SEARCH · Search NASA

Results for “human errors.”

Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

SourceResearch connectionFrom yearThrough year

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 73 records · Page 4

All sources NASA NTRS DOE OSTI

NASA NTRS2016

Tailoring a Human Reliability Analysis to Your Industry Needs

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

DeMott, D. L.↗

NASA NTRSDate not supplied

Modeling Distributed Situation Awareness in Resilience-Based Design of Complex Engineered Systems

Human operators play a major role in the resilience of complex systems–while human error is one of the biggest contributors to hazardous events, operators additionally play a critical role in mitigating hazardous events. A key factor underlying this operator resilience is situation awareness–the ability of operators to understand their environment and each other to achieve desired system functions. In contrast to situation awareness-related accident models in the literature, which are largely conceptual in nature, this work proposes the use of a dynamic simulation framework to concretely model both the effects of situation awareness-related human errors and situation awareness-related hazard-mitigating properties using the distributed situation awareness theory. This work then presents specialized model constructs to enable agents’ individual perceptions of the system state and transactions with other agents (and thus distributed situation awareness) to be represented in simulation. To demonstrate this framework, it is then adapted to an aircraft taxiway case study, where it is used to model aircraft conflicts due to lack of vision and poor communications from the air traffic controller. This demonstration shows the potential of using simulation models to rigorously understand situation awareness-related human errors and thus inform the design of resilience.

Resilience Modeling↗

NASA NTRSDate not supplied

Modeling Distributed Situation Awareness in Resilience-based Design of Complex Systems

Resilience Modeling↗

NASA NTRS2018

Understanding Risk Tolerance and Building an Effective Safety Culture

Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

Loyd, David↗

NASA NTRS2017

Lost in Translation: the Case for Integrated Testing

The building of a spacecraft is complex and often involves multiple suppliers and companies that have their own designs and processes. Standards have been developed across the industries to reduce the chances for critical flight errors at the system level, but the spacecraft is still vulnerable to the introduction of critical errors during integration of these systems. Critical errors can occur at any time during the process and in many cases, human reliability analysis (HRA) identifies human error as a risk driver. Most programs have a test plan in place that is intended to catch these errors, but it is not uncommon for schedule and cost stress to result in less testing than initially planned. Therefore, integrated testing, or "testing as you fly," is essential as a final check on the design and assembly to catch any errors prior to the mission. This presentation will outline the unique benefits of integrated testing by catching critical flight errors that can otherwise go undetected, discuss HRA methods that are used to identify opportunities for human error, lessons learned and challenges over ownership of testing will be discussed.

Young, Aaron↗

NASA NTRS1989

Toward a human-centered aircraft automation philosophy

The evolution of automation in civil aircraft is examined in order to discern trends in the respective roles and functions of automation technology and the humans who operate these aircraft. The effects of advances in automation technology on crew reaction is considered and it appears that, though automation may well have decreased the frequency of certain types of human errors in flight, it may also have enabled new categories of human errors, some perhaps less obvious and therefore more serious than those it has alleviated. It is suggested that automation could be designed to keep the pilot closer to the control of the vehicle, while providing an array of information management and aiding functions designed to provide the pilot with data regarding flight replanning, degraded system operation, and the operational status and limits of the aircraft, its systems, and the physical and operational environment. The automation would serve as the pilot's assistant, providing and calculating data, watching for the unexpected, and keeping track of resources and their rate of expenditure.

Billings, Charles E.↗

NASA NTRS1994

User type certification for advanced flight control systems

Advanced avionics through flight management systems (FMS) coupled with autopilots can now precisely control aircraft from takeoff to landing. Clearly, this has been the most important improvement in aircraft since the jet engine. Regardless of the eventual capabilities of this technology, it is doubtful that society will soon accept pilotless airliners with the same aplomb they accept driverless passenger trains. Flight crews are still needed to deal with inputing clearances, taxiing, in-flight rerouting, unexpected weather decisions, and emergencies; yet it is well known that the contribution of human errors far exceed those of current hardware or software systems. Thus human errors remain, and are even increasing in percentage as the largest contributor to total system error. Currently, the flight crew is regulated by a layered system of certification: by operation, e.g., airline transport pilot versus private pilot; by category, e.g., airplane versus helicopter; by class, e.g., single engine land versus multi-engine land; and by type (for larger aircraft and jet powered aircraft), e.g., Boeing 767 or Airbus A320. Nothing in the certification process now requires an in-depth proficiency with specific types of avionics systems despite their prominent role in aircraft control and guidance.

