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At least 19 records

Gathering Safety Intelligence from Relevant Safety Events

The notion of Safety II grew out of the realization that people are the source of resilience in any given socio-technical system and that people, in fact, produce safety far more often than reduce safety. The talk will highlight some of the key differences between Safety I and Safety II in their assumptions about the nature of operations and the nature of safety as well as some of the limitations of each approach and the ways in which they complement each other. Because we all want to make data-informed decisions and because we already collect a lot of Safety I-type data, the talk will also describe the Flight Safety Foundation’s Learning from All Operations effort which is designed to collect Safety II-type data.

resilience↗

Active Learning with Rationales for Identifying Operationally Significant Anomalies in Aviation

A major focus of the commercial aviation community is discovery of unknown safety events in flight operations data. Data-driven unsupervised anomaly detection methods are better at capturing unknown safety events compared to rule-based methods which only look for known violations. However, not all statistical anomalies that are discovered by these unsupervised anomaly detection methods are operationally significant (e.g., represent a safety concern). Subject Matter Experts (SMEs) have to spend significant time reviewing these statistical anomalies individually to identify a few operationally significant ones. In this paper we propose an active learning algorithm that incorporates SME feedback in the form of rationales to build a classifier that can distinguish between uninteresting and operationally significant anomalies. Experimental evaluation on real aviation data shows that our approach improves detection of operationally significant events by as much as 75% compared to the state-of-the-art. The learnt classifier also generalizes well to additional validation data sets.

anomaly detection↗

Ask-The-Expert: Minimizing Human Review for Big Data Analytics Through Active Learning

In this CIF project, we worked toward semi-automating knowledge discovery from anomaly detection algorithms through the use of active learning. Active learning is an area of research within machine learning that uses an "expert in the loop" to learn from large data sets that have very few annotations or labels available, and where providing such labels is expensive. In our case, the task can be defined as the identification of safety events from flight operational data. Since traditional anomaly detection algorithms cannot differentiate between operationally relevant and irrelevant statistical anomalies, Subject Matter Experts (SMEs) have a lengthy and expensive burden of investigating every example identified by the detection algorithm, classifying and labeling them as relevant or irrelevant. Active learningidentifies the unlabeled example for which a label would most improve the classifier, asks the domain expert for a label, and repeats this process until there are no more resources (time, budget) available for labeling or a minimum required performance is reached. A positive label indicates an operationally significant safety event whereas a negative label indicates otherwise. Based on these few labels we propose to build an active learning system that utilizes the SME's time in the most effective manner by iteratively asking for labels for as few informative instances as possible. Our work was proposed to be a stepping stone toward implementation and deployment of the system with user interface to be pursued by the Aviation Operations and Safety Program (AOSP) given its interest in safety monitoring and discovery of safety incidents.

aviation safety↗

Predicting Thermal Response in a Li-ion Cell on a UAV Fight Profile

As the energy storage devices continue to "pack" more energy in a small space, any damage, battery component failure, manufacturing defect, or electrically abusing the battery can lead to catastrophic thermal runaway events. A catastrophic thermal event in a cell leads to high temperature, in some instances spewing of battery materials due to gas development from side reactions initiated due to high internal temperatures. Also, a thermal runaway event can propagate from a single "failed" cell to the pack in a battery pack, leading to a more significant event. Mitigating a thermal runaway event is important in the commercial and automotive sectors. However, preventing such events in an electric aircraft (or air taxis) is paramount due to the lack of alternatives in the event of a failure. Battery prognostics algorithms allow the prediction of state-of-charge (SOC) and end-of-life (EOL) of a Li-ion battery in a UAV (unmanned air vehicle) [1]. For this presentation, we will extend this two-level battery predictive algorithm to predict SOC, EOL, and estimated maximum temperature during a simulated flight. The model is extended by integrating a lumped physics-driven thermal model for high current densities [2]. The parameters used to control SOC and EOL are maximum storable charge, time constant for Li-ion diffusivity in the carbon particles, and internal cell resistance. Cycling leads to an increase in the heat generated by an aged Li-ion cell with a LiyCoO2 (LCO) cathode and a LixC6 (MCMB) anode. The aging of a cell leads to increase in SEI layer thickness, the diffusion time for the lithium ions inside the electrodes, and the local reaction rates, in addition to the thermodynamic abuse caused by fixed cycling voltages controlled by a Battery Management System. As the battery ages, the cell resistance increases, while the onset temperature of the thermal runaway decreases (depends on the cell chemistry and cell abuse history). Any large deviation of the cell temperature from the estimated (expected) value can identify a faulty cell. Since SEI decomposition has the lowest onset temperature in the series of reactions leading to thermal runaway, the model considers the self-heating rate of the SEI decomposition as onset temperature (similar to Ref. [3]). The parameters in the Arrhenius equation for the SEI heating rate depend on the number of cycles, the cell's operating temperature, and the cell's abuse history [4,5]. Coupling the electrochemical, thermal, and aging model allow the prognostic algorithm to estimate a typical cell voltage and temperature as a function of age (cycling and calendar), whose departure from measured values from the BMS is used to identify a safety event. In addition, we will present the results from two simulated flight scenarios for a UAV: typical and extreme, since the power requirements vary significantly during take-off, landing, and changing altitudes, while the power requirements remain low during the cruise. For this presentation, the power requirement for a battery pack in a UAV is scaled to a single cell. This cell is cycled through a simulated profile, and the data is collected and used to predict a safety event.

