Search NASA⌕ Search

SEARCH · Search NASA

Results for “Human Error Mechanisms”

Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 19 records
All sourcesNASA NTRSDOE OSTI
NASA NTRSDate not supplied

Identifying Human Errors and Error Mechanisms From Accident Reports Using Large Language Models

Emerging operational concepts for aviation hinge on novel paradigms for human machine interaction. Critical to their safe operation is early consideration of human error into the design process. Existing methods for consideration of human error require significant expert input, which is challenging both in early design and in novel systems for which there is little existing safety expertise. In this research, we propose a methodology for identifying human error, error producing factors, and mechanisms in early design from historical incident reports. Additionally, we hypothesize that cross-domain sharing of lessons learned can aid with early design human considerations in circumstances where data is not relevant or incomplete. This is addressed by identifying causes of human error in aviation and railway domains through applying state-of-the art natural language processing techniques to historical incident reports. Using this method, it is possible to extract extensive reports on human error from past incidents. Using the proposed approach, we identify nine human errors from railway reports and fourteen from aviation reports, with three errors common to both domains. There is at least one error producing conditions for each human error while a majority of the errors have more than one error mechanism. We also found that a majority of the human errors, error producing factors, and error mechanisms (even if they are not common between the domains) can be used to inform safe operations across domains as long as the errors are not domain specific and are interpreted and contextualized using engineering judgement.

Human Errors↗
NASA NTRS1984

Report of the Panel on Human Factors

Human error in the operation of complex systems is the largest single cause of incidents, accidents, and the loss of lives and dollars. Therefore, it is understandable that the focus of human factors research and engineering is on increasing our understanding of the basic mechanisms of human error and on developing techniques for reducing or eliminating the various causes of human error.

Rouse, William B.↗
NASA NTRS1986

At least some errors are randomly generated (Freud was wrong)

An experiment was carried out to expose something about human error generating mechanisms. In the context of the experiment, an error was made when a subject pressed the wrong key on a computer keyboard or pressed no key at all in the time allotted. These might be considered, respectively, errors of substitution and errors of omission. Each of seven subjects saw a sequence of three digital numbers, made an easily learned binary judgement about each, and was to press the appropriate one of two keys. Each session consisted of 1,000 presentations of randomly permuted, fixed numbers broken into 10 blocks of 100. One of two keys should have been pressed within one second of the onset of each stimulus. These data were subjected to statistical analyses in order to probe the nature of the error generating mechanisms. Goodness of fit tests for a Poisson distribution for the number of errors per 50 trial interval and for an exponential distribution of the length of the intervals between errors were carried out. There is evidence for an endogenous mechanism that may best be described as a random error generator. Furthermore, an item analysis of the number of errors produced per stimulus suggests the existence of a second mechanism operating on task driven factors producing exogenous errors. Some errors, at least, are the result of constant probability generating mechanisms with error rate idiosyncratically determined for each subject.

