methods Selection Guidance for NASA"Chandler F.T., et al., NASA HQ/OSMA study group, July 2006. Outside HRA experts from academia, other federal labs, and the private sector. 50 system reliability methods considered, fourteen selected for further study, four finally selected as best suited for human spaceflight. Probabilistic Risk Analysis (PRA) + Human Reliability Analysis (HRA) enabled incorporating effects and probabilities of human errors. While four down-selected methods deemed appropriate for failure assessment, it did not appear that these methods could be concisely applied to perform major system-wide assessment of probability of failure of a conceptual design without becoming unwieldy."Engineering a Safer World", Detailed, comprehensive study external to NASA Leveson N. G., MIT, 2011.Systems-Theoretic Accident Model and Processes (STAMP). All-encompassing accident model based on systems theory analyzed accidents after they occurred and created approaches to prevent occurrence in developing systems not focused on failure prevention per se, but rather reducing hazards by influencing human behavior through use of constraints, hierarchical control structures, and process models to improve system safetySystem Theoretic Process Analysis (STPA) addresses predictive part of problem (a "hazard analysis"). Includes all causal factors identified in STAMP: "...design errors, software flaws, component interaction accidents, cognitively complex human decision-making errors, and social organizational and management factors contributing to accidents" can guide design process rather than require it to exist before-hand did not appear capable of concise application for system-wide assessment of probability of failure of a conceptual design without becoming unwieldy.

Williams, Craig H.↗
NASA NTRS2011

The Psychology of Safety

Many studies of mishaps show that human error is a factor in a significant majority of accidents. Trying to decide how to change human behavior to be safer is generally the biggest challenge of any safety program. However, understanding the human psyche is the first step to changing behavior. Many studies focus on the before and after of an accident, but what about the thoughts of a person in the commission of an unsafe act? This is a less understood area. Examining it reveals why it is not well comprehended. This paper attempts to examine a part of the thought process, with an eye to helping influence people to less hurtful actions.

Anderson, Brenda Lindley↗
NASA NTRSDate not supplied

Manual Crew Override of Vehicle Landings Following G-Transitions

BACKGROUND Manual control during exploration spaceflight consists of both planned automated supervisory control and unplanned crew override. This crew override capability is critical to enable overall mission success during landing contingencies. However, the introduction of manual override capabilities must be implemented to enable crews to mitigate risks introduced by human error. Adaptive changes in the sensorimotor system can manifest during g-transitions as spatial disorientation. While training and landing aids enable successful landing through disorientation, these adaptive changes may increase cognitive demand that needs to be accounted for in the manual control strategy. It is important to characterize these effects as soon as possible following the G-transition to develop appropriate countermeasures. METHODS In this study, we will examine operational piloting tasks following International Space Station (ISS) missions in a simulated lunar landing using a six-degree-of-freedom (6DOF) motion base. The motion-based simulation will be implemented in our laboratory at the Johnson Space Center (JSC) and will be available within hours following the return from commercial crew landings. The primary goals of this study are (1) to understand the impact of spaceflight on crew ability to perform manual crew override tasks, (2) to examine how adaptive changes in vestibular and cognitive function relate to changes in manual crew override proficiency, and (3) compare performance during late “just-in-time” on-board training with early post-flight crew performance. The impact of spaceflight on piloting capability will be assessed from pre- versus post-flight changes in crewmembers assigned to either short duration (< 30 day) or long duration (~6- month) missions to the International Space Station (ISS). Individual differences in post-flight vestibular and cognitive changes include motion sickness reports, measures of tilt motion perception accuracy and precision, and dual-task tracking. During the 6DOF lunar simulation, the crew will manually takeover attitude and rate-of-descent to the nominal or re-designated landing aim point during the approach phase. The outcome measures for the lunar crew override tasks will be the percent time maintaining actual vehicle states, e.g., attitude and rate-of-descent, within recommended guidance during the landing approach, number and maximum deviation outside limits, and root mean square error (RMSE). Given that “just-in-time” (JIT) training is an operational expectation for the Human Landing System (HLS) program, all participants will perform late inflight JIT training for each manual crew override task in which they will participate. Crew proficiency will be captured inflight during JIT training that will be implemented on a laptop with hand controllers to allow the crewmember to practice the landing task procedures like the approach implemented for JIT training with Shuttle landing and ISS telerobotic tasks. COUNTERMEASURE UPDATES The lunar lander simulation has been implemented onto a two-laptop display system where subjects select from alternative landing points, based upon avoiding hazards that the on-board system identifies during the landing. The subject makes inputs using a rotational hand controller (i.e., joystick) and a translational hand controller, which are processed by simulated vehicle dynamics to update the vehicle attitude and rate of descent. Subjects will utilize a combination of flight, situation, and status displays to monitor the state of the simulated vehicle. The simulation exports tilt and translation movements to a 6DOF motion base synced to visual movements and provides representative vestibular cues to the subject while performing the task inside an enclosed cabin featuring a simulated lunar out-the-window view and a heads-down lander cockpit view. RELEVANCE This project will deliver an operational demonstration of crew override capability following spaceflight and identify potential deficits that may require remediation. Comparison of individual vestibular and cognitive changes with crew override performance will help better characterize the manual control risks associated with sensorimotor alterations. The inclusion of “just-in-time” on-board training will ensure we are characterizing changes in override proficiency with this expected countermeasure in place. ACKNOWLEDGEMENTS: The authors acknowledge contributions from Draper, HLS Joint Test Panel, Crew HLS Interfaces for Piloting Working Group, and Dynamic Skills Trainer (DST) Lab toward the development of the lunar landing simulation. This project is funded by the Human Health Countermeasures Element.

