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At least 73 records · Page 4
All sourcesNASA NTRSDOE OSTI
NASA NTRS1993

Workload management and geographic disorientation in aviation incidents: A review of the ASRS data base

NASA's Aviation Safety Reporting System (ASRS) incident reports are reviewed in two related areas: pilots' failures to appropriately manage tasks, and breakdowns in geographic orientation. Examination of 51 relevant reports on task management breakdowns revealed that altitude busts and inappropriate runway usee were the most frequently reported consequences. Task management breakdowns appeared to occur at all levels of expertise, and prominent causal factors were related to breakdowns in crew communications, over-involvement with the flight management system and, for small (general aviation) aircraft, preoccupation with weather. Analysis of the 83 cases of geographic disorientation suggested that these too occurred at all levels of pilot experience. With regard to causal factors, a majority was related to poor cockpit resource management, in which inattention led to a loss of geographic awareness. Other leading causes were related to poor weather and poor decision making. The potential of the ASRS database for contributing to research and design issues is addressed.

Williams, Henry P.↗
NASA NTRS1980

Analysis of general aviation single-pilot IFR incident data obtained from the NASA aviation safety reporting system

Data obtained from the NASA Aviation Safety Reporting System (ASRS) data base were used to determine problems in general aviation single pilot IFR operations. The data examined consisted of incident reports involving flight safety in the National Aviation System. Only those incidents involving general aviation fixed wing aircraft flying under IFR in instrument meteorological conditions were analyzed. The data were cataloged into one of five major problem areas: (1) controller judgement and response problems; (2) pilot judgement and response problems; (3) air traffic control intrafacility and interfacility conflicts; (4) ATC and pilot communications problems; and (5) IFR-VFR conflicts. The significance of the related problems, and the various underlying elements associated with each are discussed. Previous ASRS reports covering several areas of analysis are reviewed.

Bergeron, H. P.↗
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↗
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 NTRSDate not supplied

Assessing the Use of UAS-Related Terms in ASRS Using Seed Topic Modeling

Context: The NASA Aviation Safety Reporting System (ASRS) is a voluntary confidential system that disseminates reports received from personnel involved in aviation operations after de-identifying them. These reports are used by the community to improve overall aviation system safety. Aim: We propose and execute an experiment to assess the use of seed term topic modeling over the database narratives to identify Unmanned Aircraft System (UAS) reports. The use of seed term topic modeling enables users to identify groups of conceptually similar narratives associated to a topic of their interest. Method: We use a collection of narratives, expert-selected words, and report metadata that separates UAS from non-UAS reports to assess if seed topic modeling can be used to improve ASRS searches. Results: For simpler queries, seed topic search observes a higher recall and lower precision than the existing DBOL (DataBase OnLine) search in operation. However, the best results are obtained when seed topic search is used as a search suggestion system to be executed on the DBOL. Conclusion: Utilizing a combination of both the existing method and the proposed method, users can expand their search vocabulary about subjects of interest while improving the quality of results.

Text Mining↗
NASA NTRSDate not supplied

Assessing the Use of UAS-Related Terms in ASRS using Seeds for Topic Modeling

Context: The NASA Aviation Safety Reporting System (ASRS) is a voluntary confidential system that disseminates reports received from personnel involved in aviation operations after de-identifying them. These reports are used by the community to improve overall aviation system safety. Aim: We propose and execute an experiment to assess the use of seed term topic modeling over the database narratives to identify Unmanned Aircraft System (UAS) reports. The use of seed term topic modeling enables users to identify groups of conceptually similar narratives associated to a topic of their interest. Method: We use a collection of narratives, expert-selected words, and report metadata that separates UAS from non-UAS reports to assess if seed topic modeling can be used to improve ASRS searches. Results: For simpler queries, seed topic search observes a higher recall and lower precision than the existing DBOL (DataBase OnLine) search in operation. However, the best results are obtained when seed topic search is used as a search suggestion system to be executed on the DBOL. Conclusion: Utilizing a combination of both the existing method and the proposed method, users can expand their search vocabulary about subjects of interest while improving the quality of results.

LDA↗
NASA NTRS1997

Aviation Safety Reporting System: Process and Procedures

The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.

Connell, Linda J.↗
NASA NTRSDate not supplied

ASRS for Unmanned Aviation Systems

This presentation provides an overview of NASA's Aviation Safety Reporting System (ASRS) for Unmanned Aviation Systems / drones

Aviation Safety Reporting System↗
NASA NTRSDate not supplied

Reports of Resilient Performance: Investigating Operators' Descriptions of Safety-producing Behaviors in the Aviation Safety Reporting System

While many existing taxonomies and frameworks provide a common vocabulary for describing how human operators fail in the context of sociotechnical systems, at present, there is no common vocabulary to describe how humans succeed. Such a framework would facilitate systematically collecting and analyzing data on how human performance can produce safety, not just how it can reduce safety. One potentially rich source of currently available information for exploring desired performance is the reports submitted to NASA’s Aviation Safety Reporting System (ASRS). These de-identified, confidential, and voluntary narrative reports are submitted by pilots, controllers, ground operators, and others within aviation operations. While these reports are primarily submitted to describe safety risks, incidents, and problems, they also often describe how those risks were mitigated, and provide a window into aspects of everyday work in aviation. These reports can be searched in a variety of ways. This paper describes methods for systematically examining ASRS narratives to understand how operators talk about their own resilient behaviors during adverse safety conditions and events. Guided by Erik Hollnagel’s Resilience Assessment Grid framework (i.e., anticipate, monitor, respond, learn), various approaches and tools for such inquiries are described. The approach, process, challenges, and suggestions to building an operator-based description of resilient performance are discussed, and tools to facilitate data analysis to maximize learning from these reports are described.

