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NASA NTRS2001

Searching the ASRS Database Using QUORUM Keyword Search, Phrase Search, Phrase Generation, and Phrase Discovery

To support Search Requests and Quick Responses at the Aviation Safety Reporting System (ASRS), four new QUORUM methods have been developed: keyword search, phrase search, phrase generation, and phrase discovery. These methods build upon the core QUORUM methods of text analysis, modeling, and relevance-ranking. QUORUM keyword search retrieves ASRS incident narratives that contain one or more user-specified keywords in typical or selected contexts, and ranks the narratives on their relevance to the keywords in context. QUORUM phrase search retrieves narratives that contain one or more user-specified phrases, and ranks the narratives on their relevance to the phrases. QUORUM phrase generation produces a list of phrases from the ASRS database that contain a user-specified word or phrase. QUORUM phrase discovery finds phrases that are related to topics of interest. Phrase generation and phrase discovery are particularly useful for finding query phrases for input to QUORUM phrase search. The presentation of the new QUORUM methods includes: a brief review of the underlying core QUORUM methods; an overview of the new methods; numerous, concrete examples of ASRS database searches using the new methods; discussion of related methods; and, in the appendices, detailed descriptions of the new methods.

McGreevy, Michael W.↗
NASA NTRS1995

Alaska Humans Factors Safety Study: The Northern Area

At the request of the Alaska Air Carriers Association, researchers from the NASA Aviation Safety Reporting System, at NASA Ames Research Center, conducted a study on aspects of safety in Alaskan Part 135 air taxi operations. An interview form on human factors safety issues was created by a representative team from the FAA-Alaska, NTSB-Alaska, NASAASRS, and representatives of the Alaska Air Carriers Association which was subsequently used in the interviews of pilots and managers. Because of the climate and operational differences, the study was broken into two geographical areas, the southern coastal areas and the northern portion of the state. This presentation addresses the northern area, specifically: Bethel, Fairbanks, Nome, Kotzebue, and Barrow. The interview questions dealt with many of the potential pressures on pilots and managers associated with the daily air taxi operations in Alaska. The impact of the environmental factors such as the lack of available communication, navigation and weather information systems was evaluated. The results of this study will be used by government and industry working in Alaska. These findings will contribute important information on specific Alaska safety issues for eventual incorporation into training materials and policies that will help to assure the safe conduct of air taxi flights in Alaska.

Connell, Linda↗
NASA NTRS1995

Alaska Humans Factors Safety Study: The Southern Coastal Area

At the request of the Alaska Air Carriers Association, researchers from the NASA Aviation Safety Reporting System, at NASA Ames Research Center, conducted a study on aspects of safety in Alaskan Part 135 air taxi operations. An interview form on human factors safety issues was created by a representative team from the FAA-Alaska, NTSB-Alaska, NASA-ASRS, and representatives of the Alaska Air Carriers Association which was subsequently used in the interviews of pilots and managers. Because of the climate and operational differences, the study was broken into two geographical areas, the southern coastal areas and the northern portion of the state. This presentation addresses the southern coastal areas, specifically: Anchorage, Dillingham, King Salmon, Kodiak, Cold Bay, Juneau, and Ketchikan. The interview questions dealt with many of the potential pressures on pilots and managers associated with the daily air taxi operations in Alaska. The impact of the environmental factors such as the lack of available communication, navigation and weather information systems was evaluated. The results of this study will be used by government and industry working in Alaska. These findings will contribute important information on specific Alaska safety issues for eventual incorporation into training materials and policies that will help to assure the safe conduct of air taxi flights in Alaska.

Chappell, Sheryl L.↗
NASA NTRS1995

Identifying Human Factors Issues in Aircraft Maintenance Operations

Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.