Austin M Bollinger↗
NASA NTRS2002

Skills, rules and knowledge in aircraft maintenance: errors in context

Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.

Aircraft↗
NASA NTRS1988

Human operator response to error-likely situations in complex engineering systems

The causes of human error in complex systems are examined. First, a conceptual framework is provided in which two broad categories of error are discussed: errors of action, or slips, and errors of intention, or mistakes. Conditions in which slips and mistakes might be expected to occur are identified, based on existing theories of human error. Regarding the role of workload, it is hypothesized that workload may act as a catalyst for error. Two experiments are presented in which humans' response to error-likely situations were examined. Subjects controlled PLANT under a variety of conditions and periodically provided subjective ratings of mental effort. A complex pattern of results was obtained, which was not consistent with predictions. Generally, the results of this research indicate that: (1) humans respond to conditions in which errors might be expected by attempting to reduce the possibility of error, and (2) adaptation to conditions is a potent influence on human behavior in discretionary situations. Subjects' explanations for changes in effort ratings are also explored.

Morris, Nancy M.↗
DOE OSTI2023

Development of a hybrid neural network and transfer learning model for optimized ICP-MS/MS operation

Correct function and calibration of instrumentation is a crucial assumption for any scientific experiment. One such instrument, tandem inductively coupled plasma mass spectrometer (ICP-MS/MS), has in-depth calibration settings that range across 30+ different parameters, making it difficult to determine optimal conditions without expertise and some degree of trial and error. Often, these settings are hand-tuned, a time-intensive process prone to local maxima and human error. While some automation is available, the automation also may favor local optimizations over a global optimum. In addition to these difficulties, day to day instrument variability can further complicate the calibration process. We propose a solution to this problem as a machine learning (ML) algorithm that learns how each parameter helps determine the calibration sensitivity across several elements, and re-weights parameters over time as instrument variability changes (e.g., a global neural network (NN) with a time-dependent transfer learning (TL) component). This model would be able to generate a surface of predicted calibration sensitivities and their respective parameters, and a simple multivariate algorithm would be able to pull out the optimum results with the settings associated with them. Here-in, we describe our initial findings in working towards this goal, including data extraction from historical files, exploratory data analysis, and some initial model building to better describe the data and the feasibility of our goal.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗
NASA NTRS2011

Man-Machine Integration Design and Analysis System (MIDAS) v5: Augmentations, Motivations, and Directions for Aeronautics Applications

As automation and advanced technologies are introduced into transport systems ranging from the Next Generation Air Transportation System termed NextGen, to the advanced surface transportation systems as exemplified by the Intelligent Transportations Systems, to future systems designed for space exploration, there is an increased need to validly predict how the future systems will be vulnerable to error given the demands imposed by the assistive technologies. One formalized approach to study the impact of assistive technologies on the human operator in a safe and non-obtrusive manner is through the use of human performance models (HPMs). HPMs play an integral role when complex human-system designs are proposed, developed, and tested. One HPM tool termed the Man-machine Integration Design and Analysis System (MIDAS) is a NASA Ames Research Center HPM software tool that has been applied to predict human-system performance in various domains since 1986. MIDAS is a dynamic, integrated HPM and simulation environment that facilitates the design, visualization, and computational evaluation of complex man-machine system concepts in simulated operational environments. The paper will discuss a range of aviation specific applications including an approach used to model human error for NASA s Aviation Safety Program, and what-if analyses to evaluate flight deck technologies for NextGen operations. This chapter will culminate by raising two challenges for the field of predictive HPMs for complex human-system designs that evaluate assistive technologies: that of (1) model transparency and (2) model validation.

