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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

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

Constraining Human Contributions to Observed Warming Since the Pre-industrial Period

Parties to the Paris Agreement agreed to holding global average temperature increases “well below 2 °C above pre-industrial levels and pursuing efforts to limit the temperature increase to 1.5 °C above pre-industrial levels”. Monitoring the contributions of human-induced climate forcings to warming so far is key to understanding progress towards these goals. Here we use climate model simulations from the Detection and Attribution Model Intercomparison Project, as well as regularized optimal fingerprinting, to show that anthropogenic forcings caused 0.9 to 1.3 °C of warming in global mean near-surface air temperature in 2010–2019 relative to 1850–1900, compared with an observed warming of 1.1 °C. Greenhouse gases and aerosols contributed changes of 1.2 to 1.9 °C and −0.7 to −0.1 °C, respectively, and natural forcings contributed negligibly. These results demonstrate the substantial human influence on climate so far and the urgency of action needed to meet the Paris Agreement goals.

Attribution

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

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

Habitability and Human Factors Contributions to Human Space Flight

This slide presentation reviews the work of the Habitability and Human Factors Branch in support of human space flight in two main areas: Applied support to major space programs, and Space research. The field of Human Factors applies knowledge of human characteristics for the design of safer, more effective, and more efficient systems. This work is in several areas of the human space program: (1) Human-System Integration (HSI), (2) Orion Crew Exploration Vehicle, (3) Extravehicular Activity (EVA), (4) Lunar Surface Systems, (5) International Space Station (ISS), and (6) Human Research Program (HRP). After detailing the work done in these areas, the facilities that are available for human factors work are shown.

Sumaya, Jennifer Boyer

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.

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.

Some NASA contributions to human factors engineering: A survey

This survey presents the NASA contributions to the state of the art of human factors engineering, and indicates that these contributions have a variety of applications to nonaerospace activities. Emphasis is placed on contributions relative to man's sensory, motor, decisionmaking, and cognitive behavior and on applications that advance human factors technology.

Behan, R. A.

Robotic Reconnaissance Missions to Small Bodies and Their Potential Contributions to Human Exploration

Introduction: Robotic reconnaissance missions to small bodies will directly address aspects of NASA's Asteroid Initiative and will contribute to future human exploration. The NASA Asteroid Initiative is comprised of two major components: the Grand Challenge and the Asteroid Mission. The first component, the Grand Challenge, focuses on protecting Earth's population from asteroid impacts by detecting potentially hazardous objects with enough warning time to either prevent them from impacting the planet, or to implement civil defense procedures. The Asteroid Mission involves sending astronauts to study and sample a near- Earth asteroid (NEA) prior to conducting exploration missions of the Martian system, which includes Phobos and Deimos. The science and technical data obtained from robotic precursor missions that investigate the surface and interior physical characteristics of an object will help identify the pertinent physical properties that will maximize operational efficiency and reduce mission risk for both robotic assets and crew operating in close proximity to, or at the surface of, a small body. These data will help fill crucial strategic knowledge gaps (SKGs) concerning asteroid physical characteristics that are relevant for human exploration considerations at similar small body destinations. Small Body Strategic Knowledge Gaps: For the past several years NASA has been interested in identifying the key SKGs related to future human destinations. These SKGs highlight the various unknowns and/or data gaps of targets that the science and engineering communities would like to have filled in prior to committing crews to explore the Solar System. An action team from the Small Bodies Assessment Group (SBAG) was formed specifically to identify the small body SKGs under the direction of the Human Exploration and Operations Missions Directorate (HEOMD), given NASA's recent interest in NEAs and the Martian moons as potential human destinations [1]. The action team organized the SKGs into four broad themes: 1) Identify human mission targets; 2) Understand how to work on and interact with the small body surface; 3) Understand the small body environment and its potential risk/benefit to crew, systems, and operational assets; and 4) Understand the small body resource potential. Each of these themes were then further subdivided into categories to address specific SKG issues. Robotic Precursor Contributions to SKGs: Robotic reconnaissance missions should be able to address specific aspects related to SKG themes 1 through 4. Theme 1 deals with the identification of human mission targets within the NEA population. The current guideline indicates that human missions to fastspinning, tumbling, or binary asteroids may be too risky to conduct successfully from an operational perspective. However, no spacecraft mission has been to any of these types of NEAs before. Theme 2 addresses the concerns about interacting on the small body surface under microgravity conditions, and how the surface and/or sub-surface properties affect or restrict the interaction for human exploration. The combination of remote sensing instruments and in situ payloads will provide good insight into the asteroid's surface and subsurface properties. SKG theme 3 deals with the environment in and around the small body that may present a nuisance or hazard to any assets operating in close proximity. Impact and surface experiments will help address issues related to particle size, particle longevity, internal structure, and the near-surface mechanical stability of the asteroid. Understanding or constraining these physical characteristics are important for mission planning. Theme 4 addresses the resource potential of the small body. This is a particularly important aspect of human exploration since the identification and utilization of resources is a key aspect for deep space mission architectures to the Martian system (i.e., Phobos and Deimos). Conclusions: Robotic reconnaissance of small bodies can provide a wealth of information relevant to the science and planetary defense of NEAs. However, such missions to investigate NEAs can also provide key insights into small body strategic knowledge gaps and contribute to the overall success for human exploration missions to asteroids.