Sellen, A. J.↗
NASA NTRS2010

Satellite Gravimetry Applied to Drought Monitoring

Near-surface wetness conditions change rapidly with the weather, which limits their usefulness as drought indicators. Deeper stores of water, including root-zone soil wetness and groundwater, portend longer-term weather trends and climate variations, thus they are well suited for quantifying droughts. However, the existing in situ networks for monitoring these variables suffer from significant discontinuities (short records and spatial undersampling), as well as the inherent human and mechanical errors associated with the soil moisture and groundwater observation. Remote sensing is a promising alternative, but standard remote sensors, which measure various wavelengths of light emitted or reflected from Earth's surface and atmosphere, can only directly detect wetness conditions within the first few centimeters of the land s surface. Such sensors include the Advanced Microwave Scanning Radiometer - Earth Observing System (AMSR-E) C-band passive microwave measurement system on the National Aeronautic and Space Administration's (NASA) Aqua satellite, and the combined active and passive L-band microwave system currently under development for NASA's planned Soil Moisture Active Passive (SMAP) satellite mission. These instruments are sensitive to water as deep as the top 2 cm and 5 cm of the soil column, respectively, with the specific depth depending on vegetation cover. Thermal infrared (TIR) imaging has been used to infer water stored in the full root zone, with limitations: auxiliary information including soil grain size is required, the TIR temperature versus soil water content curve becomes flat as wetness increases, and dense vegetation and cloud cover impede measurement. Numerical models of land surface hydrology are another potential solution, but the quality of output from such models is limited by errors in the input data and tradeoffs between model realism and computational efficiency. This chapter is divided into eight sections, the next of which describes the theory behind satellite gravimetry. Following that is a summary of the GRACE mission and how hydrological information is gleaned from its gravity products. The fourth section provides examples of hydrological science enabled by GRACE. The fifth and sixth sections list the challenging aspects of GRACE derived hydrology data and how they are being overcome, including the use of data assimilation. The seventh section describes recent progress in applying GRACE for drought monitoring, including the development of new soil moisture and drought indicator products, and that is followed by a discussion of future prospects in satellite gravimetry based drought monitoring.

Rodell, Matthew↗
NASA NTRS1989

Airline Crew Training

The discovery that human error has caused many more airline crashes than mechanical malfunctions led to an increased emphasis on teamwork and coordination in airline flight training programs. Human factors research at Ames Research Center has produced two crew training programs directed toward more effective operations. Cockpit Resource Management (CRM) defines areas like decision making, workload distribution, communication skills, etc. as essential in addressing human error problems. In 1979, a workshop led to the implementation of the CRM program by United Airlines, and later other airlines. In Line Oriented Flight Training (LOFT), crews fly missions in realistic simulators while instructors induce emergency situations requiring crew coordination. This is followed by a self critique. Ames Research Center continues its involvement with these programs.

Source record↗
NASA NTRS2018

A Risk Analysis Tool for Estimating the Risk of Electrical Failures Due to Human Induced Defects

Aerospace electrical systems are required to withstand and adequately operate in extremely harsh environments that include, for example, high radiation exposure, temperature extremes, intense vibrational stress and drastic temperature cycling. The nature of aerospace electronics also demands high reliability since, with very few exceptions, there is no chance for hardware servicing or repairs. Common risk mitigation techniques for this type of situation are to perform a Reliability Analysis of the system throughout the development cycle, and to use electrical components that are regarded as “high reliability” because of additional controls and requirements applied in their design, manufacturing and testing. Unfortunately, studies have shown that even though these techniques are used, many systems fail to meet mission requirements well before the predicted lifetimes. This paper presents the analysis of failures of electrical parts, experienced during various stages of system development, at NASA Goddard Space Flight Center, Greenbelt MD, between the years 2001 and 2013. These components were subjected to qualification, screening and testing in which the goal was to ensure that the components would survive the stresses of the mission. The analysis categorizes failures by part type and failure mechanisms. One of the results of the analysis was the realization that a surprising proportion of failures experienced during system integration and testing were caused by human error (i.e. human induced defect). Further analysis included the determination of root failure mechanisms and any influencing factors contributing to these failures. The major causes of these defects were attributed to electrostatic damage (ESD), electrical overstress (EOS), mechanical overstress (MOS), and thermal overstress (TOS). Finally, the study proposes a risk analysis tool which incorporates these major causes for the failures, termed error-producing conditions (EPCs), and a proportionality factor representing the number of each type of failure that has occurred at the facility under study. These factors are quantified and used to communicate the risk of human induced defects for the assembly, integration and testing of space hardware based on the system’s electrical parts list. The new risk identification can trigger risk-mitigating actions more effectively, based on the presence of component categories or other hazardous conditions that have a history of failure due to human error.

