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NASA NTRSDate not supplied

A Concept of Operations (ConOps) of an In-time Aviation Safety Management System (IASMS) for Advanced Air Mobility (AAM)

The growth of new emerging operations involving Advanced Air Mobility (AAM) necessitates developing a perspective for an In-time Aviation Safety Management System (IASMS). This perspective advances from the National Academies report on IASMS and its recommendation for developing a Concept of Operations (ConOps) for IASMS. A ConOps has been developed for In-time System-Wide Safety Assurance (ISSA) from which the IASMS ConOps pivots to provide a robust scope commensurate with the broad vision defined by the National Academies. The IASMS ConOps focuses on emerging operations and spans innovations in Unmanned Aircraft System (UAS) and an increasingly complex ecosystem comprised of a widening mix of vehicles and technologies, Urban Air Mobility (UAM) with industry-federated services, traditional operations, as well as new supersonic aircraft and space launch systems.The challenge for the IASMS ConOps is to be broad to encompass innovations in the coming years and decades while agile to ensure levels of safety compatible with operational and certification requirements of the National Airspace System (NAS). The IASMS ConOps interweaves increasing complexity of operational safety capabilities and unlocking UAS Maturity Levels (UMLs). The relationships between increased complexity of automation and automated systems, fewer operators who are not as traditionally higher skilled, more complex operational environments, and aviation operations management with mixed aircraft and equipage pose a multi-dimensional space for IASMS capabilities essential for safety assurance and risk management. Instantiating IASMS capabilities and how they would be integral to AAM operations and increasing maturity of UAM could be accomplished through a series of Safety Demonstrators. These Safety Demonstrators could provide increased understanding and insight into use of controls for risk mitigation, means of compliance for certification, and operational experience with safety services such as in relation to contingency management. The IASMS capabilities can be viewed as initially residing with the vehicle, airspace, and Supplemental Data Service Provider (SDSP). For example, vehicle capabilities include communications including the command and control link, Remote Identification (ID), conflict advisory/alerting, and UAS system monitoring. These capabilities monitor and assess data such as battery health, aircraft state, and human performance. Complexity of ISAMS capabilities depends on a number of factors. These factors are intendedonly as a notional categorization with the purpose being to reflect the complexity of the AAM ecosystem that would drive up the complexity of ISSA capabilities including systems, sensors, models, standards, and controls. Factors could include the Vehicle Flight Management, Environment, Airspace, and Contingency Management. Each of these factors can be comprised of multiple sub-factors that contribute to increasing complexity. For example, Airspace at a lower level of complexity could be dedicated to UTM operations that are unmonitored, and at a higher level of complexity could involve mixed UTM and ATM operations. The IASMS concept includes safety services that provide data and information to different participants in AAM. The roles and responsibilities of participants can be defined using the Responsible-Accountable-Consulted-Informed (RACI) analysis. For example, for the safety service involving the Remote ID, the Operator would be accountable for providing the data, the Vehicle would be responsible for transmitting it, and the USS, SDSP, Vertiports, FIMS (FAA), and Public Entities such as safety services would be informed by receiving the data. The IASMS ConOps identifies the capabilities needed for risk mitigation and safety assurance in the increasingly complex national airspace. The ConOps serves as a pathway for engaging with industry to gain operational experience including through the Safety Demonstrator series, the RACI analysis, and operational complexity factors. The ConOps serves to integrate these different perspectives to build a cohesive and cogent approach to an AAM safety management system.

