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At least 19 records
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NASA NTRS2009

Review of the Constellation Level II Safety, Reliability, and Quality Assurance (SR&QA) Requirements Documents during Participation in the Constellation Level II SR&QA Forum

At the request of the Exploration Systems Mission Directorate (ESMD) and the Constellation Program (CxP) Safety, Reliability; and Quality Assurance (SR&QA) Requirements Director, the NASA Engineering and Safety Center (NESC) participated in the Cx SR&QA Requirements forum. The Requirements Forum was held June 24-26; 2008, at GRC's Plum Brook Facility. The forums purpose was to gather all stakeholders into a focused meeting to help complete the process of refining the CxP to refine its Level II SR&QA requirements or defining project-specific requirements tailoring. Element prime contractors had raised specific questions about the wording and intent of many requirements in areas they felt were driving costs without adding commensurate value. NESC was asked to provide an independent and thorough review of requirements that contractors believed were driving Program costs, by active participation in the forum. This document contains information from the forum.

Cameron, Kenneth D.↗
NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗
NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗
NASA NTRSDate not supplied

An Approach to Identifying Aspects of Positive Pilot Behavior within the Aviation Safety Reporting System

The National Airspace System (NAS) is constantly evolving as air traffic continues to ramp up to pre-pandemic numbers and projected to grow to unprecedented levels in the coming years. As well as increasing demand to the current system, emerging operations such as Unmanned Autonomous Systems are also expected to add to complexity in the airspace. To address these issues, the industry and government agencies supporting the NAS will need to rely upon additional automation and new technologies to address future operational requirements, while continuing to be a world-leading safe transportation system. As these new technologies are implemented, the system continues to rely on human pilots and controllers in the loop to monitor the system and intervene in situations the automation cannot handle. The goal of proactively addressing safety is of foremost concern to ensure passenger confidence. The industry has implemented various Safety Monitoring Systems to identify safety risks and proactively address them before they result in a serious incident or accident. One such program is the Aviation Safety Reporting System (ASRS). ASRS is a long-established system where pilots and controllers voluntarily and anonymously report safety incidents they experienced and observed during line operations by providing rich text narratives describing the events, the environment, and conditions leading to the safety event of concern. These narratives provide insight and context around events of interest and can be used to identify emerging problems. They can trigger investigations within Flight Operational Quality Assurance or Flight Data Monitoring programs. However, this process typically focuses on the adverse events and the unsafe aspects of the operations surrounding the reported or detected events. This perspective of investigating factors that went wrong around an adverse event is commonly referred to as Safety I. Alternatively, characterizing successful actions that operators perform every day under varying conditions that keep the system within safe operating bounds is a concept referred to as Safety II. The benefit of the Safety II view is that the scope is much larger than that of Safety I since a vast majority of the operations result in successful flights. Many of the successful techniques used to manage operational threats are not documented in standard operating procedures or taught during training. They are typically acquired over time by working with experienced pilots during line operations or in many cases after experiencing a problem for the first time and reacting to it in situ, drawing from years of experience to manage the threat. In an attempt to quantify these positive actions, we are proposing an approach to extracting key behaviors within ASRS reports that can support the Safety II concept. Our analysis assumes that ASRS reports contain some descriptions of corrective actions that operators performed to prevent a situation from leading to an accident. Leveraging recent advances in Natural Language Process modeling, we have developed an approach to extract positive sentiment from reports, embed these positive statements in a vector space where they can be numerically analyzed, and clustering these statements into similar contextual categories. From these contextualized categories we can attempt to summarized and distilled aspects of the positive behavior. The goal is to identify categories of behavior that describe consistent operator techniques that supports the Safety II concept. With this information, airlines may enable learning from these positive actions, or address procedures that need to be changed to avoid having pilots implement a workaround. These insights can provide a lens into what is “going right” in the operations that may otherwise not be known widely within the community. It is envisioned that this approach can be extended to other narrative programs such as Line Operation Safety Audit or Learning Improvement Team reports where similar observed behavior can be analyzed to extract positive actions and inform the overall operations.

NLP↗
NASA NTRSDate not supplied

Gathering Safety Intelligence from Relevant Safety Events

The notion of Safety II grew out of the realization that people are the source of resilience in any given socio-technical system and that people, in fact, produce safety far more often than reduce safety. The talk will highlight some of the key differences between Safety I and Safety II in their assumptions about the nature of operations and the nature of safety as well as some of the limitations of each approach and the ways in which they complement each other. Because we all want to make data-informed decisions and because we already collect a lot of Safety I-type data, the talk will also describe the Flight Safety Foundation’s Learning from All Operations effort which is designed to collect Safety II-type data.

resilience↗
NASA NTRSDate not supplied

The Contribution of Pilots to Resilience in Normal Operations. Part II: A closer look at briefings: Anticipation and Monitoring Also Known as Planning and Coordination

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety↗
NASA NTRSDate not supplied

