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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

Incorporating Speech Recognition into a Natural User Interface

The Augmented/ Virtual Reality (AVR) Lab has been working to study the applicability of recent virtual and augmented reality hardware and software to KSC operations. This includes the Oculus Rift, HTC Vive, Microsoft HoloLens, and Unity game engine. My project in this lab is to integrate voice recognition and voice commands into an easy to modify system that can be added to an existing portion of a Natural User Interface (NUI). A NUI is an intuitive and simple to use interface incorporating visual, touch, and speech recognition. The inclusion of speech recognition capability will allow users to perform actions or make inquiries using only their voice. The simplicity of needing only to speak to control an on-screen object or enact some digital action means that any user can quickly become accustomed to using this system. Multiple programs were tested for use in a speech command and recognition system. Sphinx4 translates speech to text using a Hidden Markov Model (HMM) based Language Model, an Acoustic Model, and a word Dictionary running on Java. PocketSphinx had similar functionality to Sphinx4 but instead ran on C. However, neither of these programs were ideal as building a Java or C wrapper slowed performance. The most ideal speech recognition system tested was the Unity Engine Grammar Recognizer. A Context Free Grammar (CFG) structure is written in an XML file to specify the structure of phrases and words that will be recognized by Unity Grammar Recognizer. Using Speech Recognition Grammar Specification (SRGS) 1.0 makes modifying the recognized combinations of words and phrases very simple and quick to do. With SRGS 1.0, semantic information can also be added to the XML file, which allows for even more control over how spoken words and phrases are interpreted by Unity. Additionally, using a CFG with SRGS 1.0 produces a Finite State Machine (FSM) functionality limiting the potential for incorrectly heard words or phrases. The purpose of my project was to investigate options for a Speech Recognition System. To that end I attempted to integrate Sphinx4 into a user interface. Sphinx4 had great accuracy and is the only free program able to perform offline speech dictation. However it had a limited dictionary of words that could be recognized, single syllable words were almost impossible for it to hear, and since it ran on Java it could not be integrated into the Unity based NUI. PocketSphinx ran much faster than Sphinx4 which would've made it ideal as a plugin to the Unity NUI, unfortunately creating a C# wrapper for the C code made the program unusable with Unity due to the wrapper slowing code execution and class files becoming unreachable. Unity Grammar Recognizer is the ideal speech recognition interface, it is flexible in recognizing multiple variations of the same command. It is also the most accurate program in recognizing speech due to using an XML grammar to specify speech structure instead of relying solely on a Dictionary and Language model. The Unity Grammar Recognizer will be used with the NUI for these reasons as well as being written in C# which further simplifies the incorporation.

Chapa, Nicholas

Model Based Engineering for Software Assurance

NASA's successful development of next generation space vehicles, habitats, and robotic systems will require reliable hardware and software systems. The aim of this initiative is to develop modeling methodology and tools to support Model-Based Systems Engineering (MBSE) for software assurance and reliability analysis. This effort expands the Unified Modeling Language (UML) software design models to include fault data for the extraction of Failure Modes and Effects Criticality Analysis (FMECA) and Fault Tree Analysis (FTA) for software. We explored different modeling approaches to integrate the UML software design models with the Systems Modeling Language (SysML) system models to generate an integrated model and reliability tools that take into account software and hardware interfaces.The benefits of this concept directly affect the safety community with quick turnarounds to produce software assurance and reliability analysis artifacts and the ability to visualize failure effects, both hardware and software. The result is enhanced system design integrity and early identification of system risks. This initiative will enable software assurance activities early in the system design lifecycle, facilitating the discovery of design weaknesses and enhancing the capability to produce safe, hazard-free systems

Wang, Lui

Modeling in the State Flow Environment to Support Launch Vehicle Verification Testing for Mission and Fault Management Algorithms in the NASA Space Launch System

