NASA Aviation Safety Reporting System: Contributions to Aviation Safety
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ASRS↗
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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.↗
Measuring Pilot Contributions to Safety: Survey Design and Implementation
This is a NASA-intern briefing of work done over the summer as part of Human Contributions to Safety research on resilience. This reports on the process and rationale for developing a survey focusing on pilot reports of their own behavior and the context in which that behavior occurs.
training↗
Human Performance Contributions to Safety in Commercial Aviation
In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that contribute to routine successful outcomes, safety management and system design decisions are based on a small sample of non- representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant and largely unrecognized risk when making policy decisions about human roles and responsibilities. Opportunities exist to leverage the vast amount of data that has already been collected, or could be easily obtained, to increase our understanding of human contributions to “things going right” in commercial aviation. The principal focus of this assessment was to identify current gaps and explore methods for identifying human “success” data generated by the aviation system, from personnel and within the supporting infrastructure.
Holbrook, Jon B.↗
Human Contribution to Safety: Human Performance is Not Just About Error
- When the only data that are available are about human failure, then data-driven designs only consider that humans fail. - Designs intended to "protect" the system from "error-prone" humans can design-out the capability for humans to effectively intervene/adapt, which is a far more common behavior.
Jon Holbrook↗
Measuring Human Contributions to Safety
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Jon Holbrook↗
How Humans Contribute to Safety
We have all heard, and much too often, how human error is the leading cause of accidents. What we haven’t been hearing is how humans produce safety far more often than reduce safety. Before we embark on developing technologies to replace the error-prone human, it behooves us to understand how humans produce safety lest we lose that primary source of resilience in our aviation system.
safety↗
A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety
Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence, and are influenced by, how decision makers characterize problems and identify solutions. In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on safety-producing behaviors, safety management and system design decisions are based on a small sample of non-representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to aviation safety represents a significant and largely unrecognized risk when making policy decisions about safety management and system design. Opportunities exist to leverage the vast amount of data that have already been collected, or could be easily obtained, to increase our understanding of human contributions to safety in commercial aviation. This presentation will focus on those opportunities as well as the challenges associated with collecting and analyzing data on operators’ safety-producing behaviors.
Safety↗
A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety
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Human Contributions↗
Quantifying Pilot Contribution to Flight Safety during Drive Shaft Failure
Accident statistics cite the flight crew as a causal factor in over 60% of large transport aircraft fatal accidents. Yet, a well-trained and well-qualified pilot is acknowledged as the critical center point of aircraft systems safety and an integral safety component of the entire commercial aviation system. The latter statement, while generally accepted, cannot be verified because little or no quantitative data exists on how and how many accidents/incidents are averted by crew actions. A joint NASA/FAA high-fidelity motion-base simulation experiment specifically addressed this void by collecting data to quantify the human (pilot) contribution to safety-of-flight and the methods they use in today's National Airspace System. A human-in-the-loop test was conducted using the FAA's Oklahoma City Flight Simulation Branch Level D-certified B-737-800 simulator to evaluate the pilot's contribution to safety-of-flight during routine air carrier flight operations and in response to aircraft system failures. These data are fundamental to and critical for the design and development of future increasingly autonomous systems that can better support the human in the cockpit. Eighteen U.S. airline crews flew various normal and non-normal procedures over a two-day period and their actions were recorded in response to failures. To quantify the human's contribution to safety of flight, crew complement was used as the experiment independent variable in a between-subjects design. Pilot actions and performance during single pilot and reduced crew operations were measured for comparison against the normal two-crew complement during normal and non-normal situations. This paper details the crew's actions, including decision-making, and responses while dealing with a drive shaft failure - one of 6 non-normal events that were simulated in this experiment.
Kramer, Lynda J.↗
Quantifying Pilot Contribution to Flight Safety During Dual Generator Failure
Accident statistics cite flight crew error in over 60% of accidents involving transport category aircraft. Yet, a well-trained and well-qualified pilot is acknowledged as the critical center point of aircraft systems safety and an integral safety component of the entire commercial aviation system. No data currently exists that quantifies the contribution of the flight crew in this role. Neither does data exist for how often the flight crew handles non-normal procedures or system failures on a daily basis in the National Airspace System. A pilot-in-the-loop high fidelity motion simulation study was conducted by the NASA Langley Research Center in partnership with the Federal Aviation Administration (FAA) to evaluate the pilot's contribution to flight safety during normal flight and in response to aircraft system failures. Eighteen crews flew various normal and non-normal procedures over a two-day period and their actions were recorded in response to failures. To quantify the human's contribution, crew complement was used as the experiment independent variable in a between-subjects design. Pilot actions and performance when one of the flight crew was unavailable were also recorded for comparison against the nominal two-crew operations. This paper details diversion decisions, perceived safety of flight, workload, time to complete pertinent checklists, and approach and landing results while dealing with a complete loss of electrical generators. Loss of electrical power requires pilots to complete the flight without automation support of autopilots, flight directors, or auto throttles. For reduced crew complements, the additional workload and perceived safety of flight was considered unacceptable.
