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All sourcesNASA NTRSDOE OSTI
NASA NTRS2022

Maintenance Human Factors and Flight Safety

This chapter will chronicle the journey of the community of operators, regulators, and researchers who embarked upon the task of identifying critical human factors of maintenance and inspection, establishing a database and research tools, developing practical strategies for reducing the risks of maintenance and inspection errors, and understanding its critical role in preserving flight safety. We will take a historical perspective, developing a timeline that is largely driven by key events such as accidents and regulatory/government actions and initiatives. Part 1 focuses on how the field of maintenance human factors was built, beginning in the late 1980’s. Part 2 describes the development of methods and tools for meeting the maintenance human factors challenges identified. Finally, Part 3 updates the original chapter by focusing on issues that have persisted or emerged since 2010.

maintenance↗
NASA NTRS1991

Using Intelligent Simulation to Enhance Human Performance in Aircraft Maintenance

Human factors research and development investigates the capabilities and limitations of the human within a system. Of the many variables affecting human performance in the aviation maintenance system, training is among the most important. The advent of advanced technology hardware and software has created intelligent training simulations. This paper describes one advanced technology training system under development for the Federal Aviation Administration.

Aging Aircraft↗
NASA NTRS1991

Human factors in aircraft maintenance and inspection

The events which have led to the intensive study of aircraft structural problems have contributed in no less measure to study of the human factors which influence aircraft maintenance and inspection. Initial research emphasis on aging aircraft maintenance and inspection has since broadened to include all aircraft types, both new and old. The role of today's aircraft maintenance workforce is indeed a complex one as it is strongly influenced by the need to maintain the broad technology mix embodied in the current fleet. Technicians must be equally adept at diagnosing and repairing "old-tech" 727, DC-9 type aircraft and "new-tech" 767, and MD-ll's. Their skills must include ability to repair sheet metal and composite materials; control cables and flyby-wire systems; round dials and glass cockpits. Their work performance is heavily influenced by others such as designers, technical writers, job card authors, schedulers and trainers. This paper describes activities concerning aircraft maintenance and inspection human factors.

Aging Aircraft↗
NASA NTRS2010

Constraint and Flight Rule Management for Space Mission Operations

The exploration of space is one of the most fascinating domains to study from a human factors perspective. Like other complex work domains such as aviation (Pritchett and Kim, 2008), air traffic management (Durso and Manning, 2008), health care (Morrow, North, and Wickens, 2006), homeland security (Cooke and Winner, 2008), and vehicle control (Lee, 2006), space exploration is a large-scale sociotechnical work domain characterized by complexity, dynamism, uncertainty, and risk in real-time operational contexts (Perrow, 1999; Woods et al, 1994). Nearly the entire gamut of human factors issues - for example, human-automation interaction (Sheridan and Parasuraman, 2006), telerobotics, display and control design (Smith, Bennett, and Stone, 2006), usability, anthropometry (Chaffin, 2008), biomechanics (Marras and Radwin, 2006), safety engineering, emergency operations, maintenance human factors, situation awareness (Tenney and Pew, 2006), crew resource management (Salas et al., 2006), methods for cognitive work analysis (Bisantz and Roth, 2008) and the like -- are applicable to astronauts, mission control, operational medicine, Space Shuttle manufacturing and assembly operations, and space suit designers as they are in other work domains (e.g., Bloomberg, 2003; Bos et al, 2006; Brooks and Ince, 1992; Casler and Cook, 1999; Jones, 1994; McCurdy et al, 2006; Neerincx et aI., 2006; Olofinboba and Dorneich, 2005; Patterson, Watts-Perotti and Woods, 1999; Patterson and Woods, 2001; Seagull et ai, 2007; Sierhuis, Clancey and Sims, 2002). The human exploration of space also has unique challenges of particular interest to human factors research and practice. This chapter provides an overview of those issues and reports on some of the latest research results as well as the latest challenges still facing the field.