Majewicz, Peter J.↗
NASA NTRSDate not supplied

Leveraging Human Performance Data to Change the Narrative that People are the Safety Problem

The study of errors and failure has a long and productive history in the behavioral sciences. By studying how systems fail, we rule out various mechanisms for how those systems might work, thereby refining our theories of how they actually work. Human performance, however, includes more than errors; human performance comprises both failures and successes. A systematic bias to collect and analyze data only on error affects the decisions we make as a community by promoting the narrative that “people are the safety problem.” This narrative manifests in both obvious and subtle ways in the design of systems intended for human use. When the only safety data that are available are about human failure, then “data-driven” designs can only consider that humans fail. Changing this narrative will depend on new data and new ways to examine data – specifically, data on the processes by which human create and contribute to safety. An alternate narrative is that people represent a primary source of safety, through their capability to anticipate, monitor for, respond to, and learn from expected and unexpected change. This presentation will describe research efforts to expand the range of safety-relevant events to include not just rare safety failures but frequent safety successes. These efforts include use of data from both operations and simulations to develop methods and metrics for learning from structured observation, self-report, and system data.

Jon Holbrook↗
NASA NTRS2013

Practical Application of PRA as an Integrated Design Tool for Space Systems

This paper presents the application of the first comprehensive Probabilistic Risk Assessment (PRA) during the design phase of a joint NASA/NOAA weather satellite program, Geostationary Operational Environmental Satellite Series R (GOES-R). GOES-R is the next generation weather satellite primarily to help understand the weather and help save human lives. PRA has been used at NASA for Human Space Flight for many years. PRA was initially adopted and implemented in the operational phase of manned space flight programs and more recently for the next generation human space systems. Since its first use at NASA, PRA has become recognized throughout the Agency as a method of assessing complex mission risks as part of an overall approach to assuring safety and mission success throughout project lifecycles. PRA is now included as a requirement during the design phase of both NASA next generation manned space vehicles as well as for high priority robotic missions. The influence of PRA on GOES-R design and operation concepts are discussed in detail. The GOES-R PRA is unique at NASA for its early implementation. It also represents a pioneering effort to integrate risks from both Spacecraft (SC) and Ground Segment (GS) to fully assess the probability of achieving mission objectives. PRA analysts were actively involved in system engineering and design engineering to ensure that a comprehensive set of technical risks were correctly identified and properly understood from a design and operations perspective. The analysis included an assessment of SC hardware and software, SC fault management system, GS hardware and software, common cause failures, human error, natural hazards, solar weather and infrastructure (such as network and telecommunications failures, fire). PRA findings directly resulted in design changes to reduce SC risk from micro-meteoroids. PRA results also led to design changes in several SC subsystems, e.g. propulsion, guidance, navigation and control (GNC), communications, mechanisms, and command and data handling (C&DH). The fault tree approach assisted in the development of the fault management system design. Human error analysis, which examined human response to failure, indicated areas where automation could reduce the overall probability of gaps in operation by half. In addition, the PRA brought to light many potential root causes of system disruptions, including earthquakes, inclement weather, solar storms, blackouts and other extreme conditions not considered in the typical reliability and availability analyses. Ultimately the PRA served to identify potential failures that, when mitigated, resulted in a more robust design, as well as to influence the program's concept of operations. The early and active integration of PRA with system and design engineering provided a well-managed approach for risk assessment that increased reliability and availability, optimized lifecyc1e costs, and unified the SC and GS developments.

