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Probabilistic Risk Assessment of a Sustained Lunar Presence

The Artemis Base Camp will be our first sustainable foothold on the lunar frontier. The base camp includes a lunar surface habitat, power systems, and infrastructure needed to develop capabilities on future missions to Mars. NASA Probabilistic Risk Assessment (PRA) methodologies tend to focus on in-flight Loss of Crew (LOC) or Loss of Vehicle (LOV) risk estimates for short mission durations. However, lunar habit support systems and power generation systems will need to continuously operate. Existing risk methodologies will need to adapt to understand risk drivers in new environments under different operating conditions, such as lunar dust and increased micro-meteoroid exposure. Insights from the nuclear and oil industries can provide guidance to NASA risk practitioners to tackle this new challenge.

risk assessment↗

NASA System Safety Handbook: System Safety Framework and Concepts for Implementation - Volume 1

System safety assessment is defined in NPR 8715.3C, NASA General Safety Program Requirements as a disciplined, systematic approach to the analysis of risks resulting from hazards that can affect humans, the environment, and mission assets. Achievement of the highest practicable degree of system safety is one of NASA's highest priorities. Traditionally, system safety assessment at NASA and elsewhere has focused on the application of a set of safety analysis tools to identify safety risks and formulate effective controls.1 Familiar tools used for this purpose include various forms of hazard analyses, failure modes and effects analyses, and probabilistic safety assessment (commonly also referred to as probabilistic risk assessment (PRA)). In the past, it has been assumed that to show that a system is safe, it is sufficient to provide assurance that the process for identifying the hazards has been as comprehensive as possible and that each identified hazard has one or more associated controls. The NASA Aerospace Safety Advisory Panel (ASAP) has made several statements in its annual reports supporting a more holistic approach. In 2006, it recommended that "... a comprehensive risk assessment, communication and acceptance process be implemented to ensure that overall launch risk is considered in an integrated and consistent manner." In 2009, it advocated for "... a process for using a risk-informed design approach to produce a design that is optimally and sufficiently safe." As a rationale for the latter advocacy, it stated that "... the ASAP applauds switching to a performance-based approach because it emphasizes early risk identification to guide designs, thus enabling creative design approaches that might be more efficient, safer, or both." For purposes of this preface, it is worth mentioning three areas where the handbook emphasizes a more holistic type of thinking. First, the handbook takes the position that it is important to not just focus on risk on an individual basis but to consider measures of aggregate safety risk and to ensure wherever possible that there be quantitative measures for evaluating how effective the controls are in reducing these aggregate risks. The term aggregate risk, when used in this handbook, refers to the accumulation of risks from individual scenarios that lead to a shortfall in safety performance at a high level: e.g., an excessively high probability of loss of crew, loss of mission, planetary contamination, etc. Without aggregated quantitative measures such as these, it is not reasonable to expect that safety has been optimized with respect to other technical and programmatic objectives. At the same time, it is fully recognized that not all sources of risk are amenable to precise quantitative analysis and that the use of qualitative approaches and bounding estimates may be appropriate for those risk sources. Second, the handbook stresses the necessity of developing confidence that the controls derived for the purpose of achieving system safety not only handle risks that have been identified and properly characterized but also provide a general, more holistic means for protecting against unidentified or uncharacterized risks. For example, while it is not possible to be assured that all credible causes of risk have been identified, there are defenses that can provide protection against broad categories of risks and thereby increase the chances that individual causes are contained. Third, the handbook strives at all times to treat uncertainties as an integral aspect of risk and as a part of making decisions. The term "uncertainty" here does not refer to an actuarial type of data analysis, but rather to a characterization of our state of knowledge regarding results from logical and physical models that approximate reality. Uncertainty analysis finds how the output parameters of the models are related to plausible variations in the input parameters and in the modeling assumptions. The evaluation of unrtainties represents a method of probabilistic thinking wherein the analyst and decision makers recognize possible outcomes other than the outcome perceived to be "most likely." Without this type of analysis, it is not possible to determine the worth of an analysis product as a basis for making decisions related to safety and mission success. In line with these considerations the handbook does not take a hazard-analysis-centric approach to system safety. Hazard analysis remains a useful tool to facilitate brainstorming but does not substitute for a more holistic approach geared to a comprehensive identification and understanding of individual risk issues and their contributions to aggregate safety risks. The handbook strives to emphasize the importance of identifying the most critical scenarios that contribute to the risk of not meeting the agreed-upon safety objectives and requirements using all appropriate tools (including but not limited to hazard analysis). Thereafter, emphasis shifts to identifying the risk drivers that cause these scenarios to be critical and ensuring that there are controls directed toward preventing or mitigating the risk drivers. To address these and other areas, the handbook advocates a proactive, analytic-deliberative, risk-informed approach to system safety, enabling the integration of system safety activities with systems engineering and risk management processes. It emphasizes how one can systematically provide the necessary evidence to substantiate the claim that a system is safe to within an acceptable risk tolerance, and that safety has been achieved in a cost-effective manner. The methodology discussed in this handbook is part of a systems engineering process and is intended to be integral to the system safety practices being conducted by the NASA safety and mission assurance and systems engineering organizations. The handbook posits that to conclude that a system is adequately safe, it is necessary to consider a set of safety claims that derive from the safety objectives of the organization. The safety claims are developed from a hierarchy of safety objectives and are therefore hierarchical themselves. Assurance that all the claims are true within acceptable risk tolerance limits implies that all of the safety objectives have been satisfied, and therefore that the system is safe. The acceptable risk tolerance limits are provided by the authority who must make the decision whether or not to proceed to the next step in the life cycle. These tolerances are therefore referred to as the decision maker's risk tolerances. In general, the safety claims address two fundamental facets of safety: 1) whether required safety thresholds or goals have been achieved, and 2) whether the safety risk is as low as possible within reasonable impacts on cost, schedule, and performance. The latter facet includes consideration of controls that are collective in nature (i.e., apply generically to broad categories of risks) and thereby provide protection against unidentified or uncharacterized risks.