Analysis methods and testing processes are essential activities in the engineering development and verification of the National Aeronautics and Space Administration's (NASA) new Space Launch System (SLS). Central to mission success is reliable verification of the Mission and Fault Management (M&FM) algorithms for the SLS launch vehicle (LV) flight software. This is particularly difficult because M&FM algorithms integrate and operate LV subsystems, which consist of diverse forms of hardware and software themselves, with equally diverse integration from the engineering disciplines of LV subsystems. M&FM operation of SLS requires a changing mix of LV automation. During pre-launch the LV is primarily operated by the Kennedy Space Center (KSC) Ground Systems Development and Operations (GSDO) organization with some LV automation of time-critical functions, and much more autonomous LV operations during ascent that have crucial interactions with the Orion crew capsule, its astronauts, and with mission controllers at the Johnson Space Center. M&FM algorithms must perform all nominal mission commanding via the flight computer to control LV states from pre-launch through disposal and also address failure conditions by initiating autonomous or commanded aborts (crew capsule escape from the failing LV), redundancy management of failing subsystems and components, and safing actions to reduce or prevent threats to ground systems and crew. To address the criticality of the verification testing of these algorithms, the NASA M&FM team has utilized the State Flow environment6 (SFE) with its existing Vehicle Management End-to-End Testbed (VMET) platform which also hosts vendor-supplied physics-based LV subsystem models. The human-derived M&FM algorithms are designed and vetted in Integrated Development Teams composed of design and development disciplines such as Systems Engineering, Flight Software (FSW), Safety and Mission Assurance (S&MA) and major subsystems and vehicle elements such as Main Propulsion Systems (MPS), boosters, avionics, Guidance, Navigation, and Control (GN&C), Thrust Vector Control (TVC), liquid engines, and the astronaut crew office. Since the algorithms are realized using model-based engineering (MBE) methods from a hybrid of the Unified Modeling Language (UML) and Systems Modeling Language (SysML), SFE methods are a natural fit to provide an in depth analysis of the interactive behavior of these algorithms with the SLS LV subsystem models. For this, the M&FM algorithms and the SLS LV subsystem models are modeled using constructs provided by Matlab which also enables modeling of the accompanying interfaces providing greater flexibility for integrated testing and analysis, which helps forecast expected behavior in forward VMET integrated testing activities. In VMET, the M&FM algorithms are prototyped and implemented using the same C++ programming language and similar state machine architectural concepts used by the FSW group. Due to the interactive complexity of the algorithms, VMET testing thus far has verified all the individual M&FM subsystem algorithms with select subsystem vendor models but is steadily progressing to assessing the interactive behavior of these algorithms with LV subsystems, as represented by subsystem models. The novel SFE applications has proven to be useful for quick look analysis into early integrated system behavior and assessment of the M&FM algorithms with the modeled LV subsystems. This early MBE analysis generates vital insight into the integrated system behaviors, algorithm sensitivities, design issues, and has aided in the debugging of the M&FM algorithms well before full testing can begin in more expensive, higher fidelity but more arduous environments such as VMET, FSW testing, and the Systems Integration Lab7 (SIL). SFE has exhibited both expected and unexpected behaviors in nominal and off nominal test cases prior to full VMET testing. In many findings, these behavioral characteristics were used to correct the M&FM algorithms, enable better test coverage, and develop more effective test cases for each of the LV subsystems. This has improved the fidelity of testing and planning for the next generation of M&FM algorithms as the SLS program evolves from non-crewed to crewed flight, impacting subsystem configurations and the M&FM algorithms that control them. SFE analysis has improved robustness and reliability of the M&FM algorithms by revealing implementation errors and documentation inconsistencies. It is also improving planning efficiency for future VMET testing of the M&FM algorithms hosted in the LV flight computers, further reducing risk for the SLS launch infrastructure, the SLS LV, and most importantly the crew.

Trevino, Luis

A Vehicle Management End-to-End Testing and Analysis Platform for Validation of Mission and Fault Management Algorithms to Reduce Risk for NASAs Space Launch System