Barreiro, J.↗
NASA NTRS2010

Human Factors in Space Exploration

The exploration of space is one of the most fascinating domains to study from a human factors perspective. Like other complex work domains such as aviation (Pritchett and Kim, 2008), air traffic management (Durso and Manning, 2008), health care (Morrow, North, and Wickens, 2006), homeland security (Cooke and Winner, 2008), and vehicle control (Lee, 2006), space exploration is a large-scale sociotechnical work domain characterized by complexity, dynamism, uncertainty, and risk in real-time operational contexts (Perrow, 1999; Woods et ai, 1994). Nearly the entire gamut of human factors issues - for example, human-automation interaction (Sheridan and Parasuraman, 2006), telerobotics, display and control design (Smith, Bennett, and Stone, 2006), usability, anthropometry (Chaffin, 2008), biomechanics (Marras and Radwin, 2006), safety engineering, emergency operations, maintenance human factors, situation awareness (Tenney and Pew, 2006), crew resource management (Salas et aI., 2006), methods for cognitive work analysis (Bisantz and Roth, 2008) and the like -- are applicable to astronauts, mission control, operational medicine, Space Shuttle manufacturing and assembly operations, and space suit designers as they are in other work domains (e.g., Bloomberg, 2003; Bos et al, 2006; Brooks and Ince, 1992; Casler and Cook, 1999; Jones, 1994; McCurdy et ai, 2006; Neerincx et aI., 2006; Olofinboba and Dorneich, 2005; Patterson, Watts-Perotti and Woods, 1999; Patterson and Woods, 2001; Seagull et ai, 2007; Sierhuis, Clancey and Sims, 2002). The human exploration of space also has unique challenges of particular interest to human factors research and practice. This chapter provides an overview of those issues and reports on sorne of the latest research results as well as the latest challenges still facing the field.

FROM↗
NASA NTRS1998

MRM Evaluation Research Program

This is an interim report on the current output of the MRM evaluation research program. During 1998 this research program has used new and existing data to create an important tool for the development and improvement of "maintenance resource management" (MRM). Thousands of surveys completed by participants in airline MRM training and/or behavior change programs have, for the first time, been consolidated into a panel of "MRM Attitudes and Opinion Profiles." These profiles can be used to compare the attitudes about decision making and communication in any given company at any stage in its MRM program with attitudes of a large sample of like employees during a similar period in their MRM involvement. This panel of comparison profiles for attitudes and opinions is a tool to help audit the effectiveness of a maintenance human factors program. The profile panel is the first of several tools envisioned for applying the information accumulating in MRM databases produced as one of the program's long range objectives.

Taylor, James C.↗
NASA NTRS2000

The NASA Aviation Safety Program: Overview

In 1997, the United States set a national goal to reduce the fatal accident rate for aviation by 80% within ten years based on the recommendations by the Presidential Commission on Aviation Safety and Security. Achieving this goal will require the combined efforts of government, industry, and academia in the areas of technology research and development, implementation, and operations. To respond to the national goal, the National Aeronautics and Space Administration (NASA) has developed a program that will focus resources over a five year period on performing research and developing technologies that will enable improvements in many areas of aviation safety. The NASA Aviation Safety Program (AvSP) is organized into six research areas: Aviation System Modeling and Monitoring, System Wide Accident Prevention, Single Aircraft Accident Prevention, Weather Accident Prevention, Accident Mitigation, and Synthetic Vision. Specific project areas include Turbulence Detection and Mitigation, Aviation Weather Information, Weather Information Communications, Propulsion Systems Health Management, Control Upset Management, Human Error Modeling, Maintenance Human Factors, Fire Prevention, and Synthetic Vision Systems for Commercial, Business, and General Aviation aircraft. Research will be performed at all four NASA aeronautics centers and will be closely coordinated with Federal Aviation Administration (FAA) and other government agencies, industry, academia, as well as the aviation user community. This paper provides an overview of the NASA Aviation Safety Program goals, structure, and integration with the rest of the aviation community.

Shin, Jaiwon↗
NASA NTRS1995

Identifying Human Factors Issues in Aircraft Maintenance Operations

Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.

Veinott, Elizabeth S.↗
NASA NTRSDate not supplied

Managing Maintenance Error: Six Lessons From Aviation Maintenance

There are clear parallels between the ground processing of spacecraft and the maintenance of airline aircraft. In both cases, reliable human performance is critical to safe outcomes. Examples of human factors in airline maintenance and spacecraft ground processing illustrate the similarities between these two domains. The worldwide aviation industry began to pay close attention to human factors in maintenance after several maintenance-related disasters in the 1970s and 80s. Rather than simply applying solutions that had been developed for flight crew and air traffic controllers, the aviation industry developed human factors interventions specifically tailored for maintenance personnel. These interventions have led to safety improvements, greater reliability, and significant cost savings. Six human factors approaches from airline maintenance that can be usefully applied to enhance the quality and safety of ground processing are outlined. These are 1) Design for assembly, test, and maintenance, 2) Non technical skills training, 3) Improved design of documentation, 4) Reduction of iatrogenic quality lapses, 5) Barrier and control analysis, and 6) Continuous improvement based on learning from quality lapses.