In-Time Aviation Safety Management System↗
NASA NTRS1983

Autonomy and the human element in space

NASA is contemplating the next logical step in the U.S. space program - the permanent presence of humans in space. As currently envisioned, the initial system, planned for the early 1990's, will consist of manned and unmanned platforms situated primarily in low Earth orbit. The manned component will most likely be inhabited by 6-8 crew members performing a variety of tasks such as materials processing, satellite servicing, and life science experiments. The station thus has utility in scientific and commercial enterprises, in national security, and in the development of advanced space technology. The technical foundations for this next step have been firmly established as a result of unmanned spacecraft missions to other planets, the Apollo program, and Skylab. With the shuttle, NASA inaugurates a new era of frequent flights and more routine space operations supporting a larger variety of missions. A permanently manned space system will enable NASA to expand the scope of its activities still further. Since NASA' s inception there has been an intense debate over the relative merits of manned and unmanned space systems. Despite the generally higher costs associated with manned components, astronauts have accomplished numerous essential, complex tasks in space. The unique human talent to evaluate and respond inventively to unanticipated events has been crucial in many missions, and the presence of crews has helped arouse and sustain public interest in the space program. On the other hand, the hostile orbital environment affects astronaut physiology and productivity, is dangerous, and mandates extensive support systems. Safety and cost factors require the entire station complex, both space and ground components, to be highly automated to free people from mundane operational chores. Recent advances in computer technology, artificial intelligence (AI), and robotics have the potential to greatly extend space station operations, offering lower costs and superior productivity. Extended operations can in turn enhance critical technologies and contribute to the competitive economic abilities of the United States. A high degree of automation and autonomy may be required to reduce dependence on ground systems, reduce mission costs, diminish complexity as perceived by the crew, increase mission lifetime and expand mission versatility. However, technologies dealing with heavily automated, long duration habitable spacecraft have not yet been thoroughly investigated by NASA. A highly automated station must amalgamate the diverse capabilities of people, machines, and computers to yield an efficient system which capitalizes on unique human characteristics. The station also must have an initial design which allows evolution to a larger and more sophisticated space presence. In the early years it is likely that AI-based subsystems will be used primarily in an advisory or planning capacity. As human confidence in automated systems grows and as technology advances, machines will take on more critical and interdependent roles. The question is whether, and how much, system autonomy will lead to improved station effectiveness.

Source record↗
NASA NTRSDate not supplied

System-Theoretic Analysis of Unsafe Collaborative Control in Teaming Systems

The interactions that occur in human-teaming are inspiring novel aerospace designs aimed at improving how humans and machines, or multiple machines, work together. Unfortunately, current Systems Engineering processes are ill-equipped to handle these complex relationships and are unable to design and assure the safety for these systems. To close part of this gap, this paper introduces a novel system-theoretic analytical process to identify unsafe collaborative control actions. It is part of a broader set of techniques that extend the state-of-the-art in hazard analysis, System Theoretic Process Analysis (STPA), to systematically address collaboration. The method rigorously expresses the different ways multiple commands may be unsafe together. Using Systems Theory, it employs abstraction to manage the combinatorial complexity in enumerating control contributions from multiple collaborating components. An algorithm integrates these concepts into an end-to-end process and is supported by automation to enumerate, refine, prune, and prioritize unsafe combinations of control actions. The output of the method feeds the specification of system requirements to implement safety-guided design starting early in concept development. The process is demonstrated on a manned-unmanned aircraft teaming case study and finds new causal factors that were not previously found in a past hazard analysis of the same system.

System Safety↗
NASA NTRS1997

Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

Increasing numbers of aircraft are operating on the surface of airports throughout the world. Airport operations are forecast to grow by more that 50%, by the year 2005. Airport surface movement traffic would therefore be expected to become increasingly congested. Safety of these surface operations will become a focus as airport capacity planning efforts proceed toward the future. Several past events highlight the prevailing risks experienced while moving aircraft during ground operations on runways, taxiways, and other areas at terminal, gates, and ramps. The 1994 St. Louis accident between a taxiing Cessna crossing an active runway and colliding with a landing MD-80 emphasizes the importance of a fail-safe system for airport operations. The following study explores reports of incidents occurring on an airport surface that did not escalate to an accident event. The Aviation Safety Reporting System has collected data on surface movement incidents since 1976. This study sampled the reporting data from June, 1993 through June, 1994. The coding of the data was accomplished in several categories. The categories include location of airport, phase of ground operation, weather /lighting conditions, ground conflicts, flight crew characteristics, human factor considerations, and airport environment. These comparisons and distributions of variables contributing to surface movement incidents can be invaluable to future airport planning, accident prevention efforts, and system-wide improvements.