The engineering development of the National Aeronautics and Space Administration's (NASA) new Space Launch System (SLS) requires cross discipline teams with extensive knowledge of launch vehicle subsystems, information theory, and autonomous algorithms dealing with all operations from pre-launch through on orbit operations. The nominal and off-nominal characteristics of SLS's elements and subsystems must be understood and matched with the autonomous algorithm monitoring and mitigation capabilities for accurate control and response to abnormal conditions throughout all vehicle mission flight phases, including precipitating safing actions and crew aborts. This presents a large and complex systems engineering challenge, which is being addressed in part by focusing on the specific subsystems involved in the handling of off-nominal mission and fault tolerance with response management. Using traditional model-based system and software engineering design principles from the Unified Modeling Language (UML) and Systems Modeling Language (SysML), the Mission and Fault Management (M&FM) algorithms for the vehicle are crafted and vetted in Integrated Development Teams (IDTs) composed of multiple development disciplines such as Systems Engineering (SE), Flight Software (FSW), Safety and Mission Assurance (S&MA) and the major subsystems and vehicle elements such as Main Propulsion Systems (MPS), boosters, avionics, Guidance, Navigation, and Control (GNC), Thrust Vector Control (TVC), and liquid engines. These model-based algorithms and their development lifecycle from inception through FSW certification are an important focus of SLS's development effort to further ensure reliable detection and response to off-nominal vehicle states during all phases of vehicle operation from pre-launch through end of flight. To test and validate these M&FM algorithms a dedicated test-bed was developed for full Vehicle Management End-to-End Testing (VMET). For addressing fault management (FM) early in the development lifecycle for the SLS program, NASA formed the M&FM team as part of the Integrated Systems Health Management and Automation Branch under the Spacecraft Vehicle Systems Department at the Marshall Space Flight Center (MSFC). To support the development of the FM algorithms, the VMET developed by the M&FM team provides the ability to integrate the algorithms, perform test cases, and integrate vendor-supplied physics-based launch vehicle (LV) subsystem models. Additionally, the team has developed processes for implementing and validating the M&FM algorithms for concept validation and risk reduction. The flexibility of the VMET capabilities enables thorough testing of the M&FM algorithms by providing configurable suites of both nominal and off-nominal test cases to validate the developed algorithms utilizing actual subsystem models such as MPS, GNC, and others. One of the principal functions of VMET is to validate the M&FM algorithms and substantiate them with performance baselines for each of the target vehicle subsystems in an independent platform exterior to the flight software test and validation processes. In any software development process there is inherent risk in the interpretation and implementation of concepts from requirements and test cases into flight software compounded with potential human errors throughout the development and regression testing lifecycle. Risk reduction is addressed by the M&FM group but in particular by the Analysis Team working with other organizations such as S&MA, Structures and Environments, GNC, Orion, Crew Office, Flight Operations, and Ground Operations by assessing performance of the M&FM algorithms in terms of their ability to reduce Loss of Mission (LOM) and Loss of Crew (LOC) probabilities. In addition, through state machine and diagnostic modeling, analysis efforts investigate a broader suite of failure effects and associated detection and responses to be tested in VMET to ensure reliable failure detection, and confirm responses do not create additional risks or cause undesired states through interactive dynamic effects with other algorithms and systems. VMET further contributes to risk reduction by prototyping and exercising the M&FM algorithms early in their implementation and without any inherent hindrances such as meeting FSW processor scheduling constraints due to their target platform - the ARINC 6535-partitioned Operating System, resource limitations, and other factors related to integration with other subsystems not directly involved with M&FM such as telemetry packing and processing. The baseline plan for use of VMET encompasses testing the original M&FM algorithms coded in the same C++ language and state machine architectural concepts as that used by FSW. This enables the development of performance standards and test cases to characterize the M&FM algorithms and sets a benchmark from which to measure their effectiveness and performance in the exterior FSW development and test processes. This paper is outlined in a systematic fashion analogous to a lifecycle process flow for engineering development of algorithms into software and testing. Section I describes the NASA SLS M&FM context, presenting the current infrastructure, leading principles, methods, and participants. Section II defines the testing philosophy of the M&FM algorithms as related to VMET followed by section III, which presents the modeling methods of the algorithms to be tested and validated in VMET. Its details are then further presented in section IV followed by Section V presenting integration, test status, and state analysis. Finally, section VI addresses the summary and forward directions followed by the appendices presenting relevant information on terminology and documentation.

Trevino, Luis

A Vehicle Management End-to-End Testing and Analysis Platform for Validation of Mission and Fault Management Algorithms to Reduce Risk for NASA's Space Launch System