Abell, P. A.

Robotic Missions to Small Bodies and Their Potential Contributions to Human Exploration and Planetary Defense

Introduction: Robotic missions to small bodies will directly address aspects of NASA's Asteroid Initiative and will contribute to future human exploration and planetary defense. The NASA Asteroid Initiative is comprised of two major components: the Grand Challenge and the Asteroid Mission. The first component, the Grand Challenge, focuses on protecting Earth's population from asteroid impacts by detecting potentially hazardous objects with enough warning time to either prevent them from impacting the planet, or to implement civil defense procedures. The Asteroid Mission involves sending astronauts to study and sample a near-Earth asteroid (NEA) prior to conducting exploration missions of the Martian system, which includes Phobos and Deimos. The science and technical data obtained from robotic precursor missions that investigate the surface and interior physical characteristics of an object will help identify the pertinent physical properties that will maximize operational efficiency and reduce mission risk for both robotic assets and crew operating in close proximity to, or at the surface of, a small body. These data will help fill crucial strategic knowledge gaps (SKGs) concerning asteroid physical characteristics that are relevant for human exploration considerations at similar small body destinations. These data can also be applied for gaining an understanding of pertinent small body physical characteristics that would also be beneficial for formulating future impact mitigation procedures. Small Body Strategic Knowledge Gaps: For the past several years NASA has been interested in identifying the key SKGs related to future human destinations. These SKGs highlight the various unknowns and/or data gaps of targets that the science and engineering communities would like to have filled in prior to committing crews to explore the Solar System. An action team from the Small Bodies Assessment Group (SBAG) was formed specifically to identify the small body SKGs under the direction of the Human Exploration and Operations Missions Directorate (HEOMD), given NASA's recent interest in NEAs and the Martian moons as potential human destinations. The action team organized the SKGs into four broad themes: 1) Identify human mission targets; 2) Understand how to work on and interact with the small body surface; 3) Understand the small body environment and its potential risk/benefit to crew, systems, and operational assets; and 4) Understand the small body resource potential. Of these four SKG themes, the first three have significant overlap with planetary defense considerations. The data obtained from investigations of small body physical characteristics under these three themes can be directly applicable to planetary defense initiatives. Conclusions: Missions to investigate small bodies can address small body strategic knowledge gaps and contribute to the overall success for human exploration missions to asteroids and the Martian moons. In addition, such reconnaissance of small bodies can also provide a wealth of information relevant to the science and planetary defense of NEAs.

Abell, Paul A.

The Contribution of Pilots to Resilience in Normal Operations: A Survey Approach

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety

The Asteroid Impact and Deflection Assessment Mission and its Potential Contributions to Human Exploration of Asteroids

The joint ESA and NASA Asteroid Impact and Deflection Assessment (AIDA) mission will directly address aspects of NASA's Asteroid Initiative and will contribute to future human exploration. The NASA Asteroid Initiative is comprised of two major components: the Grand Challenge and the Asteroid Mission. The first component, the Grand Challenge, focuses on protecting Earth's population from asteroid impacts by detecting potentially hazardous objects with enough warning time to either prevent them from impacting the planet, or to implement civil defense procedures. The Asteroid Mission, involves sending astronauts to study and sample a near-Earth asteroid (NEA) prior to conducting exploration missions of the Martian system, which includes Phobos and Deimos. AIDA's primary objective is to demonstrate a kinetic impact deflection and characterize the binary NEA Didymos. The science and technical data obtained from AIDA will aid in the planning of future human exploration missions to NEAs and other small bodies. The dual robotic missions of AIDA, ESA's Asteroid Impact Monitor (AIM) and NASA's Double Asteroid Redirection Test (DART), will provide a great deal of technical and engineering data on spacecraft operations for future human space exploration while conducting in-depth scientific examinations of the binary target Didymos both prior to and after the kinetic impact demonstration. The knowledge gained from this mission will help identify asteroidal physical properties in order to maximize operational efficiency and reduce mission risk for future small body missions. The AIDA data will help fill crucial strategic knowledge gaps concerning asteroid physical characteristics that are relevant for human exploration considerations at similar small body destinations.

Abell, Paul A.

The Contribution of Pilots to Resilience in Normal Operations. Part II: A closer look at briefings: Anticipation and Monitoring Also Known as Planning and Coordination

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety