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Organizational Culture and Safety

'..only a fool perseveres in error.' Cicero. Humans will break the most advanced technological devices and override safety and security systems if they are given the latitude. Within the workplace, the operator may be just one of several factors in causing accidents or making risky decisions. Other variables considered for their involvement in the negative and often catastrophic outcomes include the organizational context and culture. Many organizations have constructed and implemented safety programs to be assimilated into their culture to assure employee commitment and understanding of the importance of everyday safety. The purpose of this paper is to examine literature on organizational safety cultures and programs that attempt to combat vulnerability, risk taking behavior and decisions and identify the role of training in attempting to mitigate unsafe acts.

Adams, Catherine A.↗

Practical Application of Sociology in Systems Engineering

Systems engineering involves both the integration of the system and the integration of the disciplines which develop and operate the system. Integrating the disciplines is a sociological effort to bring together different groups, who often have different terminology, to achieve a common goal, the system. The focus for the systems engineer is information flow through the organization, between the disciplines, to ensure the system is developed and operated will all relevant information informing system decisions. The practical application of the sociology in systems engineering brings in various organizational development concepts including the principles of planned renegotiation and the application of principles to address information barriers created by organizational culture. Concepts such as specification of ignorance, consistent terminology, opportunity structures, role-sets, and the reclama (reconsideration) process are all important sociological approaches that help address the organizational social structure (culture). In bringing the disciplines together, the systems engineer must also be wary of social ambivalence, social anomie, social dysfunction, and insider-outsider behavior. Unintended consequences can result when these social issues are present. These issues can occur when localized subcultures shift from the overarching organizational culture, or when the organizational culture prevents achievement of system goals. These sociological principles provide the systems engineer with key approaches to manage the information flow through the organization as the disciplines are integrated and share their information and provides key sociological barriers to information flow through the organization. This paper will discuss the practical application of sociological principles to systems engineering.

Watson, Michael D.↗

The space station and human productivity: An agenda for research

Organizational problems in permanent organizations in outer space were analyzed. The environment of space provides substantial opportunities for organizational research. Questions about how to organize professional workers in a technologically complex setting with novel dangers and uncertainties present in the immediate environment are examined. It is suggested that knowledge from organization theory/behavior is an underutilized resource in the U.S. space program. A U.S. space station will be operable by the mid-1990's. Organizational issues will take on increasing importance, because a space station requires the long term organization of human and robotic work in the isolated and confined environment of outer space. When an organizational analysis of the space station is undertaken, there are research implications at multiple levels of analysis: for the individual, small group, organizational, and environmental levels of analysis. The research relevant to organization theory and behavior is reviewed.

Schoonhoven, C. B.↗

Advanced CRM training for instructors and evaluators

It is seen that if the maximum operational benefit of crew resource management (CRM) is to be achieved, the evaluator group is the principal key and specialized training that is ongoing is necessary for this group. The training must be customized to fit the needs of a particular organization, and the training must address key topical issues that influence organizational dynamics. Attention is given to the use of video and full length scripted NASA research LOFTS, behavioral markers and debriefing skills, the importance of policy and written CRM standards, and line oriented simulations debriefing performance indicators.

Taggart, William R.↗

Archetypes for Organisational Safety

We propose a framework using system dynamics to model the dynamic behavior of organizations in accident analysis. Most current accident analysis techniques are event-based and do not adequately capture the dynamic complexity and non-linear interactions that characterize accidents in complex systems. In this paper we propose a set of system safety archetypes that model common safety culture flaws in organizations, i.e., the dynamic behaviour of organizations that often leads to accidents. As accident analysis and investigation tools, the archetypes can be used to develop dynamic models that describe the systemic and organizational factors contributing to the accident. The archetypes help clarify why safety-related decisions do not always result in the desired behavior, and how independent decisions in different parts of the organization can combine to impact safety.