Dezfuli, Homayoon↗

Risk management for the Space Exploration Initiative

Probabilistic Risk Assessment (PRA) is a quantitative engineering process that provides the analytic structure and decision-making framework for total programmatic risk management. Ideally, it is initiated in the conceptual design phase and used throughout the program life cycle. Although PRA was developed for assessment of safety, reliability, and availability risk, it has far greater application. Throughout the design phase, PRA can guide trade-off studies among system performance, safety, reliability, cost, and schedule. These studies are based on the assessment of the risk of meeting each parameter goal, with full consideration of the uncertainties. Quantitative trade-off studies are essential, but without full identification, propagation, and display of uncertainties, poor decisions may result. PRA also can focus attention on risk drivers in situations where risk is too high. For example, if safety risk is unacceptable, the PRA prioritizes the risk contributors to guide the use of resources for risk mitigation. PRA is used in the Space Exploration Initiative (SEI) Program. To meet the stringent requirements of the SEI mission, within strict budgetary constraints, the PRA structure supports informed and traceable decision-making. This paper briefly describes the SEI PRA process.

Buchbinder, Ben↗

Risk Management of NASA Projects

Various NASA Langley Research Center and other center projects were attempted for analysis to obtain historical data comparing pre-phase A study and the final outcome for each project. This attempt, however, was abandoned once it became clear that very little documentation was available. Next, extensive literature search was conducted on the role of risk and reliability concepts in project management. Probabilistic risk assessment (PRA) techniques are being used with increasing regularity both in and outside of NASA. The value and the usage of PRA techniques were reviewed for large projects. It was found that both civilian and military branches of the space industry have traditionally refrained from using PRA, which was developed and expanded by nuclear industry. Although much has changed with the end of the cold war and the Challenger disaster, it was found that ingrained anti-PRA culture is hard to stop. Examples of skepticism against the use of risk management and assessment techniques were found both in the literature and in conversations with some technical staff. Program and project managers need to be convinced that the applicability and use of risk management and risk assessment techniques is much broader than just in the traditional safety-related areas of application. The time has come to begin to uniformly apply these techniques. The whole idea of risk-based system can maximize the 'return on investment' that the public demands. Also, it would be very useful if all project documents of NASA Langley Research Center, pre-phase A through final report, are carefully stored in a central repository preferably in electronic format.