Kalia, Prince↗
NASA NTRS1994

A psychologist's view of validating aviation systems

All systems, no matter what they are designed to do, have shortcomings that may make them less productive than was hoped during the initial development. Such shortcomings can arise at any stage of development: from conception to the end of the implementation life cycle. While systems failure and errors of a lesser magnitude can occur as a function of mechanical or software breakdown, the majority of such problems, in aviation are usually laid on the shoulders of the human operator and, to a lesser extent, on human factors. The operator bears the responsibility and blame even though, from a human factors perspective, error may have been designed into the system. Human factors is not a new concept in aviation. The name may be new, but the issues related to operators in the loop date back to the industrial revolution of the nineteenth century and certainly to the aviation build-up for World War I. During this first global confrontation, military services from all sides discovered rather quickly that poor selection and training led to drastically increased personnel losses. While hardware design became an issue later, the early efforts were primarily focused on increased care in pilot selection and on their training. This actually involved early labor-intensive simulation, using such devices as sticks and chairs mounted on rope networks which could be manually moved in response to control input. The use of selection criteria and improved training led to more viable person-machine systems. More pilots survived training and their first ten missions in the air, a rule of thumb arrived at by experience which predicted ultimate survival better than any other. This rule was to hold through World War II. At that time, personnel selection and training became very sophisticated based on previous standards. Also, many psychologists were drafted into Army Air Corps programs which were geared towards refining the human factor. However, despite the talent involved in these programs and the tremendous build-up of aviation during the war, there were still aircraft designs that were man killers (no sexism implied since all combat pilots were men). One classic design error that was identified fifty years ago was the multipointer altimeter, which could easily be misread especially by a pilot under considerable task load. It has led to flying fully operational aircraft into the terrain. The authors of the research which formally identified this problem put 'Human Errors' in quotes to express their dissatisfaction with the traditional approach to accident investigation. It traditionally places the burden of guilt on the operator. Some of these altimeters still exist in older aircraft to this day.

Stein, Earl S.↗
NASA NTRS1986

Anisotropic responses to motion toward and away from the eye

When a rigid object moves toward the eye, it is usually perceived as being rigid. However, in the case of motion away from the eye, the motion and structure of the object are perceived nonveridically, with the percept tending to reflect the nonrigid transformations that are present in the retinal image. This difference in response to motion to and from the observer was quantified in an experiment using wire-frame computer-generated boxes which moved toward and away from the eye. Two theoretical systems are developed by which uniform three-dimensional velocity can be recovered from an expansion pattern of nonuniform velocity vectors. It is proposed that the human visual system uses two similar systems for processing motion in depth. The mechanism used for motion away from the eye produces perceptual errors because it is not suited to objects with a depth component.

Perrone, John A.↗
NASA NTRS2005

New Integrated Modeling Capabilities: MIDAS' Recent Behavioral Enhancements

The Man-machine Integration Design and Analysis System (MIDAS) is an integrated human performance modeling software tool that is based on mechanisms that underlie and cause human behavior. A PC-Windows version of MIDAS has been created that integrates the anthropometric character "Jack (TM)" with MIDAS' validated perceptual and attention mechanisms. MIDAS now models multiple simulated humans engaging in goal-related behaviors. New capabilities include the ability to predict situations in which errors and/or performance decrements are likely due to a variety of factors including concurrent workload and performance influencing factors (PIFs). This paper describes a new model that predicts the effects of microgravity on a mission specialist's performance, and its first application to simulating the task of conducting a Life Sciences experiment in space according to a sequential or parallel schedule of performance.

Gore, Brian F.↗
NASA NTRS2004

Teleoperated Modular Robots for Lunar Operations

Solar system exploration is currently carried out by special purpose robots exquisitely designed for the anticipated tasks. However, all contingencies for in situ resource utilization (ISRU), human habitat preparation, and exploration will be difficult to anticipate. Furthermore, developing the necessary special purpose mechanisms for deployment and other capabilities is difficult and error prone. For example, the Galileo high gain antenna never opened, severely restricting the quantity of data returned by the spacecraft. Also, deployment hardware is used only once. To address these problems, we are developing teleoperated modular robots for lunar missions, including operations in transit from Earth. Teleoperation of lunar systems from Earth involves a three second speed-of-light delay, but experiment suggests that interactive operations are feasible.' Modular robots typically consist of many identical modules that pass power and data between them and can be reconfigured for different tasks providing great flexibility, inherent redundancy and graceful degradation as modules fail. Our design features a number of different hub, link, and joint modules to simplify the individual modules, lower structure cost, and provide specialized capabilities. Modular robots are well suited for space applications because of their extreme flexibility, inherent redundancy, high-density packing, and opportunities for mass production. Simple structural modules can be manufactured from lunar regolith in situ using molds or directed solar sintering. Software to direct and control modular robots is difficult to develop. We have used genetic algorithms to evolve both the morphology and control system for walking modular robots3 We are currently using evolvable system technology to evolve controllers for modular robots in the ISS glove box. Development of lunar modular robots will require software and physical simulators, including regolith simulation, to enable design and test of robot software and hardware, particularly automation software. Ready access to these simulators could provide opportunities for contest-driven development ala RoboCup (http://www.robocup.org/). Licensing of module designs could provide opportunities in the toy market and for spin-off applications.