Marais, Karen↗

Automated Generation of Fault Management Artifacts from a Simple System Model

Our understanding of off-nominal behavior - failure modes and fault propagation - in complex systems is often based purely on engineering intuition; specific cases are assessed in an ad hoc fashion as a (fallible) fault management engineer sees fit. This work is an attempt to provide a more rigorous approach to this understanding and assessment by automating the creation of a fault management artifact, the Failure Modes and Effects Analysis (FMEA) through querying a representation of the system in a SysML model. This work builds off the previous development of an off-nominal behavior model for the upcoming Soil Moisture Active-Passive (SMAP) mission at the Jet Propulsion Laboratory. We further developed the previous system model to more fully incorporate the ideas of State Analysis, and it was restructured in an organizational hierarchy that models the system as layers of control systems while also incorporating the concept of "design authority". We present software that was developed to traverse the elements and relationships in this model to automatically construct an FMEA spreadsheet. We further discuss extending this model to automatically generate other typical fault management artifacts, such as Fault Trees, to efficiently portray system behavior, and depend less on the intuition of fault management engineers to ensure complete examination of off-nominal behavior.

Spinup and Orient↗

The critical role of personality and organizational factors as determinants of reactions to restricted and stressful environments

Research into the impact of personality factors on groups in various settings is reviewed as an introduction to a brief discussion of personality and group behavior research needs relevant to the space program. Significant findings of some earlier research are summarized, and methodological problems are touched on. The study of intergroup and intragroup conflict in a stressful environment, as exemplified particularly by undersea habitats, is seen as being of consequence for long-term space missions. It is concluded that adequate research can only be conducted as an adjunct to data collection from operational stressful environments, and not from laboratory experiments.

Helmreich, Robert L.↗

A flexible computer aid for conceptual design based on constraint propagation and component-modeling

The Rubber Airplane program, which combines two symbolic processing techniques with a component-based database of design knowledge, is proposed as a computer aid for conceptual design. Using object-oriented programming, programs are organized around the objects and behavior to be simulated, and using constraint propagation, declarative statements designate mathematical relationships among all the equation variables. It is found that the additional level of organizational structure resulting from the arrangement of the design information in terms of design components provides greater flexibility and convenience.

Kolb, Mark A.↗

Project Management Using Modern Guidance, Navigation and Control Theory

Implementing guidance, navigation, and control (GN&C) theory principles and applying them to the human element of project management and control is not a new concept. As both the literature on the subject and the real-world applications are neither readily available nor comprehensive with regard to how such principles might be applied, this paper has been written to educate the project manager on the "laws of physics" of his or her project (not to teach a GN&C engineer how to become a project manager) and to provide an intuitive, mathematical explanation as to the control and behavior of projects. This paper will also address how the fundamental principles of modern GN&C were applied to the National Aeronautics and Space Administration's (NASA) Constellation Program (CxP) space suit project, ensuring the project was managed within cost, schedule, and budget. A project that is akin to a physical system can be modeled and managed using the same over arching principles of GN&C that would be used if that project were a complex vehicle, a complex system(s), or complex software with time-varying processes (at times nonlinear) containing multiple data inputs of varying accuracy and a range of operating points. The classic GN&C theory approach could thus be applied to small, well-defined projects; yet when working with larger, multiyear projects necessitating multiple organizational structures, numerous external influences, and a multitude of diverse resources, modern GN&C principles are required to model and manage the project. The fundamental principles of a GN&C system incorporate these basic concepts: State, Behavior, Feedback Control, Navigation, Guidance and Planning Logic systems. The State of a system defines the aspects of the system that can change over time; e.g., position, velocity, acceleration, coordinate-based attitude, and temperature, etc. The Behavior of the system focuses more on what changes are possible within the system; this is denoted in the state of the system. The behavior of a system, as captured in the system modeling, when properly done will aid in accurately predicting future system performance. The Feedback Control system understands the state and behavior of the system and uses feedback to adjust control inputs into the system. The feedback, which is the right arm of the Control system, allows change to be affected in the overall system; it therefore is important to not only correctly identify the system feedback inputs, but also the system response to the feedback inputs. The Navigation system takes multiple data inputs and based on a priori knowledge of the inputs, develops a statistically based weighting of the inputs and measurements to determine the system's state. Guidance and Planning Logic of the system, complete with an understanding of where the system is (provided by the Navigation system), will in turn determine where the system needs to be and how to get it there. With any system/project, it is critical that the objective of the system/project be clearly defined -- not only to plan but to measure performance and to aid in guiding the system or the project. The system principles discussed above, which can be and have been applied to the current CxP space suit development project, can also be mapped to real-world constituents, thus allowing project managers to apply systems theories that are well defined in engineering and mathematics to a discipline (i.e., Project Management) that historically has been based in personal experience and intuition. This mapping of GN&C theory to Project Management will, in turn, permit a direct, methodical approach to Project Management, planning and control providing a tool to help predict (and guide) performance and an understanding of the project constraints, how the project can be controlled, and the impacts to external influences and inputs. This approach, to a project manager, flows down to the three bottom-line variables of cost, schedule, and scope ando the needed control of these three variables to successfully perform and complete a project.

