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- 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.
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.
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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.
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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.
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.
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.
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.
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Efforts to improve operational safety often focus on preventing human error. But humans don't just make mistakes. They do, in fact, make a tremendous contribution to operational safety, and there is much to learn from what goes right. To support people in their role, the operation should be human-centered. To make the operation human-centered, the framework of the 4Ps can be used to create a clear, coherent, consistent and comprehensive guidance.
NASA’s System Wide Safey (SWS) project under the Aviation Operations and Safety Program (AOSP) of the Aeronautical Research Mission Directorate (ARMD) supports work demonstrating the human contribution to safety (HC2S) and the benefits of learning from all operations including learning from what goes well. Some of this work is being done in collaboration with the Flight Safety Foundation (FSF). The presentation provides the rationale for this work, its expected benefits, and its methodology.
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.
The NASA System-Wide Safety (SWS) Project is focused on developing new technologies and operational concepts for the aviation industry to meet the increasing global demand while maintaining the current ultra-safe system safety levels. To achieve this, the SWS Project is developing research priorities, including In-time System-wide Safety Assurance (ISSA) and In-time Aviation Safety Management System (IASMS; Ellis et al., 2019). A critical component of the IASMS is the human as pilot and in other roles in aviation operations as demonstrated by SWS human factors research on rare occurrences of human error and the far more prevalent human safety producing behaviors (e.g., Hollnagel, 2016). The talk presented by Chad Stephens of NASA Langley Research Center and NASA SWS Project will describe the history of human factors research involving psychophysiological and biocybernetics methods supporting aviation safety conducted at NASA. Specific examples of recent NASA crew state monitoring research focused on a psychophysiological assessment method and system to enable Training for Attention Management will be demonstrated. Current SWS research including the SWS Operations and Technologies for Enabling Resilient In-Time Assurance (SOTERIA) flight simulation study and a data testbed created to enable study of Human Contributions to Safety (HC2S) will be presented. Ongoing collaborative research efforts with Boeing researchers will be highlighted and opportunities for further collaboration will be discussed.
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.
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.
Focusing on undesired operator behaviors is pervasive in system design and safety management cultures. 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 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. The study of human contributions to safety represents a vast and largely unexplored opportunity to learn. 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 system design, safety-related decision making and policies depends upon identifying, collecting, and interpreting safety producing behaviors in addition to safety reducing behaviors.
The identification, modelling, and analysis of root causes of accidents and incidents dominate conventional safety management approaches. However, the effect of humans’ safety-producing behavior on the overall resilience of the system is often neglected. Additionally, emerging aviation markets are giving rise to concepts of operation, such as urban air mobility and optionally piloted air cargo operations, that are leading to a shift in locus of control between humans and automation. Without an understanding of the human contribution to safety, it is difficult to assess the effects of these novel role allocations on overall system safety. In this work, safety-producing behaviors are identified and abstracted into resilient performance strategies. Production rules that encapsulate these strategies are then generated and classified in the Soar cognitive architecture. The strategies are then applied to a remotely-operated air cargo example to demonstrate how safe learning is facilitated. The learned rules and strategies are then formally verified.