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At least 91 records · Page 5

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.↗

Kaona: Deep Searching and Curating Safety Reporting Systems

Context: Several works in the literature have examined how safety narrative databases can be leveraged to share lessons learned. However, less attention has been given in augmenting existing processes of safety reporting systems. Aim: In this work, we introduce Kaona: An interface that weaves machine learning in existing aviation safety reporting systems activities. Method: We provide a use case of search, curation and newsletter writing to showcase how Kaona features build on existing processes and on its own to enhance information retrieval, curation and synthesis of narratives. Results: We created two instances of Kaona internally for evaluation, one using all public NASA's ASRS narratives and another using all public C3RS narratives. Data ranged from 1998 to 2024. Conclusion: Our tool provides a new way to explore safety narratives, serving to re-imagine how text databases can benefit of novel information retrieval mechanisms in the era of large language models.

asrs↗

Fuel Policies and Filed Alternates

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 fuel policies and alternate requirements for the aviation community highlight the human element in the complex aviation system.

Connell, Linda↗

Identification of Vehicle Health Assurance Related Trends

Trend analysis in aviation as related to vehicle health management (VHM) was performed by reviewing the most current statistical and prognostics data available from the National Transportation Safety Board (NTSB) accident, the Federal Aviation Administration (FAA) incident, and the NASA Aviation Safety Reporting System (ASRS) incident datasets. In addition, future directions in aviation technology related to VHM research areas were assessed through the Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementations (SERFIs), the National Transportation Safety Board (NTSB) Most-Wanted List and recent open safety recommendations, the National Research Council (NRC) Decadal Survey of Civil Aeronautics, and the Future Aviation Safety Team (FAST) areas of change. Future research direction in the VHM research areas is evidently strong as seen from recent research solicitations from the Naval Air Systems Command (NAVAIR), and VHM-related technologies actively being developed by aviation industry leaders, including GE, Boeing, Airbus, and UTC Aerospace Systems. Given the highly complex VHM systems, modifications can be made in the future so that the Vehicle Systems Safety Technology Project (VSST) technical challenges address inadequate maintenance crew's trainings and skills, and the certification methods of such systems as recommended by the NTSB, NRC, and FAST areas of change.

Phojanamongkolkij, Nipa↗

Ground Operations and ASRS

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

human factors↗

Cabin Safety Issues Related to Pre-Departure and Inflight Issues

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 the human element in cabin safety issues and concerns.

confidential reporting↗

Trouble with Troubleshooting

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.

Connell, Linda↗

“Terrain, Terrain Pull-up!” Air Carrier Controlled Flight Toward Terrain Incidents Reported to the NASA ASRS

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 controlled flight toward terrain incidents as reported to the NASA ASRS.

confidential reporting↗

Potential effects of the introduction of the discrete address beacon system data link on air/ground information transfer problems

This study of Aviation Safety Reporting System reports suggests that benefits should accure from implementation of discrete address beacon system data link. The phase enhanced terminal information system service is expected to provide better terminal information than present systems by improving currency and accuracy. In the exchange of air traffic control messages, discrete address insures that only the intended recipient receives and acts on a specific message. Visual displays and printer copy of messages should mitigate many of the reported problems associated with voice communications. The problems that remain unaffected include error in addressing the intended recipient and messages whose content is wrong but are otherwise correct as to format and reasonableness.

Grayson, R. L.↗

Personal Electronic Devices and Their Interference with Aircraft Systems

A compilation of data on personal electronic devices (PEDs) attributed to having created anomalies with aircraft systems. Charts and tables display 14 years of incidents reported by pilots to the Aviation Safety Reporting System (ASRS). Affected systems, incident severity, sources of anomaly detection, and the most frequently identified PEDs are some of the more significant data. Several reports contain incidents of aircraft off course when all systems indicated on course and of critical events that occurred during landings and takeoffs. Additionally, PEDs that should receive priority in testing are identified.

Ross, Elden↗

Ground Taxi Navigation Problems and Training Solutions

Adverse weather conditions can put considerable strain on the National Airspace System. Even small decreases in visibility on the airport surface can create delays, hinder safe movement and lead to errors. Studies of Aviation Safety Reporting System (ASRS) surface movement incidents support the need for technologies and procedures to improve ground operations in low-visibility conditions. This study examined 139 ASRS reports of low-visibility surface movement incidents at 10 major U.S. airports. Errors were characterized in terms of incident type, contributing factors and consequences. The incidents in the present sample were comprised of runway transgressions, taxiway excursions and ground conflicts. The primary contributing factors were Airport Layout and Markings, Communication and Distraction. In half the incidents the controller issued a new clearance or the flight crew took an evasive action and in the remaining half, no recovery attempt was made because the error was detected after the fact. By gaining a better understanding the factors that affect crew navigation in low visibility and the types of errors that are likely to occur, it will be possible to develop more robust technologies to aid pilots in the ground taxi task. Implications for crew training and procedure development for low-visibility ground taxi are also discussed.

