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This slide presentation reviews the precursor analysis for flight and ground based anomaly risk significance. It includes information on accident precursor analysis, real models vs. models, and probabilistic analysis.
Accident Precursor Analysis (APA) serves as the bridge between existing risk modeling activities, which are often based on historical or generic failure statistics, and system anomalies, which provide crucial information about the failure mechanisms that are actually operative in the system and which may differ in frequency or type from those in the various models. These discrepancies between the models (perceived risk) and the system (actual risk) provide the leading indication of an underappreciated risk. This paper presents an APA process developed specifically for NASA Earth-to-Orbit space systems. The purpose of the process is to identify and characterize potential sources of system risk as evidenced by anomalous events which, although not necessarily presenting an immediate safety impact, may indicate that an unknown or insufficiently understood risk-significant condition exists in the system. Such anomalous events are considered accident precursors because they signal the potential for severe consequences that may occur in the future, due to causes that are discernible from their occurrence today. Their early identification allows them to be integrated into the overall system risk model used to intbrm decisions relating to safety.
The JBS Foods 2021 Ransomware Attack Precursor Analysis Report leverages publicly available information about the JBS ransomware cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. In late May 2021, one of the world’s largest meat producers, JBS Foods, announced they had fallen victim to a worldwide ransomware attack, later found to be REvil ransomware. In the United States alone, JBS Foods accounts for nearly 25% of beef and roughly 20% of pork production. Adversaries initially launched a Distributed Denial of Service (DDoS) attack on the company’s Information Technology (IT) networks in Australia, but the attack impacted operations in Brazil, Canada, and the United States, as well. The attack caused plant operations in all four countries to shut down for at least one day. All nine of the U.S. meatpacking plants temporarily shut down because of the attack. The adversaries initially demanded a $\$$22 million ransom for the company’s data, but later negotiated the ransom down to $\$$11 million even after JBS Foods restored most of their systems. JBS Foods eventually paid the $\$$11 Million for reassurance from the adversaries that none of their customers’ data would be compromised in the future. Despite its short duration, the attack still caused large stocks of meat to spoil. The incident also underscored how adversaries can simultaneously compromise and move laterally through global subsidiaries of an organization. Researchers and analysts identified 22 unique techniques (in a sequence of 21 steps) utilized during the attack with a total of 361 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Sixteen of the identified techniques used during the JBS Foods cyber attack were precursors to the triggering event. Analysis identified 308 observables associated with these precursor techniques, 163 of which were assessed to have an increased likelihood of being perceived in the 75 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The BlackMatter Ransomware Attack on New Cooperative 2021 Precursor Analysis Report leverages publicly available information about the New Cooperative cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. The BlackMatter ransomware was first identified in July 2021 and is reported to have infected more than 50 corporations around the world. , The Iowa-based grain cooperative, New Cooperative, was impacted by the BlackMatter ransomware on or before 18 September 2021. The adversary likely resided on New Cooperative’s networks for 15 days prior to encrypting its network and demanding New Cooperative pay $5.9 million in ransom by 25 September to unlock systems and prevent 1 terabyte (TB) of sensitive data from being publicly released. It is not clear if New Cooperative paid the ransom. The full impact of the ransomware attack is not known; however, according to New Cooperative’s general manager, the attack caused the company’s automated processes to revert back to processes used in the 1970s. , As of 6 October, only 50 percent of New Cooperative’s operations were utilizing automated processes. The company took eight weeks to rebuild the entire network and information technology (IT) systems from the ground up, which puts the date of fully recovery around 13 November. Researchers and analysts identified 20 unique techniques utilized during the attack with a total of 404 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Seventeen of the identified techniques used during the New Cooperative cyber attack were precursors to the triggering event. Analysis identified 360 observables associated with these precursor techniques, 284 of which were assessed to have an increased likelihood of being perceived in the 15 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The Cyber Attack on Thyssenkrupp Blast Furnace 2014 Precursor Analysis Report leverages publicly available information about the Thyssenkrupp Steel Mill cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. In December 2014, the German Government’s Federal Office for Information Security (BSI) released a report detailing