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At least 163 records · Page 9

Estimating The Rate of Technology Adoption for Cockpit Weather Information Systems

In February 1997, President Clinton announced a national goal to reduce the weather related fatal accident rate for aviation by 80% in ten years. To support that goal, NASA established an Aviation Weather Information Distribution and Presentation Project to develop technologies that will provide timely and intuitive information to pilots, dispatchers, and air traffic controllers. This information should enable the detection and avoidance of atmospheric hazards and support an improvement in the fatal accident rate related to weather. A critical issue in the success of NASA's weather information program is the rate at which the market place will adopt this new weather information technology. This paper examines that question by developing estimated adoption curves for weather information systems in five critical aviation segments: commercial, commuter, business, general aviation, and rotorcraft. The paper begins with development of general product descriptions. Using this data, key adopters are surveyed and estimates of adoption rates are obtained. These estimates are regressed to develop adoption curves and equations for weather related information systems. The paper demonstrates the use of adoption rate curves in product development and research planning to improve managerial decision processes and resource allocation.

Kauffmann, Paul↗

A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety

Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence, and are influenced by, how decision makers characterize problems and identify solutions. In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on safety-producing behaviors, safety management and system design decisions are based on a small sample of non-representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to aviation safety represents a significant and largely unrecognized risk when making policy decisions about safety management and system design. Opportunities exist to leverage the vast amount of data that have already been collected, or could be easily obtained, to increase our understanding of human contributions to safety in commercial aviation. This presentation will focus on those opportunities as well as the challenges associated with collecting and analyzing data on operators’ safety-producing behaviors.

Safety↗

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.↗

Human Performance Contributions to Safety in Commercial Aviation

In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that contribute to routine successful outcomes, safety management and system design decisions are based on a small sample of non- representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant and largely unrecognized risk when making policy decisions about human roles and responsibilities. Opportunities exist to leverage the vast amount of data that has already been collected, or could be easily obtained, to increase our understanding of human contributions to “things going right” in commercial aviation. The principal focus of this assessment was to identify current gaps and explore methods for identifying human “success” data generated by the aviation system, from personnel and within the supporting infrastructure.

Holbrook, Jon B.↗

A theory of human error

Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Mcruer, D. T.↗

Technical approaches for measurement of human errors

Human error is a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents. The technical details of a variety of proven approaches for the measurement of human errors in the context of the national airspace system are presented. Unobtrusive measurements suitable for cockpit operations and procedures in part of full mission simulation are emphasized. Procedure, system performance, and human operator centered measurements are discussed as they apply to the manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations.

Clement, W. F.↗

Modes in Supervisory Control Systems: Structure and Transitions

Mode confusion is becoming a major drawback in operator interaction with systems that allow for multiple levels of automation. This drawback has manifested itself in several mode related accidents and incidents in commercial aviation, military control systems, as well as high technology medical systems. In the domain of commercial aviation, there have been four recent airline accidents, all involving highly automated aircraft, in which mode related problems were present. Mode problems, we argue, stem from three principal factors: (1) mis-identification of the current mode, (2) difficulty in apprehending current mode behavior; and (3) difficulty in predicting the consequences of the next mode transition. This combination of factors may lead to mode confusion and possibly unwanted results. We define in this paper a mode as the system's manner of behavior. Any given system or machine, may have several ways of behaving. A controller, either human or machine, provides the input that triggers the transition from one mode of behavior to another. At any point in time, a machine may be in one mode or another modes are mutually exclusive. Complex systems are typically comprised of several subsystems, or components, each one with its own set of modes. Therefore, the status of the system at any point in time can be described as a vector of all the active modes.

