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What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports

The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.

Maille, Nicolas P.↗

Improving Safety on the International Space Station: Transitioning to Electronic Emergency Procedure Books on the International Space Station

The National Aeronautics and Space Administration (NASA) originally designed the International Space Station (ISS) to operate until 2015, but have extended operations until at least 2020. As part of this very dynamic Program, there is an effort underway to simplify the certification of Commercial ]of ]the ]Shelf (COTS) hardware. This change in paradigm allows the ISS Program to take advantage of technologically savvy and commercially available hardware, such as the iPad. The iPad, a line of tablet computers designed and marketed by Apple Inc., was chosen to support this endeavor. The iPad is functional, portable, and could be easily accessed in an emergency situation. The iPad Electronic Flight Bag (EFB), currently approved for use in flight by the Federal Aviation Administration (FAA), is a fraction of the cost of a traditional Class 2 EFB. In addition, the iPad fs ability to use electronic aeronautical data in lieu of paper in route charts and approach plates can cut the annual cost of paper data in half for commercial airlines. ISS may be able to benefit from this type of trade since one of the most important factors considered is information management. Emergency procedures onboard the ISS are currently available to the crew in paper form. Updates to the emergency books can either be launched on an upcoming visiting vehicle such as a Russian Soyuz flight or printed using the onboard ISS printer. In both cases, it is costly to update hardcopy procedures. A new operations concept was proposed to allow for the use of a tablet system that would provide a flexible platform to support space station crew operations. The purpose of the system would be to provide the crew the ability to view and maintain operational data, such as emergency procedures while also allowing Mission Control Houston to update the procedures. The ISS Program is currently evaluating the safety risks associated with the use of iPads versus paper. Paper products can contribute to the flammability risk and require manual updates that take time away from research tasks. The ISS program has recently purchased three iPads for the astronauts and the certification has been approved. The crew is currently using the iPads onboard. The results of this analysis could be used to discern whether the iPad is a viable option for use in emergencies by assessing the risk posture through the development of a quantitative probabilistic risk assessment (PRA).

Carter-Journet, Katrina↗

Conceptual design study of a Harrier V/STOL research aircraft

MCAIR recently completed a conceptual design study to define modification approaches to, and derive planning prices for the conversion of a two place Harrier to a V/STOL control, display and guidance research aircraft. Control concepts such as rate damping, attitude stabilization, velocity command, and cockpit controllers are to be demonstrated. Display formats will also be investigated, and landing, navigation and guidance systems flight tested. The rear cockpit is modified such that it can be quickly adapted to faithfully simulate the controls, displays and handling qualities of a Type A or Type B V/STOL. The safety pilot always has take command capability. The modifications studied fall into two categories: basic modifications and optional modifications. Technical descriptions of the basic modifications and of the optional modifications are presented. The modification plan and schedule as well as the test plan and schedule are presented. The failure mode and effects analysis, aircraft performance, aircraft weight, and aircraft support are discussed.

Bode, W. E.↗

Simulator study of a pictorial display for general aviation instrument flight

A simulation study of a computer drawn pictorial display involved a flight task that included an en route segment, terminal area maneuvering, a final approach, a missed approach, and a hold. The pictorial display consists of the drawing of boxes which either move along the desired path or are fixed at designated way points. Two boxes may be shown at all times, one related to the active way point and the other related to the standby way point. Ground tracks and vertical profiles of the flights, time histories of the final approach, and comments were obtained from time pilots. The results demonstrate the accuracy and consistency with which the segments of the flight are executed. The pilots found that the display is easy to learn and to use; that it provides good situation awareness, and that it could improve the safety of flight. The small size of the display, the lack of numerical information on pitch, roll, and heading angles, and the lack of definition of the boundaries of the conventional glide slope and localizer areas were criticized.

