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NASA NTRS2016

Tailoring a Human Reliability Analysis to Your Industry Needs

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

DeMott, D. L.↗
NASA NTRS2020

Identification of Scenarios for System Interface Design Evaluation: CAST SE-210 Output 2 Report 5 of 6

This report is one in a series of reports describing research to develop enhanced approaches to design and evaluation of flight deck interaction. The research was conducted to support the Commercial Aviation Safety Team (CAST) response to incidents and accidents caused by failure of the flight crew to maintain aircraft attitude or energy state awareness. This report partially responds to Safety Enhancement (SE) 210.2 (CAST, 2014) by describing development of operational scenarios for evaluation of flight crew interaction. Evaluations of human performance with an interface rely on asking humans to perform operational tasks in an appropriate operational context. The report includes the major sources of material for developing operational scenarios—which include system state, operational tasks, operational context, and safety events—and a method for developing an appropriate set of operational scenarios for interface evaluation.

commercial aviation↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Five

Volume V of the Report contains appendices that were not cited in VolumeI. These consist of documents produced by NASA and other organizations, which were provided to the Columbia Accident Investigation Board in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia The contents include:. Appendix G.1 Requirements and Procedures for Certification of Flight Readiness; Appendix G.2 Appendix R, Space Shuttle Program Contingency Action Plan; Appendix G.3 CAIB Charter, with Revisions; Appendix G.4 Group 1 Matrix Brief on Maintenance, Material, and Management; Appendix G.5 Vehicle Data Mapping(VDM) Team Final Report, Jun 13, 2003; Appendix G.6 SRB Working Group Presentation to CAIB; Appendix G. 7 Starfire Team Final Report, Jun 3, 2003; Appendix G.8 Using the Data and Observations from Flight STS-107, Executive Summary; Appendix G.9 Contracts, Incentives, and Safety/Technical Excellence; Appendix G.10 Detailed Summaries: Rogers Commission Report, ASAP Report, SIAT Report; Appendix G.11 Foam Application and Production Chart; Appendix G.12 Crew Survivability Report; and Appendix G.12 Aero/Aerothermal/ Thermal/Structures Team FinalReport, August 6, 2003.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS1931

Aircraft accidents : method of analysis

The revised report includes the chart for the analysis of aircraft accidents, combining consideration of the immediate causes, underlying causes, and results of accidents, as prepared by the special committee, with a number of the definitions clarified. A brief statement of the organization and work of the special committee and of the Committee on Aircraft Accidents; and statistical tables giving a comparison of the types of accidents and causes of accidents in the military services on the one hand and in civil aviation on the other, together with explanations of some of the important differences noted in these tables.

Source record↗
NASA NTRS2004

Distribution of Causes in Selected US Aviation Accident Reports Between 1996 and 2003

This paper describes the results of an independent analysis of the probable and contributory causes of selected aviation accidents in the United States between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a variety of causal factors in the reporting of these adverse events. Although our results show that more of these high consequence accidents were attributed to human error than to any other single factor, a large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These wider issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗
NASA NTRS1932

Statistics of the Bureau Veritas

Statistics are indispensable factors for the amelioration of safety. Through the reconciliation of accidents which may appear isolated to interested parties, they permit tracking of typical causes of accidents; conversely, they can prevent, after a serious accident due to some fortuitous cause, the taking of incautious measures under the pressure of public opinion, which always inclines to gauge the gravity of the causes by that of the results. Lastly, they permit appraisal of the efficacy of rules in force. We should add that statistics provide an agency of prevention for future accidents. A careful inspection of all signs of malfunction of material quite often prevents the occurrence of an accident. In this respect, many pilot's report, perfectly normal in every way as far as operation is concerned, can reveal much more interesting technical data than an accident, although it does not diminish the importance of statistics. Therefore, from the inception of its aeronautical service, at the end of 1922, the Bureau Veritas has kept annual statistics of all accidents which occurred in French civil aviation. In order to correctly perform their proper function, the statistics must be exact and sufficiently explicit and complete. To be exact, they must bear on all pertinent events, and on these alone. It is a matter then, first of all, defining the accident in such a way that no sinister detail bearing on the definition may escape control. The consideration of accidents to personnel only has appeared too limited. One of the essential qualities of statistics is to permit the taking of averages and in consequence to apply them ot a sufficiently large number; such is happily not the case in accidents to personnel.