Li-ion↗

Verification and Implementation of Operations Safety Controls for Flight Missions

There are several engineering disciplines, such as reliability, supportability, quality assurance, human factors, risk management, safety, etc. Safety is an extremely important engineering specialty within NASA, and the consequence involving a loss of crew is considered a catastrophic event. Safety is not difficult to achieve when properly integrated at the beginning of each space systems project/start of mission planning. The key is to ensure proper handling of safety verification throughout each flight/mission phase. Today, Safety and Mission Assurance (S&MA) operations engineers continue to conduct these flight product reviews across all open flight products. As such, these reviews help ensure that each mission is accomplished with safety requirements along with controls heavily embedded in applicable flight products. Most importantly, the S&MA operations engineers are required to look for important design and operations controls so that safety is strictly adhered to as well as reflected in the final flight product.

Smalls, James R.↗

Ulysses mission design after Challenger

The delay of the Ulysses launch from May 1986 to October 1990, because of the Challenger disaster, has altered both the constraints under which the mission must be designed and the timing of several mission critical events. Safety and launch reliability concerns from the Shuttle have increased the effective launch window to durations greater than one hour. Fortuitously high declinations of the launch asymptote (DLA), of the order of the launch site latitude, ameliorate the impact of the new constraints on the launch window. Target overlays in the first hour of the launch window provide higher departure energies that improve mission performance and avoid a science schedule conflict at second opposition near the time of closest Jupiter approach. The mission design starts with the maximum earth departure energy that the upper stage can deliver within the launch constraints. The Jupiter arrival asymptotes are chosen from the optimal point of mission performance in the mission space defined in the Jupiter B-plane by contours mapped by the science and spacecraft constraints. More than half the orbital energy of the earth-to-Jupiter transfer orbit is lost in the Jupiter flyby, and the Jupiter gravitational assist rotates the orbit plane out of the ecliptic to an inclination of about 80 degrees.

Luthey, Joe L.↗

Identification of Scenarios for System Interface Design Evaluation: CAST SE-210 Output 2 Report 5 of 6

This report is one in a series of reports describing research to develop enhanced approaches to design and evaluation of flight deck interaction. The research was conducted to support the Commercial Aviation Safety Team (CAST) response to incidents and accidents caused by failure of the flight crew to maintain aircraft attitude or energy state awareness. This report partially responds to Safety Enhancement (SE) 210.2 (CAST, 2014) by describing development of operational scenarios for evaluation of flight crew interaction. Evaluations of human performance with an interface rely on asking humans to perform operational tasks in an appropriate operational context. The report includes the major sources of material for developing operational scenarios—which include system state, operational tasks, operational context, and safety events—and a method for developing an appropriate set of operational scenarios for interface evaluation.

commercial aviation↗

Adaptive Stress Testing of Collision Avoidance Systems for Small UASs with Deep Reinforcement Learning

The next-generation Airborne Collision Avoidance System for smaller UASs (ACAS sXu) is currently being developed and tested by the Federal Aviation Administration (FAA) to provide detect-and-avoid capability for small unmanned aircraft operating beyond line-of-sight. Due to the complexity and safety-critical nature of the system, safety validation is important not only for the certification of the final system, but also for informing changes during the iterative development process. In this paper, we analyze a prototype of ACAS sXu in simulated aircraft encounters to discover scenarios of small near mid-air collisions (sNMACs), an important safety event in which two aircraft come closer than 50 feet horizontally and 15 feet vertically. Due to the size and complexity of the system as well as rarity of sNMAC events, traditional methods such as Monte Carlo testing often require informed setup and targeting to elicit failures. However, such a dependence on domain knowledge can be incompatible with the independent verification and validation (IV&V) process, the aim of which is to discover unforeseen issues. To address these challenges, we apply an accelerated validation method called adaptive stress testing (AST) to find the most likely sNMAC scenarios without reliance on system introspection. AST uses reinforcement learning to adapt the search towards the most promising areas of the search space as it progresses. We use a state-of-the-art deep reinforcement learning algorithm, proximate policy optimization, to more efficiently search the large and continuous state space. We find that this approach significantly improves the performance of AST compared to a prior approach based on Monte Carlo tree search. We perform experiments using AST to find sNMAC events under various encounter configurations, varying parameters pertaining to dynamics and coordination. Our experiments show AST to be very effective at finding sNMAC scenarios. We summarize our findings, presenting high-level categories of discovered sNMACs and specific examples of encounters in each category.

