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Decision Making in Action: Applying Research to Practice

The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and 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. 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 relations between leadership, communication, decision making and overall crew performance. Implications of these findings for spaceflight and training for offshore installations will be discussed.

Orasanu, Judith↗

Decision Making in Action

The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and 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. 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 relations between leadership, communication, decision making and overall crew performance. Implications of these findings for spaceflight and training for offshore installations will be discussed.

Orasanu, Judith↗

Decision Making in Action: Applying Research to Practice

The importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment: Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and 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 good decisions are appropriate to the demands of the situation. 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 relations between leadership, communication, decision making and overall crew performance. Implications of these findings for training will be discussed.

Orasanu, Judith↗

Decision Making in the Airplane

The Importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful In improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and 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. 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 relations between leadership, communication, decision making and overall crew performance. Implications of these findings for training will be discussed.

Orasanu, Judith↗

WTEC panel report on European nuclear instrumentation and controls

Control and instrumentation systems might be called the 'brain' and 'senses' of a nuclear power plant. As such they become the key elements in the integrated operation of these plants. Recent developments in digital equipment have allowed a dramatic change in the design of these instrument and control (I&C) systems. New designs are evolving with cathode ray tube (CRT)-based control rooms, more automation, and better logical information for the human operators. As these new advanced systems are developed, various decisions must be made about the degree of automation and the human-to-machine interface. Different stages of the development of control automation and of advanced digital systems can be found in various countries. The purpose of this technology assessment is to make a comparative evaluation of the control and instrumentation systems that are being used for commercial nuclear power plants in Europe and the United States. This study is limited to pressurized water reactors (PWR's). Part of the evaluation includes comparisons with a previous similar study assessing Japanese technology.

White, James D.↗

Decision Making In A High-Tech World: Automation Bias and Countermeasures

Automated decision aids and decision support systems have become essential tools in many high-tech environments. In aviation, for example, flight management systems computers not only fly the aircraft, but also calculate fuel efficient paths, detect and diagnose system malfunctions and abnormalities, and recommend or carry out decisions. Air Traffic Controllers will soon be utilizing decision support tools to help them predict and detect potential conflicts and to generate clearances. Other fields as disparate as nuclear power plants and medical diagnostics are similarly becoming more and more automated. Ideally, the combination of human decision maker and automated decision aid should result in a high-performing team, maximizing the advantages of additional cognitive and observational power in the decision-making process. In reality, however, the presence of these aids often short-circuits the way that even very experienced decision makers have traditionally handled tasks and made decisions, and introduces opportunities for new decision heuristics and biases. Results of recent research investigating the use of automated aids have indicated the presence of automation bias, that is, errors made when decision makers rely on automated cues as a heuristic replacement for vigilant information seeking and processing. Automation commission errors, i.e., errors made when decision makers inappropriately follow an automated directive, or automation omission errors, i.e., errors made when humans fail to take action or notice a problem because an automated aid fails to inform them, can result from this tendency. Evidence of the tendency to make automation-related omission and commission errors has been found in pilot self reports, in studies using pilots in flight simulations, and in non-flight decision making contexts with student samples. Considerable research has found that increasing social accountability can successfully ameliorate a broad array of cognitive biases and resultant errors. To what extent these effects generalize to performance situations is not yet empirically established. The two studies to be presented represent concurrent efforts, with student and professional pilot samples, to determine the effects of accountability pressures on automation bias and on the verification of the accurate functioning of automated aids. Students (Experiment 1) and commercial pilots (Experiment 2) performed simulated flight tasks using automated aids. In both studies, participants who perceived themselves as accountable for their strategies of interaction with the automation were significantly more likely to verify its correctness, and committed significantly fewer automation-related errors than those who did not report this perception.