Degani, Asaf↗

Testing of Advanced Capabilities to Enable In-time Safety Management and Assurance for Future Flight Operations

In order to refine an initial Concept of Operations, explore Concepts of Use, and expose/validate requirements for future In-Time Aviation Safety Management Systems (IASMS), testing architectures were created, along with a set of capabilities and underlying information exchange protocols. These systems were conceived and developed based on hazards associated with two envisioned urban area flight domains: (1) highly autonomous small uncrewed aerial systems (sUAS) operating at low altitudes, and (2) highly autonomous air taxis. The initial scope of this development is described in [1]; this report provides an update, focusing on the subsequent developments and test activities. As stated in [1], it is important to note that there are many capabilities already in use by the industry (or soon to be in use) that will play critical roles in future IASMS designs. Those reported here were developed to address a gap in the current state-of-the-art regarding specific hazards/risks, and/or to allow for investigation of the interplay between and across hazard types — particularly regarding how overall safety risk can be reduced or managed effectively. Results of testing and development activities are organized by the operational phase wherein a particular capability would be employed (i.e., preflight, in-flight, and post-flight/off-line). Pre-flight: A set of capabilities were developed to help mitigate safety risk prior to flight (e.g., during flight and mission planning). Results of testing summarize (1) validation activities to raise the Technology Readiness Level (TRL) and (2) evaluation activities where the capabilities were applied to flight/mission planning procedures and used by operators/pilots. For the latter, flight plans were automatically assessed, and operators/pilots were notified of hazardous flight segments so as to enable adjustment of the flight plan and re-evaluation, and/or to better inform go/no-go decisions. Capabilities addressed hazards associated with power consumption, third-party risk, wind, navigation system performance, radiofrequency interference, and proximity to geo-spatial threats (e.g., buildings, trees, and no-fly zones). In-flight: Flight experiments tested capabilities that detect and respond to hazards encountered during flight. In the first series, safety hazards were monitored and assessed onboard, and system-generated mitigation maneuvers were recorded (but not acted upon by the vehicle). In the second series, mitigation maneuver commands directed the aircraft in response to safety hazards (i.e., auto-mitigation). The sUAS used for testing is described in full, as is the test architecture, which included commercial avionics, research avionics, and onboard software designed to detect, assess, and respond to hazards. The onboard system was designed as a run-time assurance framework, consistent with [2] and supportive of both supervisory and automated modes. The primary functions included: real-time risk assessment (RTRA), auto-pilot monitoring, constraint monitoring, and contingency select/triggering. RTRA performs integrated risk assessment considering data from several hazard-related monitors (e.g., battery, motors, navigation, communications, population density, and loss-of-control). Post-flight/off-line: Data monitored and recorded during flights can enable IASMS capabilities that execute after flights have completed (or “off-line”). These include: (1) the ability to identify anomalies and trends that may only be observable when comparing data spanning a number of similar flights; (2) the ability to update and validate pre-flight and in-flight capabilities and any underlying models to improve their performance; (3) the ability to report anomalies/off-nominals that may indicate design changes or maintenance actions are needed; and (4) the ability for humans involved in operations to report safety-relevant observations to help in understanding the flight data and/or the operational context of a flight. Progress on three such capabilities is summarized; the first investigates anomaly detection given a limited set of flight logs and applies an approach previously used for space operations. The second explores what could be identified using a larger set of flight logs, including from web-based forums where flight logs are posted by sUAS autopilot users. The third creates a new means of collecting information on UAS incidents and accidents via the Aviation Safety Reporting System (ASRS).

sUAS↗

Investigating Interruptions: Implications for Flightdeck Performance

A fundamental aspect of multiple task management is attending to new stimuli and integrating associated task requirements into an ongoing task set; this is "interruption management" (IM). Anecdotal evidence and field studies indicate the frequency and consequences of interruptions, however experimental investigations of mechanisms influencing IM are scarce. Interruptions on commercial flightdecks are numerous, of various forms, and have been cited as contributing factors in many aviation incident and accident reports. This research grounds an experimental investigation of flightdeck interruptions in a proposed IM stage model. This model organizes basic research, identifies influencing mechanisms, and suggests appropriate dependent measures for IM. Fourteen airline pilots participated in a flightdeck simulation experiment to investigate the general effects of performing an interrupting task and interrupted procedure, and the effects of specific task factors: (1) modality; (2) embeddedness, or goal-level, of an interruption; (3) strength of association, or coupling-strength, between interrupted tasks; (4) semantic similarity; and (5) environmental stress. General effects of interruptions were extremely robust. All individual task factors significantly affected interruption management, except "similarity." Results extend the Interruption Management model, and are interpreted for their implications for interrupted flightdeck performance and intervention strategies for mitigating their effects on the flightdeck.