Quinn, Cheryl↗

Testing of Advanced Capabilities to Enable In-time Safety Management and Assurance for Future Flight Operations

In order to refine an initial Concept of Operations, explore Concepts of Use, and expose/validate requirements for future In-Time Aviation Safety Management Systems (IASMS), testing architectures were created, along with a set of capabilities and underlying information exchange protocols. These systems were conceived and developed based on hazards associated with two envisioned urban area flight domains: (1) highly autonomous small uncrewed aerial systems (sUAS) operating at low altitudes, and (2) highly autonomous air taxis. The initial scope of this development is described in [1]; this report provides an update, focusing on the subsequent developments and test activities. As stated in [1], it is important to note that there are many capabilities already in use by the industry (or soon to be in use) that will play critical roles in future IASMS designs. Those reported here were developed to address a gap in the current state-of-the-art regarding specific hazards/risks, and/or to allow for investigation of the interplay between and across hazard types — particularly regarding how overall safety risk can be reduced or managed effectively. Results of testing and development activities are organized by the operational phase wherein a particular capability would be employed (i.e., preflight, in-flight, and post-flight/off-line). Pre-flight: A set of capabilities were developed to help mitigate safety risk prior to flight (e.g., during flight and mission planning). Results of testing summarize (1) validation activities to raise the Technology Readiness Level (TRL) and (2) evaluation activities where the capabilities were applied to flight/mission planning procedures and used by operators/pilots. For the latter, flight plans were automatically assessed, and operators/pilots were notified of hazardous flight segments so as to enable adjustment of the flight plan and re-evaluation, and/or to better inform go/no-go decisions. Capabilities addressed hazards associated with power consumption, third-party risk, wind, navigation system performance, radiofrequency interference, and proximity to geo-spatial threats (e.g., buildings, trees, and no-fly zones). In-flight: Flight experiments tested capabilities that detect and respond to hazards encountered during flight. In the first series, safety hazards were monitored and assessed onboard, and system-generated mitigation maneuvers were recorded (but not acted upon by the vehicle). In the second series, mitigation maneuver commands directed the aircraft in response to safety hazards (i.e., auto-mitigation). The sUAS used for testing is described in full, as is the test architecture, which included commercial avionics, research avionics, and onboard software designed to detect, assess, and respond to hazards. The onboard system was designed as a run-time assurance framework, consistent with [2] and supportive of both supervisory and automated modes. The primary functions included: real-time risk assessment (RTRA), auto-pilot monitoring, constraint monitoring, and contingency select/triggering. RTRA performs integrated risk assessment considering data from several hazard-related monitors (e.g., battery, motors, navigation, communications, population density, and loss-of-control). Post-flight/off-line: Data monitored and recorded during flights can enable IASMS capabilities that execute after flights have completed (or “off-line”). These include: (1) the ability to identify anomalies and trends that may only be observable when comparing data spanning a number of similar flights; (2) the ability to update and validate pre-flight and in-flight capabilities and any underlying models to improve their performance; (3) the ability to report anomalies/off-nominals that may indicate design changes or maintenance actions are needed; and (4) the ability for humans involved in operations to report safety-relevant observations to help in understanding the flight data and/or the operational context of a flight. Progress on three such capabilities is summarized; the first investigates anomaly detection given a limited set of flight logs and applies an approach previously used for space operations. The second explores what could be identified using a larger set of flight logs, including from web-based forums where flight logs are posted by sUAS autopilot users. The third creates a new means of collecting information on UAS incidents and accidents via the Aviation Safety Reporting System (ASRS).

sUAS↗

Loss of Situation Awareness in Pilots: Analysis of Incident Reports

Approximately 75% of all aviation accidents and incidents are attributable to human failures in monitoring, managing, and operating system. Tactical decision errors were found to be a factor in 25 of 37 major US air transport accidents between 1978 and 1990. These two facts demonstrate the inability of some pilots to maintain situation awareness. Situation awareness (SA) is defined as 'the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future". Thus, when a pilot loses SA, he or she is unable to ether perceive, comprehend, or project the status of the aircraft. In pilots terms, he or she has 'fallen behind the airplane'. Our study this summer involved an analysis of 190 NASA Aviation Safety Reporting System (ASRS) reports.