Adams, J. J.↗

Lunar Dust Simulant in Mechanical Component Testing - Paradigm and Practicality

Due to the uniquely harsh lunar surface environment, terrestrial test activities may not adequately represent abrasive wear by lunar dust likely to be experienced in mechanical systems used in lunar exploration. Testing to identify potential moving mechanism problems has recently begun within the NASA Engineering and Safety Center Mechanical Systems Lunar Dust Assessment activity in coordination with the Exploration Technology and Development Program Dust Management Project, and these complimentary efforts will be described. Specific concerns about differences between simulant and lunar dust, and procedures for mechanical component testing with lunar simulant will be considered. In preparing for long term operations within a dusty lunar environment, the three fundamental approaches to keeping mechanical equipment functioning are dust avoidance, dust removal, and dust tolerance, with some combination of the three likely to be found in most engineering designs. Methods to exclude dust from contact with mechanical components would constitute mitigation by dust avoidance, so testing seals for dust exclusion efficacy as a function of particle size provides useful information for mechanism design. Dust of particle size less than a micron is not well documented for impact on lunar mechanical components. Therefore, creating a standardized lunar dust simulant in the particulate size range of ca. 0.1 to 1.0 micrometer is useful for testing effects on mechanical components such as bearings, gears, seals, bushings, and other moving mechanical assemblies. Approaching actual wear testing of mechanical components, it is beneficial to first establish relative wear rates caused by dust on commonly used mechanical component materials. The wear mode due to dust within mechanical components, such as abrasion caused by dust in grease(s), needs to be considered, as well as the effects of vacuum, lunar thermal cycle, and electrostatics on wear rate.

Jett, T.↗

High Performance COPVs for In-Space Storage of High Pressure Cryogenic Fuels

Polymeric composite overwrapped pressure vessels (COPVs) provide an attractive material system to support developing commercial launch business and alternate fuel ventures. However to be able to design with these materials, the mechanical behavior of the materials must be understood with regards to processing, performance, damage tolerance, and environment. For the storage of cryogenic propellants, it is important to evaluate the materials performance and impact damage resistance at cryogenic temperatures in order to minimize weight and to ensure safety and reliability. As part of this study, material tests of candidate fiber and resin systems were used as the basis for the selection of the material combinations for evaluation in a COPV at cryogenic conditions. This comprehensive approach has also been expanded to address issues with impact damage tolerance and material degradation due to environmental factors. KEY WORDS: Cryogenic testing, evaluation and applications for pressure vessels, COPVs, tanks, or storage vessels.

Schneider, Judy↗

Implementation of an Adaptive Controller System from Concept to Flight Test

The National Aeronautics and Space Administration Dryden Flight Research Center (Edwards, California) is conducting ongoing flight research using adaptive controller algorithms. A highly modified McDonnell-Douglas NF-15B airplane called the F-15 Intelligent Flight Control System (IFCS) is used to test and develop these algorithms. Modifications to this airplane include adding canards and changing the flight control systems to interface a single-string research controller processor for neural network algorithms. Research goals include demonstration of revolutionary control approaches that can efficiently optimize aircraft performance in both normal and failure conditions and advancement of neural-network-based flight control technology for new aerospace system designs. This report presents an overview of the processes utilized to develop adaptive controller algorithms during a flight-test program, including a description of initial adaptive controller concepts and a discussion of modeling formulation and performance testing. Design finalization led to integration with the system interfaces, verification of the software, validation of the hardware to the requirements, design of failure detection, development of safety limiters to minimize the effect of erroneous neural network commands, and creation of flight test control room displays to maximize human situational awareness; these are also discussed.