Latorella, Kara A.↗

Communication Research in Aviation and Space Operations: Symptoms and Strategies of Crew Coordination

The day-to-day operators of today's aerospace systems work under increasing pressures to accomplish more with less. They work in operational systems which are complex, technology-based, and high-risk; in which incidents and accidents have far-reaching and costly consequences. For these and other reasons, there is concern that the safety net formerly built upon redundant systems and abundant resources may become overburdened. Although we know that human ingenuity can overcome incredible odds, human nature can also fail in unpredictable ways. Over the last 20 years, a large percentage of aviation accidents and incidents have been attributed to human errors rather than hardware or environmental factors alone. A class of errors have been identified which are not due to a lack of individual, technical competencies. Rather, they are due to the failure of teams to utilize readily available resources or information in a timely fashion. These insights began a training revolution in the aviation industry called Cockpit Resource Management, which later became known as Crew Resource Management (CRM) as its concepts and applications extended to teams beyond the flightdeck. Then, as now, communication has been a cornerstone in CRM training since crew coordination and resource management largely resides within information transfer processes--both within flightcrews, and between flightcrews and the ground operations teams that support them. The research I will describe takes its roots in CRM history as we began to study communication processes in order to discover symptoms of crew coordination problems, as well as strategies of effective crew management. On the one hand, communication is often the means or the tool by which team members manage their resources, solve problems, maintain situational awareness and procedural discipline. Conversely, it is the lack of planning and resource management, loss of vigilance and situational awareness, and non-standard communications that are implicated in accidents and incidents. NASA/Ames Crew Factors researchers have been developing a model of effective crew coordination in order to understand the sources of performance breakdowns, and to develop effective solutions and interventions. Because communication is a primary mechanism by which information is received and transmitted, and because it is observable behavior, we focus on these group processes in order to identify patterns of communication that distinguish effective from less effective crew performance. Since a prime objective is to develop training recommendations for enhancing communication skills, we interpret our findings in the context of relevant task and environmental conditions, role and procedural constraints, and the normal real-time parameters of flight operations. Another research objective is to consider how communication and coordination can be enhanced through design. For example, flight deck and hardware design as well as procedural and software design may greatly influence the efficiency with which crews communicate and coordinate their work. In addition, teams and tasks may be designed, organized, and trained so that team interactions with each other are based upon appropriately shared knowledge, procedures and situation awareness. In short, we are interested in enhancing communication practices through (1) the training of specific communication skills, and (2) the design of equipment, tasks, procedures, and teams that optimize smooth, unambiguous communication processes. Two examples of communication research will be described; one in aviation and one in space operations. The first example is a high-fidelity full mission simulation study which investigates the affect of flightdeck automation on crew coordination and communication (contrasting crew performance in the DC-9 vs. MD88). Additional information is contained in the original extended abstract.

Kanki, Barbara G.↗

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.↗

Shared Problem Models and Crew Decision Making

The importance of crew decision making to aviation safety has been well established through NTSB accident analyses: Crew judgment and decision making have been cited as causes or contributing factors in over half of all accidents in commercial air transport, general aviation, and military aviation. Yet the bulk of research on decision making has not proven helpful in improving the quality of decisions in the cockpit. One reason is that traditional analytic decision models are inappropriate to the dynamic complex nature of cockpit decision making and do not accurately describe what expert human decision makers do when they make decisions. A new model of dynamic naturalistic decision making is offered that may prove more useful for training or aiding cockpit decision making. Based on analyses of crew performance in full-mission simulation and National Transportation Safety Board accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation and reflect the crew's metacognitive skill. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that all crew members have essential information, but it also regulates and coordinates crew actions and is the medium of collective thinking in response to a problem. This presentation will examine the relation between communication that serves to build performance. Implications of these findings for crew training will be discussed.

