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Human Performance Contributions to Safety in Commercial Aviation

Every day in aviation, pilots, air traffic controllers, and other front-line personnel perform countless correct judgments and actions in a variety of operational environments. These judgments and actions are often the difference between an accident and a non-event. Ironically, data on these behaviors are rarely collected or analyzed. Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence how decision makers characterize problems and identify solutions. Large volumes of data are collected on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that result in routine successful outcomes, safety management and system design decisions are based on a small sample of nonrepresentative safety data. This assessment aimed to find and document “safety successes” made possible by human operators. With many Aeronautics Research Mission Directorate (ARMD) Programs and Projects focusing on increased automation and autonomy and decreased human involvement, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant risk — a risk that has not been recognized to date. Without understanding how humans contribute to safety, any estimate of predicted safety of autonomous capabilities is incomplete and inherently suspect. Furthermore, understanding the ways in which humans contribute to safety can promote strategic interactions among safety technologies, functions, procedures and the people using them. Without this understanding, the full benefits of an integrated, optimized human/technology or autonomous system will not be realized. Historically, safety has been consistently defined in terms of the occurrence of accidents or recognized risks (i.e., in terms of things that go wrong). These adverse outcomes are explained by identifying their causes, and safety is restored by eliminating or mitigating these causes. An alternative to this approach is to focus on what goes right and identify how to replicate that process. Focusing on the rare cases of failures attributed to “human error” provides little information about why human performance routinely prevents adverse events. Hollnagel has proposed that things go right because people continuously adjust their work to match their operating conditions. These adjustments become increasingly important as systems continue to grow in complexity. Thus, the definition of safety should reflect not only “avoiding things that go wrong” but “ensuring that things go right.” The basis for safety management requires developing an understanding of everyday activities. However, few mechanisms to monitor everyday work exist in the aviation domain, which limits opportunities to learn how designs function in reality. This concept of safety thinking and safety management is reflected in the emerging field of resilience engineering. According to Hollnagel, a system is resilient if it can sustain required operations under expected and unexpected conditions by adjusting its functioning prior to, during, or following changes, disturbances, and opportunities. To explore “positive” behaviors that contribute to resilient performance in commercial aviation, the assessment team examined a range of existing sources of data about pilot and air traffic control (ATC) tower controller performance, including subjective interviews with domain experts and objective aircraft flight data records. These data were used to identify strategies that support resilient performance, methods for exploring and refining those strategies in existing data, and proposed methods for capturing and analyzing new data.

Null, Cynthia H.↗

NASA System-Wide Safety Wildland Firefighting Operations Workshop Report

On March 9-11, 2022, NASA’s System-Wide Safety Wildland Firefighting Operations Workshop engaged the broader wildland firefighting management ecosystem in a safety-oriented discussion via a virtual platform. This enabled a better understanding of how NASA and community expertise can be leveraged in the safe development of current and future firefighting systems and operations. The goals of the workshop were to: (1) identify and prioritize the top safety-oriented risks, gaps in capabilities, and emerging technologies to enhance wildland firefighting for both near-term and far-term concepts, with a specific focus on aviation operations and (2) engage the stakeholder community in defining emergent safety-oriented scope, roles, responsibilities, and procedures for agents undergoing increasingly complex wildland firefighting operations in information-rich, but uncertain environments. Workshop participants were solicited from wildland firefighting stakeholders across government, industry, and academia. All levels of government were engaged, as NASA sought attendees from federal, state, local, and tribal government agencies. Industry participants from traditional wildland firefighting domains such as data visualization and equipment manufacturers were invited, and corporate attendees from novel application domains such as aerial robotics and autonomous systems were present as well. The top three findings were as follows: (1) Enhancing situation awareness is a safety priority, especially in the use of aerial assets; (2) Timely access to information along with data fusion and integrated displays will enhance safety-critical decision-making both inside and outside aviation contexts; and (3) Tailorable standards and common operating pictures in the field will enhance inter-agency cooperation in the wildland firefighting lifecycle and enable the optimal use of limited resources such as aerial assets. The workshop helped inform NASA of the relevant safety-related wildland firefighting concerns and aided the broader ecosystem in understanding the potential safety-oriented role NASA might play in this community. Increased engagement with crucial governmental stakeholders (e.g., U.S. Forest Service, CAL FIRE, etc.) along with industry partners in cutting- edge information -centric domains is a fundamental next step. Additionally, the workshop findings will help define the first of a series of operationally challenging demonstrations, held in concert with strategic ecosystem partners, known as the Safety Demonstrator Series for NASA’s System-Wide Safety project. The first demonstration is set in the wildland firefighting application domain and will: (1) examine high risk operational scenarios to reduce their overall risk via services, functions or capabilities that act as risk mitigators (or transfer that risk to automated systems better able to tolerate it) and (2) explore novel tools and technologies that will enhance safety margins by enabling non-traditional or neoteric operational paradigms.

wildland firefighting↗

NASA Engineering and Safety Center Technical Bulletin No. 23-01: Including Key Design Features in Safety-Critical Pyrotechnic Firing Circuits

Pyrotechnic systems often fall into a unique category in that inadvertent activation of these systems resulting from a fault and/or lack of safe margins can lead directly to loss of crew. For example, untimely activation of pyrotechnics used for a flight termination system could override an abort capability. Over the years, NASA and the military have learned lessons about safe pyrotechnic circuit design and test, many of which are codified. However, with NASA’s recent efforts to move toward a development model than leans more heavily on Commercial Partners these requirements have not always been directly levied on projects and in some cases been misinterpreted. This bulletin describes key safety features of pyrotechnic firing circuit design and provides rationale for inclusion of each feature.

Pyrotechnic Firing Curcuits↗