Larson, Richard R.↗

Usability Evaluation of Fleet Management Interface for High Density Vertiplex Environments

To meet the rising demand for an Advanced Air Mobility (AAM) (i.e. urban and rural unmanned aircraft systems) ecosystem, the NASA Aeronautics Research Mission Directorate (ARMD) is hosting a series of simulations and flight tests under the High Density Vertiplex sub-project (HDV) to prototype and study the effectiveness AAM capabilities under various operational contexts. HDV aims to develop an integrated automation architecture to support terminal area flight operations. The HDV simulations and flight tests address safety, integration, and operational challenges, while integrated systems and software demonstrate design readiness, robustness, and interoperability. During the initial HDV simulation in 2021, a prototype traffic management tool developed by NASA called the Fleet Management Interface (FMI) was tested. FMI was designed to introduce an advanced level of human-automation interaction to aid both Ground Control Station Operators (GCSOs) and Fleet Managers (FMs) in remotely managing flights under their ownership. In a human-in-the-loop simulation, a usability study was conducted with the FMI to identify optimal approaches for displaying information to human operators using subjective measures of usability, workload, situation awareness, risk, and trust, along with qualitative feedback. This study consisted of task analysis in which GCSO and FM subjects used an Urban Air Mobility (UAM) environment to develop and execute a plan for two different traffic scenarios of remotely controlled vehicles. In each scenario, a remotely controlled vehicle completed a takeoff, active flight, and landing sequence while simulated traffic flew in the background at a rate of 20 operations per hour. In the first scenario, the controlled vehicle flew a nominal route with takeoff and landing at the same vertiport. In the second scenario, the controlled vehicle started on the nominal route, then diverted to an unplanned location mid-flight. Results showed that self- reported performance, usability, trust, and situation awareness ratings of FMI were moderately to strongly high. There were small differences between scenarios, with Scenario 2 being perceived as more unstable, complex, variable, risky, and potentially harmful than Scenario 1. Furthermore, participants described improvements that could be made to create a better user experience. For example, users suggested customizable interfaces to accommodate information display preferences, and the ability to review routes before assigning them. The results from this study will inform future development of the FMI with the end goal of creating a reference automation tool for airspace management procedures in AAM. The FMI could serve to reduce dependency on traditional air navigation services through increased automation in high density vertiplex environments.

Fleet manager↗

AI/ML Components in Safety-Critical Aviation Systems: Selected Concepts and Underlying Principles

The objective of the AI Roadmap meeting is to engage with all stakeholders in aviation in an open conversation about our approach and the guiding principles that can help us in moving forward in the technological landscape of AI/ML. The objective of the Technical Exchange Meeting is to identify categories of safety concerns associated with having an AI component in the aircraft we identified in the previous Technical Exchange Meetings. The speakers will bring their experience to the discussion to stimulate active participation with all stakeholders.

Design Safety↗

A Demonstration of Advanced Safety Analysis Tools and Methods Applied to Large Break LOCA and Fuel Analysis for PWRs

The U.S. Nuclear Regulatory Commission (NRC) is currently proposing a rulemaking designated as 10 CFR 50.46c to revise the loss-of-coolant accident (LOCA)/emergency core cooling system acceptance criteria to include the effects of higher burnup on fuel/cladding performance. We propose a demonstration problem of a representative four-loop PWR plant to study the impact of this new rule in the US nuclear fleet. Within the scope of evaluation for the 10 CFR 50.46c rule, aspects of safety, operations, and economics are considered in the industry application demonstration presented in this paper. An advanced safety analysis approach is used, by integrating the probabilistic element with deterministic methods for LOCA analysis, a novel approach to solving these types of multi-physics, multi-scale problems.

LOCA RIMM RISMC RELAP-7↗

Molybdenum Sleeves Experiments in the Sandia Critical Experiments Facility

Sandia National Laboratories and the Institut de Radioprotection et de Sûreté Nucléaire have collaborated on the design and execution of a set of critical experiments that explore the effects of molybdenum in water-moderated fuel-rod arrays. The molybdenum was included as sleeves on some of the fuel rods in the critical experiment fuel arrays. Approach-to-critical experiments were performed on five configurations of fuel and molybdenum sleeves using the 7uPCX fuel in core hardware that set the triangular fuel rod pitch at 15.494 mm. The experiments are evaluated as benchmark critical experiments for the 2023 edition of the International Criticality Safety Benchmark Evaluation Project (ICSBEP) Handbook as LEU-COMP-THERM-111.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