Veinott, Elizabeth S.↗
NASA NTRS1995

"Oops, It didn't arm." - A Case Study of Two Automation Assisted Altitude Deviations

Altitude deviations are the most common pilot error reported to the Aviation Safety Reporting System. Last year, altitude deviations were reported to the ASRS at the rate of about one per hour. The reporting pilot's narrative is usually our only source of information about what happened in these incidents. In a recent line-oriented, simulator study, twenty-two airline crews flew a realistic, two-hour mission in a DC-9 and an MD-88 aircraft. This paper will describe and analyze two of the five altitude deviations that were observed during this study. The paper focuses on the flight crews' use (or misuse) of the autopilot and autothrottle during these incidents.

Plamer, Everett↗
NASA NTRS1996

Translating Research Into Airline Practice: Case Studies In Collaboration

Airline training departments are avid customers for research that will help them enhance the effectiveness of training and the safety of flight operations. However, various factors often make it difficult for training department managers to draw upon the large body of human factors research, e.g.: research may not address the specific questions facing the training departments, the research literature may not be in a form that training managers can readily interpret, researchers' recommendations may be too expensive or impractical to implement, etc. This panel will discuss ways in which researchers can work with training departments to design research and translate findings into products that airlines can use readily. This collaboration is most effective when it is an integral part of the study from its inception. To illustrate the process of collaboration we will use as a case study the recently completed LOFT (Line Oriented Flight Training) Debriefing research project. We will summarize the findings from that study and discuss how we translated those findings into two training tools: a manual on how to facilitate LOFT debriefings and a video that illustrates facilitation techniques in a realistically enacted debriefing. In some cases, instead of starting a new research project, training department needs can be addressed by reviewing the existing research literature and using expert opinion to develop products that specifically address those needs. To illustrate this approach we will discuss a recent informal working group of scientists and airline personnel that met to develop training material to enhance situation awareness. This group reviewed scientific literature and ASRS (Aviation Safety Reporting System) reports, analyzed contributing factors, and produced a model for managing situation awareness.

Dismukes, R. Key↗
NASA NTRS1996

Cross-Cultural Barriers to Effective Communication in Aviation

Communication is essential to safe flight, as evidenced by several accidents in which crew communicates was found to have contributed to the accidents. This chapter documents the essential role of explicit efficient communication to flight safety with a global context. It addresses communication between flight crews and air traffic controllers in regions a the world where pilots and controllers speak different native languages, as well as cases in which crew members within the flight deck represent different native languages and cultures. It also addresses problems associated with "exporting" crew resource management training programs to parts of the world which values and norms differ from those of the United States, where these programs were initially developed. This chapter is organized around several central questions: (1) What are various kinds of communication failures and what are their consequences; (2) What are the causes of communication failure; (3) What are features of effective crew communication; (4) What can be done to enhance communication success? To explore a wider range of communication failures than available from accident reports, we examined a set of incident reports from the Aviation Safety Reporting System. These could be classified into three major categories: those in which language actually interfered with transmission of a message; those in which transmission was adequate but the context was not expressed unambiguously and thus the message received was not the same as the message intended; and those in which the message was received as intended, but was not adequately understood or acted upon, mainly because of cultural factors. The consequences of failed communication can be flight errors (such as when a clearance is not received correctly), loss of situation awareness, or failure of crew members (or ATC and pilots) to build a shared understanding of a situation. Causes of misunderstanding can be traced to a number of sources, often grounded in faulty assumptions held by one or both parties to a conversation. Speakers and listeners often experience "illusionary understanding" in which they think they understand each other, but in fact do not. While this problem can exist within a single culture, it is much more serious across cultures. Training in effective explicit communication is a component of Crew Resource Management training programs developed in the U.S. These programs are being adopted by airlines around the world, with varying degrees of success. The level of success in part depends on how similar the conversational and social styles of those cultures are to those of the U.S. A factor that influences conversational style is a culture's relative positioned on two major dimensions that distinguish national cultural groups: individualism vs. collectivism and degree of power distance. The chapter concludes with a discussion of techniques for overcoming the various classes of communication failures and for effectively adapting training programs to fit the values and norms of cultures around the globe.