a cyber attack on a German steel mill that occurred earlier that year, though exact dates and details of the attack were not revealed. While the report did not specify the name of the company, multiple sources identified the victim as one of Europe’s largest steel manufacturers, Thyssenkrupp AG. Further, Thyssenkrupp announced on 16 May of that year that Europe’s largest blast furnace, “Schwelgern 2,” located at its facility in Duisburg, Germany, would be offline for several weeks for repairs and upgrades, suggesting Schwelgern 2 was likely the target of the attack. The attack began in early 2014, when adversaries infiltrated the victim steel mill’s Information Technology (IT) network via a spearphishing campaign, then worked their way into the Operational Technology (OT) environment, where they executed software that caused denial of service, denial of control, and eventually a loss of control. This led to the blast furnace shutting down without proper safety procedures, resulting in catastrophic physical damage. No lives were lost in the incident, but ThyssenKrupp suffered $4 million in damage to the blast furnace and an additional $6 million in lost revenue. The adversaries required specialized knowledge and expertise in steel production, which enabled them to compromise a variety of internal systems and components across both IT and OT networks. The attack also demonstrated detailed knowledge of the industrial control systems (ICS) and production processes being used. This combination resulted in one of the earliest known publicly reported cybersecurity incidents resulting in physical damage to ICS equipment. Researchers and analysts identified 19 unique techniques (used in a sequence of 20 steps) utilized during the attack with a total of 454 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Fifteen of the identified techniques used during the Thyssenkrupp cyber attack were precursors to the triggering event. Analysis identified 369 observables associated with these precursor techniques, 316 of which were assessed to have an increased likelihood of being perceived in the 120 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The DoppelPaymer Ransomware Attack on Petroleos Mexicanos (PEMEX) 2019 Precursor Analysis Report leverages publicly available information about the PEMEX cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. The 2019 DoppelPaymer ransomware attack on PEMEX, Mexico’s nationalized petroleum corporation, highlights a unique threat that ransomware and cybercriminal extortion poses to Operational Technology (OT) environments in critical infrastructure. The incident began with an employee downloading commodity malware that allowed adversaries to gain initial access to PEMEX’s enterprise environment. After conducting privilege escalation, tool ingress, and data exfiltration, the adversaries deployed DoppelPaymer ransomware throughout the PEMEX enterprise environment, resulting in the company having to take dozens of systems offline for at least several days. Although PEMEX stated that their operations were not affected, the data exfiltrated from PEMEX was made available for download on DoppelPaymer’s leak site, as well as on other illicit criminal forums. This stolen data included not only company information, but also sensitive OT-specific configuration data. This incident showcases how cybercriminal exfiltration and posting of sensitive OT architecture documentation can pose security concerns for the targeted organization for years due to the long lifespan of OT assets and architectures. Researchers and analysts identified 18 unique techniques utilized during the attack with a total of 190 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Fifteen of the identified techniques used during the DoppelPaymer ransomware attack were precursors to the triggering event. Analysis identified 163 observables associated with these precursor techniques, 34 of which were assessed to have an increased likelihood of being perceived in the 60 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
Accident Precursor Analysis (APA) serves as the bridge between existing risk modeling activities, which are often based on historical or generic failure statistics, and system anomalies, which provide crucial information about the failure mechanisms that are actually operative in the system. APA docs more than simply track experience: it systematically evaluates experience, looking for under-appreciated risks that may warrant changes to design or operational practice. This paper presents the pilot application of the NASA APA process to Space Shuttle Orbiter systems. In this effort, the working sessions conducted at Johnson Space Center (JSC) piloted the APA process developed by Information Systems Laboratories (ISL) over the last two years under the auspices of NASA's Office of Safety & Mission Assurance, with the assistance of the Safety & Mission Assurance (S&MA) Shuttle & Exploration Analysis Branch. This process is built around facilitated working sessions involving diverse system experts. One important aspect of this particular APA process is its focus on understanding the physical mechanism responsible for an operational anomaly, followed by evaluation of the risk significance of the observed anomaly as well as consideration of generalizations of the underlying mechanism to other contexts. Model completeness will probably always be an issue, but this process tries to leverage operating experience to the extent possible in order to address completeness issues before a catastrophe occurs.