Globus, Al↗
NASA NTRSDate not supplied

Vacuum Sealable Container (VSC) and Astronaut Lunar Drill (ALD) for Artemis

Introduction: NASA’s Artemis Program is under development to send first woman and next man to the Moon. Artemis will utilize a suite of new technology for Lunar exploration, including new space vehicles, new space suits, and new Astronaut Tools. Honeybee Robotics has been working with NASA JSC to develop a new Vacuum Sealable Container (VSC) and new Astronaut Lunar Drill (ALD) for the upcoming Artemis missions. Vacuum Sealable Container: Sample return continues to be the “Holy Grail” of space exploration, allowing for the analysis of materials using Earth-based laboratories instead of needing to miniaturize and ruggedize instrumentation for space. The Apollo missions to the Moon had several kinds of Sealable Containers which brought back Lunar samples for analysis [1]. These samples are still being analyzed, fifty years later. The VSC requirements are different from that for Apollo containers and as such, new development was required. One major difference between Artemis samples and those from Apollo is the desire to bring back volatiles which may be part of lunar regolith. The VSC is designed to withstand a high-pressure differential caused by sublimating volatiles. Because of the new, stricter sealing requirements, additional features have been added to the VSC. For example, the seal on the container is required to be more robust, thus required more force to actuate, and the seal must be locked in place with a secondary mechanism. Astronaut Lunar Drill: The ALD is designed to be a multi-functional platform for Lunar sample acquisition. The drill builds on lessons learned from the Apollo Lunar Surface Drill (ALSD), as well as Honeybee’s long history of mechanized sample acquisition devices for space [2]. The main functionality of the ALD is Deep Core Regolith Drilling. Additional functionality includes Surface Rock Coring (SRC), and GeoTech Tools (GTT). The ALD is a rotary-percussive drill designed with deep drilling in mind. The ALD is currently designed to have decoupled rotary and percussion subsystems to allow for maximum battery life and reduced fatigue on the crewmember. Honeybee drill technology will automatically engage the percussion when needed to drill at maximum efficiency. The mechanized drill stand helps improve drilling efficiency; the system utilizes advanced drilling algorithms which only require the crewmember to hold a single switch. Additionally, the stand aids in extraction of deep cores, something which was a problem on Apollo. The SRC functionality of the ALD utilizes Honeybee’s Eccentric Tube Core Breakoff technology to collect and retain rock core samples. This technology has also been infused into the Perseverance rover mission. The ALD is removable from the stand to allow crewmembers to collect samples from large boulders. Bringing back rock cores samples instead of full rocks allows for a wider variety of samples to be returned to Earth for study and puts them in a uniform form-factor for effective sealing and analysis. SRC bits will utilize the power of the drill’s percussion system to drill hard Lunar rocks and expedite sample acquisition. The mechanized stand on the ALD allows for additional attachments for taking geotechnical measurements with a Static Cone Penetrometer (SCP) and a Shear Vane (SV). With the stand, the ALD can take SCP measurements with the touch of a button, storing data for return to Earth. SV measurements utilize the ALD’s Rotary motor to spin the vanes in a controlled manner, getting clean data untampered by human error. References: [1] Bar Cohen and Zacny (2009), Drilling in Extreme Environments - Penetration and Sampling on Earth and Other Planets, Wiley. [2] Bar-Cohen and Zacny, Advances in Terrestrial and Extraterrestrial Drilling, CRC Press. [3] Myrick (2003), Core Break-off Mechanism. US Patent No. 6,550,549 Acknowledgements: This work has been supported by NASA via SBIR Phase 3.

