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At least 145 records · Page 8

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NASA NTRS1993

Altitude deviations: Breakdowns of an error-tolerant system

Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

Palmer, Everett A.↗

NASA NTRSDate not supplied

Extracting Lessons of Resilience Using Machine Mining of the ASRS Database

NASA’s Aviation Safety Reporting System (ASRS) database is the world's largest repository of voluntary, confidential safety information provided by aviation's frontline personnel, including pilots, air traffic controllers, mechanics, flight attendants, dispatchers, and other members of the aviation community and the public. The database contains close to 2 million narratives, many of which describe everyday situations in which people saved the day. In these situations, people’s resilient behavior solved a problem, dealt with a malfunction, and maintained a safe operation despite a serious perturbation. To be able to extract lessons of such resilience from this large database, the use of machine learning algorithms is being explored. In this report, we describe a comparison between two such algorithms: Perilog and Word2Vec. An identical search using both programs was done on a database containing approximately 470,000 ASRS reports submitted between 1988 and 2022. The comparison reveals some of the strength and weaknesses of each algorithm as well as the challenges inherent in using such algorithms to extract lessons of resilience from the ASRS database.

resilience↗

NASA NTRS1998

Joint ASRS and NASA Callback on FANS-1 Datalink Operational Incidents

The recent certification and implementation of the Future Air Navigation System (FANS- 1) was based on the benefits of reduced separation minima, ability to optimize flight plans enroute, and the prompt transmission and reception of messages between oceanic controllers and 747-400 aircraft transiting the Pacific. In addition, FANS was intended to supersede High Frequency (HF) radio which has been the staple, yet problematic, long distance communication link for years. However, in the three initial years of operation, FANS has revealed its own unique operational issues. Although some technical and engineering problems have been studied and addressed, little research has been conducted on human factors issues associated with the use of FANS on the flight deck. This lack of prior data on the operational use of FANS prompted a joint NASA/Aviation Safety Reporting System (ASRS) inquiry into FANS datalink. In addition, two foreign air carriers and their respective safety agencies were recruited to participate. This international FANS research effort consisting of three aviation safety agencies and three international commercial air-carriers has provided a unique opportunity for conducting human factors research in an operational environment. An ASRS 'callback' format was chosen for the study as a practical and viable method for capturing FANS events on the flight deck. Initially, 747-400 pilots were encouraged to submit reports to their respective safety agencies if they had experienced any positive or negative incidents with the use of FANS. Upon receipt of a report, it was evaluated and if deemed pertinent to the study, a telephone interview or 'callback' was conducted on the FANS incident to elicit further details, capture the key events, and gather contextual information. Once the operational data collection phase was completed, the reports and interviews were analyzed with two purposes in mind: primarily to identify and address problematic human factors issues with current FANS technology, and, secondarily, to provide 'lessons learned' for future datalink systems and implementation.

Moses, John↗

NASA NTRS2013

Identification of Crew-Systems Interactions and Decision Related Trends

NASA Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified technical challenges. Statistical data and published safety priority lists from academic, industry and other government agencies were reviewed and analyzed by NASA Aviation Safety Program (AvSP) systems analysis personnel to identify issues and future research needs related to one of VSST's technical challenges, Crew Decision Making (CDM). The data examined in the study were obtained from the National Transportation Safety Board (NTSB) Aviation Accident and Incident Data System, Federal Aviation Administration (FAA) Accident/Incident Data System and the NASA Aviation Safety Reporting System (ASRS). In addition, this report contains the results of a review of safety priority lists, information databases and other documented references pertaining to aviation crew systems issues and future research needs. The specific sources examined were: Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementation (SERFIs), Flight Deck Automation Issues (FDAI) and NTSB Most Wanted List and Open Recommendations. Various automation issues taxonomies and priority lists pertaining to human factors, automation and flight design were combined to create a list of automation issues related to CDM.

Jones, Sharon Monica↗

NASA NTRSDate not supplied

Assessing the Use of UAS-Related Terms in ASRS Using Seed Topic Modeling

Context: The NASA Aviation Safety Reporting System (ASRS) is a voluntary confidential system that disseminates reports received from personnel involved in aviation operations after de-identifying them. These reports are used by the community to improve overall aviation system safety. Aim: We propose and execute an experiment to assess the use of seed term topic modeling over the database narratives to identify Unmanned Aircraft System (UAS) reports. The use of seed term topic modeling enables users to identify groups of conceptually similar narratives associated to a topic of their interest. Method: We use a collection of narratives, expert-selected words, and report metadata that separates UAS from non-UAS reports to assess if seed topic modeling can be used to improve ASRS searches. Results: For simpler queries, seed topic search observes a higher recall and lower precision than the existing DBOL (DataBase OnLine) search in operation. However, the best results are obtained when seed topic search is used as a search suggestion system to be executed on the DBOL. Conclusion: Utilizing a combination of both the existing method and the proposed method, users can expand their search vocabulary about subjects of interest while improving the quality of results.

