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NASA System Safety Handbook: System Safety Framework and Concepts for Implementation - Volume 1

System safety assessment is defined in NPR 8715.3C, NASA General Safety Program Requirements as a disciplined, systematic approach to the analysis of risks resulting from hazards that can affect humans, the environment, and mission assets. Achievement of the highest practicable degree of system safety is one of NASA's highest priorities. Traditionally, system safety assessment at NASA and elsewhere has focused on the application of a set of safety analysis tools to identify safety risks and formulate effective controls.1 Familiar tools used for this purpose include various forms of hazard analyses, failure modes and effects analyses, and probabilistic safety assessment (commonly also referred to as probabilistic risk assessment (PRA)). In the past, it has been assumed that to show that a system is safe, it is sufficient to provide assurance that the process for identifying the hazards has been as comprehensive as possible and that each identified hazard has one or more associated controls. The NASA Aerospace Safety Advisory Panel (ASAP) has made several statements in its annual reports supporting a more holistic approach. In 2006, it recommended that "... a comprehensive risk assessment, communication and acceptance process be implemented to ensure that overall launch risk is considered in an integrated and consistent manner." In 2009, it advocated for "... a process for using a risk-informed design approach to produce a design that is optimally and sufficiently safe." As a rationale for the latter advocacy, it stated that "... the ASAP applauds switching to a performance-based approach because it emphasizes early risk identification to guide designs, thus enabling creative design approaches that might be more efficient, safer, or both." For purposes of this preface, it is worth mentioning three areas where the handbook emphasizes a more holistic type of thinking. First, the handbook takes the position that it is important to not just focus on risk on an individual basis but to consider measures of aggregate safety risk and to ensure wherever possible that there be quantitative measures for evaluating how effective the controls are in reducing these aggregate risks. The term aggregate risk, when used in this handbook, refers to the accumulation of risks from individual scenarios that lead to a shortfall in safety performance at a high level: e.g., an excessively high probability of loss of crew, loss of mission, planetary contamination, etc. Without aggregated quantitative measures such as these, it is not reasonable to expect that safety has been optimized with respect to other technical and programmatic objectives. At the same time, it is fully recognized that not all sources of risk are amenable to precise quantitative analysis and that the use of qualitative approaches and bounding estimates may be appropriate for those risk sources. Second, the handbook stresses the necessity of developing confidence that the controls derived for the purpose of achieving system safety not only handle risks that have been identified and properly characterized but also provide a general, more holistic means for protecting against unidentified or uncharacterized risks. For example, while it is not possible to be assured that all credible causes of risk have been identified, there are defenses that can provide protection against broad categories of risks and thereby increase the chances that individual causes are contained. Third, the handbook strives at all times to treat uncertainties as an integral aspect of risk and as a part of making decisions. The term "uncertainty" here does not refer to an actuarial type of data analysis, but rather to a characterization of our state of knowledge regarding results from logical and physical models that approximate reality. Uncertainty analysis finds how the output parameters of the models are related to plausible variations in the input parameters and in the modeling assumptions. The evaluation of unrtainties represents a method of probabilistic thinking wherein the analyst and decision makers recognize possible outcomes other than the outcome perceived to be "most likely." Without this type of analysis, it is not possible to determine the worth of an analysis product as a basis for making decisions related to safety and mission success. In line with these considerations the handbook does not take a hazard-analysis-centric approach to system safety. Hazard analysis remains a useful tool to facilitate brainstorming but does not substitute for a more holistic approach geared to a comprehensive identification and understanding of individual risk issues and their contributions to aggregate safety risks. The handbook strives to emphasize the importance of identifying the most critical scenarios that contribute to the risk of not meeting the agreed-upon safety objectives and requirements using all appropriate tools (including but not limited to hazard analysis). Thereafter, emphasis shifts to identifying the risk drivers that cause these scenarios to be critical and ensuring that there are controls directed toward preventing or mitigating the risk drivers. To address these and other areas, the handbook advocates a proactive, analytic-deliberative, risk-informed approach to system safety, enabling the integration of system safety activities with systems engineering and risk management processes. It emphasizes how one can systematically provide the necessary evidence to substantiate the claim that a system is safe to within an acceptable risk tolerance, and that safety has been achieved in a cost-effective manner. The methodology discussed in this handbook is part of a systems engineering process and is intended to be integral to the system safety practices being conducted by the NASA safety and mission assurance and systems engineering organizations. The handbook posits that to conclude that a system is adequately safe, it is necessary to consider a set of safety claims that derive from the safety objectives of the organization. The safety claims are developed from a hierarchy of safety objectives and are therefore hierarchical themselves. Assurance that all the claims are true within acceptable risk tolerance limits implies that all of the safety objectives have been satisfied, and therefore that the system is safe. The acceptable risk tolerance limits are provided by the authority who must make the decision whether or not to proceed to the next step in the life cycle. These tolerances are therefore referred to as the decision maker's risk tolerances. In general, the safety claims address two fundamental facets of safety: 1) whether required safety thresholds or goals have been achieved, and 2) whether the safety risk is as low as possible within reasonable impacts on cost, schedule, and performance. The latter facet includes consideration of controls that are collective in nature (i.e., apply generically to broad categories of risks) and thereby provide protection against unidentified or uncharacterized risks.