Artemis↗
NASA NTRSDate not supplied

FEA-Based Failure Analysis of Post-Buckled Composite Multi-Hat Stiffened Panel Under Static Compression

The aerospace industry uses composite multi-hat stiffened panels for skins because of their high strength-to-weight and stiffness-to-weight ratios. However, laminated composites with initial flaws are susceptible to delamination under buckling loads. The goal is to ensure damage initiation occurs past the buckled state, only stable damage progression at loads below the ultimate compressive load, and debonding failure past the ultimate compressive load. This approach reduces weight and addresses a potential design review for future aircraft repairs. The need exists to better understand damage initiation and growth mechanisms in composite structures while assisting in the design, analysis, and sustainment methods. Teflon inserts simulate damage defects during manufacturing, while barely visible impact helps capture human error during manufacturing. This work shows the interaction between the skin-stringer and ply-ply separations at the post-buckled state for both defect events using Abaqus Virtual Crack Closure Technique (VCCT). The initial configuration for the Teflon case was to leave the Teflon region unbonded, and the initial impact damage region approximation came from the experimental data and was considered the initial configuration. When compared against the experimental data produced through the NASA Advanced Composites Project (ACP), the present model captured damage transition from skin-hat to ply1-ply2. The model validations were within ~5% of the experimental data.

composite↗
NASA NTRS1998

A Conceptual Framework for Predicting Error in Complex Human-Machine Environments

We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.

Freed, Michael↗
NASA NTRS1994

A rose by any other name: Certification seen as process rather than content

Green (1990) believes that the two main factors safeguarding flying from human error are both related to certification and regulation. First is the increasingly proceduralized nature of flying whereby as much as possible is reduced to a rule-based activity. Second is the emphasis placed upon training and competency checking of aircrew in simulators and in the air, both generally and for all particular types of aircraft flown. This leaves, believes Green, other human factors that are relatively unaddressed as yet and which can give rise to human reliability problems. These include: hardware factors and especially pilot/co-pilot relationships; and system factors including fatigue and cost/safety trade-offs. He also, importantly, identifies problems with the integration of the 'electronic crew member' following increased automation. Human reliability failures with artificial intelligence and automation, due to over-reliance on the system fail-safe mechanisms, or to operator under- confidence in the integrity or self-regulating capacity of the system, or to out-of-loop effects, are widely accepted as being due to deficiencies in plant design, planning, management and maintenance more than to 'operator error' - Reason's (1990) latent error or organization pathogens argument. Reliability failures in complex systems are well enough documented to give cause for concern and at least promote a debate on the merits of a full certification program. The purpose of this short paper is to seek out and explore what is valuable in certification, at the least to show that the benefits outweigh the disadvantages and at best to identify positive outcomes perhaps not obtainable in other ways. On both sides of the debate on certification there is general agreement on the need for a better human factors perspective and effort in complex aviation systems design. What is at issue is how this is to be promoted. It is incumbent upon opponents of certification to say how else such promotion be enabled. This is an exploratory and philosophical review, not a focused and specific one, and it will draw upon much that is not firmly in the domain of complex aviation systems.

Wilson, John R.↗
NASA NTRS2012

Human Systems Engineering for Launch processing at Kennedy Space Center (KSC)

Launch processing at Kennedy Space Center (KSC) is primarily accomplished by human users of expensive and specialized equipment. In order to reduce the likelihood of human error, to reduce personal injuries, damage to hardware, and loss of mission the design process for the hardware needs to include the human's relationship with the hardware. Just as there is electrical, mechanical, and fluids, the human aspect is just as important. The focus of this presentation is to illustrate how KSC accomplishes the inclusion of the human aspect in the design using human centered hardware modeling and engineering. The presentations also explain the current and future plans for research and development for improving our human factors analysis tools and processes.

Henderson, Gena↗
NASA NTRS2002

Skills, rules and knowledge in aircraft maintenance: errors in context

Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.

Aircraft↗