The engineering development of the new Space Launch System (SLS) launch vehicle requires cross discipline teams with extensive knowledge of launch vehicle subsystems, information theory, and autonomous algorithms dealing with all operations from pre-launch through on orbit operations. The characteristics of these spacecraft systems must be matched with the autonomous algorithm monitoring and mitigation capabilities for accurate control and response to abnormal conditions throughout all vehicle mission flight phases, including precipitating safing actions and crew aborts. This presents a large and complex system engineering challenge, which is being addressed in part by focusing on the specific subsystems involved in the handling of off-nominal mission and fault tolerance with response management. Using traditional model based system and software engineering design principles from the Unified Modeling Language (UML) and Systems Modeling Language (SysML), the Mission and Fault Management (M&FM) algorithms for the vehicle are crafted and vetted in specialized Integrated Development Teams (IDTs) composed of multiple development disciplines such as Systems Engineering (SE), Flight Software (FSW), Safety and Mission Assurance (S&MA) and the major subsystems and vehicle elements such as Main Propulsion Systems (MPS), boosters, avionics, Guidance, Navigation, and Control (GNC), Thrust Vector Control (TVC), and liquid engines. These model based algorithms and their development lifecycle from inception through Flight Software certification are an important focus of this development effort to further insure reliable detection and response to off-nominal vehicle states during all phases of vehicle operation from pre-launch through end of flight. NASA formed a dedicated M&FM team for addressing fault management early in the development lifecycle for the SLS initiative. As part of the development of the M&FM capabilities, this team has developed a dedicated testbed that integrates specific M&FM algorithms, specialized nominal and off-nominal test cases, and vendor-supplied physics-based launch vehicle subsystem models. Additionally, the team has developed processes for implementing and validating these algorithms for concept validation and risk reduction for the SLS program. The flexibility of the Vehicle Management End-to-end Testbed (VMET) enables thorough testing of the M&FM algorithms by providing configurable suites of both nominal and off-nominal test cases to validate the developed algorithms utilizing actual subsystem models such as MPS. The intent of VMET is to validate the M&FM algorithms and substantiate them with performance baselines for each of the target vehicle subsystems in an independent platform exterior to the flight software development infrastructure and its related testing entities. In any software development process there is inherent risk in the interpretation and implementation of concepts into software through requirements and test cases into flight software compounded with potential human errors throughout the development lifecycle. Risk reduction is addressed by the M&FM analysis group working with other organizations such as S&MA, Structures and Environments, GNC, Orion, the Crew Office, Flight Operations, and Ground Operations by assessing performance of the M&FM algorithms in terms of their ability to reduce Loss of Mission and Loss of Crew probabilities. In addition, through state machine and diagnostic modeling, analysis efforts investigate a broader suite of failure effects and associated detection and responses that can be tested in VMET to ensure that failures can be detected, and confirm that responses do not create additional risks or cause undesired states through interactive dynamic effects with other algorithms and systems. VMET further contributes to risk reduction by prototyping and exercising the M&FM algorithms early in their implementation and without any inherent hindrances such as meeting FSW processor scheduling constraints due to their target platform - ARINC 653 partitioned OS, resource limitations, and other factors related to integration with other subsystems not directly involved with M&FM such as telemetry packing and processing. The baseline plan for use of VMET encompasses testing the original M&FM algorithms coded in the same C++ language and state machine architectural concepts as that used by Flight Software. This enables the development of performance standards and test cases to characterize the M&FM algorithms and sets a benchmark from which to measure the effectiveness of M&FM algorithms performance in the FSW development and test processes.

Trevino, Luis

Exploration Medical System Trade Study Tools Overview

ExMC is creating an ecosystem of tools to enable well-informed medical system trade studies. The suite of tools address important system implementation aspects of the space medical capabilities trade space and are being built using knowledge from the medical community regarding the unique aspects of space flight. Two integrating models, a systems engineering model and a medical risk analysis model, tie the tools together to produce an integrated assessment of the medical system and its ability to achieve medical system target requirements. This presentation will provide an overview of the various tools that are a part of the tool ecosystem. Initially, the presentation's focus will address the tools that supply the foundational information to the ecosystem. Specifically, the talk will describe how information that describes how medicine will be practiced is captured and categorized for efficient utilization in the tool suite. For example, the talk will include capturing what conditions will be planned for in-mission treatment, planned medical activities (e.g., periodic physical exam), required medical capabilities (e.g., provide imaging), and options to implement the capabilities (e.g., an ultrasound device). Database storage and configuration management will also be discussed. The presentation will include an overview of how these information tools will be tied to parameters in a Systems Modeling Language (SysML) model, allowing traceability to system behavioral, structural, and requirements content. The discussion will also describe an HRP-led enhanced risk assessment model developed to provide quantitative insight into each capability's contribution to mission success. Key outputs from these various tools, to be shared with the space medical and exploration mission development communities, will be assessments of medical system implementation option satisfaction of requirements and per-capability contributions toward achieving requirements.

Mindock, J.