Gore, Brian F.↗
NASA NTRSDate not supplied

Resilience Modeling in Complex Engineered Systems with Human-Machine Interactions

In recent times, there has been a growing interest in resilience-based design. Resilience-based design operates on the concept that failures and unexpected events will happen, and when they occur, complex engineered systems should be able to operate within acceptable bounds and recover reasonably. Humans can contribute to the resilience of a system by quickly detecting unforeseen events and taking corrective measures. To this effect, researchers have proposed guidelines and design approaches that can help promote human-system resilience. However, there is no early design stage tool to validate if a system is indeed resilient after applying these guidelines and design methods. In this research, we integrate the Human Error and Functional Failure Reasoning (HEFFR) framework into the fmdtools toolkit to enable designers to model the combined (machine, human, and joint) failures, including their propagation and dynamic effects, during early design stages. This integrated tool also allows designers to model the effects of performance shaping factors, team dynamics, and human-machine interactions in systems of systems. A demonstrative example of a remotely operated rover is explored to demonstrate how this approach can be applied to understand resilience in complex engineered systems with human interactions.

Lukman Irshad↗
NASA NTRSDate not supplied

Multitasking

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 doctor’s 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 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 routine airline flight 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↗
DOE OSTI2022

Demonstration and Evaluation of the Human-Technology Integration Function Allocation Methodology

There is an imminent need for the existing nuclear power plants to reduce their operating and maintenance (O&M) costs to remain economically viable. Digital technology, including automation, provides a significant opportunity for the existing nuclear power plant fleet to transform the way in which work is accomplished, reducing O&M costs, and allowing the fleet to remain economically competitive. One notable opportunity to significantly reduce O&M costs pertains to modifications to the plant equipment and main control room (MCR). Existing instrumentation and control (I&C) technologies in the MCR are highly analog, costly to operate and maintain, and demand a high cognitive and physical workload from plant staff (i.e., operators). Digitalizing the MCR has a range of broad economic benefits, including improved plant performance and reduced manual work. Further, digital I&C systems can fundamentally change the way in which plant staff operate the plant; this is the concept of operation. Human-technology integration is important to ensure that impacts to the concept of operation are done in a way that account for capabilities of people and technology. Human-technology integration employs human factors engineering (HFE) methods and principles to maximize the benefits of digital technology, reducing human error, improving overall decision-making and usability. The U.S. Department of Energy Light Water Reactor Sustainability Program is applying human-technology integration research to ensure digital technologies are safe, reliable, and efficient. This paper documents the demonstration of the human-technology guidance developed by the Light Water Reactor Sustainability Program from a first-of-a-kind digital I&C upgrade, specifically addressing function analysis and allocation for a new digital I&C system that included changes in automation levels. The program’s specific approach is included in this work, following lessons learned. This document serves as a resource for industry to follow in applying human-technology integration and HFE to digital modifications, specific to function analysis and allocation. The lessons learned should be considered in the planning and execution of HFE activities that support such digital modifications.

99 GENERAL AND MISCELLANEOUS↗
NASA NTRS1985

Investigation of technology needs for avoiding helicopter pilot error related accidents

Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.

Chais, R. I.↗
NASA NTRS1988

Human factors: Aeronautics

The objectives of the Aeronautics Human Factors Research and Technology program are to provide the technology base and capability to design effective crew-cockpit systems and to advance solutions to human problems affecting air transport and rotorcraft effectiveness and safety. Advanced automation technologies, information display capabilities under computer control, and concern for the effects of human error in flight operations are elements which drive the directions of the program. Thus, the program has four thrusts: flight management, human engineering methods, rotorcraft, and subsonic transports.

Jenkins, James P.↗
NASA NTRS2012

Human Systems Engineering for Launch processing at Kennedy Space Center (KSC)

Launch processing at Kennedy Space Center (KSC) is primarily accomplished by human users of expensive and specialized equipment. In order to reduce the likelihood of human error, to reduce personal injuries, damage to hardware, and loss of mission the design process for the hardware needs to include the human's relationship with the hardware. Just as there is electrical, mechanical, and fluids, the human aspect is just as important. The focus of this presentation is to illustrate how KSC accomplishes the inclusion of the human aspect in the design using human centered hardware modeling and engineering. The presentations also explain the current and future plans for research and development for improving our human factors analysis tools and processes.