maintenance human factors↗
NASA NTRS1994

A human factors evaluation using tools for automated knowledge engineering

A human factors evaluation of the MH-53J helicopter cockpit is described. This evaluation was an application and futher development of Tools for Automated Knowledge Engineering (TAKE). TAKE is used to acquire and analyze knowledge from domain experts (aircrew members, system designers, maintenance personnel, human factors engineers, or others). TAKE was successfully utilized for the purpose of recommending improvements for the man-machine interfaces (MMI) in the MH-53J cockpit.

Gomes, Marie E.↗
NASA NTRS2012

The Analysis of the Contribution of Human Factors to the In-Flight Loss of Control Accidents

In-flight loss of control (LOC) is currently the leading cause of fatal accidents based on various commercial aircraft accident statistics. As the Next Generation Air Transportation System (NextGen) emerges, new contributing factors leading to LOC are anticipated. The NASA Aviation Safety Program (AvSP), along with other aviation agencies and communities are actively developing safety products to mitigate the LOC risk. This paper discusses the approach used to construct a generic integrated LOC accident framework (LOCAF) model based on a detailed review of LOC accidents over the past two decades. The LOCAF model is comprised of causal factors from the domain of human factors, aircraft system component failures, and atmospheric environment. The multiple interdependent causal factors are expressed in an Object-Oriented Bayesian belief network. In addition to predicting the likelihood of LOC accident occurrence, the system-level integrated LOCAF model is able to evaluate the impact of new safety technology products developed in AvSP. This provides valuable information to decision makers in strategizing NASA's aviation safety technology portfolio. The focus of this paper is on the analysis of human causal factors in the model, including the contributions from flight crew and maintenance workers. The Human Factors Analysis and Classification System (HFACS) taxonomy was used to develop human related causal factors. The preliminary results from the baseline LOCAF model are also presented.

Ancel, Ersin↗
NASA NTRS1997

Operational Interventions to Maintenance Error

A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

Kanki, Barbara G.↗
NASA NTRS1997

Reduction of Maintenance Error Through Focused Interventions

It is well known that a significant proportion of aviation accidents and incidents are tied to human error. In flight operations, research of operational errors has shown that so-called "pilot error" often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the "team" concept for maintenance operations and in tailoring programs to fit the needs of technical operations. Nevertheless, there remains a dual challenge: to develop human factors interventions which are directly supported by reliable human error data, and to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

Kanki, Barbara G.↗
NASA NTRS1983

Space station needs, attributes, and architectural options: Technology development

The technology development of the space station is examined as it relates to space station growth and equipment requirements for future missions. Future mission topics are refined and used to establish a systems data base. Technology for human factors engineering, space maintenance, satellite design, and laser communications and tracking is discussed.

Robert, A. C.↗
NASA NTRS1991

Probabilistic simulation of the human factor in structural reliability

Many structural failures have occasionally been attributed to human factors in engineering design, analyses maintenance, and fabrication processes. Every facet of the engineering process is heavily governed by human factors and the degree of uncertainty associated with them. Factors such as societal, physical, professional, psychological, and many others introduce uncertainties that significantly influence the reliability of human performance. Quantifying human factors and associated uncertainties in structural reliability require: (1) identification of the fundamental factors that influence human performance, and (2) models to describe the interaction of these factors. An approach is being developed to quantify the uncertainties associated with the human performance. This approach consists of a multi factor model in conjunction with direct Monte-Carlo simulation.

Shah, Ashwin R.↗
NASA NTRS2001

Integrating Safety in the Aviation System: Interdepartmental Training for Pilots and Maintenance Technicians

The study of human factors has had a decisive impact on the aviation industry. However, the entire aviation system often is not considered in researching, training, and evaluating human factors issues especially with regard to safety. In both conceptual and practical terms, we argue for the proactive management of human error from both an individual and organizational systems perspective. The results of a multidisciplinary research project incorporating survey data from professional pilots and maintenance technicians and an exploratory study integrating students from relevant disciplines are reported. Survey findings suggest that latent safety errors may occur during the maintenance discrepancy reporting process because pilots and maintenance technicians do not effectively interact with one another. The importance of interdepartmental or cross-disciplinary training for decreasing these errors and increasing safety is discussed as a primary implication.