Sarper, Hueseyin↗

Methods and Techniques for Risk Prediction of Space Shuttle Upgrades

Since the Space Shuttle Accident in 1986, NASA has been trying to incorporate probabilistic risk assessment (PRA) in decisions concerning the Space Shuttle and other NASA projects. One major study NASA is currently conducting is in the PRA area in establishing an overall risk model for the Space Shuttle System. The model is intended to provide a tool to predict the Shuttle risk and to perform sensitivity analyses and trade studies including evaluation of upgrades. Marshall Space Flight Center (MSFC) and its prime contractors including Pratt and Whitney (P&W) are part of the NASA team conducting the PRA study. MSFC responsibility involves modeling the External Tank (ET), the Solid Rocket Booster (SRB), the Reusable Solid Rocket Motor (RSRM), and the Space Shuttle Main Engine (SSME). A major challenge that faced the PRA team is modeling the shuttle upgrades. This mainly includes the P&W High Pressure Fuel Turbopump (HPFTP) and the High Pressure Oxidizer Turbopump (HPOTP). The purpose of this paper is to discuss the various methods and techniques used for predicting the risk of the P&W redesigned HPFTP and HPOTP.

Hoffman, Chad R.↗

The Use of Probabilistic Methods to Evaluate the Systems Impact of Component Design Improvements on Large Turbofan Engines

Probabilistic Structural Analysis (PSA) is now commonly used for predicting the distribution of time/cycles to failure of turbine blades and other engine components. These distributions are typically based on fatigue/fracture and creep failure modes of these components. Additionally, reliability analysis is used for taking test data related to particular failure modes and calculating failure rate distributions of electronic and electromechanical components. How can these individual failure time distributions of structural, electronic and electromechanical component failure modes be effectively combined into a top level model for overall system evaluation of component upgrades, changes in maintenance intervals, or line replaceable unit (LRU) redesign? This paper shows an example of how various probabilistic failure predictions for turbine engine components can be evaluated and combined to show their effect on overall engine performance. A generic model of a turbofan engine was modeled using various Probabilistic Risk Assessment (PRA) tools (Quantitative Risk Assessment Software (QRAS) etc.). Hypothetical PSA results for a number of structural components along with mitigation factors that would restrict the failure mode from propagating to a Loss of Mission (LOM) failure were used in the models. The output of this program includes an overall failure distribution for LOM of the system. The rank and contribution to the overall Mission Success (MS) is also given for each failure mode and each subsystem. This application methodology demonstrates the effectiveness of PRA for assessing the performance of large turbine engines. Additionally, the effects of system changes and upgrades, the application of different maintenance intervals, inclusion of new sensor detection of faults and other upgrades were evaluated in determining overall turbine engine reliability.

Packard, Michael H.↗

Reducing the Risk of Human Space Missions with INTEGRITY

The INTEGRITY Program will design and operate a test bed facility to help prepare for future beyond-LEO missions. The purpose of INTEGRITY is to enable future missions by developing, testing, and demonstrating advanced human space systems. INTEGRITY will also implement and validate advanced management techniques including risk analysis and mitigation. One important way INTEGRITY will help enable future missions is by reducing their risk. A risk analysis of human space missions is important in defining the steps that INTEGRITY should take to mitigate risk. This paper describes how a Probabilistic Risk Assessment (PRA) of human space missions will help support the planning and development of INTEGRITY to maximize its benefits to future missions. PRA is a systematic methodology to decompose the system into subsystems and components, to quantify the failure risk as a function of the design elements and their corresponding probability of failure. PRA provides a quantitative estimate of the probability of failure of the system, including an assessment and display of the degree of uncertainty surrounding the probability. PRA provides a basis for understanding the impacts of decisions that affect safety, reliability, performance, and cost. Risks with both high probability and high impact are identified as top priority. The PRA of human missions beyond Earth orbit will help indicate how the risk of future human space missions can be reduced by integrating and testing systems in INTEGRITY.