Eric B. Villeda↗

Emergency medical service (EMS): A unique flight environment

The EMS flight environment is unique in today's aviation. The pilots must respond quickly to emergency events and often fly to landing zones where they have never been before . The time from initially receiving a call to being airborne can be as little as two to three minutes. Often the EMS pilot is the only aviation professional on site, they have no operations people or other pilots to aid them in making decisons. Further, since they are often flying to accident scenes, not airports, there is often complete weather and condition information. Therefore, the initial decision that the pilot must make, accepting or declining a flight, can become very difficult. The accident rate of EMS helicopters has been relatively high over the past years. NASA-Ames research center has taken several steps in an attempt to aid EMS pilots in their decision making and situational awareness. A preflight risk assessment system (SAFE) was developed to aid pilots in their decision making, and was tested at an EMS service. The resutls of the study were promising and a second version incorporating the lessons learned is under development. A second line of research was the development of a low cost electronic chart display (ECD). This is a digital map display to help pilots maintain geographical orientation. Another thrust was undertaken in conjunction with the Aviation Safety Reporting System (ASRS). This involved publicizing the ASRS to EMS pilots and personnel, and calling each of the reporters back to gather additional information. This paper will discuss these efforts and how they may positively impact the safety of EMS operations.

Shively, R. Jay↗

Human Factors Considerations for Area Navigation Departure and Arrival Procedures

Area navigation (RNAV) procedures are being implemented in the United States and around the world as part of a transition to a performance-based navigation system. These procedures are providing significant benefits and have also caused some human factors issues to emerge. Under sponsorship from the Federal Aviation Administration (FAA), the National Aeronautics and Space Administration (NASA) has undertaken a project to document RNAV-related human factors issues and propose areas for further consideration. The component focusing on RNAV Departure and Arrival Procedures involved discussions with expert users, a literature review, and a focused review of the NASA Aviation Safety Reporting System (ASRS) database. Issues were found to include aspects of air traffic control and airline procedures, aircraft systems, and procedure design. Major findings suggest the need for specific instrument procedure design guidelines that consider the effects of human performance. Ongoing industry and government activities to address air-ground communication terminology, design improvements, and chart-database commonality are strongly encouraged. A review of factors contributing to RNAV in-service errors would likely lead to improved system design and operational performance.

Barhydt, Richard↗

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.↗

BERT-Based Topic Modeling and Information Retrieval to Support Fishbone Diagramming for Safe Integration of Unmanned Aircraft Systems in Wildfire Response

Recent concepts for emerging wildfire response operations have included unmanned aircraft systems (UAS) due to their increasing accessibility and capabilities. To integrate UAS into wildfire response safely, researchers have studied the use of large repositories of historic incident reports to improve the scope of root cause analysis. Recent work has emphasized applying state-of-the-art natural language processing techniques to extract useful information from these repositories. However, it has not yet been studied how these results can be interpreted and integrated into the systems engineering process. In this work, we propose a process in which Bidirectional Encoder Representations from Transformers (BERT)-based topic modeling and information retrieval are applied to a relevant set of documents in order to support the development of a fishbone diagram in a semiautomated process. High-level themes in the document set are identified using topic modeling, which are then refined and interpreted by a human analyst. Then, the themes are used to guide a finer search using information retrieval, which returns specific incident reports of relevance. This provides traceability to specific incidents as well as broader categorizations that comprise the fishbone branches. We apply the proposed process to relevant documents from NASA’s Aviation Safety Reporting System (ASRS). The proposed process is widely applicable when relevant documents are available, and the results from this study will be useful to identifying potential causes of wildfire response UAS incidents.

Hazard analysis↗

BERT-based Topic Modeling and Information Retrieval to Support Fishbone Diagramming for Safe Integration of Unmanned Aircraft Systems in Wildfire Response

Recent concepts for emerging wildfire response operations have included unmanned aircraft systems (UAS) due to their increasing accessibility and capabilities. To integrate UAS into wildfire response safely, researchers have studied the use of large repositories of historic incident reports to improve the scope of root cause analysis. Recent work has emphasized applying state-of-the-art natural language processing techniques to extract useful information from these repositories. However, it has not yet been studied how these results can be interpreted and integrated into the systems engineering process. In this work, we propose a process in which Bidirectional Encoder Representations from Transformers (BERT)-based topic modeling and information retrieval are applied to a relevant set of documents in order to support the development of a fishbone diagram in a semiautomated process. High-level themes in the document set are identified using topic modeling, which are then refined and interpreted by a human analyst. Then, the themes are used to guide a finer search using information retrieval, which returns specific incident reports of relevance. This provides traceability to specific incidents as well as broader categorizations that comprise the fishbone branches. We apply the proposed process to relevant documents from NASA’s Aviation Safety Reporting System (ASRS). The proposed process is widely applicable when relevant documents are available, and the results from this study will be useful to identifying potential causes of wildfire response UAS incidents.

hazard analysis↗