Orasanu, Judith↗

Methods Developed by the Tools for Engine Diagnostics Task to Monitor and Predict Rotor Damage in Real Time

Tools for Engine Diagnostics is a major task in the Propulsion System Health Management area of the Single Aircraft Accident Prevention project under NASA s Aviation Safety Program. The major goal of the Aviation Safety Program is to reduce fatal aircraft accidents by 80 percent within 10 years and by 90 percent within 25 years. The goal of the Propulsion System Health Management area is to eliminate propulsion system malfunctions as a primary or contributing factor to the cause of aircraft accidents. The purpose of Tools for Engine Diagnostics, a 2-yr-old task, is to establish and improve tools for engine diagnostics and prognostics that measure the deformation and damage of rotating engine components at the ground level and that perform intermittent or continuous monitoring on the engine wing. In this work, nondestructive-evaluation- (NDE-) based technology is combined with model-dependent disk spin experimental simulation systems, like finite element modeling (FEM) and modal norms, to monitor and predict rotor damage in real time. Fracture mechanics time-dependent fatigue crack growth and damage-mechanics-based life estimation are being developed, and their potential use investigated. In addition, wireless eddy current and advanced acoustics are being developed for on-wing and just-in-time NDE engine inspection to provide deeper access and higher sensitivity to extend on-wing capabilities and improve inspection readiness. In the long run, these methods could establish a base for prognostic sensing while an engine is running, without any overt actions, like inspections. This damage-detection strategy includes experimentally acquired vibration-, eddy-current- and capacitance-based displacement measurements and analytically computed FEM-, modal norms-, and conventional rotordynamics-based models of well-defined damages and critical mass imbalances in rotating disks and rotors.

Baaklini, George Y.↗

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.↗

Multiple Kernel Learning for Heterogeneous Anomaly Detection: Algorithm and Aviation Safety Case Study

The world-wide aviation system is one of the most complex dynamical systems ever developed and is generating data at an extremely rapid rate. Most modern commercial aircraft record several hundred flight parameters including information from the guidance, navigation, and control systems, the avionics and propulsion systems, and the pilot inputs into the aircraft. These parameters may be continuous measurements or binary or categorical measurements recorded in one second intervals for the duration of the flight. Currently, most approaches to aviation safety are reactive, meaning that they are designed to react to an aviation safety incident or accident. In this paper, we discuss a novel approach based on the theory of multiple kernel learning to detect potential safety anomalies in very large data bases of discrete and continuous data from world-wide operations of commercial fleets. We pose a general anomaly detection problem which includes both discrete and continuous data streams, where we assume that the discrete streams have a causal influence on the continuous streams. We also assume that atypical sequence of events in the discrete streams can lead to off-nominal system performance. We discuss the application domain, novel algorithms, and also discuss results on real-world data sets. Our algorithm uncovers operationally significant events in high dimensional data streams in the aviation industry which are not detectable using state of the art methods

Das, Santanu↗

The Role of Alerting System Failures in Loss of Control Accidents CAST SE-210 Output 2

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane's energy state or attitude and enters an upset condition. In a report by the Commercial Aviation Safety Team, an analysis of accidents and incidents related to loss of airplane state awareness determined that hazard alerting was not effective in producing the appropriate pilot response to a hazard (CAST, 2014). In the current report, we take a detailed look at 28 airplane state awareness accidents and incidents to determine how well the hazard alerting worked. We describe a five-step integrated alerting-to-recovery sequence that prescribes how hazard alerting should lead to effective flight crew actions for managing the hazard. Then, for each hazard in each of the 28 events, we determine if that sequence failed and, if so, how it failed. The results show that there was an alerting failure in every one of the 28 safety events, and that the most frequent failure (20/28) was tied to the flight crew not orienting to (not being aware of) the hazard. The discussion section summarizes findings and identifies alerting issues that are being addressed and issues that are not currently being addressed. We identify a few recent upgrades that have addressed certain alerting failures. Two of these upgrades address alerting design, but one response to the safety events is to upgrade training for approach to stall and stall recovery. We also describe issues that are not being addressed adequately: better alert integration for flight path management types of hazards, airplanes in the fleet that do not meet the current alerting regulations, a lack of innovation for addressing cases of channelized attention, and existing vulnerabilities in managing data validity.