Connell, Linda J.↗
NASA NTRS2017

An Assessment of Reduced Crew and Single Pilot Operations in Commercial Transport Aircraft Operations

Future reduced crew operations or even single pilot operations for commercial airline and on-demand mobility applications are an active area of research. These changes would reduce the human element and thus, threaten the precept that "a well-trained and well-qualified pilot is the critical center point of aircraft systems safety and an integral safety component of the entire commercial aviation system." NASA recently completed a pilot-in-the-loop high fidelity motion simulation study in partnership with the Federal Aviation Administration (FAA) attempting to quantify the pilot's contribution to flight safety during normal flight and in response to aircraft system failures. Crew complement was used as the experiment independent variable in a between-subjects design. These data show significant increases in workload for single pilot operations, compared to two-crew, with subjective assessments of safety and performance being significantly degraded as well. Nonetheless, in all cases, the pilots were able to overcome the failure mode effects in all crew configurations. These data reflect current-day flight deck equipage and help identify the technologies that may improve two-crew operations and/or possibly enable future reduced crew and/or single pilot operations.

Bailey, Randall E.↗
NASA NTRS2006

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↗
NASA NTRS2019

Does Seed Sanitization Affect the Plant Rhizosphere Microbiome and Its Ability to Compete with the Human Associated Pathogen, E. coli on Salad Crops?

Cultivation of crops in controlled environmental agricultural systems may limit microbial colonization and reduce diversity of the microbial communities. Practices like seed and growth medium sanitization may further impact microbial communities in the mature plant and the plant’s capacity to limit the growth of pathogens through competition. As humans expand their travels to space, understanding plant growth, health, and development in closed environments will be critical to the success of producing a safe, supplemental food source for astronauts. To determine the persistence of a potential human pathogen in plant growth and development, sanitized and unsanitized seeds from, mizuna (Brassica rapa var japonica) and red romaine lettuce (Lactuca sativa cultivar ‘Outredgeous’), were inoculated with Escherichia coli, ATCC 21445, germinated under simulated International Space Station (ISS) environmental conditions and harvested every 7 days until maturity. The persistence of E. coli in the rhizosphere was determined by plating on selective media, real time PCR (Polymerase Chain Reaction) and community sequencing of the rhizosphere communities. E. coli was detected in the crops’ roots and leaves for several weeks post germination. At day 28, plants from sanitized seeds had significantly higher counts of E. coli on the roots than those from unsanitized seeds. E. coli was also detected on a few uninoculated plants indicating airborne cross contamination among plants in the same growth chamber and suggesting an influence of the natural microbiome on human pathogen survival and persistence in leafy greens. Sequencing analysis revealed variations in composition and diversity between the communities. Understanding the microbial community of the rhizospheric microbiome is only the first step in determining the relationships between plants. Additional studies to include genotypic and phenotypic variations in the plants should be considered to determine if the natural microbes in the rhizosphere may contribute to the health and therefore, safety of the edible plants.

Khodadad, Christina L. M.↗
NASA NTRS1975

Astronaut activity

Human factors pertinent to the design and operation of spacecraft are considered. The geometric characteristics of spacecraft that define the degree and type of confinement imposed on the crew and the character of equipment management and housekeeping necessary for hygiene, comfort and safety are discussed. The controls and displays of various spacecraft are described to indicate the degree to which crew functions become integral to functions of the total spacecraft. The contributions of the crew to system reliability and performance are summarized and the increasing significance of the crew's role in scientific observation and experimentation is noted.

Loftus, J. P., Jr.↗
NASA NTRS2007

The Naturalistic Flight Deck System: An Integrated System Concept for Improved Single-Pilot Operations

This paper reviews current and emerging operational experiences, technologies, and human-machine interaction theories to develop an integrated flight system concept designed to increase the safety, reliability, and performance of single-pilot operations in an increasingly accommodating but stringent national airspace system. This concept, know as the Naturalistic Flight Deck (NFD), uses a form of human-centered automation known as complementary-automation (or complemation) to structure the relationship between the human operator and the aircraft as independent, collaborative agents having complimentary capabilities. The human provides commonsense knowledge, general intelligence, and creative thinking, while the machine contributes specialized intelligence and control, extreme vigilance, resistance to fatigue, and encyclopedic memory. To support the development of the NFD, an initial Concept of Operations has been created and selected normal and non-normal scenarios are presented in this document.

