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NASA NTRS2013

Identification of Crew-Systems Interactions and Decision Related Trends

NASA Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified technical challenges. Statistical data and published safety priority lists from academic, industry and other government agencies were reviewed and analyzed by NASA Aviation Safety Program (AvSP) systems analysis personnel to identify issues and future research needs related to one of VSST's technical challenges, Crew Decision Making (CDM). The data examined in the study were obtained from the National Transportation Safety Board (NTSB) Aviation Accident and Incident Data System, Federal Aviation Administration (FAA) Accident/Incident Data System and the NASA Aviation Safety Reporting System (ASRS). In addition, this report contains the results of a review of safety priority lists, information databases and other documented references pertaining to aviation crew systems issues and future research needs. The specific sources examined were: Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementation (SERFIs), Flight Deck Automation Issues (FDAI) and NTSB Most Wanted List and Open Recommendations. Various automation issues taxonomies and priority lists pertaining to human factors, automation and flight design were combined to create a list of automation issues related to CDM.

Jones, Sharon Monica↗

DOE OSTI2023

Examining Rail Transportation Route of Crude Oil in the United States Using Crowdsourced Social Media Data

Safety issues associated with transporting crude oil by rail have been a concern since the boom of the U.S. domestic shale oil production in 2012. During the last decade, over 300 crude-oil-by-rail incidents have occurred in the United States. Some of them have caused adverse consequences including fire and hazardous materials leakage. However, only limited information on crude-on-rail routes and their associated risks is available to the public. To this end, this study proposed an unconventional way to reconstruct crude-on-rail routes using geotagged photos harvested from the Flickr website. The proposed method linked the geotagged photos of crude oil trains posted online with national railway networks to identify potential railway segments that those crude oil trains were traveling on. Here, a shortest path-based method was applied to infer the complete crude-on-rail routes, by utilizing the confirmed railway segments as well as their directional information. Validation of the inferred routes was performed using a public map and official crude oil incident data. The results suggested that the inferred routes based on geotagged photos had high coverage, with approximately 96% of the documented crude oil incidents aligned with the reconstructed crude-on-rail network. The inferred crude oil train routes were found to pass through several metropolitan areas of high population density, who were exposed to potential risk. These findings could improve situational awareness for policy makers and transportation planners. In addition, with the inferred routes, this study has established a good foundation for future crude oil train risk-analyses along the rail route.

42 ENGINEERING↗

DOE OSTI2021

Projecting the number of new HIV infections to formulate the "Getting to Zero" strategy in Illinois, USA

Objectives: Getting to Zero (GTZ) initiatives focus on expanding use of antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) to eliminate new HIV infections. Computational models help inform policies for implementation of ART and PrEP continuums. Such models, however, vary in their design, and may yield inconsistent predictions. Using multiple approaches can help assess the consistency in results obtained from varied modeling frameworks, and can inform optimal implementation strategies. Methods: A study using three different modeling approaches is conducted. Two approaches use statistical time series analysis techniques that incorporate temporal HIV incidence data. A third approach uses stochastic stimulation, conducted using an agent-based network model (ABNM). All three approaches are used to project HIV incidence among a key population, young Black MSM (YBMSM), over the course of the GTZ implementation period (2016-2030). Results: All three approaches suggest that simultaneously increasing PrEP and ART uptake is likely to be more effective than increasing only one, but increasing ART and PrEP by 20% points may not eliminate new HIV infections among YBMSM. The results further suggest that a 20% increase in ART is likely to be more effective than a 20% increase in PrEP. All three methods consistently project that increasing ART and PrEP by 30% simultaneously can help reach GTZ goals. Conclusions: Increasing PrEP and ART uptake by about 30% might be necessary to accomplish GTZ goals. Such scale-up may require addressing psychosocial and structural barriers to engagement in HIV and PrEP care continuums. ABNMs and other flexible modeling approaches can be extended to examine specific interventions that address these barriers and may provide important data to guide the successful intervention implementation.

60 APPLIED LIFE SCIENCES↗

NASA NTRS2016

Pilot Critical Incident Reports as a Means to Identify Human Factors of Remotely Piloted Aircraft

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies. Pilots participated willingly and enthusiastically in the study, and generally had little difficulty recalling critical incidents. The results suggest that pilot interviews can be a productive method of gathering information on incidents that might not otherwise be reported. Some of the issues described in the reports have received significant attention in the literature, or are analogous to human factors of manned aircraft. In other cases, incident reports involved human factors that are poorly understood, and have not yet been the subject of extensive study. Although many of the reported incidents were related to pilot error, the participants also provided examples of the positive contribution that humans make to the operation of highly-automated systems.

