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NASA NTRS2012

Avoiding Human Error in Mission Operations: Cassini Flight Experience

Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.

guidance and control↗

NASA NTRS1993

Analyzing human errors in flight mission operations

A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.

Bruno, Kristin J.↗

NASA NTRS2017

Spaceport Command and Control System Automated Verification Software Development

For as long as we have walked the Earth, humans have always been explorers. We have visited our nearest celestial body and sent Voyager 1 beyond our solar system1 out into interstellar space. Now it is finally time for us to step beyond our home and onto another planet. The Spaceport Command and Control System (SCCS) is being developed along with the Space Launch System (SLS) to take us on a journey further than ever attempted. Within SCCS are separate subsystems and system level software, each of which have to be tested and verified. Testing is a long and tedious process, so automating it will be much more efficient and also helps to remove the possibility of human error from mission operations. I was part of a team of interns and full-time engineers who automated tests for the requirements on SCCS, and with that was able to help verify that the software systems are performing as expected.

Automation↗

NASA NTRS1988

OMV man/system simulation integration: A preliminary analysis and recommendation

The Orbital Maneuvering Vehicle (OMV) presents a series of challenges to the human operator. Some are unique to the OMV system itself, and are largely due to remote control versus control from the cockpit. Other challenges are not necessarily unique to the OMV, but are characteristic of many man-machine space flight systems. All of these challenges affect the operator's ability to perform his portion of the mission, and could lead to human error which might jeopardize the vehicle, mission, or both. It is imperative to make every effort to design the control and displays to facilitate the operator's task. The experimental program should address the perceptual, mediational, and motor dimensions of operator performance. With this in mind, a literature review with relevant design considerations was initiated, and a comprehensive outline of control/display parameters were developed. Out of this, a series of questions not answered in the literature was derived which can be converted into experimental protocols for the simulation program. A major task of the aircraft pilot as well as the OMV operator is prediction. Certain display principles have proved to enhance the pilot's ability to predict. A brief examination of some of these principles in relationship to OMV may be useful.

Rogers, Jon G.↗

NASA NTRS2025

Limitations and Feasibility of Mini X-Ray Devices in Space Environments

LIMITATIONS AND FEASIBILITY OF MINI X-RAY DEVICES IN SPACE ENVIRONMENTS As space exploration advances toward long-duration missions, reliable medical diagnostic tools become increasingly critical. The miniature x-ray (XR) technology demonstrations by the Exploration Medical Capability (ExMC) and the Exploration Medical Integrated Product Team (XMIPT) aim to assess the feasibility and utility of miniature XR devices in spaceflight. This abstract explores the limitations of current miniature XR systems, the challenges of training crew members, the potential role of clinical decision support systems (CDSS), and the feasibility of ground-based image interpretation. We also propose the integration of miniature XR into other ExMC efforts aimed at identifying the capabilities and resources needed for future exploration class missions. One of the primary challenges with miniature XR devices is the ability to achieve specific anatomical views, particularly in the confined and weightless conditions of a spacecraft. Operators may struggle to acquire diagnostic-quality images when space is limited for proper patient positioning and the volume of the imaging device. Since space radiation and detector limitations may further impact image quality, the flexibility of the operating procedures of these devices will be critical for their success in space applications. CHALLENGES IN TRAINING CREW TO OPERATE IMAGING DEVICES Training in the skills necessary to acquire diagnostic-quality scans may be a barrier for non-clinician crewmembers. The curriculum developed for crew medical officers (CMOs) will require simplification and adaptation to fit into the highly truncated pre-flight training period. Therefore, hands-on familiarization and simulation, both pre-flight and just-in-time training during missions, will be crucial to ensuring the crew can operate the devices in real-life situations. The ability to adjust acquisition parameters must be simplified or made automatic through exam selections on equipment user interfaces, and subject and operator positioning should be assisted with laser guidance and pictorial guides. POTENTIAL FOR CDSS OR ARTIFICIAL INTELLIGENCE (AI)-ASSISTED CDSS CDSS and AI-assisted CDSS offer significant promise in assisting crew members with limited medical training. These systems could provide real-time feedback on image quality and interpretation, helping to mitigate the risks of human error during space missions. Integrating procedural guidance tools, such as virtual and augmented reality, will support crewmembers in accurately positioning patients and obtaining high-quality images. However, the success of such systems will depend on the development of robust training datasets, integration with spaceflight-rated hardware, and the medical decision-making capabilities of operators. FEASIBILITY OF GROUND INTERPRETATION AND DATA TRANSMISSION Reliance on ground-based interpretation may prove difficult for acute care during exploration class-missions due to delays in transmission with increasing distance from Earth or complete communication blackout periods. In such instances where immediate interpretation for clinical intervention is required, crew must be able to interpret the images independently or utilize AI-based assistance to do so. File sizes for XR exams can also be large if numerous images are acquired and bandwidth constraints may limit data transmissions for both radiography and ultrasound exams. FUTURE WORK AND INTEGRATION INTO THE EVIDENCE LIBRARY Future work proposes integrating miniature XR devices into NASA’s Evidence Library to address medical conditions identified as significant contributors to crew morbidity and mortality. The possibility of combining miniature XR with other imaging modalities, such as ultrasound devices, is also under investigation. In conclusion, while miniature XR technology holds potential for extraterrestrial medical systems, there are significant challenges to overcome. Training, integration of AI tools, dedicated exam protocols for microgravity, and improved data transmission systems will be key to realizing the full benefits of miniature XR technology in space.