The Ryuk Ransomware Attack on Universal Health Services (UHS) 2020 Precursor Analysis Report leverages publicly available information about the 2020 UHS cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. UHS manages over 400 hospitals and is one of the largest healthcare providers in the United States with 3.5 million patients each year. On 27 September 2020, UHS suffered a widespread ransomware attack that resulted in a denial of service to critical internet-dependent healthcare systems including workstations, phones, and data centers. Employees resorted to filing patient details with pen and paper, while other facilities had to redirect ambulances and urgent patients to other facilities for adequate care. Adversaries carried out the attack with Ryuk, a ransomware that encrypts data and generates a RyukReadMe.txt ransom note with the ransom fee to decrypt the data, varying from 15 Bitcoin (BTC) to 50 BTC, equivalent to roughly $\$$353,892 to $\$$964,617. UHS did not pay the ransom and was able to recover data through backups, but still reported an impact of $\$$67 million dollars in recovery costs. On 29 October, one month after the attack, UHS made an official statement that their systems had been restored and they were resuming normal operations. Researchers and analysts identified 18 unique techniques (used in a sequence of 19 steps) utilized during the attack with a total of 185 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Fourteen of the identified techniques used during the UHS cyber attack were precursors to the triggering event. Analysis identified 106 observables associated with these precursor techniques, 82 of which were assessed to have an increased likelihood of being perceived in the 30 days to two hours preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The Remote Access Attack on Oldsmar Water Treatment Facility 2021 Precursor Analysis Report leverages publicly available information about the Oldsmar cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. On 5 February 2021, an adversary gained unauthorized remote access to Bruce T. Haddock Water Treatment Plant in Oldsmar, Florida, which provides treated water to 15,000 customers. The adversary accessed the facility’s Supervisory Control and Data Acquisition (SCADA) workstation and human machine interface (HMI) to change the chemical concentration of sodium hydroxide, commonly referred to as lye and used to regulate acidity levels, from 100 parts per million (PPM) to 11,100 PPM. The chemical was raised to lethal levels that if ingested could lead to serious soft tissue damage, burns, or even death. The facility, however, had redundancies and alarms in place to alert personnel of dangerous chemical levels, and facility officials stated it would have taken 24 to 36 hours for the chemical changes to affect the water supply. Researchers and analysts identified six unique techniques utilized during the attack with a total of 23 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Four of the identified techniques used during the Oldsmar cyber attack were precursors to the triggering event. Analysis identified 21 observables associated with these precursor techniques, 20 of which were assessed to have an increased likelihood of being perceived in the minutes preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The Industroyer2 and Wiper Malware Targeting Ukrainian Energy Provider 2022 Precursor Analysis Report leverages publicly available information about the Industroyer2 cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. An adversary attempted to cause a blackout in Ukraine in April 2022 by using the Industroyer2 malware against a regional Ukrainian energy provider. The adversary targeted eight high-voltage electrical substations and utilized the malware in tandem with disk wipers for Windows, Linux, and Solaris operating systems in an attempt to make response and recovery efforts more difficult. The adversary reused a piece of the original Industroyer malware designed to open circuit breakers and de-energize target substations. The adversary gained initial access to the victim’s enterprise network through unknown means in February 2022 and was able to perform reconnaissance, pivot to the operations network, and reside in the system for at least 51 days. This gave the adversary a detailed understanding of the environment and allowed them to customize the Industroyer2 malware to the victim’s operations network. However, defenders detected and stopped the attack before the adversary could achieve their intended impact. Had the Industroyer2 attack been successful, it could have caused a blackout for more than two million people during the early stages of Russia’s invasion of Ukraine. Researchers and analysts identified 22 unique techniques (used in a sequence of 31 steps) utilized during the attack with a total of 297 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Twenty-three of the identified techniques used during the Industroyer2 cyber attack were precursors to the triggering event. Analysis identified 224 observables associated with these precursor techniques, 122 of which were assessed to have an increased likelihood of being perceived in the 51 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The Industroyer Targeting Ukraine Electric Power Transport Utility (Ukrenergo) 2016 Precursor Analysis Report leverages publicly available information about the December 2016 cyber attack against the Ukrainian Ukrenergo electric transmission utility and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. Industroyer is a modular malware framework designed to deploy several Industrial Control System (ICS) protocol-specific attack payloads to disrupt electricity distribution. Adversaries deployed Industroyer within the target network on a Microsoft Windows endpoint capable of directly manipulating or