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At least 73 records · Page 4
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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 NTRS2013

System Driven Workarounds

The Aviation Safety Reporting System (ASRS) in a partnership between the National Aeronautics and Space Administration (NASA), the Federal Aviation Administration (FAA), participating carriers, and labor organizations. It is designed to improve the National Airspace System by collecting and studying reports detailing unsafe conditions and events in the aviation industry. Employees are able to report safety issues or concerns with confidentiality and without fear of discipline. Safety reports highlighting system driven workarounds for the aviation community highlight the human workaround for the complex aviation system.

aviation safety↗
NASA NTRS2023

SafeAeroBERT: Towards a Safety-Informed Aerospace-Specific Language Model

As aviation systems continue to operate with high traffic, large amounts of documents containing safety-relevant data continue to be generated via reporting systems such as the ASRS. Advanced natural language processing techniques, specifically pre-trained language models, have shown great success in domain-specific applications; however, the text in aviation safety reports is inundated with jargon and thus not fully utilized by general pre-trained models. In this research, we work towards developing a safety-informed aerospace-specific language model by pre-training a Bidirectional Encoder Representations from Transformer (BERT) model on reports from the Aviation Safety Reporting System and the National Transportation Safety Board. The resulting model, called SafeAeroBERT, is fine-tuned for the specific task of document classification, and can be further tuned for named-entity recognition, relation detection, information retrieval, and summarization. Results from the classification task are compared between SafeAeroBERT, the base BERT, and SciBERT models and show SafeAeroBERT outperforms the general BERT and SciBERT on classifying reports about human factors, aircraft, and procedure. SafeAeroBERT can be used on custom tasks, not limited to document classification, and is intended to aid an intelligent knowledge manager for safety report repositories.

Aviation↗
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 NTRS2002

A New Cure for Medical Errors

In May 2000, senior officials of the U.S. Department of Veterans Affairs (VA) and NASA signed an agreement that would commit the two agencies to create the Patient Safety Reporting System (PSRS) to report: events or situations that could have resulted in accident, injury, or illness, but did not, either by chance or through timely intervention (close-calls); unexpected serious occurrences that involved a patient or employee's death, physical injury, or psychological injury; lessens learned; and safety ideas. The VA provided NASA with funding for the initial development of the new system, which automatically removes all personal names, facility names and locations, and other potentially identifying information before entering reports into its database. Designed to complement the VA's current internal reporting systems, the PSRS is modeled after NASA's Aviation Safety Reporting System, which was established in 1975 under a Memorandum of Agreement between the Federal Aviation Administration and NASA and began operation in 1976.

Source record↗
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 NTRSDate not supplied

Extracting Lessons of Resilience Using Machine Mining of the ASRS Database

NASA’s Aviation Safety Reporting System (ASRS) database is the world's largest repository of voluntary, confidential safety information provided by aviation's frontline personnel, including pilots, air traffic controllers, mechanics, flight attendants, dispatchers, and other members of the aviation community and the public. The database contains close to 2 million narratives, many of which describe everyday situations in which people saved the day. In these situations, people’s resilient behavior solved a problem, dealt with a malfunction, and maintained a safe operation despite a serious perturbation. To be able to extract lessons of such resilience from this large database, the use of machine learning algorithms is being explored. In this report, we describe a comparison between two such algorithms: Perilog and Word2Vec. An identical search using both programs was done on a database containing approximately 470,000 ASRS reports submitted between 1988 and 2022. The comparison reveals some of the strength and weaknesses of each algorithm as well as the challenges inherent in using such algorithms to extract lessons of resilience from the ASRS database.

resilience↗
NASA NTRS2018

An Analysis of the Role of Safety Nets in the National Airspace System

Safe operations of aircraft in the National Airspace System (NAS) may be attributed to many factors, including the application of a variety of safety nets (SNs) as a last line of defense. In preparation for the Next Generation Air Transportation System (NextGen), a review of Aviation Safety Reporting System (ASRS) reports for incidents with positive outcomes was conducted to investigate the importance of current safety nets. The examination of positive outcomes not only shows what went wrong, but also what went right to prevent accidents and “save the day.” More than 400 incident reports for 2015 from the voluntary ASRS reporting database were studied in detail to create event sequence diagrams (ESDs), illustrating the effectiveness of SNs. The developed ESDs are considered top-level, representative models and are limited with respect to being reliably quantitative because they are based on only reports from a single year. The ESDs could offer insights into human systems integration research, such as strategically using technologies as SNs without human interface or alleviating human workload with new technologies to provide resilient recovery from off-nominal conditions ensuring flight safety.

Geuther, Steven↗
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 NTRS1993

Altitude deviations: Breakdowns of an error-tolerant system

Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

Palmer, Everett A.↗