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At least 19 records
All sourcesNASA NTRSDOE OSTI
NASA NTRS1981

A theory of human error

Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Mcruer, D. T.↗
NASA NTRS2002

Stochastic Models of Human Errors

Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.

Elshamy, Maged↗
NASA NTRS1980

A theory of human error

Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Mcruer, D. T.↗
NASA NTRS1980

Technical approaches for measurement of human errors

Human error is a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents. The technical details of a variety of proven approaches for the measurement of human errors in the context of the national airspace system are presented. Unobtrusive measurements suitable for cockpit operations and procedures in part of full mission simulation are emphasized. Procedure, system performance, and human operator centered measurements are discussed as they apply to the manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations.

Clement, W. F.↗
NASA NTRSDate not supplied

Human Error Analysis for Human-Rated Space Systems

Humans bring unique capabilities to space systems and contribute to mission success in a manner that cannot be matched by machines. Nevertheless, from time to time, human error can present a threat to system performance, and system designers must anticipate and manage this risk. NASA’s Human-Rating Requirements for Space Systems call for program managers to conduct a human error analysis (HEA) during system development but does not specify how to do this. In 2018, NASA’s Engineering and Safety Center asked the authors to develop a guidance document on HEA. The resulting position paper outlines a suggested method for HEA and makes it clear that error analysis is about identifying and mitigating problems at a system level, and not about finding fault with individuals. Error management strategies must be directed at error-producing conditions, thereby reducing the likelihood of human error, while retaining the positive contribution that humans make to system operations.

human error human-rated space↗
NASA NTRS2007

Human Error: A Concept Analysis

Human error is the subject of research in almost every industry and profession of our times. This term is part of our daily language and intuitively understood by most people however, it would be premature to assume that everyone's understanding of human error s the same. For example, human error is used to describe the outcome or consequence of human action, the causal factor of an accident, deliberate violations,a nd the actual action taken by a human being. As a result, researchers rarely agree on the either a specific definition or how to prevent human error. The purpose of this article is to explore the specific concept of human error using Concept Analysis as described by Walker and Avant (1995). The concept of human error is examined as currently used in the literature of a variety of industries and professions. Defining attributes and examples of model, borderline, and contrary cases are described. The antecedents and consequences of human error are also discussed and a definition of human error is offered.

Hansen, Frederick D.↗
NASA NTRS2017

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

human error↗
NASA NTRS2017

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

mishaps↗
NASA NTRS2017

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

human error↗
NASA NTRS1983

Analysis and classification of human error

The literature on human error is reviewed with emphasis on theories of error and classification schemes. A methodology for analysis and classification of human error is then proposed which includes a general approach to classification. Identification of possible causes and factors that contribute to the occurrence of errors is also considered. An application of the methodology to the use of checklists in the aviation domain is presented for illustrative purposes.

Rouse, W. B.↗
NASA NTRS2020

Guidance for Human Error Analysis (HEA)

NASA’s Human-Rating Requirements for Space Systems in NASA Procedural Requirements (NPR) 8705.2C requires Program Managers to conduct a human error analysis (HEA) for all mission phases. The purpose of the HEA is to enable programs to understand and manage potential catastrophic hazards that could be caused by human error, understand the relative risks and uncertainties within the system design, and influence decisions throughout the system lifecycle. This document provides guidance to NASA civil servants and contractors on how the Agency’s HEA requirement can be fulfilled.

Human Error Analysis; NASA Procedural Requirement;↗
NASA NTRSDate not supplied

Identifying Human Errors and Error Mechanisms From Accident Reports Using Large Language Models

Emerging operational concepts for aviation hinge on novel paradigms for human machine interaction. Critical to their safe operation is early consideration of human error into the design process. Existing methods for consideration of human error require significant expert input, which is challenging both in early design and in novel systems for which there is little existing safety expertise. In this research, we propose a methodology for identifying human error, error producing factors, and mechanisms in early design from historical incident reports. Additionally, we hypothesize that cross-domain sharing of lessons learned can aid with early design human considerations in circumstances where data is not relevant or incomplete. This is addressed by identifying causes of human error in aviation and railway domains through applying state-of-the art natural language processing techniques to historical incident reports. Using this method, it is possible to extract extensive reports on human error from past incidents. Using the proposed approach, we identify nine human errors from railway reports and fourteen from aviation reports, with three errors common to both domains. There is at least one error producing conditions for each human error while a majority of the errors have more than one error mechanism. We also found that a majority of the human errors, error producing factors, and error mechanisms (even if they are not common between the domains) can be used to inform safe operations across domains as long as the errors are not domain specific and are interpreted and contextualized using engineering judgement.

Human Errors↗
NASA NTRS2003

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.

Wiegmann, Douglas A.↗
DOE OSTI2024

Estimating the Contributions to Human Error Probability from the Convolution of the Distribution of Time Available and Time Required

As part of their duties, Human Reliability Analysis must often evaluate if crews in nuclear power plants (NPPs) can complete tasks associated with a human-failure event within time limits. For example, the time required in NPP scenarios is determined by systematic and structured walkthroughs, feasibility studies, recorded times from training exercises, and interviews with experienced operators and experts. Typically, a point estimate is derived for the estimate (mean, maximum, or 95th percentile of time required). Using point-estimate values can mask the risk associated with variability among crews, plant conditions and set-up, environmental conditions, and other impact factors under which these actions are executed. While point estimates for time required and time available have served the industry well, without considering the uncertainty they could lead to biased understanding about the risk. The Integrated Human Event Analysis System - General Methodology (IDHEAS-G) model (developed by the US Nuclear Regulatory Commission, NRC) for human error probability calculates human error probability by summing two probabilities: insufficient time and cognitive error. As such, the model takes a more holistic approach by considering the full distributions for time required and time available to calculate the human error probability because the time available to complete the task is insufficient. In this study, we expand on the work of the NRC and discuss methods for estimating these time considerations. For example, for the time required, the impact of Performance Influencing Factors (PIFs) on the distribution was divided into impacts that are aleatory in nature, such as crew-to-crew variability, and those that are epistemic (i.e., the PIFs). Starting with the factors that introduce aleatory uncertainty, a first-order distribution was developed from a large set of time required (i.e., NPP task completion times) data for the range of operator actions that occur in the NPP control room under simulated accident conditions. The first-order distribution can then be adjusted to account for epistemic uncertainty using research associated with the impact of applicable PIFs on the time required. We also develop guidance for analysts to address the probability distributions for the time available. The guidance we developed on how to estimate time required and time available distributions is based on the identification of pertinent research and data, data analyses, and expert knowledge elicitation.

human error probability, human performance, time e↗
NASA NTRS1989

Human error and the search for blame

Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.

Denning, Peter J.↗
NASA NTRS2012

Avoiding Human Error in Mission Operations: Cassini Flight Experience

Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.

guidance and control↗
NASA NTRS1993

Intervention strategies for the management of human error

This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

Wiener, Earl L.↗
NASA NTRS1988

Human error in aviation operations

The role of human error in commercial and general aviation accidents and the techniques used to evaluate it are reviewed from a human-factors perspective. Topics addressed include the general decline in accidents per million departures since the 1960s, the increase in the proportion of accidents due to human error, methods for studying error, theoretical error models, and the design of error-resistant systems. Consideration is given to information acquisition and processing errors, visually guided flight, disorientation, instrument-assisted guidance, communication errors, decision errors, debiasing, and action errors.

Nagel, David C.↗