Jones, Harry W.↗

Assessment and Control of Spacecraft Charging Risks on the International Space Station

The International Space Station (ISS) operates in the F2 region of Earth's ionosphere, orbiting at altitudes ranging from 350 to 450 km at an inclination of 51.6 degrees. The relatively dense, cool F2 ionospheric plasma suppresses surface charging processes much of the time, and the flux of relativistic electrons is low enough to preclude deep dielectric charging processes. The most important spacecraft charging processes in the ISS orbital environment are: 1) ISS electrical power system interactions with the F2 plasma, 2) magnetic induction processes resulting from flight through the geomagnetic field and, 3) charging processes that result from interaction with auroral electrons at high latitude. Recently, the continuing review and evaluation of putative ISS charging hazards required by the ISS Program Office revealed that ISS charging could produce an electrical shock hazard to the ISS crew during extravehicular activity (EVA). ISS charging risks are being evaluated in an ongoing measurement and analysis campaign. The results of ISS charging measurements are combined with a recently developed model of ISS charging (the Plasma Interaction Model) and an exhaustive analysis of historical ionospheric variability data (ISS Ionospheric Specification) to evaluate ISS charging risks using Probabilistic Risk Assessment (PRA) methods. The PRA combines estimates of the frequency of occurrence and severity of the charging hazards with estimates of the reliability of various hazard controls systems, as required by NASA s safety and risk management programs, to enable design and selection of a hazard control approach that minimizes overall programmatic and personnel risk. The PRA provides a quantitative methodology for incorporating the results of the ISS charging measurement and analysis campaigns into the necessary hazard reports, EVA procedures, and ISS flight rules required for operating ISS in a safe and productive manner.

Koontz, Steve↗

Uncertainty Considerations for Ballistic Limit Equations

The overall risk for any spacecraft system is typically determined using a Probabilistic Risk Assessment (PRA). A PRA attempts to determine the overall risk associated with a particular mission by factoring in all known risks (and their corresponding uncertainties, if known) to the spacecraft during its mission. The threat to mission and human life posed by the mircro-meteoroid & orbital debris (MMOD) environment is one of the risks. NASA uses the BUMPER II program to provide point estimate predictions of MMOD risk for the Space Shuttle and the International Space Station. However, BUMPER II does not provide uncertainty bounds or confidence intervals for its predictions. With so many uncertainties believed to be present in the models used within BUMPER II, providing uncertainty bounds with BUMPER II results would appear to be essential to properly evaluating its predictions of MMOD risk. The uncertainties in BUMPER II come primarily from three areas: damage prediction/ballistic limit equations, environment models, and failure criteria definitions. In order to quantify the overall uncertainty bounds on MMOD risk predictions, the uncertainties in these three areas must be identified. In this paper, possible approaches through which uncertainty bounds can be developed for the various damage prediction and ballistic limit equations encoded within the shuttle and station versions of BUMPER II are presented and discussed. We begin the paper with a review of the current approaches used by NASA to perform a PRA for the Space Shuttle and the International Space Station, followed by a review of the results of a recent sensitivity analysis performed by NASA using the shuttle version of the BUMPER II code. Following a discussion of the various equations that are encoded in BUMPER II, we propose several possible approaches for establishing uncertainty bounds for the equations within BUMPER II. We conclude with an evaluation of these approaches and present a recommendation regarding which of them would be the most appropriate to follow.