Schutte, Paul C.↗
NASA NTRS2011

Microbiological Lessons Learned from the Space Shuttle

After 30 years of being the centerpiece of NASA s human spacecraft, the Space Shuttle will retire. This highly successful program provided many valuable lessons for the International Space Station (ISS) and future spacecraft. Major microbiological risks to crewmembers include food, water, air, surfaces, payloads, animals, other crewmembers, and ground support personnel. Adverse effects of microorganisms are varied and can jeopardize crew health and safety, spacecraft systems, and mission objectives. Engineering practices and operational procedures can minimize the negative effects of microorganisms. To minimize problems associated with microorganisms, appropriate steps must begin in the design phase of new spacecraft or space habitats. Spacecraft design must include requirements to control accumulation of water including humidity, leaks, and condensate on surfaces. Materials used in habitable volumes must not contribute to microbial growth. Use of appropriate materials and the implementation of robust housekeeping that utilizes periodic cleaning and disinfection will prevent high levels of microbial growth on surfaces. Air filtration can ensure low levels of bioaerosols and particulates in the breathing air. The use of physical and chemical steps to disinfect drinking water coupled with filtration can provide safe drinking water. Thorough preflight examination of flight crews, consumables, and the environment can greatly reduce pathogens in spacecraft. The advances in knowledge of living and working onboard the Space Shuttle formed the foundation for environmental microbiology requirements and operations for the International Space Station (ISS) and future spacecraft. Research conducted during the Space Shuttle Program resulted in an improved understanding of the effects of spaceflight on human physiology, microbial properties, and specifically the host-microbe interactions. Host-microbe interactions are substantially affected by spaceflight. Astronaut immune functions were found to be altered. Selected microorganisms were found to become more virulent during spaceflight. The increased knowledge gained on the Space Shuttle resulted in further studies of the host-microbe interactions on the ISS to determine if countermeasures were necessary. Lessons learned from the Space Shuttle Program were integrated into the ISS resulting in the safest space habitat to date.

Pierson, Duane L.↗
NASA NTRS2001

Sixth International Microgravity Combustion Workshop

This conference proceedings document is a compilation of papers presented orally or as poster displays to the Sixth International Microgravity Combustion Workshop held in Cleveland, Ohio on May 22-24, 2001. The purpose of the workshop is to present and exchange research results from theoretical and experimental work in combustion science using the reduced-gravity environment as a research tool. The results are contributed by researchers funded by NASA throughout the United States at universities, industry and government research agencies, and by researchers from international partner countries that are also participating in the microgravity combustion science research discipline. These research results are intended for use by public and private sector organizations for academic purposes, for the development of technologies needed for Human Exploration and Development of Space, and to improve Earth-bound combustion and fire-safety related technologies.

Sacksteder, Kurt↗
DOE OSTI2023

The Development of the Pooled Rideshare Acceptance Model (PRAM)

Due to the advancements in real-time information communication technologies and sharing economies, rideshare services have gained significant momentum by offering dynamic and/or on-demand services. Rideshare service companies evolved from personal rideshare, where riders traveled solo or with known individuals, into pooled rideshare (PR), where riders can travel with one to multiple unknown riders. Similar to other shared economy services, pooled rideshare is beneficial as it efficiently utilizes resources, resulting in reduced energy usage, as well as reduced costs for the riders. However, previous research has demonstrated that riders have concerns about using pooled rideshare, especially regarding personal safety. A U.S. national survey with 5385 participants was used to understand human factor-related barriers and user preferences to develop a novel Pooled Rideshare Acceptance Model (PRAM). This model used a covariance-based structural equation model (CB-SEM) to identify the relationships between willingness to consider PR factors (time/cost, privacy, safety, service experience, and traffic/environment) and optimizing one’s experience of PR factors (vehicle technology/accessibility, convenience, comfort/ease of use, and passenger safety), resulting in the higher-order factor trust service. We examined the factors’ relative contribution to one’s willingness/attitude towards PR and user acceptance of PR. Privacy, safety, trust service, and convenience were statistically significant factors in the model, as were the comfort/ease of use factor and the service experience, traffic/environment, and passenger safety factors. The only two non-significant factors in the model were time/cost and vehicle technology/accessibility; it is only when a rider feels safe that individuals then consider the additional non-significant variables of time, cost, technology, and accessibility. Privacy, safety, and service experience were factors that discouraged the use of PR, whereas the convenience factor greatly encouraged the acceptance of PR. Despite the time/cost factor’s lack of significance, individual items related to time and cost were crucial when viewed within the context of convenience. This highlights that while user perceptions of privacy and safety are paramount to their attitude towards PR, once safety concerns are addressed, and services are deemed convenient, time and cost elements significantly enhance their trust in pooled rideshare services. This study provides a comprehensive understanding of user acceptance of PR services and offers actionable insights for policymakers and rideshare companies to improve their services and increase user adoption.