Mattson, Marifran↗
NASA NTRS2016

3D Printing in Zero G Technology Demonstration Mission: Summary of On-Orbit Operations, Material Testing, and Future Work

Human space exploration to date has been limited to low Earth orbit and the moon. The International Space Station (ISS), an orbiting laboratory 200 miles above the earth, provides a unique and incredible opportunity for researchers to prove out the technologies that will enable humans to safely live and work in space for longer periods of time and venture farther into the solar system. The ability to manufacture parts in-space rather than launch them from earth represents a fundamental shift in the current risk and logistics paradigm for human spaceflight. In particularly, additive manufacturing (or 3D printing) techniques can potentially be deployed in the space environment to enhance crew safety (by providing an on-demand part replacement capability) and decrease launch mass by reducing the number of spare components that must be launched for missions where cargo resupply is not a near-term option. In September 2014, NASA launched the 3D Printing in Zero G technology demonstration mission to the ISS to explore the potential of additive manufacturing for in-space applications and demonstrate the capability to manufacture parts and tools on-orbit. The printer for this mission was designed and operated by the company Made In Space under a NASA SBIR (Small Business Innovation Research) phase III contract. The overarching objectives of the 3D print mission were to use ISS as a testbed to further maturation of enhancing technologies needed for long duration human exploration missions, introduce new materials and methods to fabricate structure in space, enable cost-effective manufacturing for structures and mechanisms made in low-unit production, and enable physical components to be manufactured in space on long duration missions if necessary. The 3D print unit for fused deposition modeling (FDM) of acrylonitrile butadiene styrene (ABS) was integrated into the ISS Microgravity Science Glovebox (MSG) in November 2014 and phase I printing operations took place from November through December of that year. Phase I flight operations yielded 14 unique parts (21 total specimens) that could be directly compared against ground-based prints of identical geometry manufactured using the printer prior to its launch to ISS. The 3DP unit functioned safely and produced specimens necessary to advance the understanding of the critical design and operational parameters for the FDM process as affected by the microgravity environment. From the standpoint of operations, 3DP demonstrated the ability to remove parts from the build-tray on-orbit, teleoperate the printer from the ground, perform critical maintenance functions within defined human factors limits, produce a functional tool that could be evaluated for form/fit/function, and uplink a new part file from the ground and produce it on the printer. The flight parts arrived at NASA Marshall Space Flight Center in Huntsville, Alabama in April 2015, where they underwent months of testing in the materials and processes laboratory. Ground and flight prints completed the following phases of testing: photographic/visual inspection, mass and density evaluation, structured light scanning, XRay and CT, mechanical testing, optical microscopy, scanning electron microscopy, and chemical analysis. This presentation will discuss the results of this testing as well as phase II operations for the printer, which took place in June and July of 2016. Lessons learned from the tech demo and their impacts on the design and development of the second generation 3D printer for ISS, the Additive Manufacturing Facility (AMF) by Made In Space will also be presented. In addition, progress in other elements of NASA's In Space Manufacturing (ISM) initiative such as the on-demand ISM utilization catalog, in-space Recycler ISS Technology Demonstration development, launch packaging recycling, in-space printable electronics, development of higher strength polymeric materials for 3D printing and Additive Construction by Mobile Emplacement (ACME) will also be addressed.

Prater, Tracie↗
NASA NTRS2008

The Application of the Human Engineering Modeling and Performance Laboratory for Space Vehicle Ground Processing Tasks at Kennedy Space Center

The introduction of United Space Alliance's Human Engineering Modeling and Performance Laboratory began in early 2007 in an attempt to address the problematic workspace design issues that the Space Shuttle has imposed on technicians performing maintenance and inspection operations. The Space Shuttle was not expected to require the extensive maintenance it undergoes between flights. As a result, extensive, costly resources have been expended on workarounds and modifications to accommodate ground processing personnel. Consideration of basic human factors principles for design of maintenance is essential during the design phase of future space vehicles, facilities, and equipment. Simulation will be needed to test and validate designs before implementation.

Woodbury, Sarah K.↗