Schonberg, W. P.↗

Uncertainty Considerations for Ballistic Limit Equations

The overall risk for any spacecraft system is typically determined using a Probabilistic Risk Assessment (PRA). A PRA determines the overall risk associated with a particular mission by factoring in all known risks to the spacecraft during its mission. The threat to mission and human life posed by the micro-meteoroid and orbital debris (MMOD) environment is one of the risks. NASA uses the BUMPER II program to provide point estimate predictions of MMOD risk for the Space Shuttle and the ISS. However, BUMPER II does not provide uncertainty bounds or confidence intervals for its predictions. In this paper, we present possible approaches through which uncertainty bounds can be developed for the various damage prediction and ballistic limit equations encoded within the Shuttle and Station versions of BUMPER II.

Schonberg, W. P.↗

Knowledge Representation Standards and Interchange Formats for Causal Graphs

In many domains, automated reasoning tools must represent graphs of causally linked events. These include fault-tree analysis, probabilistic risk assessment (PRA), planning, procedures, medical reasoning about disease progression, and functional architectures. Each of these fields has its own requirements for the representation of causation, events, actors and conditions. The representations include ontologies of function and cause, data dictionaries for causal dependency, failure and hazard, and interchange formats between some existing tools. In none of the domains has a generally accepted interchange format emerged. The paper makes progress towards interoperability across the wide range of causal analysis methodologies. We survey existing practice and emerging interchange formats in each of these fields. Setting forth a set of terms and concepts that are broadly shared across the domains, we examine the several ways in which current practice represents them. Some phenomena are difficult to represent or to analyze in several domains. These include mode transitions, reachability analysis, positive and negative feedback loops, conditions correlated but not causally linked and bimodal probability distributions. We work through examples and contrast the differing methods for addressing them. We detail recent work in knowledge interchange formats for causal trees in aerospace analysis applications in early design, safety and reliability. Several examples are discussed, with a particular focus on reachability analysis and mode transitions. We generalize the aerospace analysis work across the several other domains. We also recommend features and capabilities for the next generation of causal knowledge representation standards.

Throop, David R.↗

Taking the Risk Out of Risk Assessment

The ability to understand risks and have the right strategies in place when risky events occur is essential in the workplace. More and more organizations are being confronted with concerns over how to measure their risks or what kind of risks they can take when certain events transpire that could have a negative impact. NASA is one organization that faces these challenges on a daily basis, as effective risk management is critical to the success of its missions especially the Space Shuttle missions. On July 29, 1996, former NASA Administrator Daniel Goldin charged NASA s Office of Safety and Mission Assurance with developing a probabilistic risk assessment (PRA) tool to support decisions on the funding of Space Shuttle upgrades. When issuing the directive, Goldin said, "Since I came to NASA [in 1992], we've spent billions of dollars on Shuttle upgrades without knowing how much they improve safety. I want a tool to help base upgrade decisions on risk." Work on the PRA tool began immediately. The resulting prototype, the Quantitative Risk Assessment System (QRAS) Version 1.0, was jointly developed by NASA s Marshall Space Flight Center, its Office of Safety and Mission Assurance, and researchers at the University of Maryland. QRAS software automatically expands the reliability logic models of systems to evaluate the probability of highly detrimental outcomes occurring in complex systems that are subject to potential accident scenarios. Even in its earliest forms, QRAS was used to begin PRA modeling of the Space Shuttle. In parallel, the development of QRAS continued, with the goal of making it a world-class tool, one that was especially suited to NASA s unique needs. From the beginning, an important conceptual goal in the development of QRAS was for it to help bridge the gap between the professional risk analyst and the design engineer. In the past, only the professional risk analyst could perform, modify, use, and perhaps even adequately understand PRA. NASA wanted to change this by developing a PRA tool that would be friendlier, more understandable, and more useful to the broader engineering community. This concept ultimately led to the look, feel, and functionality that QRAS has today.