Hill, Terry R.↗

A Decision Tool that Combines Discrete Event Software Process Models with System Dynamics Pieces for Software Development Cost Estimation and Analysis

The development process for a large software development project is very complex and dependent on many variables that are dynamic and interrelated. Factors such as size, productivity and defect injection rates will have substantial impact on the project in terms of cost and schedule. These factors can be affected by the intricacies of the process itself as well as human behavior because the process is very labor intensive. The complex nature of the development process can be investigated with software development process models that utilize discrete event simulation to analyze the effects of process changes. The organizational environment and its effects on the workforce can be analyzed with system dynamics that utilizes continuous simulation. Each has unique strengths and the benefits of both types can be exploited by combining a system dynamics model and a discrete event process model. This paper will demonstrate how the two types of models can be combined to investigate the impacts of human resource interactions on productivity and ultimately on cost and schedule.

Mizell, Carolyn Barrett↗

Behavioral Components Of NASA’s 2021 Astronaut Selection Cycle

To successfully implement the behavioral aspects required to select and screen for long-duration missions on the International Space Station and for Artemis Program lunar missions, a multi-phase process combining best practice elements from the fields of industrial-organizational psychology, operational psychology, aerospace psychology and aerospace psychiatry, are needed. Furthermore, this process should preferably be implemented by professionals with extensive experience in human spaceflight operations.

Gary Edward Beven↗

Advancing the practice of systems engineering at JPL

In FY 2004, JPL launched an initiative to improve the way it practices systems engineering. The Lab's senior management formed the Systems Engineering Advancement (SEA) Project in order to "significantly advance the practice and organizational capabilities of systems engineering at JPL on flight projects and ground support tasks." The scope of the SEA Project includes the systems engineering work performed in all three dimensions of a program, project, or task: 1. the full life-cycle, i.e., concept through end of operations 2. the full depth, i.e., Program, Project, System, Subsystem, Element (SE Levels 1 to 5) 3. the full technical scope, e.g., the flight, ground and launch systems, avionics, power, propulsion, telecommunications, thermal, etc. The initial focus of their efforts defined the following basic systems engineering functions at JPL: systems architecture, requirements management, interface definition, technical resource management, system design and analysis, system verification and validation, risk management, technical peer reviews, design process management and systems engineering task management, They also developed a list of highly valued personal behaviors of systems engineers, and are working to inculcate those behaviors into members of their systems engineering community. The SEA Project is developing products, services, and training to support managers and practitioners throughout the entire system lifecycle. As these are developed, each one needs to be systematically deployed. Hence, the SEA Project developed a deployment process that includes four aspects: infrastructure and operations, communication and outreach, education and training, and consulting support. In addition, the SEA Project has taken a proactive approach to organizational change management and customer relationship management - both concepts and approaches not usually invoked in an engineering environment. This paper'3 describes JPL's approach to advancing the practice of systems engineering at the Lab. It describes the general approach used and how they addressed the three key aspects of change: people, process and technology. It highlights a list of highly valued personal behaviors of systems engineers, discusses the various products, services and training that were developed, describes the deployment approach used, and concludes with several lessons learned.