Gilson, Richard D.↗

NASA NTRS2000

The NASA Aviation Safety Program: Overview

In 1997, the United States set a national goal to reduce the fatal accident rate for aviation by 80% within ten years based on the recommendations by the Presidential Commission on Aviation Safety and Security. Achieving this goal will require the combined efforts of government, industry, and academia in the areas of technology research and development, implementation, and operations. To respond to the national goal, the National Aeronautics and Space Administration (NASA) has developed a program that will focus resources over a five year period on performing research and developing technologies that will enable improvements in many areas of aviation safety. The NASA Aviation Safety Program (AvSP) is organized into six research areas: Aviation System Modeling and Monitoring, System Wide Accident Prevention, Single Aircraft Accident Prevention, Weather Accident Prevention, Accident Mitigation, and Synthetic Vision. Specific project areas include Turbulence Detection and Mitigation, Aviation Weather Information, Weather Information Communications, Propulsion Systems Health Management, Control Upset Management, Human Error Modeling, Maintenance Human Factors, Fire Prevention, and Synthetic Vision Systems for Commercial, Business, and General Aviation aircraft. Research will be performed at all four NASA aeronautics centers and will be closely coordinated with Federal Aviation Administration (FAA) and other government agencies, industry, academia, as well as the aviation user community. This paper provides an overview of the NASA Aviation Safety Program goals, structure, and integration with the rest of the aviation community.

Shin, Jaiwon↗

NASA NTRS2015

How To Make the Most of Your Human: Design Considerations for Single Pilot Operations

Reconsidering the function allocation between automation and the pilot in the flight deck is the next step in improving aviation safety. The current allocation, based on who does what best, makes poor use of the pilot's resources and abilities. In some cases it may actually handicap pilots from performing their role. Improving pilot performance first lies in defining the role of the pilot - why a human is needed in the first place. The next step is allocating functions based on the needs of that role (rather than fitness), then using automation to target specific human weaknesses in performing that role. Examples are provided (some of which could be implemented in conventional cockpits now). Along the way, the definition of human error and the idea that eliminating/automating the pilot will reduce instances of human error will be challenged.

Schutte, Paul C.↗

NASA NTRS2013

Practical Application of PRA as an Integrated Design Tool for Space Systems

This paper presents the application of the first comprehensive Probabilistic Risk Assessment (PRA) during the design phase of a joint NASA/NOAA weather satellite program, Geostationary Operational Environmental Satellite Series R (GOES-R). GOES-R is the next generation weather satellite primarily to help understand the weather and help save human lives. PRA has been used at NASA for Human Space Flight for many years. PRA was initially adopted and implemented in the operational phase of manned space flight programs and more recently for the next generation human space systems. Since its first use at NASA, PRA has become recognized throughout the Agency as a method of assessing complex mission risks as part of an overall approach to assuring safety and mission success throughout project lifecycles. PRA is now included as a requirement during the design phase of both NASA next generation manned space vehicles as well as for high priority robotic missions. The influence of PRA on GOES-R design and operation concepts are discussed in detail. The GOES-R PRA is unique at NASA for its early implementation. It also represents a pioneering effort to integrate risks from both Spacecraft (SC) and Ground Segment (GS) to fully assess the probability of achieving mission objectives. PRA analysts were actively involved in system engineering and design engineering to ensure that a comprehensive set of technical risks were correctly identified and properly understood from a design and operations perspective. The analysis included an assessment of SC hardware and software, SC fault management system, GS hardware and software, common cause failures, human error, natural hazards, solar weather and infrastructure (such as network and telecommunications failures, fire). PRA findings directly resulted in design changes to reduce SC risk from micro-meteoroids. PRA results also led to design changes in several SC subsystems, e.g. propulsion, guidance, navigation and control (GNC), communications, mechanisms, and command and data handling (C&DH). The fault tree approach assisted in the development of the fault management system design. Human error analysis, which examined human response to failure, indicated areas where automation could reduce the overall probability of gaps in operation by half. In addition, the PRA brought to light many potential root causes of system disruptions, including earthquakes, inclement weather, solar storms, blackouts and other extreme conditions not considered in the typical reliability and availability analyses. Ultimately the PRA served to identify potential failures that, when mitigated, resulted in a more robust design, as well as to influence the program's concept of operations. The early and active integration of PRA with system and design engineering provided a well-managed approach for risk assessment that increased reliability and availability, optimized lifecyc1e costs, and unified the SC and GS developments.