communicating with ICS. Industroyer abuses the functionality of a targeted ICS’s legitimate control system to achieve its intended impact. Adversaries likely first gained access to Ukrenergo enterprise networks in early 2016 after a successful spearphishing campaign against organizations in the electric power sector. Adversaries then began capturing credentials beginning on 1 December 2016. This allowed access to the ICS environment at the Pivnichna electric transmission substation outside Kyiv through a device dual-homed on the Information Technology (IT) and ICS networks. Adversaries conducted discovery, targeting, and access to this device using information and previously captured credentials from compromised enterprise IT machines. Finally, the adversaries deployed and launched the Industroyer malware just before midnight on 17 December. By midnight, Ukrenergo had lost control of a targeted substation, resulting in electric power outages for over an hour in the city of Kyiv and the Kyiv region. Researchers and analysts identified 31 unique techniques (used in a sequence of 33 steps) utilized during the attack with a total of 846 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Twenty-nine of the identified techniques used during the Industroyer cyber attack were precursors to the triggering event. Analysis identified 548 observables associated with these precursor techniques, 353 of which were assessed to have an increased likelihood of being perceived in the 300 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The Conti Ransomware Attack on the Health Service Executive (HSE) of Ireland 2021 Precursor Analysis Report leverages publicly available information about the attack and catalogs anomalous observables for each technique employed by the adversary. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. The HSE provides public healthcare corporate services and operational services throughout Ireland, with critical functions including the acute national ambulance service, acute hospital service, and community healthcare service. On 14 May 2021, Conti ransomware encrypted 80 percent of the HSE’s Information Technology (IT) infrastructure across corporate, hospital, community, and electronic health record services. Conti is a ransomware-as-a-service operation that encrypts local files, uses double extortion against victims, and is facilitated by many intrusion tools. The attack forced the HSE to shut down its entire IT infrastructure to contain the ransomware, forcing employees to revert to pen and paper recordkeeping and leading to the cancellation of many appointments and procedures. The adversary also exfiltrated 700 GB of data, compromising the confidentiality of patients’ protected health information. Had the adversary targeted the COVID-19 cloud systems or operational technology assets, such as Internet of Medical Things medical devices or smart building management systems, the impact of the attack would almost certainly have been far more severe. Researchers and analysts identified 21 unique techniques (used in a sequence of 23 steps) likely utilized during the attack with a total of 1,185 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Twenty-one of the identified techniques used during the attack on the HSE were precursors to the triggering event. Analysis identified 1,086 observables associated with these precursor techniques, 850 of which were assessed to have an increased likelihood of being perceived in the 57 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
The SQL Slammer Worm Infection of Davis-Besse Nuclear Power Plant 2003 Precursor Analysis Report leverages publicly available information about Davis-Besse’s 2003 cyber attack and catalogs anomalous observables for each technique employed in the attack. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. On 25 January 2003, the SQL Slammer worm infected more than 90% of vulnerable hosts and crashed the internet in 10 to 15 minutes, making it one of the fastest spreading worms in history. SQL Slammer is a fileless, memory-resident worm that remotely exploits a stack-based buffer overflow vulnerability on local hosts to intensively scan and rapidly self-propagate across the internet. The worm infected approximately 300,000 unpatched hosts running Microsoft Structured Query Language (SQL) Server 2000 or Microsoft Desktop Engine (MSDE) 2000 with SQL Server Resolution Service. The SQL Slammer worm indirectly infected FirstEnergy’s Davis-Besse nuclear power plant by first infecting a consultant’s company network server and then propagating through an external misconfigured connection into Davis-Besse’s site network. The infection caused major network congestion, slow performance, data overloads, and the inability of local hosts to communicate with each other, which eventually caused a loss of availability and a loss of view when the Safety Parameter Display System (SPDS) and Plant Process Computer (PPC) crashed. At the time of the infection, the plant was already offline, the digital monitoring systems had redundant analog backups, and the plant control and safety functions were not affected, so there were no concerns of a safety breach. However, this incident resulted in many lessons learned and spawned important discussions about cybersecurity’s role in nuclear safety and electric power reliability regulation, policy, and guidance. Researchers and analysts identified 10 unique techniques utilized during the attack with a total of 640 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Eight of the identified techniques used during Davis-Besse cyber attack were precursors to the triggering event. Analysis identified 596 observables associated with these precursor techniques, 428 of which were assessed to have an increased likelihood of being perceived in the 331 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.