process improvement↗

Project Management Using Modern Guidance, Navigation and Control Theory

The idea of control theory and its application to project management is not new, however literature on the topic and real-world applications is not as readily available and comprehensive in how all the principals of Guidance, Navigation and Control (GN&C) apply. This paper will address how the fundamental principals of modern GN&C Theory have been applied to NASA's Constellation Space Suit project and the results in the ability to manage the project within cost, schedule and budget. A s with physical systems, projects can be modeled and managed with the same guiding principles of GN&C as if it were a complex vehicle, system or software with time-varying processes, at times non-linear responses, multiple data inputs of varying accuracy and a range of operating points. With such systems the classic approach could be applied to small and well-defined projects; however with larger, multi-year projects involving multiple organizational structures, external influences and a multitude of diverse resources, then modern control theory is required to model and control the project. The fundamental principals of G N&C stated that a system is comprised of these basic core concepts: State, Behavior, Control system, Navigation system, Guidance and Planning Logic, Feedback systems. The state of a system is a definition of the aspects of the dynamics of the system that can change, such as position, velocity, acceleration, coordinate-based attitude, temperature, etc. The behavior of the system is more of what changes are possible rather than what can change, which is captured in the state of the system. The behavior of a system is captured in the system modeling and if properly done, will aid in accurate system performance prediction in the future. The Control system understands the state and behavior of the system and feedback systems to adjust the control inputs into the system. The Navigation system takes the multiple data inputs and based upon a priori knowledge of the input, will develop a statistical-based weighting of the input to determine where the system currently is located. Guidance and Planning logic of the system with the understanding of where it is (provided by the navigation system) will in turn determine where it needs to be and how to get there. Lastly, the system Feedback system is the right arm of the control system to allow it to affect change in the overall system and therefore it is critical to not only correctly identify the system feedback inputs but also the system response to the feedback inputs. And with any systems project it is critical that the objective of the system be clearly defined for not only planning but to be used to measure performance and to aid in the guidance of the system or project.

Hill, Terry↗

A national survey of policies on disclosure of conflicts of interest in biomedical research

BACKGROUND: Conflicts of interest pose a threat to the integrity of scientific research. The current regulations of the U.S. Public Health Service and the National Science Foundation require that medical schools and other research institutions report the existence of conflicts of interest to the funding agency but allow the institutions to manage conflicts internally. The regulations do not specify how to do so. METHODS: We surveyed all medical schools (127) and other research institutions (170) that received more than $5 million in total grants annually from the National Institutes of Health or the National Science Foundation; 48 journals in basic science and clinical medicine; and 17 federal agencies in order to analyze their policies on conflicts of interest. RESULTS: Of the 297 institutions, 250 (84 percent) responded by March 2000, as did 47 of the 48 journals and 16 of the 17 federal agencies. Fifteen of the 250 institutions (6 percent)--5 medical schools and 10 other research institutions--reported that they had no policy on conflicts of interest. Among the institutions that had policies, there was marked variation in the definition and management of conflicts. Ninety-one percent had policies that adhered to the federal threshold for disclosure ($10,000 in annual income or equity in a relevant company or 5 percent ownership), and 9 percent had policies that exceeded the federal guidelines. Only 8 percent had policies requiring disclosure to funding agencies, only 7 percent had such policies regarding journals, and only 1 percent had policies requiring the disclosure of information to the relevant institutional review boards or to research subjects. Twenty journals (43 percent) reported that they had policies requiring disclosure of conflicts of interest. Only four federal agencies had policies that explicitly addressed conflicts of interest in extramural research, and all but one of the agencies relied primarily on institutional discretion. CONCLUSIONS: There is substantial variation among policies on conflicts of interest at medical schools and other research institutions. This variation, combined with the fact that many scientific journals and funding agencies do not require disclosure of conflicts of interest, suggests that the current standards may not be adequate to maintain a high level of scientific integrity.