Characterizing the Potential for Sustainable Azelaic Acid Production from High-Oleic Vegetable Oil Using Two-Step Oxidative Cleavage

Azelaic acid is a renewable monomer conventionally produced via the energy-intensive ozonolysis of oleic acid. Recent advancements have enabled the use of high-oleic vegetable oils (rather than tallow-derived oleic acid) and replaced ozonolysis with two-step oxidative cleavage using hydrogen and oxygen. Although this shift would improve process safety, the financial viability and environmental implications remain uncertain. In this study, we characterized the sustainability of azelaic acid production from high-oleic vegetable oil using two-step oxidative cleavage. Process design, simulation, technoeconomic analysis (TEA), and life cycle assessment (LCA) were executed under uncertainty using BioSTEAM. The modeled system produces azelaic acid at a market-competitive minimum selling price (MSP) of 8.32 [4.93−13.34] $\$kg$ −1 (median 5th−95th percentiles), below the minimum estimated market price of 9.93 $\$kg$ −1 . Further, it has the potential to approach carbon neutrality (0.0 [−5.5 to 5.6] kg of CO 2 -eq kg −1 ) under displacement allocation. Improvements to dihydroxylation (86 to 99%) and oxidative cleavage conversions (93 to 99%) would reduce MSP to $\$5.24$ kg −1 and carbon intensity to −1.90 kg of CO 2 -eq kg −1 (displacement). Additionally, increasing the feedstock triolein content (75 to 85%) lowers MSP by $\$0.82$ kg −1 . Overall, this research demonstrates the potential for financially viable production of azelaic acid from vegetable oils and the utility of agile TEA/LCA.

37 INORGANIC, ORGANIC, PHYSICAL, AND ANALYTICAL CH↗

Evaluating Behaviorally Oriented Aviation Maintenance Resource Management (MRM) Training and Programs: Methods, Results, and Conclusions

Assessment of the impact of Aviation Resource Management Programs on aviation culture and performance has compelled a considerable body of research (Taylor & Robertson, 1995; Taylor, 1998; Taylor & Patankar, 2001). In recent years new methods have been applied to the problem of maintenance error precipitated by factors such as the need for self-assessment of communication and trust. The present study - 2002 -- is an extension of that past work. This research project was designed as the conclusion of a larger effort to help understand, evaluate and validate the impact of Maintenance Resource Management (MRM) training programs, and other MRM interventions on participant attitudes, opinions, behaviors, and ultimately on enhanced safety performance. It includes research and development of evaluation methodology as well as examination of psychological constructs and correlates of maintainer performance. In particular, during 2002, three issues were addressed. First, the evaluation of two (independent & different) MRM programs for changing behaviors was undertaken. In one case we were able to further apply the approach to measuring written communication developed during 2001 (Taylor, 2002; Taylor & Thomas, 2003). Second, the MRM/TOQ surveys were made available for completion on the internet. The responses from these on-line surveys were automatically linked to a results calculator (like the one developed and described in Taylor, 2002) to aid industry users in analyzing and evaluating their local survey data on the internet. Third, the main trends and themes from our research about MRM programs over the past dozen years were reviewed.

Taylor, James C.↗

Achieving Space Shuttle Abort-to-Orbit Using the Five-Segment Booster

The Five-Segment Booster design concept was evaluated by a team that determined the concept to be feasible and capable of achieving the desired abort-to-orbit capability when used in conjunction with increased Space Shuttle main engine throttle capability. The team (NASA Johnson Space Center, NASA Marshall Space Flight Center, ATK Thiokol Propulsion, United Space Alliance, Lockheed-Martin Space Systems, and Boeing) selected the concept that provided abort-to-orbit capability while: 1) minimizing Shuttle system impacts by maintaining the current interface requirements with the orbiter, external tank, and ground operation systems; 2) minimizing changes to the flight-proven design, materials, and processes of the current four-segment Shuttle booster; 3) maximizing use of existing booster hardware; and 4) taking advantage of demonstrated Shuttle main engine throttle capability. The added capability can also provide Shuttle mission planning flexibility. Additional performance could be used to: enable implementation of more desirable Shuttle safety improvements like crew escape, while maintaining current payload capability; compensate for off nominal performance in no-fail missions; and support missions to high altitudes and inclinations. This concept is a low-cost, low-risk approach to meeting Shuttle safety upgrade objectives. The Five-Segment Booster also has the potential to support future heavy-lift missions.