Dezfuli, Homayoon

Epistemic Questions and Answers for Software System Safety

System safety is primarily concerned with epistemic questions, that is, questions concerning knowledge and the degree of confidence that can be placed in that knowledge. For systems with which human experience is long, such as roads, bridges, and mechanical devices, knowledge about what is required to make the systems safe is deep and detailed. High confidence can be placed in the validity of that knowledge. For other systems, however, with which human experience is comparatively short, such as those that rely in part or in whole on software, knowledge about what is required to ensure safety tends to be shallow and general. The confidence that can be placed in the validity of that knowledge is consequently low. In a previous paper, we enumerated a collection of foundational epistemic questions concerning software system safety. In this paper, we review and refine the questions, discuss some difficulties that attend to answering the questions today, and speculate on possible research to improve the situation.

Holloway, C. M.

In-space propellant systems safety. Volume 2: System safety guidelines and requirements

Detailed system safety guidelines/requirements were developed. Each one describes a safety measure which is suggested as a means of eliminating or reducing a particular hazard, or group of hazards, to an acceptable level, and which, if followed would tend to increase the level of safety in supplying propellants to a user in orbit. The first goal was to identify those actions that should be taken to make propellant logistics operations as safe as possible. The second was to serve as a checklist to verify that these actions had been taken in the design and operation of this and similar programs, or that they had been considered and rejected. The safety measures described in the GLR's are directed toward the prevention of hazards, the avoidance of undesired events, and the protection of the crew.

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In-space propellant systems safety. Volume 3: System safety analysis

The primary objective was to examine from a system safety viewpoint in-space propellant logistic elements and operations to define the potential hazards and to recommend means to reduce, eliminate or control them. A secondary objective was to conduct trade studies of specific systems or operations to determine the safest of alternate approaches.

Source record

Analysis of Aviation Safety Reporting System Incident Data Associated With the Technical Challenges of the Vehicle Systems Safety Technology Project

This analysis was conducted to support the Vehicle Systems Safety Technology (VSST) Project of the Aviation Safety Program (AVsP) milestone VSST4.2.1.01, "Identification of VSST-Related Trends." In particular, this is a review of incident data from the NASA Aviation Safety Reporting System (ASRS). The following three VSST-related technical challenges (TCs) were the focus of the incidents searched in the ASRS database: (1) Vechicle health assurance, (2) Effective crew-system interactions and decisions in all conditions; and (3) Aircraft loss of control prevention, mitigation, and recovery.

Withrow, Colleen A.