Volmerange, Andre↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Three

The Columbia Accident Investigation Board's (CAIB) independent investigation into the February 1, 2003 destruction of the Space Shuttle Columbia produced a six volume report. This is Volume III of the report. Volume III contains other technical documents produced by NASA and other organizations, which were provided to the CAIB in support of its inquiry into the tragedy. Technical documents included in the report are: Appendix E.1 CoFR Endorsements; Appendix E.2 STS-107 Image Analysis Team Final Report; Appendix E.3 An Assessment of Potential Material Candidates for the 'Flight Day 2', Radar Object Observed during the NASA Mission STS-107; Appendix E.4 Columbia Early Sighting Assessment Team Final Report.

STS-107↗
NASA NTRS2014

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗
NASA NTRS1974

Control Characteristics of Alcohol-Impaired Operators

Although the operation of vehicles like airplanes, cars, and bicycles involves a complex array of perceptual, decision and control activities, most accident statistics clearly show that intoxicated operators are a dominant cause of accidents, and not the difficulty of the task itself. This paper summarizes some recent research on the nature of the impairment of operator control under blood alcohol concentrations (BAC) up to above 0.16 percent. Alcohol toxicity is shown to be quite specific with respect to visual-motor functions involved in control of a vehicle, and experiments with a generalized workload task and special driving simulator show how these are reflected in terms of changes in operator control parameters such as response latency, gains, stability margins, and coherency.

Jex, Henry R.↗
NASA NTRS1971

The practical application of mishap data in Army aircraft system safety programs

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

James T. Darrah, Jr↗
NASA NTRS2007

An Application of CICCT Accident Categories to Aviation Accidents in 1988-2004

Interventions or technologies developed to improve aviation safety often focus on specific causes or accident categories. Evaluation of the potential effectiveness of those interventions is dependent upon mapping the historical aviation accidents into those same accident categories. To that end, the United States civil aviation accidents occurring between 1988 and 2004 (n=26,117) were assigned accident categories based upon the taxonomy developed by the CAST/ICAO Common Taxonomy Team (CICTT). Results are presented separately for four main categories of flight rules: Part 121 (large commercial air carriers), Scheduled Part 135 (commuter airlines), Non-Scheduled Part 135 (on-demand air taxi) and Part 91 (general aviation). Injuries and aircraft damage are summarized by year and by accident category.

Evans, Joni K.↗
NASA NTRS2009

Software Health Management: A Short Review of Challenges and Existing Techniques

Modern spacecraft (as well as most other complex mechanisms like aircraft, automobiles, and chemical plants) rely more and more on software, to a point where software failures have caused severe accidents and loss of missions. Software failures during a manned mission can cause loss of life, so there are severe requirements to make the software as safe and reliable as possible. Typically, verification and validation (V&V) has the task of making sure that all software errors are found before the software is deployed and that it always conforms to the requirements. Experience, however, shows that this gold standard of error-free software cannot be reached in practice. Even if the software alone is free of glitches, its interoperation with the hardware (e.g., with sensors or actuators) can cause problems. Unexpected operational conditions or changes in the environment may ultimately cause a software system to fail. Is there a way to surmount this problem? In most modern aircraft and many automobiles, hardware such as central electrical, mechanical, and hydraulic components are monitored by IVHM (Integrated Vehicle Health Management) systems. These systems can recognize, isolate, and identify faults and failures, both those that already occurred as well as imminent ones. With the help of diagnostics and prognostics, appropriate mitigation strategies can be selected (replacement or repair, switch to redundant systems, etc.). In this short paper, we discuss some challenges and promising techniques for software health management (SWHM). In particular, we identify unique challenges for preventing software failure in systems which involve both software and hardware components. We then present our classifications of techniques related to SWHM. These classifications are performed based on dimensions of interest to both developers and users of the techniques, and hopefully provide a map for dealing with software faults and failures.