Craft, Joe↗

Human Factors Research for Space Exploration: Measurement, Modeling, and Mitigation

As part of NASA's Human Research Program, the Space Human Factors Engineering Project serves as the bridge between Human Factors research and Human Spaceflight applications. Our goal is to be responsive to the operational community while addressing issues at a sufficient level of abstraction to ensure that our tools and solutions generalize beyond the point design. In this panel, representatives from four of our research domains will discuss the challenges they face in solving current problems while also enabling future capabilities. Historically, engineering-dominated organizations have tended to view good Human Factors (HF) as a desire rather than a requirement in system design and development. Our field has made significant gains in the past decade, however; the Department of Defense, for example, now recognizes Human-System Integration (HSI), of which HF is a component, as an integral part of their divisions hardware acquisition processes. And our own agency was far more accepting of HF/HSI requirements during the most recent vehicle systems definition than in any prior cycle. Nonetheless, HF subject matter experts at NASA often find themselves in catch up mode... coping with legacy systems (hardware and software) and procedures that were designed with little regard for the human element, and too often with an attitude of we can deal with any operator issues during training. Our challenge, then, is to segregate the true knowledge gaps in Space Human Factors from the prior failures to incorporate best (or even good) HF design principles. Further, we strive to extract the overarching core HF issues from the point-design-specific concerns that capture the operators (and managers) attention. Generally, our approach embraces a 3M approach to Human Factors: Measurement, Modeling, and Mitigation. Our first step is to measure human performance, to move from subjective anecdotes to objective, quantified data. Next we model the phenomenon, using appropriate methods in our field, modifying them to suit the unique aspects of the space environment. Finally, we develop technologies, tools, and procedures to mitigate the decrements in human performance and capabilities that occur in space environments. When successful, we decrease risks to crew safety and to mission success. When extremely successful (or lucky), we devise generalizable solutions that advance the state of our practice. Our panel is composed of researchers from diverse domains of our project... from different boxes, if you will, of the Human Factors Analysis and Classification System (HFACS).

Kaiser, Mary K.↗

Design of P-3 Nadir Port

This project details the design and analysis of a structure to replace the interface of the P-3B nadir port with an optimized interface for science installations. A new nadir port plug has been designed to replace the OEM (Original Equipment Manufacturer) plug (Lockheed PN 910169) currently used in Nadir ports 1 and 2 on the NASA P-3B aircraft. The plug consists of a milled frame that can be outfitted with customizable flat plates to meet a broad range of science needs. The frame slides into place using the existing P-3B rail system using a lever and tie-rod assembly. The seal interface will contact the Fuselage skin of the aircraft and consists of a bulb E-seal that is riveted around the perimeter of the frame. The flat plate (20 inches x 31 inches) provides a large profile that can be outfitted based on science mission goals and requirements to attach multiple instruments. This is a significant increase to the aircraft capability. Previously, the OEM plug had to be modified to hold very small plates, windows, or instruments limiting the use of the ports.There were several challenges for this project that included a constrained schedule, lack of historical references, and reverse engineering. The unusually tight schedule for design, manufacture, and install limited potential approaches. In addition, design of a new interface to replace the existing plug, on an aircraft designed in the 1960's by Lockheed for the Navy with little to no documentation, required substantial reverse engineering. In order to accomplish this, a suitable method to determine interface requirements with the aircraft had to be solved. After several iterations, the solution was to implement laser scanning techniques to scan the aircraft and the OEM plug and generate a 3D model to capture the design envelope. The structure is designed to maintain a positive margin of safety when subjected to the inertial, pressure, and aerodynamic load requirements for an external installation on the P-3B, as described in the Wallops' P-3B Design Requirements 548-RQMT-0001 Rev. A . A finite element model is created in FEMAP (Finite Element Modeling And Postprocessing) and is run through NX Nastran solver to analyze the structure. After several iterations of analysis, the structure was enveloped to hold 115 pounds evenly distributed on the plate.