Human↗

Analytical design of intelligent machines

The problem of designing 'intelligent machines' to operate in uncertain environments with minimum supervision or interaction with a human operator is examined. The structure of an 'intelligent machine' is defined to be the structure of a Hierarchically Intelligent Control System, composed of three levels hierarchically ordered according to the principle of 'increasing precision with decreasing intelligence', namely: the organizational level, performing general information processing tasks in association with a long-term memory; the coordination level, dealing with specific information processing tasks with a short-term memory; and the control level, which performs the execution of various tasks through hardware using feedback control methods. The behavior of such a machine may be managed by controls with special considerations and its 'intelligence' is directly related to the derivation of a compatible measure that associates the intelligence of the higher levels with the concept of entropy, which is a sufficient analytic measure that unifies the treatment of all the levels of an 'intelligent machine' as the mathematical problem of finding the right sequence of internal decisions and controls for a system structured in the order of intelligence and inverse order of precision such that it minimizes its total entropy. A case study on the automatic maintenance of a nuclear plant illustrates the proposed approach.

Saridis, George N.↗

A Prognostic Launch Vehicle Probability of Failure Assessment Methodology for Conceptual Systems Predicated on Human Causal Factors

Create an improved method to calculate reliability of a conceptual launch vehicle system prior to fabrication by using historic data of actual root causes of failures. While failures have unique "proximate causes", there are typically a finite amount of common "root causes". Heretofore launch vehicle reliability evaluation typically hardware-centric statistical analyses, while most root causes of failures are been shown to be human-centric. A method based on human-centric root causes can be used to quantify reliability assessments and focus proposed actions to mitigate problems. Existing methods have been optimistic in their projections of launch vehicle reliability compared to actuals. Hypothesis: reliability of a conceptual launch vehicle can be more accurately evaluated based on a rational, probabilistic approach using past failure assessment teams' findings predicated on human-centric causes."Human Reliability Analysis Methods Selection Guidance for NASA"Chandler F.T., et al., NASA HQ/OSMA study group, July 2006. Outside HRA experts from academia, other federal labs, and the private sector. 50 system reliability methods considered, fourteen selected for further study, four finally selected as best suited for human spaceflight. Probabilistic Risk Analysis (PRA) + Human Reliability Analysis (HRA) enabled incorporating effects and probabilities of human errors. While four down-selected methods deemed appropriate for failure assessment, it did not appear that these methods could be concisely applied to perform major system-wide assessment of probability of failure of a conceptual design without becoming unwieldy."Engineering a Safer World", Detailed, comprehensive study external to NASA Leveson N. G., MIT, 2011.Systems-Theoretic Accident Model and Processes (STAMP). All-encompassing accident model based on systems theory analyzed accidents after they occurred and created approaches to prevent occurrence in developing systems not focused on failure prevention per se, but rather reducing hazards by influencing human behavior through use of constraints, hierarchical control structures, and process models to improve system safetySystem Theoretic Process Analysis (STPA) addresses predictive part of problem (a "hazard analysis"). Includes all causal factors identified in STAMP: "...design errors, software flaws, component interaction accidents, cognitively complex human decision-making errors, and social organizational and management factors contributing to accidents" can guide design process rather than require it to exist before-hand did not appear capable of concise application for system-wide assessment of probability of failure of a conceptual design without becoming unwieldy.

Williams, Craig H.↗

Staffing implications of software productivity models

The attributes of software project staffing and productivity implied by equating the effects of two popular software models in a small neighborhood of a given effort-duration point are investigated. The first model presupposes that organizational productivity decreases as a function of the project staff size due to interfacing and intercommunication. The second, the so-called software equation, relates the product size to effort and duration through a power law tradeoff formula. The conclusions that may be reached by assuming that both of these describe project behavior, the former as a global phenomenon and the latter as a localized effect in a small neighborhood of a given effort duration point, are that (1) there is a calculable maximum effective staff level, which, if exceeded, reduces the project production rate, (2) there is a calculable maximum extent to which effort and time may be traded effectively, (3) it becomes ineffective in a practical sense to expend more than an additional 25 to 50% of resources in order to reduce delivery time, and (4) the team production efficiency can be computed directly from the staff level, the slope of the intercommunication loss function, and the ratio of exponents in the software equation.

Tausworthe, R. C.↗