Kalia, Prince↗

NASA NTRS2007

Safety and Performance Analysis of the Non-Radar Oceanic/Remote Airspace In-Trail Procedure

This document presents a safety and performance analysis of the nominal case for the In-Trail Procedure (ITP) in a non-radar oceanic/remote airspace. The analysis estimates the risk of collision between the aircraft performing the ITP and a reference aircraft. The risk of collision is only estimated for the ITP maneuver and it is based on nominal operating conditions. The analysis does not consider human error, communication error conditions, or the normal risk of flight present in current operations. The hazards associated with human error and communication errors are evaluated in an Operational Hazards Analysis presented elsewhere.

Carreno, Victor A.↗

NASA NTRS2002

Human Factors Directions for Civil Aviation

Despite considerable progress in understanding human capabilities and limitations, incorporating human factors into aircraft design, operation, and certification, and the emergence of new technologies designed to reduce workload and enhance human performance in the system, most aviation accidents still involve human errors. Such errors occur as a direct or indirect result of untimely, inappropriate, or erroneous actions (or inactions) by apparently well-trained and experienced pilots, controllers, and maintainers. The field of human factors has solved many of the more tractable problems related to simple ergonomics, cockpit layout, symbology, and so on. We have learned much about the relationships between people and machines, but know less about how to form successful partnerships between humans and the information technologies that are beginning to play a central role in aviation. Significant changes envisioned in the structure of the airspace, pilots and controllers' roles and responsibilities, and air/ground technologies will require a similarly significant investment in human factors during the next few decades to ensure the effective integration of pilots, controllers, dispatchers, and maintainers into the new system. Many of the topics that will be addressed are not new because progress in crucial areas, such as eliminating human error, has been slow. A multidisciplinary approach that capitalizes upon human studies and new classes of information, computational models, intelligent analytical tools, and close collaborations with organizations that build, operate, and regulate aviation technology will ensure that the field of human factors meets the challenge.

Hart, Sandra G.↗

NASA NTRS2007

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Johnson, C. W.↗

NASA NTRS1984

NASA: Model development for human factors interfacing

The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.

Smith, L. L.↗

NASA NTRS1975

A Method for the Study of Human Factors in Aircraft Operations

A method for the study of human factors in the aviation environment is described. A conceptual framework is provided within which pilot and other human errors in aircraft operations may be studied with the intent of finding out how, and why, they occurred. An information processing model of human behavior serves as the basis for the acquisition and interpretation of information relating to occurrences which involve human error. A systematic method of collecting such data is presented and discussed. The classification of the data is outlined.

Barnhart, W.↗

NASA NTRS2017

Designing and Developing Web-Based Administrative Tools for Program Management

The task assigned for this internship was to develop a new tool for tracking projects, their subsystems, the leads, backups, and other employees assigned to them, as well as all the relevant information related to the employee (WBS (time charge) codes, time distribution, certifications, and assignments). Currently, this data is tracked manually using a number of different spreadsheets and other tools simultaneously by a number of different people; some of these documents are then merged into one large document. This often leads to inconsistencies and loss in data due to human error. By simplifying the process of tracking this data and aggregating it into a single tool, it is possible to significantly decrease the potential for human error and time spent collecting and checking this information. II. Objective The main objective of this internship is to develop a web-based tool using Ruby on Rails to serve as a method of easily tracking projects, subsystems, and points of contact, along with employees, their assignments, time distribution, certifications, and contact information. Additionally, this tool must be capable of generating a number of different reports based on the data collected. It was important that this tool deliver all of this information using a readable and intuitive interface.

Material↗

NASA NTRS1989

Airline Crew Training

The discovery that human error has caused many more airline crashes than mechanical malfunctions led to an increased emphasis on teamwork and coordination in airline flight training programs. Human factors research at Ames Research Center has produced two crew training programs directed toward more effective operations. Cockpit Resource Management (CRM) defines areas like decision making, workload distribution, communication skills, etc. as essential in addressing human error problems. In 1979, a workshop led to the implementation of the CRM program by United Airlines, and later other airlines. In Line Oriented Flight Training (LOFT), crews fly missions in realistic simulators while instructors induce emergency situations requiring crew coordination. This is followed by a self critique. Ames Research Center continues its involvement with these programs.

Source record↗

NASA NTRS2003

Associations between errors and contributing factors in aircraft maintenance

In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.

Professional Competence↗