unmanned aircraft systems↗

NASA NTRS2016

C2-Related Incidents Reported by UAS Pilots

unmanned aircraft systems↗

NASA NTRS2016

Human Factors of Remotely Piloted Aircraft Systems: Lessons from Incident Reports

incidents↗

NASA NTRS2010

Certification

Objective 1: Provide regulators with a methodology for development of airworthiness requirements for certification of UAS. a) Rationale: a comprehensive methodology does not currently exist to support development of regulation for certification of UAS. Regulation is essential to enable routine access to the NAS. b) Approach: 1) assess existing approaches and classification schemes for deriving acceptable means of compliance to airworthiness requirements. 2) investigate a service-based approach to classification of UAS. 3) conduct comparative analysis of different methodologies. 4) work with FAA to determine best approach and conduct case study. 5) participate in regulatory/standards organizations developing safety and performance requirements for UAS. Objective 2: Provide regulators and industry with hazard and risk-related data to support criteria for UAS type design. a) Rationale: There is presently little UAS specific data (incident, accident, and reliability), especially in a civil context, to support risk assessment and development of standards and regulation. b) Approach: Identify gaps in existing data, provide measured data as needed, and formulate recommendations by: 1) evaluating UAS incident/accident data collection efforts and determining additional support necessary for regulation. 2) assessing UAS-specific hazards and risks. 3) evaluating need for reliability data for UAS-unique systems, components and subsystem, and determining additional measurement requirements. 4) developing guidance and best practices for UAS type design.

Hayhurst, Kelly↗

NASA NTRS2016

The Collection of Human Factors Incident Reports via UAS Pilot Focus Groups

There is a need for incident data relevant to the operation of civilian unmanned aircraft systems (UAS) in the National Air Space (NAS). Currently, the tightly-restricted civilian UAS industry has produced relatively few incident reports that shed light on the human factors of UAS operations. An exploratory study is being conducted to examine the feasibility of using the critical incident technique (Flanagan, 1954) to collect reports from UAS pilots. The information is being used to identify areas where human factors guidelines will be of assistance. Experienced UAS pilots are participating in small focus groups in which they are prompted to describe critical incidents that either reveal a system flaw, or highlight a case where the human operator contributed to system resilience or mission success. To date, 90 incidents have been reported by UAS pilots. The de-identified incidents are being analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot in dealing with the incident..

Hobbs, Alan↗

NASA NTRS2011

An Examination of Commercial Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

The Integrated Vehicle Health Management (IVHM) Project is one of the four projects within the National Aeronautics and Space Administration's (NASA) Aviation Safety Program (AvSafe). The IVHM Project conducts research to develop validated tools and technologies for automated detection, diagnosis, and prognosis that enable mitigation of adverse events during flight. Adverse events include those that arise from system, subsystem, or component failure, faults, and malfunctions due to damage, degradation, or environmental hazards that occur during flight. Determining the causal factors and adverse events related to IVHM technologies will help in the formulation of research requirements and establish a list of example adverse conditions against which IVHM technologies can be evaluated. This paper documents the results of an examination of the most recent statistical/prognostic accident and incident data that is available from the Aviation Safety Information Analysis and Sharing (ASIAS) System to determine the causal factors of system/component failures and/or malfunctions in U.S. commercial aviation accidents and incidents.

Reveley, Mary S.↗

NASA NTRS1979

Summary report of the Lightning and Static Electricity Committee

Lightning protection technology as applied to aviation and identifying these technology needs are presented. The flight areas of technical needs include; (1) the need for In-Flight data on lightning electrical parameters; (2) technology base and guidelines for protection of advanced systems and structures; (3) improved laboratory test techniques; (4) analysis techniques for predicting induced effects; (5) lightning strike incident data from General Aviation; (6) lightning detection systems; (7) obtain pilot reports of lightning strikes; and (8) better training in lightning awareness. The nature of each problem, timeliness, impact of solutions, degree of effort required, and the roles of government and industry in achieving solutions are discussed.

Plumer, J. A.↗

NASA NTRS1982

Analysis of the nature and cause of turbulence upset using airline flight records

The development and application of methods for determining aircraft motions and related winds, using data normally recorded during airline flight operations, are described. The methods are being developed, in cooperation with the National Transportation Safety Board, to aid in the analysis and understanding of circumstances associated with aircraft accidents or incidents. Data from a recent DC-10 encounter with severe, high-altitude turbulence are used to illustrate the methods. The analysis of this encounter shows the turbulence to be a series of equally spaced horizontal swirls known as 'cat's eyes' vortices. The use of flight-data analysis methods to identify this type of turbulence phenomenon is presented for the first time.