Etherington, Timothy J.↗
Quantifying Pilot Contribution to Flight Safety During an In-Flight Airspeed Failure
Accident statistics cite the flight crew as a causal factor in over 60% of large transport fatal accidents. Yet a well-trained and well-qualified crew is acknowledged as the critical center point of aircraft systems safety and an integral component of the entire commercial aviation system. A human-in-the-loop test was conducted using a Level D certified Boeing 737-800 simulator to evaluate the pilot's contribution to safety-of-flight during routine air carrier flight operations and in response to system failures. To quantify the human's contribution, crew complement was used as an independent variable in a between-subjects design. This paper details the crew's actions and responses while dealing with an in-flight airspeed failure. Accident statistics often cite flight crew error (Baker, 2001) as the primary contributor in accidents and incidents in transport category aircraft. However, the Air Line Pilots Association (2011) suggests "a well-trained and well-qualified pilot is acknowledged as the critical center point of the aircraft systems safety and an integral safety component of the entire commercial aviation system." This is generally acknowledged but cannot be verified because little or no quantitative data exists on how or how many accidents/incidents are averted by crew actions. Anecdotal evidence suggest crews handle failures on a daily basis and Aviation Safety Action Program data generally supports this assertion, even if the data is not released to the public. However without hard evidence, the contribution and means by which pilots achieve safety of flight is difficult to define. Thus, ways to improve the human ability to contribute or overcome deficiencies are ill-defined.
Etherington, Timothy J.↗
Quantifying Pilot Contribution to Flight Safety during Hydraulic Systems Failure
Accident statistics cite the flight crew as a causal factor in over 60% of large transport aircraft fatal accidents. Yet, a well-trained and well-qualified pilot is acknowledged as the critical center point of aircraft systems safety and an integral safety component of the entire commercial aviation system. The latter statement, while generally accepted, cannot be verified because little or no quantitative data exists on how and how many accidents/incidents are averted by crew actions. A joint NASA/FAA high-fidelity motion-base human-in-the-loop test was conducted using a Level D certified Boeing 737-800 simulator to evaluate the pilot's contribution to safety-of-flight during routine air carrier flight operations and in response to aircraft system failures. To quantify the human's contribution, crew complement (two-crew, reduced crew, single pilot) was used as the independent variable in a between-subjects design. This paper details the crew's actions, including decision-making, and responses while dealing with a hydraulic systems leak - one of 6 total non-normal events that were simulated in this experiment.
Kramer, Lynda J.↗
A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety
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Aviation Safety↗
Exploring Methods to Collect and Analyze Data on Human Contributions to Aviation Safety: A Panel Discussion
Focusing on undesired operator behaviors is pervasive in system design and safety management cultures in aviation. This focus limits the data that are collected, the questions that are asked during data analysis, and therefore our understanding of what operators do in everyday work. Human performance represents a significant source of aviation safety data that includes both desired and undesired actions. When safety is characterized only in terms of errors and failures, the vast majority of human impacts on system safety and performance are ignored. The outcomes of safety data analyses dictate what is learned from those data, which in turn informs safety policies and safety-related decision making. When learning opportunities are systematically restricted by focusing only on rare failure events, not only do we learn less (and less often), but we can draw misleading conclusions by relying on a non-representative sample of human performance data. Changes in how we define and think about safety can highlight new opportunities for collection and analysis of safety-relevant data. Developing an integrated safety picture to better inform safety-related decision making and policies depends upon identifying, collecting, and interpreting safety-producing behaviors in addition to safety-reducing behaviors. Opportunities and challenges in collecting and analyzing the largely unexploited data on desired, safety-producing operator behaviors are discussed.
Aviation Safety↗
Exploring Methods to Collect and Analyze Data on Human Contributions to Aviation Safety: A Panel Discussion
Focusing on undesired operator behaviors is pervasive in system design and safety management cultures in aviation. This focus limits the data that are collected, the questions that are asked during data analysis, and therefore our understanding of what operators do in everyday work. Human performance represents a significant source of aviation safety data that includes both desired and undesired actions. When safety is characterized only in terms of errors and failures, the vast majority of human impacts on system safety and performance are ignored. The outcomes of safety data analyses dictate what is learned from those data, which in turn informs safety policies and safety-related decision making. When learning opportunities are systematically restricted by focusing only on rare failure events, not only do we learn less (and less often), but we can draw misleading conclusions by relying on a non-representative sample of human performance data. Changes in how we define and think about safety can highlight new opportunities for collection and analysis of safety-relevant data. Developing an integrated safety picture to better inform safety-related decision making and policies depends upon identifying, collecting, and interpreting safety producing behaviors in addition to safety reducing behaviors. The panel will discuss opportunities and challenges in collecting and analyzing the largely unexploited data on desired, safety-producing operator behaviors.
aviation safety↗
Tracing NASA Contributions Toward Aviation Safety Stakeholder Guidance
The System-Wide Safety project at NASA is developing the concept and a subset of supporting technologies for evolving safety management from a post-accident iterative improvement on safety performed by large commercial operators only to predictive and increasingly autonomous safety functions that are performed during operations across vehicles, airports, and services. The system of interest is the In-time Aviation Safety Management System (IASMS), recommended by the National Academies for NASA to develop the concept in coordination with the broad and diverse community of stakeholders in aviation safety. Because the system context is the airspace and aviation industry, it is important to create and maintain traceability from the research work and system architecture elements developed at NASA to community-created roadmaps and aviation agency guidance.
IASMS↗
Energize the Future - Systems Engineering Processes and Methods: Tracing NASA Contributions Toward Aviation Safety Stakeholder Guidance
The System-Wide Safety project at NASA is developing the concept and a subset of supporting technologies for evolving safety management from a post-accident iterative improvement on safety performed by large commercial operators only to predictive and increasingly autonomous safety functions that are performed during operations across vehicles, airports, and services. The system of interest is the In-time Aviation Safety Management System (IASMS), recommended by the National Academies for NASA to develop the concept in coordination with the broad and diverse community of stakeholders in aviation safety. Because the system context is the airspace and aviation industry, it is important to create and maintain traceability from the research work and system architecture elements developed at NASA to community-created roadmaps and aviation agency guidance.
MBSE↗