This viewgraph presentation reviews the implementation of Accident Precursor Analysis (APA), as well as the evaluation of In-Flight Investigations (IFI) and Problem Reporting and Corrective Action (PRACA) data for the identification of unrecognized accident potentials on the International Space Station.
Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.
Almost every year there is at least one technological disaster that highlights the challenge of managing technological risk. On February 1, 2003, the space shuttle Columbia and her crew were lost during reentry into the atmosphere. In the summer of 2003, there was a blackout that left millions of people in the northeast United States without electricity. Forensic analyses, congressional hearings, investigations by scientific boards and panels, and journalistic and academic research have yielded a wealth of information about the events that led up to each disaster, and questions have arisen. Why were the events that led to the accident not recognized as harbingers? Why were risk-reducing steps not taken? This line of questioning is based on the assumption that signals before an accident can and should be recognized. To examine the validity of this assumption, the National Academy of Engineering (NAE) undertook the Accident Precursors Project in February 2003. The project was overseen by a committee of experts from the safety and risk-sciences communities. Rather than examining a single accident or incident, the committee decided to investigate how different organizations anticipate and assess the likelihood of accidents from accident precursors. The project culminated in a workshop held in Washington, D.C., in July 2003. This report includes the papers presented at the workshop, as well as findings and recommendations based on the workshop results and committee discussions. The papers describe precursor strategies in aviation, the chemical industry, health care, nuclear power and security operations. In addition to current practices, they also address some areas for future research.
We utilized high-energy x-ray tomography to characterize Ti-6Al-4V metal powders (both as-received and recycled) used in powder-bed additive manufacturing process. The image processing workflow was developed to process and analyze large amount of data objectively by computer program. The distribution of size and shape of the metal particles as well as defect (mainly porosity) inside the particles was analyzed with the statistical representation and resolution in micrometer. The result revealed that circular-shaped porosity with various sizes could be embedded in the powder particles. These porosities could potentially be transferred to the 3D printed part and critically affect the mechanical performance of the component. The present study shows the effectiveness of characterizing metal powders using x-ray imaging techniques where sufficient number of particles can be sampled within tens of minutes with a minimum sample preparation and high accuracy. Clear structural differences in the as-received and recycled powders were delineated that helps in determining the feasibility of using the recycled powders.
Although studies of many respiratory viruses and pollens are often framed by both seasonal and health related perspectives, pollen has yet to be extensively examined as an important covariate to seasonal respiratory viruses (SRVs) in any context, including a causal one. This study contributes to those goals through an investigation of SRVs and pollen counts at selected regions across the Western Hemisphere. Two complementary decadal-scaled geospatial profiles were developed. One laterally spanned the US and was anchored by detailed pollen information for Albuquerque, New Mexico. The other straddled the equator to include Fortaleza, Brazil. We found that the geospatial and climatological patterns of pollen advancement and decline across the US every year presented a statistically significant correlation to the subsequent emergence and decline of SRVs. Other significant covariates included winds, temperatures, and atmospheric moisture. Our study indicates that areas of the US with lower geostrophic wind baselines are typically areas of persistently higher and earlier influenza like illness (ILI) cases. In addition to that continental- scaled contrast, many sites indicated seasonal highs of geostrophic winds and ILI which were closely aligned. These observations suggest extensive scale-dependent connectivity of viruses to geostrophic circulation. Pollen emergence and its own scale-dependent circulation may contribute to the geospatial and seasonal patterns of ILI. We explore some uncertainties associated with this investigation, and consider the possibility that in a temperate climate, following a Spring pollen emergence, a resulting increase in pollen triggered human Immunoglobulin E (IgE) antibodies may suppress ILIs for several months.