Fischer, U.↗
NASA NTRS1997

Identification of Error Patterns in Terminal-Area ATC Communications

Advancing air traffic management technologies have enabled a greater number of aircraft to use the same airspace more effectively. As aircraft separations are reduced and final approaches are more finely timed, there is less room for error. The present study examined 122 terminal-area, loss-of-separation and procedure violation incidents reported to the Aviation Safety Reporting System (ASRS) by air traffic controllers. Narrative description codes were used for the incidents for type of violation, contributing factors, recovery strategies, and consequences. Usually multiple errors occurred prior to the violation. Error sequences were analyzed and common patterns of errors were identified. In half of the incidents, errors were noticed in time to correct mistakes. Of these, almost 43% committed additional errors during the recovery attempt. This analysis shows that redundancies in the present air traffic control system may not be sufficient to support large increases in traffic density. Error prevention and design considerations for air traffic management systems are discussed.

Quinn, Cheryl↗
NASA NTRS2002

Crew Factors in Flight Operations XIV: Alertness Management in Regional Flight Operations Education Module

Regional operations encompass a broad range of pilots and equipment. This module is intended to help all those involved in regional aviation, including pilots, schedulers, dispatchers, maintenance technicians, policy makers, and others, to understand the physiological factors underlying fatigue, how flight operations affect fatigue, and what can be done to counteract fatigue and maximize alertness and performance in their operations. The overall purpose of this module is to promote aviation safety, performance, and productivity. It is intended to meet three specific objectives: (1) to explain the current state of knowledge about the physiological mechanisms underlying fatigue; (2) to demonstrate how this knowledge can be applied to improving flight crew sleep, performance, and alertness; and (3) to offer strategies for alertness management. Aviation Safety Reporting System (ASRS) and National Transportation Safety Board (NISH) reports are used throughout this module to demonstrate that fatigue is a safety issue in the regional operations community. The appendices at the end of this module include the ASRS reports used for the examples contained in this publication, brief introductions to sleep disorders and relaxation techniques, summaries of relevant NASA publications, and a list of general readings on sleep, sleep disorders, and circadian rhythms.

Rosekind, Mark R.↗
NASA NTRS2002

Crew Factors in Flight Operations XV: Alertness Management in General Aviation Education Module

Regional operations encompass a broad range of pilots and equipment. This module is intended to help all those involved in regional aviation, including pilots, schedulers, dispatchers, maintenance technicians, policy makers, and others, to understand the physiological factors underlying fatigue, how flight operations affect fatigue, and what can be done to counteract fatigue and maximize alertness and performance in their operations. The overall purpose of this module is to promote aviation safety, performance, and productivity. It is intended to meet three specific objectives: (1) to explain the current state of knowledge about the physiological mechanisms underlying fatigue; (2) to demonstrate how this knowledge can be applied to improving flight crew sleep, performance, and alertness; and (3) to offer strategies for alertness management. Aviation Safety Reporting System (ASRS) and National Transportation Safety Board (NISH) reports are used throughout this module to demonstrate that fatigue is a safety issue in the regional operations community. The appendices at the end of this module include the ASRS reports used for the examples contained in this publication, brief introductions to sleep disorders and relaxation techniques, summaries of relevant NASA publications, and a list of general readings on sleep, sleep disorders, and circadian rhythms.

Rosekind, Mark R.↗
NASA NTRS2004

Analysis of Adverse Events in Identifying GPS Human Factors Issues

The purpose of this study was to analyze GPS related adverse events such as accidents and incidents (A/I), Aviation Safety Reporting System (ASRS) reports and Pilots Deviations (PDs) to create a framework for developing a human factors risk awareness program. Although the occurrence of directly related GPS accidents is small the frequency of PDs and ASRS reports indicated there is a growing problem with situational awareness in terminal airspace related to different types of GPs operational issues. This paper addresses the findings of the preliminary research and a brief discussion of some of the literature on related GPS and automation issues.