Henderson, Gena↗
NASA NTRS2018

The Story of Multitasking

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...but, nurses also prepare injections while responding to doctor's calls, and air traffic controllers direct aircraft in one sector while handling aircraft 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. Accumulating 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 natural proclivity to manage them all concurrently make human performance in this and in any work domain vulnerable to potentially serious errors and to accidents.

Barshi, Immanuel↗
NASA NTRSDate not supplied

Design and Applications of Tethered Spacecraft Simulators

Small, tethered spacecraft, or space tugs, are a promising space capability. They can be deployed on tethers and used for a wide variety of in-space activities; a large portion of which fall under in-space servicing, assembly, manufacturing (ISAM) functions. This includes functions such as structural mating and assembly, servicing, proximity operations, capture, docking, mating, and relocation. However, there is a great deal of work to be done to raise the Technology Readiness Level (TRL) of the capabilities needed to fully realize these capabilities. The Flat Floor Robotics Lab (FFRL) at NASA’s Marshall Spaceflight Center (MSFC) has been working on space tug development for several years. The eponymous floor is 44 by 86 feet, made from a self-leveling epoxy. This creates an extremely smooth surface that air bearings can float on with very little friction, creating a simulation of zero gravity in a two-dimensional plane. The lab has several platforms of various sizes that act as vehicle simulators for testing sensors, control algorithms, mechanisms, etc. One of these platforms is a small spacecraft simulator, which can be tethered to simulate a space tug. In the last several months, the FFRL team has been working with MSFC’s welding group to conduct a laser beam welding demonstration on air bearing platforms. This demo is utilizing a space tug simulator to fly up to a floating weld platform, where two parts are clamped together and laser welded. The space tug simulator has an air bearing to provide float, as well as several actuated air thrusters to provide propulsion and make the simulator maneuverable. Currently, flights of this simulator are completed by a human operator. An RF hand controller sends signals to both actuate and fire three sets of thrusters on the simulator. This makes any maneuvers of the space tug highly subject to human error, and operators must have dedicated practice time before being able to perform maneuvers with any sufficient reliability. For the current laser welding demonstration, human operated performance is sufficient, but future implementations of in-space welding and other ISAM efforts will require higher precision, reliability, and autonomy. MSFC has funded a project that will allow a small team in the FFRL to develop the next generation of space tug simulator, which will be automated. Closed loop control will allow a user to command a position, or set of positions, that the simulator will be able to “fly” to on its own. This Maneuverable Automated Tethered Spacecraft (MATS) simulator will have configurable design, to allow a variety of payloads and mission configurations to be demonstrated on the air bearing floor. This will be an invaluable test bed for low and mid TRL advancement for space tether mission subsystems, such as more advanced demonstrations of in-space welding. Once one MATSS is constructed and demonstrated effectively, several more can be built, enabling more advanced tether missions; Electric Sail test beds, sensor arrays, and other science-enabling missions. This paper will detail the design and test of the FFRL’s MATS simulator, including efforts to establish closed loop control and autonomous capabilities. It will also detail use cases for this technology, and how it will further develop both develop science and exploration missions.

Space Tethers↗
DOE OSTI2025

The Impact of Cultural Values and Organizational Processes on Nuclear Security Operations

Human performance is a pivotal factor in the design, testing, maintenance, and operation of security systems. The effectiveness of these systems relies not only on the capabilities, limitations, motives, and attitudes of the individuals involved, but also on the quality of training, instructional content, and evaluation methods provided. To uphold security standards, seamless integration between technologies and operators necessitates reliable human input. In security operations, human errors, often attributed to blame, sanctions, low motivation, individual accountability, or complacency, are primary causes of system failures. Complacency, characterized by a false sense of security, reflects a lack of awareness of potential threats and is a significant contributing factor to lapses in security. Security incidents arise from various factors, many extend beyond individual control, highlighting the need for a holistic approach to human performance that integrates organizational processes and team collaboration. Historically, errors have been attributed to individual moral or cognitive failures. However, insights from Operational Experiences (OEs) suggest that organizational processes weakness and deficiencies in nuclear cultural values contribute more significantly to security failures than individual mistakes. This paper consolidates lessons learned from diverse international nuclear security cultures and aims to highlight the importance of security culture in shaping global perspectives on nuclear security. It underscores the role of cultural values in shaping nuclear security practices and enhancing the resilience of security systems in the nuclear sector.

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