The Contribution of Pilots to Resilience in Normal Operations: A Survey Approach

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety↗
NASA NTRS2018

Identification of Safety Metrics for Airport Surface Operations

A large fraction of safety incidents occurs on the ground during airport surface operations. Although these incidents are mostly non-fatal with a few exceptions, they are high profile incidents that remain a source of concern for the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), major airlines, and other stakeholders of the National Airspace System (NAS). These incidents have historically been mitigated by implementing changes to regulations, policies, and procedures over time. This approach has minimized but not eliminated the risk of occurrences. It is thus important to develop integrated techniques to assess, model, and prevent these incidents by analyzing the risk and likelihood of occurrence and communicating results of the analysis to decision-making personnel who can mitigate and prevent incidents in real time. The research presented in this report builds on prior work of researchers at the NASA Ames Research Center who developed an automated framework, Real-Time Safety Monitoring (RTSM), to enable monitoring and prediction of the safety of the NAS. In the RTSM framework, hazards to flight are translated to safety metrics such as wake vortex encounters or loss of separation, that can be modeled and analyzed offline and also predicted and monitored in real time (online). The intent of this report is to integrate predictable incidents that occur during surface and ground operations into the safety portfolio of the RTSM project by (i) identifying suitable information sources from which ground incidents can be studied, (ii) developing safety metrics correlated with surface operations, and (iii) recommending suitable data sources that can be quantified and used for the computation of pertinent safety metrics.

ground operations↗
NASA NTRS2018

Identification of Safety Metrics for Airport Surface Operations

A large fraction of safety incidents occurs on the ground during airport surface operations. Although these incidents are mostly non-fatal with a few exceptions, they are high profile incidents that remain a source of concern for the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), major airlines, and other stakeholders of the National Airspace System (NAS). These incidents have historically been mitigated by implementing changes to regulations, policies, and procedures over time. This approach has minimized but not eliminated the risk of occurrence of safety incidents. It is thus important to develop integrated techniques to assess, model, and prevent these incidents by analyzing the risk and likelihood of occurrence and communicating results of the analysis to decision-making personnel who can mitigate and prevent incidents in real time. The work presented in this paper builds on a previously developed architecture for safety, Real-Time Safety Monitoring (RTSM), to enable monitoring and prediction of the safety of the NAS. In the RTSM framework, hazards to flight are translated to safety metrics such as wake vortex encounters or loss of separation, that can be modeled and analyzed offline and also predicted and monitored in real time (online). The intent of this paper is to integrate predictable incidents that occur during surface and ground operations into the safety portfolio of the RTSM project by (i) identifying suitable information sources from which ground incidents can be studied, (ii) developing safety metrics correlated with surface operations, and (iii) recommending suitable data sources that can be quantified and used for the computation of pertinent safety metrics.

safety↗
NASA NTRSDate not supplied

Exploring Methods to Collect and Analyze Data on Human Contributions to Aviation Safety: A Panel Discussion

Focusing on undesired operator behaviors is pervasive in system design and safety management cultures in aviation. This focus limits the data that are collected, the questions that are asked during data analysis, and therefore our understanding of what operators do in everyday work. Human performance represents a significant source of aviation safety data that includes both desired and undesired actions. When safety is characterized only in terms of errors and failures, the vast majority of human impacts on system safety and performance are ignored. The outcomes of safety data analyses dictate what is learned from those data, which in turn informs safety policies and safety-related decision making. When learning opportunities are systematically restricted by focusing only on rare failure events, not only do we learn less (and less often), but we can draw misleading conclusions by relying on a non-representative sample of human performance data. Changes in how we define and think about safety can highlight new opportunities for collection and analysis of safety-relevant data. Developing an integrated safety picture to better inform safety-related decision making and policies depends upon identifying, collecting, and interpreting safety-producing behaviors in addition to safety-reducing behaviors. Opportunities and challenges in collecting and analyzing the largely unexploited data on desired, safety-producing operator behaviors are discussed.

Aviation Safety↗
NASA NTRSDate not supplied

How Do Different Knowledge Frameworks Help Us Learn From Aviation Line Observations?

Human performance includes actions that increase safety, as well as actions that can reduce safety. Ensuring safety in complex dynamic operations like commercial aviation depends on the ability to institute appropriate responses based on what is learned from flightcrew performance and the contexts in which it occurs. To do this systemically at the organization level requires collecting data on flightcrew performance, developing effective approaches to analyzing those data, and understanding how to translate what has been learned into policies, procedures, and practice. Systematic observation of front-line operators is a vital source of human performance data. Much has been learned from such observations, including methodological principles. Most observations have been based on a framework focused on managing safety challenges and the ensuing unsafe events. A complementary perspective focuses on flexibility and actions that promote continued safe and effective operation. We consider lessons learned about observational methods from an established framework focused on undesired actions and how these might be extended for a framework focused on desired actions.

safety↗
NASA NTRS2021

Resilience Engineering's Potential for Advanced Air Mobility (AAM)

The national airspace (NAS) will rapidly evolve in the next ten to twenty years. Plans for Advanced Air Mobility (AAM) during that period envision highly automated airspace management systems and electrically powered vehicles. AAM concepts also anticipate limited human roles. The goal of limiting the human role is to minimize the potential for misadventures, yet how the human role is limited needs to be carefully considered in order to also preserve the potential for human successes. The field of resilience engineering (RE) focuses on how systems can change in order to seize an opportunity or withstand an unforeseen challenge. RE methods rely on the use of empirical data to optimize the ability of any system to adapt. RE studies have shown how individual and team initiatives ensure resilient system performance by creating safety through flexibility. Benefits of the RE approach include improved awareness of operational circumstances and how system elements depend on each other, and the ability to allocate limited resources and prepare for surprise. RE offers the ability to account for and incorporate the human role as an essential element in order to ensure NAS systems’ resilient performance. Data on the human contribution to safe and resilient system performance, which is termed “work as done,” are available but are not being considered as the NAS evolves. We present an approach that describes how use of RE can enable the evolving NAS to adapt, and perform, in a resilient manner.

Aviation Safety↗