dynamic rideshare system↗
NASA NTRS2000

Collision in space

On June 25, 1997, the Russian supply spacecraft Progress 234 collided with the Mir space station, rupturing Mir's pressure hull, throwing it into an uncontrolled attitude drift, and nearly forcing evacuation of the station. Like many high-profile accidents, this collision was the consequence of a chain of events leading to the final piloting errors that were its immediate cause. The discussion in this article does not resolve the relative contributions of the actions and decisions in this chain. Neither does it suggest corrective measures, many of which are straightforward and have already been implemented by the National Aeronautics and Space Administration (NASA) and the Russian Space Agency. Rather, its purpose is to identify the human factors that played a pervasive role in the incident. Workplace stress, fatigue, and sleep deprivation were identified by NASA as contributory factors in the Mir-Progress collision (Culbertson, 1997; NASA, forthcoming), but other contributing factors, such as requiring crew to perform difficult tasks for which their training is not current, could potentially become important factors in future situations.

Mir Project↗
NASA NTRS2010

Modeling Flight: The Role of Dynamically Scaled Free-Flight Models in Support of NASA's Aerospace Programs

The state of the art in aeronautical engineering has been continually accelerated by the development of advanced analysis and design tools. Used in the early design stages for aircraft and spacecraft, these methods have provided a fundamental understanding of physical phenomena and enabled designers to predict and analyze critical characteristics of new vehicles, including the capability to control or modify unsatisfactory behavior. For example, the relatively recent emergence and routine use of extremely powerful digital computer hardware and software has had a major impact on design capabilities and procedures. Sophisticated new airflow measurement and visualization systems permit the analyst to conduct micro- and macro-studies of properties within flow fields on and off the surfaces of models in advanced wind tunnels. Trade studies of the most efficient geometrical shapes for aircraft can be conducted with blazing speed within a broad scope of integrated technical disciplines, and the use of sophisticated piloted simulators in the vehicle development process permits the most important segment of operations the human pilot to make early assessments of the acceptability of the vehicle for its intended mission. Knowledgeable applications of these tools of the trade dramatically reduce risk and redesign, and increase the marketability and safety of new aerospace vehicles. Arguably, one of the more viable and valuable design tools since the advent of flight has been testing of subscale models. As used herein, the term "model" refers to a physical article used in experimental analyses of a larger full-scale vehicle. The reader is probably aware that many other forms of mathematical and computer-based models are also used in aerospace design; however, such topics are beyond the intended scope of this document. Model aircraft have always been a source of fascination, inspiration, and recreation for humans since the earliest days of flight. Within the scientific community, Leonardo da Vinci, George Cayley, and the Wright brothers are examples of early aviation pioneers who frequently used models during their scientific efforts to understand and develop flying machines. Progress in the technology associated with model testing in worldwide applications has firmly established model aircraft as a key element in new aerospace research and development programs. Models are now routinely used in many applications and roles, including aerodynamic data gathering in wind tunnel investigations for the analysis of full-scale aircraft designs, proof-of-concept demonstrators for radical aeronautical concepts, and problem-solving exercises for vehicles already in production. The most critical contributions of aerospace models are to provide confidence and risk reduction for new designs and to enhance the safety and efficiency of existing configurations.