Mosier, Kathleen L.↗

Man-Machine Interaction Design and Analysis System (MIDAS): Memory Representation and Procedural Implications for Airborne Communication Modalities

The Man-Machine Interaction Design and Analysis System (MIDAS) has been under development for the past ten years through a joint US Army and NASA cooperative agreement. MIDAS represents multiple human operators and selected perceptual, cognitive, and physical functions of those operators as they interact with simulated systems. MIDAS has been used as an integrated predictive framework for the investigation of human/machine systems, particularly in situations with high demands on the operators. Specific examples include: nuclear power plant crew simulation, military helicopter flight crew response, and police force emergency dispatch. In recent applications to airborne systems development, MIDAS has demonstrated an ability to predict flight crew decision-making and procedural behavior when interacting with automated flight management systems and Air Traffic Control. In this paper we describe two enhancements to MIDAS. The first involves the addition of working memory in the form of an articulatory buffer for verbal communication protocols and a visuo-spatial buffer for communications via digital datalink. The second enhancement is a representation of multiple operators working as a team. This enhanced model was used to predict the performance of human flight crews and their level of compliance with commercial aviation communication procedures. We show how the data produced by MIDAS compares with flight crew performance data from full mission simulations. Finally, we discuss the use of these features to study communications issues connected with aircraft-based separation assurance.

Corker, Kevin M.↗

Instrumentation and Control Needs for Reliable Operation of Lunar Base Surface Nuclear Power Systems

As one of the near-term goals of the President's Vision for Space Exploration, establishment of a multi-person lunar base will require high-endurance power systems which are independent of the sun, and can operate without replenishment for several years. These requirements may be obtained using nuclear power systems specifically designed for use on the lunar surface. While it is envisioned that such a system will generally be supervised by humans, some of the evolutions required maybe semi or fully autonomous. The entire base complement for near-term missions may be less than 10 individuals, most or all of which may not be qualified nuclear plant operators and may be off-base for extended periods thus, the need for power system autonomous operation. Startup, shutdown, and load following operations will require the application of advanced control and health management strategies with an emphasis on robust, supervisory, coordinated control of, for example, the nuclear heat source, energy conversion plant (e.g., Brayton Energy Conversion units), and power management system. Autonomous operation implies that, in addition to being capable of automatic response to disturbance input or load changes, the system is also capable of assessing the status of the integrated plant, determining the risk associated with the possible actions, and making a decision as to the action that optimizes system performance while minimizing risk to the mission. Adapting the control to deviations from design conditions and degradation due to component failures will be essential to ensure base inhabitant safety and mission success. Intelligent decisions will have to be made to choose the right set of sensors to provide the data needed to do condition monitoring and fault detection and isolation because of liftoff weight and space limitations, it will not be possible to have an extensive set of instruments as used for earth-based systems. Advanced instrumentation and control technologies will be needed to enable this critical functionality of autonomous operation. It will be imperative to consider instrumentation and control requirements in parallel to system configuration development so as to identify control-related, as well as integrated system-related, problem areas early to avoid potentially expensive work-arounds . This paper presents an overview of the enabling technologies necessary for the development of reliable, autonomous lunar base nuclear power systems with an emphasis on system architectures and off-the-shelf algorithms rather than hardware. Autonomy needs are presented in the context of a hypothetical lunar base nuclear power system. The scenarios and applications presented are hypothetical in nature, based on information from open-literature sources, and only intended to provoke thought and provide motivation for the use of autonomous, intelligent control and diagnostics.

Turso, James↗

Common Cause Failure Modeling

Common Cause Failures (CCFs) are a known and documented phenomenon that defeats system redundancy. CCFS are a set of dependent type of failures that can be caused by: system environments; manufacturing; transportation; storage; maintenance; and assembly, as examples. Since there are many factors that contribute to CCFs, the effects can be reduced, but they are difficult to eliminate entirely. Furthermore, failure databases sometimes fail to differentiate between independent and CCF (dependent) failure and data is limited, especially for launch vehicles. The Probabilistic Risk Assessment (PRA) of NASA's Safety and Mission Assurance Directorate at Marshall Space Flight Center (MFSC) is using generic data from the Nuclear Regulatory Commission's database of common cause failures at nuclear power plants to estimate CCF due to the lack of a more appropriate data source. There remains uncertainty in the actual magnitude of the common cause risk estimates for different systems at this stage of the design. Given the limited data about launch vehicle CCF and that launch vehicles are a highly redundant system by design, it is important to make design decisions to account for a range of values for independent and CCFs. When investigating the design of the one-out-of-two component redundant system for launch vehicles, a response surface was constructed to represent the impact of the independent failure rate versus a common cause beta factor effect on a system's failure probability. This presentation will define a CCF and review estimation calculations. It gives a summary of reduction methodologies and a review of examples of historical CCFs. Finally, it presents the response surface and discusses the results of the different CCFs on the reliability of a one-out-of-two system.