aviation safety↗

Rating the Relevance of QUORUM-Selected ASRS Incident Narratives to a "Controlled Flight into Terrain" Accident

An exploratory study was conducted to identify commercial aviation incidents that are relevant to a "controlled flight into terrain" (CFIT) accident using a NASA-developed text processing method. The QUORUM method was used to rate 67820 incident narratives, virtually all of the narratives in the Aviation Safety Reporting System (ASRS) database, according to their relevance to two official reports on the crash of American Airlines Flight 965 near Cali, Colombia in December 1995. For comparison with QUORUM's ratings, three experienced ASRS analysts read the reports of the crash and independently rated the relevance of the 100 narratives that were most highly rated by QUORUM, as well as 100 narratives randomly selected from the database. Eighty-four of 100 QUORUM-selected narratives were rated as relevant to the Cali accident by one or more of the analysts. The relevant incidents involved a variety of factors, including, over-reliance on automation, confusion and changes during descent/approach, terrain avoidance, and operations in foreign airspace. In addition, the QUORUM collection of incidents was found to be significantly more relevant than the random collection.

McGreevy, Michael W.↗

Path-Integrated Stereo X-Ray Digital Image Correlation: Resolving the Violation of Conservation of Intensity

In this study, x-ray imaging addresses many challenges with visible light imaging in extreme environments, where optical diagnostics such as digital image correlation (DIC) and particle image velocimetry (PIV) suffer biases from index of refraction changes and/or cannot penetrate visibly occluded objects. However, conservation of intensity—the fundamental principle of optical image correlation algorithms—may be violated if ancillary components in the X-ray path besides the surface or fluid of interest move during the test. The test series treated in this work sought to characterize the safe use of fiber-epoxy composites in aerospace and aviation industries during fire accident scenarios. Stereo X-ray DIC was employed to measure test unit deformation in an extreme thermal environment involving a visibly occluded test unit, incident surface heating to temperatures above 600°C, and flames and soot from combusting epoxy decomposition gasses. The objective of the current work is to evaluate two solutions to resolve the violation of conservation of intensity that resulted from both the test unit and the thermal chamber deforming during the test. The first solution recovered conservation of intensity by pre-processing the path-integrated X-ray images to isolate the DIC pattern of the test unit from the thermal chamber components. These images were then correlated with standard, optical DIC software. The second solution, called Path-Integrated Digital Image Correlation (PI-DIC), modified the fundamental matching criterion of DIC to account for multiple, independently-moving components contributing to the final image intensity. The PI-DIC algorithm was extended from a 2D framework to a stereo framework and implemented in a custom DIC software. Both solutions accurately measured the cylindrical shape of the undeformed test unit, recovering radii values of R = 76.20±0.12 mm compared to the theoretical radius of R theor = 76.20 mm. During the test, the test unit bulged asymmetrically as decomposition gasses pressurized the interior and eventually burned in a localized jet. Both solutions measured the heterogeneous radius of this bulge, which reached a maximum of approximately R = 91 mm, with a discrepancy of 2–3% between the two solutions. Two solutions that resolve the violation of conservation of intensity for path-integrated X-ray images were developed. Both were successfully employed in a stereo X-ray DIC configuration to measure deformation of an aluminum-skinned, fiber-epoxy composite test unit in a fire accident scenario.

47 OTHER INSTRUMENTATION↗