Chance, Monica↗

Multiphysics Demonstration of Temperature-Driven Assembly Bowing in SFRs using MOOSE-Based Codes

Core bowing is an important passive safety mechanism in liquid metal cooled fast reactors. When the core restraint system is properly designed, temperature and flux gradients influence assemblies in the core to bow into less reactive configurations during accident scenarios, resulting in negative reactivity feedback. Prediction of core bowing involves complex interplay of radiation transport, impacts of fluid flow and heat transfer on duct temperature, and mechanical responses to the induced temperature and flux gradients. Under the U.S. Department of Energy Office of Nuclear Energy’s Advanced Modeling and Simulation (NEAMS) Program [1], an integrated multiphysics approach is being developed to model the core bowing phenomena in liquid metal-cooled fast reactors with the Multiphysics Object Oriented Simulation Environment (MOOSE) [2]. In this methodology, the MOOSE-based reactor physics code Griffin [3] will solve the neutron transport equation and determine the power distribution. With the detailed power distribution from Griffin, the subchannel analysis codes MOOSE-Subchannel [4] and Pronghorn [5] are utilized to calculate the assembly temperature distribution. MOOSE’s Solid Mechanics [6] and Contact [7] Modules are leveraged to calculate the thermal expansion and duct bowing displacement with the duct wall temperature from thermal hydraulics calculation. In this work, an initial one-way coupling demonstration of the integrated multiphysics approach has been performed on a seven-assembly problem based on the sodium-cooled fast reactor ABR-1000 design [8]. The neutronics calculation with Griffin is not yet involved in the current simulation. MOOSE-Subchannel and Pronghorn evaluate fluid and solid temperature based on a fixed power distribution. In addition, one-way coupling is utilized in this coupled calculation, via Pronghorn passing the duct temperature data to the MOOSE Solid Mechanics calculation. An assessment of the Solid Mechanics module was performed in parallel to verify duct bowing behavior with duct-to-duct contact phenomenon [9]. The displacement from MOOSE Solid Mechanics is not yet transferred back and utilized in the Pronghorn and MOOSE-Subchannel calculation. This model will be available on the National Reactor Innovation Center (NRIC) Virtual Test Bed (VTB) repository [10]. Future stages of this work will involve solving problems of increasing complexity as well as adding more physics (e.g. reactor physics) to the integrated workflow to reach the end goal of modeling the core bowing phenomenon with an integrated multiphysics workflow.

22 - GENERAL STUDIES OF NUCLEAR REACTORS↗

Controlling dendrite propagation in solid-state batteries with engineered stress

Metal-dendrite penetration is a mode of electrolyte failure that threatens the viability of metal-anode-based solid-state batteries. Whether dendrites are driven by mechanical failure or electrochemical degradation of solid electrolytes remains an open question. If internal mechanical forces drive failure, superimposing a compressive load that counters internal stress may mitigate dendrite penetration. Here, we investigate this hypothesis by dynamically applying mechanical loads to growing dendrites in Li 6.6 La 3 Zr 1.6 Ta 0.4 O 12 solid electrolytes. Operando microscopy reveals marked deflection in the dendrite growth trajectory at the onset of compressive loading. For sufficient loading, this deflection averts cell failure. Using fracture mechanics, we quantify the impact of stack pressure and in-plane stresses on dendrite trajectory, chart the residual stresses required to prevent short-circuit failure, and propose design approaches to achieve such stresses. For the materials studied here, we show that dendrite propagation is dictated by electrolyte fracture, with electronic leakage playing a negligible role.

25 ENERGY STORAGE↗