Adams, Catherine A.↗
NASA NTRS2008

Patterns of Error in Confidential Maintenance Incident Reports

Confidential reports of maintenance incidents are a valuable source of information on maintenance errors and the contexts within which they occur. NASA's Aviation Safety Reporting System (ASRS) has been receiving an increasing number of maintenance incident reports since a specialized maintenance reporting form was introduced in 1996. In a series of studies, the database of ASRS maintenance incidents was examined using correspondence analysis, a statistical technique that converts complex data tables into a visual form. The analyses revealed patterns within the ASRS data set that would have otherwise been difficult to detect. The results have implications for a range of purposes including human factors training, the design of procedures, and the identification of improvements in aircraft design.

Hobbs, Alan↗
NASA NTRS2010

Causal Factors and Adverse Conditions of Aviation Accidents and Incidents Related to Integrated Resilient Aircraft Control

The causal factors of accidents from the National Transportation Safety Board (NTSB) database and incidents from the Federal Aviation Administration (FAA) database associated with loss of control (LOC) were examined for four types of operations (i.e., Federal Aviation Regulation Part 121, Part 135 Scheduled, Part 135 Nonscheduled, and Part 91) for the years 1988 to 2004. In-flight LOC is a serious aviation problem. Well over half of the LOC accidents included at least one fatality (80 percent in Part 121), and roughly half of all aviation fatalities in the studied time period occurred in conjunction with LOC. An adverse events table was updated to provide focus to the technology validation strategy of the Integrated Resilient Aircraft Control (IRAC) Project. The table contains three types of adverse conditions: failure, damage, and upset. Thirteen different adverse condition subtypes were gleaned from the Aviation Safety Reporting System (ASRS), the FAA Accident and Incident database, and the NTSB database. The severity and frequency of the damage conditions, initial test conditions, and milestones references are also provided.

Reveley, Mary S.↗
NASA NTRS2011

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

Reveley, Mary S.↗
NASA NTRS2018

Part 121 Taxi/Parked Ground Conflict Related Incidents

This presentation reviews voluntary safety reports received by NASA's Aviation Safety Reporting System pertaining to Part 121 Taxi/Parked Ground Conflicts. Ground Conflict, Critical • Two or more aircraft (one may be airborne) in conflict, or an aircraft in conflict with a vehicle/person/object in which the reporter or other involved party took evasive action to avoid a collision, or a collision that almost occurred in cases where evasive action was not taken or possible. The evasive action can include an emergency go-around, veering on a taxiway/runway, rejected takeoff/abort, emergency braking, or an aircraft overflying another aircraft 50 feet or less.  Ground Conflict, Less Severe • Two or more aircraft (one may be airborne) in conflict, or an aircraft in conflict with a vehicle/person/object in which the reporter or other involved party may, or may not have taken precautionary avoidance action, and in which a collision hazard was not imminent.  Ground Event / Encounter – Aircraft • Actual physical contact with another aircraft when aircraft is on the ground. All Aircraft Involved in Incidents Conflicting Aircraft by Weight Classification Flight Conditions and Time (Quarter of Day) Contributing Factors and Human Factors (Event)

taxi↗
NASA NTRSDate not supplied

Informing NLP Learning Tasks by Tracking User Features: An ASRS Use Case using Kaona

There has been growing interest in utilizing natural language processing (NLP) algorithms in Aviation Safety. This interest has extended to leveraging the decades of records publicly available on the Aviation Safety Reporting System (ASRS). While related literature has given more emphasis in lessons learned from the narratives, our prior work has focused on using NLP to support narrative search in the ASRS. Specifically, we evaluated if the use of alternative search mechanisms to keyword search, such as the retrieval of related narratives even without matching keywords could improve narrative discovery. A difficulty in experimenting alternative search mechanisms in any information retrieval task is the lack of ground truth. To address this limitation, we propose Kaona, a lightweight interface which enables the prototyping of alternative search retrieval tasks, by tracking user experience both explicitly (user-specified feedback), or implicitly (user navigation through interface affordances). Differently from distracting requests for feedback during user navigation, Kaona collects explicit feedback from users by mapping them to affordances which support the user workflow, while obtaining ground truth information for learning tasks.

human-computer-interaction↗