Enabling Space Exploration Medical System Development Using a Tool Ecosystem

The NASA Human Research Program’s (HRP) Exploration Medical Capability (ExMC) Element is utilizing a Model Based Systems Engineering (MBSE) approach to enhance the development of systems engineering products that will be used to advance medical system designs for exploration missions beyond Low Earth Orbit. In support of future missions, the team is capturing content such as system behaviors, functional decompositions, architecture, system requirements and interfaces, and recommendations for clinical capabilities and resources in Systems Modeling Language (SysML) models. As these products mature, SysML models provide a way for ExMC to capture relationships among the various products, which includes supporting more integrated and multi-faceted views of future medical systems. In addition to using SysML models, HRP and ExMC are developing supplementary tools to support two key functions: 1) prioritizing current and future research activities for exploration missions in an objective manner; and 2) enabling risk-informed and evidence-based trade space analysis for future space vehicles, missions, and systems. This paper will discuss the long-term HRP and ExMC vision for the larger ecosystem of tools, which include dynamic Probabilistic Risk Assessment (PRA) capabilities, additional SysML models, a database of system component options, and data visualizations. It also includes a review of an initial Pilot Project focused on enabling medical system trade studies utilizing data that is coordinated across tools for consistent outputs (e.g., mission risk metrics that are associated with medical system mass values and medical conditions addressed). This first Pilot Project demonstrated successful operating procedures and integration across tools. Finally, the paper will also cover a second Pilot Project that utilizes tool enhancements such as medical system optimization capabilities, post-processing, and visualization of generated data for subject matter expert review, and increased integration amongst the tools themselves.

Amador, Jennifer R.

Enabling Space Exploration Medical System Development Using a Tool Ecosystem

The NASA Human Research Program's (HRP) Exploration Medical Capability (ExMC) Element is utilizing a Model Based Systems Engineering (MBSE) approach to enhance the development of systems engineering products that will be used to advance medical system designs for exploration missions beyond Low Earth Orbit. In support of future missions, the team is capturing content such as system behaviors, functional decompositions, architecture, system requirements and interfaces, and recommendations for clinical capabilities and resources in Systems Modeling Language (SysML) models. As these products mature, SysML models provide a way for ExMC to capture relationships among the various products, which includes supporting more integrated and multi-faceted views of future medical systems. In addition to using SysML models, HRP and ExMC are developing supplementary tools to support two key functions: 1) prioritizing current and future research activities for exploration missions in an objective manner; and 2) enabling risk-informed and evidence-based trade space analysis for future space vehicles, missions, and systems. This paper will discuss the long-term HRP and ExMC vision for the larger ecosystem of tools, which include dynamic Probabilistic Risk Assessment (PRA) capabilities, additional SysML models, a database of system component options, and data visualizations. It also includes a review of an initial Pilot Project focused on enabling medical system trade studies utilizing data that is coordinated across tools for consistent outputs (e.g., mission risk metrics that are associated with medical system mass values and medical conditions addressed). This first Pilot Project demonstrated successful operating procedures and integration across tools. Finally, the paper will also cover a second Pilot Project that utilizes tool enhancements such as medical system optimization capabilities, post-processing, and visualization of generated data for subject matter expert review, and increased integration amongst the tools themselves.

Amador, Jennifer R.

Impact, a Tool Suite for Crew Health and Performance System Trade Analyses and Decision Support - Status of Development

Mission planners, systems engineers, and clinicians that support crew health and performance face very difficult choices on upcoming exploration missions. Given that there will be a heavily constrained mass and volume allocation for a medical system on these missions, what medical capability should be manifested to minimize both medical risk and mission risk? Given that not all promising research and technology proposals can be funded, how can proposals be prioritized so that those funded research investments produce the maximum benefit in reducing overall medical risk? The Informing Mission Planning via Analysis of Complex Tradespaces (IMPACT) project seeks to answer these kinds of questions and others to support upcoming exploration missions. IMPACT enables risk-informed and evidence-based trade space analysis for future space vehicles, missions, and systems. This presentation will discuss the long-term HRP and ExMC vision for the larger ecosystem of tools, which include an updated medical database (consisting of an Evidence Library for medical conditions and a medical item database (MedID) for medical resources), dynamic Probabilistic Risk Assessment (PRA) capabilities, System Modeling Language (SysML) models, and contextual data visualizations of output data. IMPACT is the result of a multi-center collaborative effort. The trade space analyses performed by IMPACT can directly inform mission, vehicle, and habitat development by quantifying medical risk, given a design reference mission, crew attributes and a set of medical capabilities. This presentation will update the audience on the development status of the tool suite, its constituent parts and the plans for when it will deploy as an operational product, currently scheduled for the end of FY22. Recent development successes on the IMPACT project include the ability to cluster medical resources into medical capabilities and mutually-dependent bundles, the ability to perform trade analyses on different medical sets, different DRMs, and different crew complements, and the ability to specify mission segments as periods of time assigned to one or more members of the crew during which unique mission events occur (e.g., extravehicular activities, surface operations, gravity well adaptations, etc.). IMPACT is gearing up for its verification and validation phase to compile the data package necessary for a successful Transition to Operations (TtO), per the guidance in NPR 8900.1B .

IMPACT