ASRS narratives↗
NASA NTRSDate not supplied

Augmenting Topic Finding in the NASA Aviation Safety Reporting System using Topic Modeling

Context: The NASA Aviation and Safety Reporting System (ASRS) provides various publications to the aviation community (including individual anonymous reports, Callback, Database Search Requests, Directline, and Alerting Messages). Key to these publications are the timely processing of new reports, which is currently done mostly manually by ASRS staff, and which the volume increases yearly. Aim: We investigate whether existing topic modelling techniques are suitable to ease some of the manual effort, and to enhance it with additional visual cues regarding the process of grouping, sense making and labeling incoming (and previous) reports. Method: We evaluate the applicability of WarpLDA topic modelling results combined with three visualization tools, the first two of which have been extended by us in this work for ASRS: Termite, TopicFlow, and LDAVis. Based on the identified limitations in these tools, we propose a methodology for improving them, and evaluate their outputs using ASRS as our test dataset. Results: The user interfaces of Termite, Topicflow and LDAVis were found insufficient for sense-making of the narratives. Moreover, concerns regarding the stability of results due to the inherent randomness of topic modelling, and the lack of a measurable approach for evaluation against the existing ASRS manual workflow were also noted. Conclusion: While many tools to topic modeling and visualization have been proposed, more work is necessary before they can be applied in practical situations to improve existing manual workflows. The methodology presented and applied in this work contribute towards this effort.

ASRS↗
NASA NTRSDate not supplied

Reports of Resilient Performance: Investigating Operators' Descriptions of Safety-producing Behaviors in the Aviation Safety Reporting System

While many existing taxonomies and frameworks provide a common vocabulary for describing how human operators fail in the context of sociotechnical systems, at present, there is no common vocabulary to describe how humans succeed. Such a framework would facilitate systematically collecting and analyzing data on how human performance can produce safety, not just how it can reduce safety. One potentially rich source of currently available information for exploring desired performance is the reports submitted to NASA’s Aviation Safety Reporting System (ASRS). These de-identified, confidential, and voluntary narrative reports are submitted by pilots, controllers, ground operators, and others within aviation operations. While these reports are primarily submitted to describe safety risks, incidents, and problems, they also often describe how those risks were mitigated, and provide a window into aspects of everyday work in aviation. This paper describes an analysis of ASRS narratives to understand how operators talk about their own resilient behaviors during adverse safety conditions and events. Guided by Erik Hollnagel’s Resilience Assessment Grid framework (i.e., anticipate, monitor, respond, learn), we illustrate our approach and methodology with examples from reports. We also highlight some of the challenges and how further research is needed in developing a taxonomy of operators’ descriptions of resilient performance.

resilient behaviors↗
NASA NTRS2008

Patterns of Error in Confidential Maintenance Incident Reports

Confidential reports of maintenance incidents are a valuable source of information on maintenance errors and the contexts within which they occur. NASA's Aviation Safety Reporting System (ASRS) has been receiving an increasing number of maintenance incident reports since a specialized maintenance reporting form was introduced in 1996. In a series of studies, the database of ASRS maintenance incidents was examined using correspondence analysis, a statistical technique that converts complex data tables into a visual form. The analyses revealed patterns within the ASRS data set that would have otherwise been difficult to detect. The results have implications for a range of purposes including human factors training, the design of procedures, and the identification of improvements in aircraft design.

Hobbs, Alan↗
NASA NTRS1983

Incident reporting: Its role in aviation safety and the acquisition of human error data

The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

Reynard, W. D.↗
NASA NTRS1991

The automatic human

An overview is presented of the growth and role of automation in civil aircraft operations for both cockpit management and ground control. NASA has initiated a research program centered on furthering automation and developing a consistent and rational philosophy of human centered aircraft and air traffic control automation. Introduction of the NASA Aviation Safety Reporting System (ASRS) has proved successful in bringing together pilots and ground controllers to report incidents of operational anomalies that can then be analyzed, leading to corrective action to prevent similar reoccurrences. Attention is given to the growing trend of extensive automation in the cockpit that appears to be leading to a diminution of management control of the aircraft by the decreasing number of flight crew members. A majority of reports indicate that there is a serious mismatch between new aircraft capabilities and ATC procedures, which were designed for older aircraft. ASRS has also kept research oriented toward real problems and community needs.

Billings, Charles↗
NASA NTRS1993

Initial exploration of the ASRS database

We applied a standard classification algorithm to a subset of NASA/FAA Aviation Safety Reporting System (ASRS) database. The subset concerned incidents of aircraft altitude deviations. We are exploring the database to address questions such as: Are there 'natural' classes into which the data will fall? How would these classes correspond to recognizable events or situations? Beyond addressing these we want the data to determine directions for further study. We conducted experiments on different data subsections and analyzed diagnostics such as 'message length reduction'; these characterize the classification in terms of its significance and information content. The classification effort was successful in revealing relationships in the data that were in consonance with other studies of the data and expert opinion.

Kraft, Richard↗