aircraft collision avoidance↗

Limitations on the Use of Eye-Tracking Data to Understand Operator Awareness

Safety events in commercial aviation have implicated failures of attention and awareness, and the need for improved attention and awareness has pushed trainers toward eye-tracking systems as a primary tool for evaluating monitoring performance. Further, in the last 15 years, eye-tracking technology has become easier to acquire and use in operationally realistic settings. Although we believe that eye-tracking can be a useful evaluation tool, this paper describes basic limitations on relying on eye-tracking as the sole means for evaluating attention and awareness. A set of other measures are offered that can better identify where performance breakdowns occur.

aviation↗

NASA C3RS: Communication Works For Those Who Work At It!

The objective of the study is to learn about Communication Breakdown related to safety events reported to the Confidential Close Call Reporting System (C3RS). Studying the reported close calls can yield information about communication breakdowns that may be present in the railroad operations.

Confidential Close Call Reporting System↗

Safety Culture at the World’s Premier Multi-User Spaceport

NASA’s Agency-wide Safety Culture is implemented at the Kennedy Space Center (KSC) using a unique strategy due an unparalleled approach in making human spaceflight history. Kennedy Space Center, the world’s premier multi-user spaceport, enables U.S. government and commercial space access, while providing the world a resource to allow the exploration of and the ability to work in space. A consistently healthy safety culture at KSC is imperative for mission success: desired achievements, protection of space flight hardware, and ultimately, the preservation of human life requires the support of a healthy safety culture. Emphasis on the NASA Agency-wide development of Safety Culture began with the conception of the NASA Agency Safety Culture Working Group. After the devastating loss of life and mission of the Space Shuttle Colombia, a broken safety culture was identified as an organizational cause by the Columbia Accident Investigation Board Report. Thus, the Agency Safety Culture Working Group was developed in 2009 to assess the status of the Agency’s Safety Culture, while addressing safety culture concerns at the NASA Center-level. A Five-factor model was developed to serve as the guiding principles for Safety Culture: 1) Reporting Culture, 2) Just Culture, 3) Flexible Culture, 4) Learning Culture, and 5) Engaged Culture. These five factors are included in the NASA Safety Culture logo, which was intentionally designed as a DNA double helix to prompt the permeation of safety into day-to-day work. KSC specifically implements the NASA Agency-wide Safety Culture principles in a tailored approach that is relevant to the diversity of work being performed. An emphasis is placed on the implementation to include safety at home, not exclusively at work. This emphasis is a KSC-specific element that has been intentionally added to promote a closed loop Safety Culture. To advertise the safety culture, various safety and health events are held throughout the calendar year, providing innovative speakers and engaging activities, while also promoting a wide range of curated safety initiatives. Development and continuous improvement of the KSC safety tracking database, allows for advanced tracking-to-closure, along with providing data sets used to identify areas of emphasis. Other safety initiatives rely solely on employee participation, such as the photo challenges; participants are encouraged to identify and capture themselves, coworkers, or family members participating in safe or healthy activities to share with others within the Center and at Agency levels. Fabrication of exclusive videos and graphics are utilized to advertise and inform employee of safety initiatives, upcoming safety events, and general dispersion of safety information. In addition, an anonymous Agency-wide Safety Culture Survey is advertised, administered, and analyzed at Kennedy Space Center, with the purpose of receiving basic feedback on Safety Culture perceptions to help prevent future incidents from occurring. Through these briefly identified means, and many other forms of employee engagement, Kennedy Space Center aims to maintain safety in the forefront, while creating an environment where everyone trusts that safety is a priority.