Hark, Frank↗

Common Cause Failure Modeling

Common Cause Failures (CCFs) are a known and documented phenomenon that defeats system redundancy. CCFS are a set of dependent type of failures that can be caused by: system environments; manufacturing; transportation; storage; maintenance; and assembly, as examples. Since there are many factors that contribute to CCFs, the effects can be reduced, but they are difficult to eliminate entirely. Furthermore, failure databases sometimes fail to differentiate between independent and CCF (dependent) failure and data is limited, especially for launch vehicles. The Probabilistic Risk Assessment (PRA) of NASA's Safety and Mission Assurance Directorate at Marshal Space Flight Center (MFSC) is using generic data from the Nuclear Regulatory Commission's database of common cause failures at nuclear power plants to estimate CCF due to the lack of a more appropriate data source. There remains uncertainty in the actual magnitude of the common cause risk estimates for different systems at this stage of the design. Given the limited data about launch vehicle CCF and that launch vehicles are a highly redundant system by design, it is important to make design decisions to account for a range of values for independent and CCFs. When investigating the design of the one-out-of-two component redundant system for launch vehicles, a response surface was constructed to represent the impact of the independent failure rate versus a common cause beta factor effect on a system's failure probability. This presentation will define a CCF and review estimation calculations. It gives a summary of reduction methodologies and a review of examples of historical CCFs. Finally, it presents the response surface and discusses the results of the different CCFs on the reliability of a one-out-of-two system.

Hark, Frank↗

Strategies for Quantifying Human Space Flight Performance in the Crew Health and Performance System

The Crew Health and Performance-Probabilistic Risk Assessment (CHP-PRA) team at NASA Glenn Research Center is planning a customized approach to quantify human spaceflight performance changes with respect to changes to the CHP system functions and capabilities. Using the Directed Acyclic Graphs (DAG) initiated by NASA’s Human Systems Risk Board (HSRB) [1], the team is surveying potential candidate models and novel strategies that generate metrics suitable for supporting decision making related to how the CHP system may influence human system performance risk. One such investigation includes classic Human Reliability Analysis (HRA) models. Traditionally, HRA methods estimate the occurrence of human errors and their impact on the success of an activity when designing and operating a system. While humans perceive, interpret, decide on, and carry out a course of action, the factors affecting performance and error likelihood are commonly referred to as performance shaping factors (PSFs). Originally developed to alleviate safety concerns related to nuclear power plant operations, HRA methods such as THERP [2] and CREAM [3] dismantle an activity into tasks, requiring elemental steps to be executed, and assess their failure due to predefined PSFs. In this study, we compare generic HRA methods and those that incorporate some human spaceflight aspects, such as sleep conditions (SCREAM [4]), with respect to how they may be adopted to capture performance with an intention to mitigate detrimental outcomes elucidated by the HSRB DAGs. We suggest strategies to quantify astronaut performance specific to spaceflight activities and illustrate how such concepts may help in optimizing the CHP system capabilities with respect to Artemis missions.

dag↗

Inflight and Preflight Detection of Pitot Tube Anomalies

The health and integrity of aircraft sensors play a critical role in aviation safety. Inaccurate or false readings from these sensors can lead to improper decision making, resulting in serious and sometimes fatal consequences. This project demonstrated the feasibility of using advanced data analysis techniques to identify anomalies in Pitot tubes resulting from blockage such as icing, moisture, or foreign objects. The core technology used in this project is referred to as noise analysis because it relates sensors' response time to the dynamic component (noise) found in the signal of these same sensors. This analysis technique has used existing electrical signals of Pitot tube sensors that result from measured processes during inflight conditions and/or induced signals in preflight conditions to detect anomalies in the sensor readings. Analysis and Measurement Services Corporation (AMS Corp.) has routinely used this technology to determine the health of pressure transmitters in nuclear power plants. The application of this technology for the detection of aircraft anomalies is innovative. Instead of determining the health of process monitoring at a steady-state condition, this technology will be used to quickly inform the pilot when an air-speed indication becomes faulty under any flight condition as well as during preflight preparation.

Mitchell, Darrell W.↗