Pipatsrisawat, Knot↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Two

Volume II of the Report contains appendices that were cited in Volume I. The Columbia Accident Investigation Board produced many of these appendices as working papers during the investigation into the February 1, 2003 destruction of the Space Shuttle Columbia. Other appendices were produced by other organizations (mainly NASA) in support of the Board investigation. In the case of documents that have been published by others, they are included here in the interest of establishing a complete record, but often at less than full page size. Contents include: CAIB Technical Documents Cited in the Report: Reader's Guide to Volume II; Appendix D. a Supplement to the Report; Appendix D.b Corrections to Volume I of the Report; Appendix D.1 STS-107 Training Investigation; Appendix D.2 Payload Operations Checklist 3; Appendix D.3 Fault Tree Closure Summary; Appendix D.4 Fault Tree Elements - Not Closed; Appendix D.5 Space Weather Conditions; Appendix D.6 Payload and Payload Integration; Appendix D.7 Working Scenario; Appendix D.8 Debris Transport Analysis; Appendix D.9 Data Review and Timeline Reconstruction Report; Appendix D.10 Debris Recovery; Appendix D.11 STS-107 Columbia Reconstruction Report; Appendix D.12 Impact Modeling; Appendix D.13 STS-107 In-Flight Options Assessment; Appendix D.14 Orbiter Major Modification (OMM) Review; Appendix D.15 Maintenance, Material, and Management Inputs; Appendix D.16 Public Safety Analysis; Appendix D.17 MER Manager's Tiger Team Checklist; Appendix D.18 Past Reports Review; Appendix D.19 Qualification and Interpretation of Sensor Data from STS-107; Appendix D.20 Bolt Catcher Debris Analysis.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Six

In the course of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia, the Columbia Accident Investigation Board conducted a series of public hearings at Houston, Texas; Cape Canaveral, Florida; and Washington, DC. Testimony from these hearings was recorded and then transcribed. This appendix, Volume VI of the Report, is a compilation of those transcripts. Contents: Transcripts of Board Public Hearings; Appendix H.1 March 6, 2003 Houston, Texas; Appendix H.2 March 17, 2003 Houston, Texas; Appendix H.3 March 18, 2003 Houston, Texas; Appendix H. 4 March 25, 2003 Cape Canaveral, Florida; Appendix H.5 March 26, 2003 Cape Canaveral, Florida; Appendix H.6 April 7, 2003 Houston, Texas; Appendix H.7 April 8, 2003 Houston, Texas; Appendix H.8 April 23, 2003 Houston, Texas; Appendix H.9 May 6, 2003 Houston, Texas; Appendix H.10 June 12, 2003 Washington, DC.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS1996

Early Warning: Development of Confidential Incident Reporting Systems

Accidents hardly ever happen without warning. The combination, or sequence, of failures and mistakes that cause an accident may indeed be unique but the individual failures and mistakes rarely are. In the USA in 1974 the crews on two different aircraft misunderstood the same aeronautical chart and descended towards their destination dangerously early towards a mountain. The first crew were in good weather conditions and could see the mountain and resolved their misinterpretation of the chart. The second crew six weeks later were not so lucky. In cloud they had no clues to point out their mistake nor the presence of the mountain. The resulting crash and the ensuing inquiry, which brought to light the previous incident, shocked the country but gave it the impetus to instigate a safety reporting system. This system eventually became the NASA's Aviation Safety Reporting System (ASRS). The programme collects incident reports from pilots, controllers, mechanics, cabin attendants and many others involved in aviation operations. By disseminating this safety information the ASRS has helped enormously to give US airlines and airspace the highest safety standards. Accident prevention is a goal sought by everyone in the aviation industry and establishing effective incident reporting programmes can go a long way toward achieving that goal. This article will describe the steps and issues required to establish an incident reporting system. The authors summarize the lessons learned from the ASRS, now in its twentieth year of operation and from the Confidential Human Factors Reporting (HER) Programme run by British Airways, an airline that is a recognized world leader in safety reporting and analysis. The differences between government and airline operation of confidential safety reporting systems will be addressed.

OLeary, Mike J.↗
NASA NTRS2007

Image Analysis Based on Soft Computing and Applied on Space Shuttle During the Liftoff Process

Imaging techniques based on Soft Computing (SC) and developed at Kennedy Space Center (KSC) have been implemented on a variety of prototype applications related to the safety operation of the Space Shuttle during the liftoff process. These SC-based prototype applications include detection and tracking of moving Foreign Objects Debris (FOD) during the Space Shuttle liftoff, visual anomaly detection on slidewires used in the emergency egress system for the Space Shuttle at the laJlIlch pad, and visual detection of distant birds approaching the Space Shuttle launch pad. This SC-based image analysis capability developed at KSC was also used to analyze images acquired during the accident of the Space Shuttle Columbia and estimate the trajectory and velocity of the foam that caused the accident.

Dominquez, Jesus A.↗