Text Mining↗

NASA NTRSDate not supplied

Assessing the Use of UAS-Related Terms in ASRS using Seeds for Topic Modeling

LDA↗

NASA NTRS2018

An Analysis of the Role of Safety Nets in the National Airspace System

Safe operations of aircraft in the National Airspace System (NAS) may be attributed to many factors, including the application of a variety of safety nets (SNs) as a last line of defense. In preparation for the Next Generation Air Transportation System (NextGen), a review of Aviation Safety Reporting System (ASRS) reports for incidents with positive outcomes was conducted to investigate the importance of current safety nets. The examination of positive outcomes not only shows what went wrong, but also what went right to prevent accidents and “save the day.” More than 400 incident reports for 2015 from the voluntary ASRS reporting database were studied in detail to create event sequence diagrams (ESDs), illustrating the effectiveness of SNs. The developed ESDs are considered top-level, representative models and are limited with respect to being reliably quantitative because they are based on only reports from a single year. The ESDs could offer insights into human systems integration research, such as strategically using technologies as SNs without human interface or alleviating human workload with new technologies to provide resilient recovery from off-nominal conditions ensuring flight safety.

Geuther, Steven↗

NASA NTRS1981

An investigation of reports of Controlled Flight Toward Terrain (CFTT)

Some 258 reports from more than 23,000 documents in the files of the Aviation Safety Reporting System (ASRS) were found to be to the hazard of flight into terrain with no prior awareness by the crew of impending disaster. Examination of the reports indicate that human error was a casual factor in 64% of the incidents in which some threat of terrain conflict was experienced. Approximately two-thirds of the human errors were attributed to controllers, the most common discrepancy being a radar vector below the Minimum Vector Altitude (MVA). Errors by pilots were of a much diverse nature and include a few instances of gross deviations from their assigned altitudes. The ground proximity warning system and the minimum safe altitude warning equipment were the initial recovery factor in some 18 serious incidents and were apparently the sole warning in six reported instances which otherwise would most probably have ended in disaster.

Porter, R. F.↗

NASA NTRS1989

Fatigue, pilot deviations and time of day

The relationships between pilot fatigue, pilot deviations, reported incidents, and time of day are examined. A sample of 200 Aviation Safety Reporting System (ASRS) reports were analyzed from 1985 and 200 reports from 1987, plus 100 reports from late 1987 and early 1988 that were selected because of possible association with fatigue. The FAA pilot deviation data and incident data were analyzed in relation to denominator data that summarized the hourly operations (landings and takeoffs of scheduled flights) at major U.S. airports. Using as numerators FAA data on pilot deviations and incidents reported to the FAA, the rates by time of day were calculated. Pilot age was also analyzed in relation to the time of day, phase of flight, and type of incident.

Baker, Susan P.↗

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 NTRS1967

Data management study. Appendix M - Contractor data requirements safety /SA/ FINAL report

Contractor data requirements to insure safety of personnel, facilities, and equipment of Voyager operations

DATA RECORDING↗

NASA NTRS1991

FY 1991 safety program status report

In FY 1991, the NASA Safety Division continued efforts to enhance the quality and productivity of its safety oversight function. Recent initiatives set forth in areas such as training, risk management, safety assurance, operational safety, and safety information systems have matured into viable programs contributing to the safety and success of activities throughout the Agency. Efforts continued to develop a centralized intra-agency safety training program with establishment of the NASA Safety Training Center at the Johnson Space Center (JSC). The objective is to provide quality training for NASA employees and contractors on a broad range of safety-related topics. Courses developed by the Training Center will be presented at various NASA locations to minimize travel and reach the greatest number of people at the least cost. In FY 1991, as part of the ongoing efforts to enhance the total quality of NASA's safety work force, the Safety Training Center initiated development of a Certified Safety Professional review course. This course provides a comprehensive review of the skills and knowledge that well-rounded safety professionals must possess to qualify for professional certification. FY 1992 will see the course presented to NASA and contractor employees at all installations via the NASA Video Teleconference System.

Source record↗

NASA NTRS2008

Influence Map Methodology for Evaluating Systemic Safety Issues

"Raising the bar" in safety performance is a critical challenge for many organizations, including Kennedy Space Center. Contributing-factor taxonomies organize information about the reasons accidents occur and therefore are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This project successfully addressed the following two problems: (1) methods and metrics to support the design of effective taxonomies are limited and (2) influence relationships among contributing factors are not explicitly modeled within a taxonomy.

Source record↗

NASA NTRS1993

Emergency medical service (EMS): A unique flight environment

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

Shively, R. Jay↗

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 NTRS2014

Identification of Vehicle Health Assurance Related Trends

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

Phojanamongkolkij, Nipa↗

NASA NTRSDate not supplied

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

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

hazard analysis↗