NASA System Safety Handbook. Volume 2: System Safety Concepts, Guidelines, and Implementation Examples

This is the second of two volumes that collectively comprise the NASA System Safety Handbook. Volume 1 (NASASP-210-580) was prepared for the purpose of presenting the overall framework for System Safety and for providing the general concepts needed to implement the framework. Volume 2 provides guidance for implementing these concepts as an integral part of systems engineering and risk management. This guidance addresses the following functional areas: 1.The development of objectives that collectively define adequate safety for a system, and the safety requirements derived from these objectives that are levied on the system. 2.The conduct of system safety activities, performed to meet the safety requirements, with specific emphasis on the conduct of integrated safety analysis (ISA) as a fundamental means by which systems engineering and risk management decisions are risk-informed. 3.The development of a risk-informed safety case (RISC) at major milestone reviews to argue that the systems safety objectives are satisfied (and therefore that the system is adequately safe). 4.The evaluation of the RISC (including supporting evidence) using a defined set of evaluation criteria, to assess the veracity of the claims made therein in order to support risk acceptance decisions.

Safety Case

Manned space flight nuclear system safety. Volume 5: Nuclear System safety guidelines. Part 1: Space base nuclear safety

The design and operations guidelines and requirements developed in the study of space base nuclear system safety are presented. Guidelines and requirements are presented for the space base subsystems, nuclear hardware (reactor, isotope sources, dynamic generator equipment), experiments, interfacing vehicles, ground support systems, range safety and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

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Manned space flight nuclear system safety. Volume 6: Space base nuclear system safety plan

A qualitative identification of the steps required to assure the incorporation of radiological system safety principles and objectives into all phases of a manned space base program are presented. Specific areas of emphasis include: (1) radiological program management, (2) nuclear system safety plan implementation, (3) impact on program, and (4) summary of the key operation and design guidelines and requirements. The plan clearly indicates the necessity of considering and implementing radiological system safety recommendations as early as possible in the development cycle to assure maximum safety and minimize the impact on design and mission plans.

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Manned space flight nuclear system safety. Voluem 5: Nuclear system safety guidelines. Part 2: Space shuttle/nuclear payloads safety

The design and operations guidelines and requirements developed in the study of space shuttle nuclear system transportation are presented. Guidelines and requirements are presented for the shuttle, nuclear payloads (reactor, isotope-Brayton and small isotope sources), ground support systems and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

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Manned space flight nuclear system safety. Volume 1: base nuclear system safety

The mission and terrestrial nuclear safety aspects of future long duration manned space missions in low earth orbit are discussed. Nuclear hazards of a typical low earth orbit Space Base mission (from natural sources and on-board nuclear hardware) have been identified and evaluated. Some of the principal nuclear safety design and procedural considerations involved in launch, orbital, and end of mission operations are presented. Areas of investigation include radiation interactions with the crew, subsystems, facilities, experiments, film, interfacing vehicles, nuclear hardware and the terrestrial populace. Results of the analysis indicate: (1) the natural space environment can be the dominant radiation source in a low earth orbit where reactors are effectively shielded, (2) with implementation of safety guidelines the reactor can present a low risk to the crew, support personnel, the terrestrial populace, flight hardware and the mission, (3) ten year missions are feasible without exceeding integrated radiation limits assigned to flight hardware, and (4) crew stay-times up to one year are feasible without storm shelter provisions.

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System Safety Analysis of Complex NASA Systems with Model-Based Engineering (REV B)

The emergence of model-based engineering is transforming design and analysis methodologies. A recognized benefit of model-based engineering is the existence of a “single source of truth” about the system that becomes the authoritative source of data and information for designers, analysts, and developers. This promotes consistency and efficiency as the design emerges and can be used to further optimize the design. Integrating System Safety Engineers to the “single source of truth” will ensure that the outputs of their assessments and analyses are relevant to the design as it evolves. Use of an integrated system model enables near immediate evaluation of a design change as well as development of operational processes for risk assessment and communication. Such models can enable efficient and timely analysis of system hazards (e.g., hazard fault tree analysis and procedure simulations) and produce complete, accurate, and more consistent products (e.g., hazard reports and safety requirement evaluations). Therefore, an agency-sponsored team at Goddard Space Flight Center (GSFC) recently completed a System Safety Study of modeling and testing capabilities as part of a Model-Based Safety and Mission Assurance Initiative (MBSMAI). Using an existing model developed for reliability analyses, GSFC modeling and system safety experts performed system safety analysis/modeling and produced safety products. The team evaluated model-based feasibility to support System Safety Engineering, developed safety analysis modeling processes, and identified tool capability advancement/development needs. These study results indicate model-based engineering is valid and useable for System Safety Engineering for NASA if adequate modeling processes and environment are established.

