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Guidance for Human Error Analysis (HEA)

NASA’s Human-Rating Requirements for Space Systems in NASA Procedural Requirements (NPR) 8705.2C requires Program Managers to conduct a human error analysis (HEA) for all mission phases. The purpose of the HEA is to enable programs to understand and manage potential catastrophic hazards that could be caused by human error, understand the relative risks and uncertainties within the system design, and influence decisions throughout the system lifecycle. This document provides guidance to NASA civil servants and contractors on how the Agency’s HEA requirement can be fulfilled.

Human Error Analysis; NASA Procedural Requirement;

Review of Significant Incidents and Close Calls in Human Spaceflight from a Human Factors Perspective

This project aims to identify poor human factors design decisions that led to error-prone systems, or did not facilitate the flight crew making the right choices; and to verify that NASA is effectively preventing similar incidents from occurring again. This analysis was performed by reviewing significant incidents and close calls in human spaceflight identified by the NASA Johnson Space Center Safety and Mission Assurance Flight Safety Office. The review of incidents shows whether the identified human errors were due to the operational phase (flight crew and ground control) or if they initiated at the design phase (includes manufacturing and test). This classification was performed with the aid of the NASA Human Systems Integration domains. This in-depth analysis resulted in a tool that helps with the human factors classification of significant incidents and close calls in human spaceflight, which can be used to identify human errors at the operational level, and how they were or should be minimized. Current governing documents on human systems integration for both government and commercial crew were reviewed to see if current requirements, processes, training, and standard operating procedures protect the crew and ground control against these issues occurring in the future. Based on the findings, recommendations to target those areas are provided.

Silva-Martinez, Jackelynne

Extending Validated Human Performance Models to Explore NextGen Concepts

To meet the expected increases in air traffic demands, NASA and FAA are researching and developing Next Generation Air Transportation System (NextGen) concepts. NextGen will require substantial increases in the data available to pilots on the flight deck (e.g., weather,wake, traffic trajectory predictions, etc.) to support more precise and closely coordinated operations (e.g., self-separation, RNAV/RNP, and closely spaced parallel operations, CSPOs). These NextGen procedures and operations, along with the pilot's roles and responsibilities, must be designed with consideration of the pilot's capabilities and limitations. Failure to do so will leave the pilots, and thus the entire aviation system, vulnerable to error. A validated Man-machine Integration and design Analysis System (MIDAS) v5 model was extended to evaluate anticipated changes to flight deck and controller roles and responsibilities in NextGen approach and Land operations. Compared to conditions when the controllers are responsible for separation on decent to land phase of flight, the output from these model predictions suggest that the flight deck response time to detect the lead aircraft blunder will decrease, pilot scans to the navigation display will increase, and workload will increase.

Gore, Brian Francis

Advanced Air Traffic Management Research (Human Factors and Automation): NASA Research Initiatives in Human-Centered Automation Design in Airspace Management

NASA has initiated a significant thrust of research and development focused on providing the flight crew and air traffic managers automation aids to increase capacity in en route and terminal area operations through the use of flexible, more fuel-efficient routing, while improving the level of safety in commercial carrier operations. In that system development, definition of cognitive requirements for integrated multi-operator dynamic aiding systems is fundamental. The core processes of control and the distribution of decision making in that control are undergoing extensive analysis. From our perspective, the human operators and the procedures by which they interact are the fundamental determinants of the safe, efficient, and flexible operation of the system. In that perspective, we have begun to explore what our experience has taught will be the most challenging aspects of designing and integrating human-centered automation in the advanced system. We have performed a full mission simulation looking at the role shift to self-separation on board the aircraft with the rules of the air guiding behavior and the provision of a cockpit display of traffic information and an on-board traffic alert system that seamlessly integrates into the TCAS operations. We have performed and initial investigation of the operational impact of "Dynamic Density" metrics on controller relinquishing and reestablishing full separation authority. (We follow the assumption that responsibility at all times resides with the controller.) This presentation will describe those efforts as well as describe the process by which we will guide the development of error tolerant systems that are sensitive to shifts in operator work load levels and dynamic shifts in the operating point of air traffic management.

Corker, Kevin M.

Development of Human System Integration at NASA

Human Systems Integration seeks to design systems around the capabilities and limitations of the humans which use and interact with the system, ensuring greater efficiency of use, reduced error rates, and less rework in the design, manufacturing and operational deployment of hardware and software. One of the primary goals of HSI is to get the human factors practitioner involved early in the design process. In doing so, the aim is to reduce future budget costs and resources in redesign and training. By the preliminary design phase of a project nearly 80% of the total cost of the project is locked in. Potential design changes recommended by evaluations past this point will have little effect due to lack of funding or a huge cost in terms of resources to make changes. Three key concepts define an effective HSI program. First, systems are comprised of hardware, software, and the human, all of which operate within an environment. Too often, engineers and developers fail to consider the human capacity or requirements as part of the system. This leads to poor task allocation within the system. To promote ideal task allocation, it is critical that the human element be considered early in system development. Poor design, or designs that do not adequately consider the human component, could negatively affect physical or mental performance, as well as, social behavior. Second, successful HSI depends upon integration and collaboration of all the domains that represent acquisition efforts. Too often, these domains exist as independent disciplines due to the location of expertise within the service structure. Proper implementation of HSI through participation would help to integrate these domains and disciplines to leverage and apply their interdependencies to attain an optimal design. Via this process domain interests can be integrated to perform effective HSI through trade-offs and collaboration. This provides a common basis upon which to make knowledgeable decisions. Finally, HSI must be considered early in the requirements development phase of system design and acquisition. This will provide the best opportunity to maximize return on investment (ROI) and system performance. HSI requirements must be developed in conjunction with capability ]based requirements generation through functional. HSI requirements will drive HSI metrics and embed HSI issues within the system design. After a system is designed, implementation of HSI oversights can be very expensive. An HSI program should be included as an integral part of a total system approach to vehicle and habitat development. This would include, but not limited to, workstation design, D&C development, volumetric analysis, training, operations, and human -robotic interaction. HSI is a necessary process for Human Space Flight programs to meet the Agency Human ]System standards and thus mitigate human risks to acceptable levels. NASA has been involved in HSI planning, procedures development, process, and implementation for many years, and has been building several internal and publicly accessible products to facilitate HSI fs inclusion in the NASA Systems Engineering Lifecycle. Some of these products include: NASA STD 3001 Volumes 1 and 2, Human Integration Design Handbook, NASA HSI Implementation Plan, NASA HSI Implementation Plan Templates, NASA HSI Implementation Handbook, and a 2 ]hour short course on HSI delivered as part of the NASA Space and Life Sciences Directorate Academy. These products have been created leveraging industry best practices and lessons learned from other Federal Government agencies.

Whitmore, Mihriban