Chambers, Joseph↗
DOE OSTI2023

Analysis of a Runtime Data Sharing Architecture over LTE for a Heterogeneous CAV Fleet

This paper describes a lightweight runtime architecture for telemetry, communication, and control of cars deployed with advanced driver assistance systems where a human is in the loop with the car, via an LTE connection. The system architecture supports both local control decisions based on car sensors and safety algorithms as well as high-level input from external systems that may provide insight into traffic state ahead of sensor data. Implementation of the architecture is done in ROS and depends on open-source software packages for runtime decoding of information from the vehicle’s controller area network (CAN) and integration of GPS data from accompanying sensors. The contribution of the paper is to describe the overall architecture, the data it can communicate to other systems, performance of the system at runtime, and challenges faced when deploying the architecture across a heterogeneous fleet. Preliminary results from analysis of test data will provide insights into whether the use of high-latency communication can be effective for societal-scale intelligent transportation systems when applied in future scenarios

Richardson, Alex↗
DOE OSTI2023

Cross-cutting concepts to transform agricultural research

Agriculture is an important link to many issues that challenge society today, including adaptation to and mitigation of climate change, food security, and communicable and non-communicable diseases in animals and humans. Transformation of agriculture and food systems has become a priority for a range of federal agencies and global organizations. It is imperative that food and agricultural researchers effectively harness the global convergence of priorities to overcome research “silos” through deep and sustained systemic change. Herein, we identify intersections in federal and global initiatives encompassing climate adaptation and mitigation; human health and nutrition; animal health and welfare; food safety and security; and equity and inclusion. Many agencies and organizations share these priorities, but efforts to address them remain uncoordinated and opportunities for collaboration untapped. Based on the interconnectedness of the identified priority areas, we present a research framework to catalyze agricultural transformation, beginning with the research enterprise. We propose that transformation in agricultural research should incorporate (1) innovation, (2) integration, (3) implementation, and (4) evaluation. This framework provides approaches for food and agricultural research to contribute to sustainable, flexible, and coordinated transformation in the agricultural sector.

60 APPLIED LIFE SCIENCES↗
NASA NTRS2004

A Formal Methods Approach to the Analysis of Mode Confusion

The goal of the new NASA Aviation Safety Program (AvSP) is to reduce the civil aviation fatal accident rate by 80% in ten years and 90% in twenty years. This program is being driven by the accident data with a focus on the most recent history. Pilot error is the most commonly cited cause for fatal accidents (up to 70%) and obviously must be given major consideration in this program. While the greatest source of pilot error is the loss of situation awareness , mode confusion is increasingly becoming a major contributor as well. The January 30, 1995 issue of Aviation Week lists 184 incidents and accidents involving mode awareness including the Bangalore A320 crash 2/14/90, the Strasbourg A320 crash 1/20/92, the Mulhouse-Habsheim A320 crash 6/26/88, and the Toulouse A330 crash 6/30/94. These incidents and accidents reveal that pilots sometimes become confused about what the cockpit automation is doing. Consequently, human factors research is an obvious investment area. However, even a cursory look at the accident data reveals that the mode confusion problem is much deeper than just training deficiencies and a lack of human-oriented design. This is readily acknowledged by human factors experts. It seems that further progress in human factors must come through a deeper scrutiny of the internals of the automation. It is in this arena that formal methods can contribute. Formal methods refers to the use of techniques from logic and discrete mathematics in the specification, design, and verification of computer systems, both hardware and software. The fundamental goal of formal methods is to capture requirements, designs and implementations in a mathematically based model that can be analyzed in a rigorous manner. Research in formal methods is aimed at automating this analysis as much as possible. By capturing the internal behavior of a flight deck in a rigorous and detailed formal model, the dark corners of a design can be analyzed. This paper will explore how formal models and analyses can be used to help eliminate mode confusion from flight deck designs and at the same time increase our confidence in the safety of the implementation. The paper is based upon interim results from a new project involving NASA Langley and Rockwell Collins in applying formal methods to a realistic business jet Flight Guidance System (FGS).

Butler, Ricky W.↗
NASA NTRS1998

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Orasanu, Judith↗