Source record↗

Derivation of Failure Rates and Probability of Failures for the International Space Station Probabilistic Risk Assessment Study

National Aeronautics and Space Administration s (NASA) International Space Station (ISS) Program uses Probabilistic Risk Assessment (PRA) as part of its Continuous Risk Management Process. It is used as a decision and management support tool to not only quantify risk for specific conditions, but more importantly comparing different operational and management options to determine the lowest risk option and provide rationale for management decisions. This paper presents the derivation of the probability distributions used to quantify the failure rates and the probability of failures of the basic events employed in the PRA model of the ISS. The paper will show how a Bayesian approach was used with different sources of data including the actual ISS on orbit failures to enhance the confidence in results of the PRA. As time progresses and more meaningful data is gathered from on orbit failures, an increasingly accurate failure rate probability distribution for the basic events of the ISS PRA model can be obtained. The ISS PRA has been developed by mapping the ISS critical systems such as propulsion, thermal control, or power generation into event sequences diagrams and fault trees. The lowest level of indenture of the fault trees was the orbital replacement units (ORU). The ORU level was chosen consistently with the level of statistically meaningful data that could be obtained from the aerospace industry and from the experts in the field. For example, data was gathered for the solenoid valves present in the propulsion system of the ISS. However valves themselves are composed of parts and the individual failure of these parts was not accounted for in the PRA model. In other words the failure of a spring within a valve was considered a failure of the valve itself.

Vitali, Roberto↗

Simulation Assisted Risk Assessment: Blast Overpressure Modeling

A probabilistic risk assessment (PRA) approach has been developed and applied to the risk analysis of capsule abort during ascent. The PRA is used to assist in the identification of modeling and simulation applications that can significantly impact the understanding of crew risk during this potentially dangerous maneuver. The PRA approach is also being used to identify the appropriate level of fidelity for the modeling of those critical failure modes. The Apollo launch escape system (LES) was chosen as a test problem for application of this approach. Failure modes that have been modeled and/or simulated to date include explosive overpressure-based failure, explosive fragment-based failure, land landing failures (range limits exceeded either near launch or Mode III trajectories ending on the African continent), capsule-booster re-contact during separation, and failure due to plume-induced instability. These failure modes have been investigated using analysis tools in a variety of technical disciplines at various levels of fidelity. The current paper focuses on the development and application of a blast overpressure model for the prediction of structural failure due to overpressure, including the application of high-fidelity analysis to predict near-field and headwinds effects.

Lawrence, Scott L.↗

Design for Reliability and Safety Approach for the New NASA Launch Vehicle

The United States National Aeronautics and Space Administration (NASA) is in the midst of a space exploration program intended for sending crew and cargo to the international Space Station (ISS), to the moon, and beyond. This program is called Constellation. As part of the Constellation program, NASA is developing new launch vehicles aimed at significantly increase safety and reliability, reduce the cost of accessing space, and provide a growth path for manned space exploration. Achieving these goals requires a rigorous process that addresses reliability, safety, and cost upfront and throughout all the phases of the life cycle of the program. This paper discusses the "Design for Reliability and Safety" approach for the NASA new launch vehicles, the ARES I and ARES V. Specifically, the paper addresses the use of an integrated probabilistic functional analysis to support the design analysis cycle and a probabilistic risk assessment (PRA) to support the preliminary design and beyond.

Safie, Fayssal M.↗

Probabilistic Risk Model for Organ Doses and Acute Health Effects of Astronauts on Lunar Missions

Exposure to large solar particle events (SPEs) is a major concern during EVAs on the lunar surface and in Earth-to-Lunar transit. 15% of crew times may be on EVA with minimal radiation shielding. Therefore, an accurate assessment of SPE occurrence probability is required for the mission planning by NASA. We apply probabilistic risk assessment (PRA) for radiation protection of crews and optimization of lunar mission planning.

Kim, Myung-Hee Y.↗

The Importance of HRA in Human Space Flight: Understanding the Risks

Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (~12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.

Hamlin, Teri↗

The Importance of Human Reliability Analysis in Human Space Flight: Understanding the Risks

HRA is a method used to describe, qualitatively and quantitatively, the occurrence of human failures in the operation of complex systems that affect availability and reliability. Modeling human actions with their corresponding failure in a PRA (Probabilistic Risk Assessment) provides a more complete picture of the risk and risk contributions. A high quality HRA can provide valuable information on potential areas for improvement, including training, procedural, equipment design and need for automation.

Hamlin, Teri L.↗