NASA

Integrating system safety into the basic systems engineering process

The basic elements of a systems engineering process are given along with a detailed description of what the safety system requires from the systems engineering process. Also discussed is the safety that the system provides to other subfunctions of systems engineering.

John W. Griswold

System Safety Analysis of Complex NASA Systems with Model Based Engineering

The emergence of model-based engineering is transforming design and analysis methodologies [5]. A recognized benefit of model-based engineering is the existence of a “single source of truth” about the system that becomes the authoritative source of data and information for designers, analysts, and developers. This promotes consistency and efficiency as the design emerges and can be used to further optimize the design. Integrating System Safety Engineers to the “single source of truth” will ensure that the outputs of their assessments and analyses are relevant to the design as it evolves. Use of an integrated system model enables near immediate evaluation of a design change as well as development of operational processes for risk assessment and communication. Such models can enable efficient and timely analysis of system hazards (e.g., hazard fault tree analysis and procedure simulations) and produce complete, accurate, and more consistent products (e.g., hazard reports and safety requirement evaluations). Therefore, an agency-sponsored team at Goddard Space Flight Center (GSFC) recently completed a System Safety Study of modeling and testing capabilities as part of a Model-Based Safety and Mission Assurance Initiative (MBSMAI). Using an existing model developed for reliability analyses [1], GSFC modeling and system safety experts performed system safety analysis/modeling and produced safety products. The team evaluated model-based feasibility to support System Safety Engineering, developed safety analysis modeling processes, and identified tool capability advancement/development needs. These study results indicate model-based engineering is valid and useable for System

Model Based Engineering

System Safety Analysis of Complex NASA Systems with Model-Based Engineering

The emergence of model-based engineering is transforming design and analysis methodologies [5]. A recognized benefit of model-based engineering is the existence of a “single source of truth” about the system that becomes the authoritative source of data and information for designers, analysts, and developers. This promotes consistency and efficiency as the design emerges and can be used to further optimize the design. Integrating System Safety Engineers to the “single source of truth” will ensure that the outputs of their assessments and analyses are relevant to the design as it evolves. Use of an integrated system model enables near immediate evaluation of a design change as well as development of operational processes for risk assessment and communication. Such models can enable efficient and timely analysis of system hazards (e.g., hazard fault tree analysis and procedure simulations) and produce complete, accurate, and more consistent products (e.g., hazard reports and safety requirement evaluations). Therefore, an agency-sponsored team at Goddard Space Flight Center (GSFC) recently completed a System Safety Study of modeling and testing capabilities as part of a Model-Based Safety and Mission Assurance Initiative (MBSMAI). Using an existing model developed for reliability analyses [1], GSFC modeling and system safety experts performed system safety analysis/modeling and produced safety products. The team evaluated model-based feasibility to support System Safety Engineering, developed safety analysis modeling processes, and identified tool capability advancement/development needs. These study results indicate model-based engineering is valid and useable for System

NASA

Application of system safety to rail transit systems

Management emphasis on system safety in the rapid transit industry includes the granting and use of funds by the Federal Government according to systematic analysis of safety hazards in advance. Likelihood predictions that those hazards will be activated by exposure of the system to a system failure, a human error, external conditions, or combinations of these aspects determine alternatives to the assumption of risk and recommend corrections before the system is operational. Rigorous safety analyses are projected to assure operational safety for prolonged periods under varied maintenance conditions; these analysis encompass station accident possibilities as well as train-person collisions, car equipment and design, traffic control systems, and tunnel design problems.

Thomas DeW. Styles

System safety education focused on system management

System safety is defined and characteristics of the system are outlined. Some of the principle characteristics include role of humans in hazard analysis, clear language for input and output, system interdependence, self containment, and parallel analysis of elements.

Vernon L. Grose