Larrin E. Moody↗

Leveraging Human Performance Data to Change the Narrative that People are the Safety Problem

The study of errors and failure has a long and productive history in the behavioral sciences. By studying how systems fail, we rule out various mechanisms for how those systems might work, thereby refining our theories of how they actually work. Human performance, however, includes more than errors; human performance comprises both failures and successes. A systematic bias to collect and analyze data only on error affects the decisions we make as a community by promoting the narrative that “people are the safety problem.” This narrative manifests in both obvious and subtle ways in the design of systems intended for human use. When the only safety data that are available are about human failure, then “data-driven” designs can only consider that humans fail. Changing this narrative will depend on new data and new ways to examine data – specifically, data on the processes by which human create and contribute to safety. An alternate narrative is that people represent a primary source of safety, through their capability to anticipate, monitor for, respond to, and learn from expected and unexpected change. This presentation will describe research efforts to expand the range of safety-relevant events to include not just rare safety failures but frequent safety successes. These efforts include use of data from both operations and simulations to develop methods and metrics for learning from structured observation, self-report, and system data.

Jon Holbrook↗

Applications of Anomaly Detection and Precursor Identification in Airspace Operations

As we continue to advance the U.S. National Airspace into the next generation of air traffic, we face challenges in both increase in complexity, as well as, a significant growth in traffic volume. Addressing these challenges, while maintaining the same level of safety is an important application of data mining. Because of these significant shifts in airspace design and usage there is a need to identify current and emergent safety risks along with their potential precursors. In recent years NASA has made advancements in developing scalable methods to address this effort in the Big Data paradigm. Multiple kernel anomaly detection approaches have been employed on both surveillance radar data and flight operational quality assurance data to identify operationally significant safety risks. Additionally, events have been explored with a recently developed precursor identification tool to discover states that reveal an increased probability of a safety event. These tools can be used to discover emerging safety risks that may not be currently monitored, which allows for mitigation tactics to be employed and ultimately make the overall airspace safer. This talk will discuss an overview of these methods and a discussion of the findings.

anomaly detection↗

The National Aviation Operational Monitoring Service (NAOMS): A Documentation of the Development of a Survey Methodology

The National Aviation Operational Monitoring Service (NAOMS) was a research project under NASA s Aviation Safety Program during the years from 2000 to 2005. The purpose of this project was to develop a methodology for gaining reliable information on changes over time in the rates-of-occurrence of safety-related events as a means of assessing the safety of the national airspace. The approach was a scientifically designed survey of the operators of the aviation system concerning their safety-related experiences. This report presents the results of the methodology developed and a demonstration of the NAOMS concept through a survey of nearly 20,000 randomly selected air-carrier pilots. Results give evidence that the NAOMS methodology can provide a statistically sound basis for evaluating trends of incidents that could compromise safety. The approach and results are summarized in the report and supporting documentation and complete analyses of results are presented in 14 appendices.

Connors, Mary M.↗

Nuclear safety for the space exploration initiative

The results of a study to identify potential hazards arising from nuclear reactor power systems for use on the lunar and Martian surfaces, related safety issues, and resolutions of such issues by system design changes, operating procedures, and other means are presented. All safety aspects of nuclear reactor power systems from prelaunch ground handling to eventual disposal were examined consistent with the level of detail for SP-100 reactor design at the 1988 System Design Review and for launch vehicle and space transport vehicle designs and mission descriptions as defined in the 90-day Space Exploration Initiative (SEI) study. Information from previous aerospace nuclear safety studies was used where appropriate. Safety requirements for the SP-100 space nuclear reactor system were compiled. Mission profiles were defined with emphasis on activities after low earth orbit insertion. Accident scenarios were then qualitatively defined for each mission phase. Safety issues were identified for all mission phases with the aid of simplified event trees. Safety issue resolution approaches of the SP-100 program were compiled. Resolution approaches for those safety issues not covered by the SP-100 program were identified. Additionally, the resolution approaches of the SP-100 program were examined in light of the moon and Mars missions.

Dix, Terry E.↗

System-Level Prognostics for the National Airspace

In the National Airspace System (NAS), safety is assured through a set of rules, regulations, and procedures to respond to unsafe events. However, safety stands to benefit immensely from the introduction of tools and methodologies from Prognostics and Health Management (PHM). PHM will enable the NAS to stochastically predict unsafe states within the NAS, enabling a proactive preventative response strategy, as opposed to a reactive mitigative one. However, current PHM methods do not directly apply to the NAS for several reasons: they typically apply only at the component level, are implemented in a centralized manner, and are focused only on predicting remaining useful life. In this paper, we extend the model-based prognostics approach to PHM in order to provide a framework that can be applied to the NAS. We offer a system-level approach that supports a distributed implementation, and provide algorithms to predict the probability of an unsafe state, either at a specific time or within a time interval, and to predict the time of an unsafe state. Experimental results in simulation demonstrate the new approach.

prognostics↗

NASA Aviation Safety Reporting System (ASRS)

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 900,000 reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 5,500 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides de-identified report information through the online ASRS Database at http://asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation \vill discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

Connell, Linda↗