Parks, E. K.↗

DOE OSTI2022

A data-centric weak supervised learning for highway traffic incident detection

Using the data from loop detector sensors for near-real-time detection of traffic incidents on highways is crucial to averting major traffic congestion. While recent supervised machine learning methods offer solutions to incident detection by leveraging human-labeled incident data, the false alarm rate is often too high to be used in practice. Specifically, the inconsistency in the human labeling of the incidents significantly affects the performance of supervised learning models. To that end, we focus on a data-centric approach to improve the accuracy and reduce the false alarm rate of traffic incident detection on highways. We develop a weak supervised learning workflow to generate high-quality training labels for the incident data without the ground truth labels, and we use those generated labels in the supervised learning setup for final detection. This approach comprises three stages. First, we introduce a data preprocessing and curation pipeline that processes traffic sensor data to generate high-quality training data through leveraging labeling functions, which can be domain knowledge-related or simple heuristic rules. Second, we evaluate the training data generated by weak supervision using three supervised learning models-random forest, k-nearest neighbors, and a support vector machine ensemble-and long short-term memory classifiers. The results show that the accuracy of all of the models improves significantly after using the training data generated by weak supervision. Third, we develop an online real-time incident detection approach that leverages the model ensemble and the uncertainty quantification while detecting incidents. Finally, we show that our proposed weak supervised learning workflow achieves a high incident detection rate (0.90) and low false alarm rate (0.08).

97 MATHEMATICS AND COMPUTING↗

NASA NTRS1989

Air-ground information transfer in the National Airspace System

This paper reviews NASA's Aviation Safety Reporting System incident data for a two-year period in order to identify the frequency of air-ground information transfer errors and the factors associated with their occurrence. Of the more than 14,000 primary reports received during the 1985 and 1986 reporting period, one out of four reports concerned problems of information transfer between aircraft and ATC. Approximately half of these errors were associated directly or indirectly with aircraft deviations from assigned heading or altitude. The majority of incidents cited some human-system problem such as workload, cockpit distractions, etc., as the primary contributing factor. Improvements in air-ground information transfer using existing and future (e.g., data link) technology are proposed centering on the development and application of user-centered information management principles.

Lee, Alfred T.↗

NASA NTRS2008

Subsonic Aircraft Safety Icing Study

NASA's Integrated Resilient Aircraft Control (IRAC) Project is one of four projects within the agency s Aviation Safety Program (AvSafe) in the Aeronautics Research Mission Directorate (ARMD). The IRAC Project, which was redesigned in the first half of 2007, conducts research to advance the state of the art in aircraft control design tools and techniques. A "Key Decision Point" was established for fiscal year 2007 with the following expected outcomes: document the most currently available statistical/prognostic data associated with icing for subsonic transport, summarize reports by subject matter experts in icing research on current knowledge of icing effects on control parameters and establish future requirements for icing research for subsonic transports including the appropriate alignment. This study contains: (1) statistical analyses of accident and incident data conducted by NASA researchers for this "Key Decision Point", (2) an examination of icing in other recent statistically based studies, (3) a summary of aviation safety priority lists that have been developed by various subject-matter experts, including the significance of aircraft icing research in these lists and (4) suggested future requirements for NASA icing research. The review of several studies by subject-matter experts was summarized into four high-priority icing research areas. Based on the Integrated Resilient Aircraft Control (IRAC) Project goals and objectives, the IRAC project was encouraged to conduct work in all of the high-priority icing research areas that were identified, with the exception of the developing of methods to sense and document actual icing conditions.

Jones, Sharon Monica↗

NASA NTRS2017

Crew State Monitoring and Line-Oriented Flight Training for Attention Management

Loss of control - inflight (LOC-I) has historically represented the largest category of commercial aviation fatal accidents. A review of worldwide transport airplane accidents (2001-2010) indicated that loss of airplane state awareness (ASA) was responsible for the majority of the LOC-I fatality rate. The Commercial Aviation Safety Team (CAST) ASA study identified 12 major themes that were indicated across the ASA accident and incident events. One of the themes was crew distraction or ineffective attention management, which was found to be involved in all 18 events including flight crew channelized attention, startle/surprise, diverted attention, and/or confirmation bias. Safety Enhancement (SE)-211, "Training for Attention Management" was formed to conduct research to develop and assess commercial airline training methods and realistic scenarios that can address these attention-related human performance limitations. This paper describes NASA SE-211 research for new design approaches and validation of line-oriented flight training (LOFT). Recent accident and incident data suggests that Spatial Disorientation (SD) and Loss-of-Energy State Awareness (LESA) for transport category aircraft are becoming an increasingly prevalent safety concern in all domestic and international operations (Commercial Aviation Safety Team, 2014a). SD is defined as an erroneous perception of aircraft attitude that can lead directly to a Loss-of-Control Inflight (LOC-I) event and result in an accident or incident. LESA is typically characterized by a failure to monitor or understand energy state indications (e.g., airspeed, altitude, vertical speed, commanded thrust) and a resultant failure to maintain safe flight.

Stephens, Chad↗

NASA NTRS1987

Empirical models for use in designing decompression procedures for space operations

Empirical models for predicting the incidence of Type 1 altitude decompression sickness (DCS) and venous gas emboli (VGE) during space extravehicular activity (EVA), and for use in designing safe denitrogenation decompression procedures are developed. The models are parameterized using DCS and VGE incidence data from NASA and USAF manned altitude chamber decompression tests using 607 male and female subject tests. These models, and procedures for their use, consist of: (1) an exponential relaxation model and procedure for computing tissue nitrogen partial pressure resulting from a specified prebreathing and stepped decompression sequence; (2) a formula for calculating Tissue Ratio (TR), a tissue decompression stress index; (3) linear and Hill equation models for predicting the total incidence of VGE and DCS attendant with a particular TR; (4) graphs of cumulative DCS and VGE incidence (risk) versus EVA exposure time at any specified TR; and (5) two equations for calculating the average delay period for the initial detection of VGE or indication of Type 1 DCS in a group after a specific denitrogenation decompression procedure. Several examples of realistic EVA preparations are provided.

Conkin, Johnny↗

NASA NTRS2013

Systems Analysis of NASA Aviation Safety Program: Final Report

A three-month study (February to April 2010) of the NASA Aviation Safety (AvSafe) program was conducted. This study comprised three components: (1) a statistical analysis of currently available civilian subsonic aircraft data from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system to identify any significant or overlooked aviation safety issues; (2) a high-level qualitative identification of future safety risks, with an assessment of the potential impact of the NASA AvSafe research on the National Airspace System (NAS) based on these risks; and (3) a detailed, top-down analysis of the NASA AvSafe program using an established and peer-reviewed systems analysis methodology. The statistical analysis identified the top aviation "tall poles" based on NTSB accident and FAA incident data from 1997 to 2006. A separate examination of medical helicopter accidents in the United States was also conducted. Multiple external sources were used to develop a compilation of ten "tall poles" in future safety issues/risks. The top-down analysis of the AvSafe was conducted by using a modification of the Gibson methodology. Of the 17 challenging safety issues that were identified, 11 were directly addressed by the AvSafe program research portfolio.

Jones, Sharon M.↗

NASA NTRS1998

Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation

Advances in technology and new levels of automation on commercial jet transports has had many effects. There have been positive effects from both an economic and a safety point of view. The technology changes on the flight deck also have had reverberating effects on many other aspects of the aviation system and different aspects of human performance. Operational experience, research investigations, incidents, and occasionally accidents have shown that new and sometimes surprising problems have arisen as well. What are these problems with cockpit automation, and what should we learn from them? Do they represent over-automation or human error? Or instead perhaps there is a third possibility - they represent coordination breakdowns between operators and the automation? Are the problems just a series of small independent glitches revealed by specific accidents or near misses? Do these glitches represent a few small areas where there are cracks to be patched in what is otherwise a record of outstanding designs and systems? Or do these problems provide us with evidence about deeper factors that we need to address if we are to maintain and improve aviation safety in a changing world? How do the reverberations of technology change on the flight deck provide insight into generic issues about developing human-centered technologies and systems (Winograd and Woods, 1997)? Based on a series of investigations of pilot interaction with cockpit automation (Sarter and Woods, 1992; 1994; 1995; 1997a, 1997 b), supplemented by surveys, operational experience and incident data from other studies (e.g., Degani et al., 1995; Eldredge et al., 1991; Tenney et al., 1995; Wiener, 1989), we too have found that the problems that surround crew interaction with automation are more than a series of individual glitches. These difficulties are symptoms that indicate deeper patterns and phenomena concerning human-machine cooperation and paths towards disaster. In addition, we find the same kinds of patterns behind results from studies of physician interaction with computer-based systems in critical care medicine (e.g., Moll van Charante et al., 1993; Obradovich and Woods, 1996; Cook and Woods, 1996). Many of the results and implications of this kind of research are synthesized and discussed in two comprehensive volumes, Billings (1996) and Woods et al. (1994). This paper summarizes the pattern that has emerged from our research, related research, incident reports, and accident investigations. It uses this new understanding of why problems arise to point to new investment strategies that can help us deal with the perceived "human error" problem, make automation more of a team player, and maintain and improve safety.

Woods, David D.↗