A M Nelson↗

NASA NTRS2013

Psychophysiology of Spaceflight and Aviation

In space, the absence of gravity alone causes unique physiological stress. Significant biomedical changes, across multiple organ systems, such as body fluid redistribution, diminished musculoskeletal strength, changes in cardiac function and sensorimotor control have been reported. The time course of development of these disorders and severity of symptoms experienced by individuals varies widely. Space motion sickness (SMS) is an example of maladaptation to microgravity, which occurs early in the mission and can have profound effects on physical health and crew performance. Disturbances in sleep quality, perception, emotional equilibrium and mood have also been reported, with impact to health and performance varying widely across individuals. And lastly, post-flight orthostatic intolerance, low blood pressure experienced after returning to Earth, is also of serious concern. Both the Russian and American space programs have a varied list of human errors and mistakes, which adversely impacted mission goals. Continued probability of human exposure to microgravity for extended time periods provides a rationale for the study of the effects of stress. The primary focus of this research group is directed toward examining individual differences in: (a) prediction of susceptibility to these disorders, (b) assessment of symptom severity, (c) evaluation of the effectiveness of countermeasures, and (d) developing and testing a physiological training method, Autogenic-Feedback Training Exercise (AFTE) as a countermeasure with multiple applications. The present paper reports on the results of a series of human flight experiments with AFTE aboard the Space Shuttle and Mir Space Station, and during emergency flight scenarios on Earth.

Cowings, Patricia↗

NASA NTRS2020

Guidance for Human Error Analysis (HEA)

NASA’s Human-Rating Requirements for Space Systems in NASA Procedural Requirements (NPR) 8705.2C requires Program Managers to conduct a human error analysis (HEA) for all mission phases. The purpose of the HEA is to enable programs to understand and manage potential catastrophic hazards that could be caused by human error, understand the relative risks and uncertainties within the system design, and influence decisions throughout the system lifecycle. This document provides guidance to NASA civil servants and contractors on how the Agency’s HEA requirement can be fulfilled.

Human Error Analysis; NASA Procedural Requirement;↗

NASA NTRS2010

The Importance of HRA in Human Space Flight: Understanding the Risks

Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (~12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.

Hamlin, Teri↗

NASA NTRS2011

Automatic Facial Expression Recognition and Operator Functional State

The prevalence of human error in safety-critical occupations remains a major challenge to mission success despite increasing automation in control processes. Although various methods have been proposed to prevent incidences of human error, none of these have been developed to employ the detection and regulation of Operator Functional State (OFS), or the optimal condition of the operator while performing a task, in work environments due to drawbacks such as obtrusiveness and impracticality. A video-based system with the ability to infer an individual's emotional state from facial feature patterning mitigates some of the problems associated with other methods of detecting OFS, like obtrusiveness and impracticality in integration with the mission environment. This paper explores the utility of facial expression recognition as a technology for inferring OFS by first expounding on the intricacies of OFS and the scientific background behind emotion and its relationship with an individual's state. Then, descriptions of the feedback loop and the emotion protocols proposed for the facial recognition program are explained. A basic version of the facial expression recognition program uses Haar classifiers and OpenCV libraries to automatically locate key facial landmarks during a live video stream. Various methods of creating facial expression recognition software are reviewed to guide future extensions of the program. The paper concludes with an examination of the steps necessary in the research of emotion and recommendations for the creation of an automatic facial expression recognition program for use in real-time, safety-critical missions.

Blanson, Nina↗

NASA NTRS2012

Automatic Facial Expression Recognition and Operator Functional State

Blanson, Nina↗

NASA NTRS1993

Mission Operations and Command Assurance: Flight Operations Quality Improvements

Flight mission operations systems place human operators in demanding, high risk environments. The objective of Mission Operations and Command Assurance (MO&CA) is to help improve the operational reliability of flight projects by reducing error -- Pareto Analysis shows that the human is the largest error category. MO&CA is a system level task reporting to project flight management and JPL Systems Assurance Division. MO&CA provides direct transfer of knowledge, continuous process improvement, and communication facilitation.

mission↗

NASA NTRSDate not supplied

Human Error Analysis for Human-Rated Space Systems

Humans bring unique capabilities to space systems and contribute to mission success in a manner that cannot be matched by machines. Nevertheless, from time to time, human error can present a threat to system performance, and system designers must anticipate and manage this risk. NASA’s Human-Rating Requirements for Space Systems call for program managers to conduct a human error analysis (HEA) during system development but does not specify how to do this. In 2018, NASA’s Engineering and Safety Center asked the authors to develop a guidance document on HEA. The resulting position paper outlines a suggested method for HEA and makes it clear that error analysis is about identifying and mitigating problems at a system level, and not about finding fault with individuals. Error management strategies must be directed at error-producing conditions, thereby reducing the likelihood of human error, while retaining the positive contribution that humans make to system operations.

human error human-rated space↗

NASA NTRS2012

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

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

Henderson, Gena↗

NASA NTRS2018

GPM Mission's Best Practices: PERP

Similar to other missions, the Global Precipitation Measurement (GPM) Core Observatory's Command and Data Handling (C&DH) subsystem is critical for operations of the spacecraft. The onboard C&DH system comprises of two fully redundant boxes - a primary and a cold backup. Within each box, amongst other components, is a Single Board Computer (SBC) that hosts the flight software (FSW) system. In the event of an SBC reset, the Flight Operations Team (FOT) is poised with a lengthy task of restoring the SBC to nominal configuration. Due to the complexity of the C&DH system, this may take many days at a time to complete. The spacecraft's FSW applications are located in Electronically Erasable Programmable Read-Only Memory (EEPROM) and are copied into Random Access Memory (RAM) upon SBC initialization/reset. Each SBC has two banks of EEPROM, with each bank containing a copy of the FSW. Since launch, there have been many configuration changes to tables and applications that have been loaded into just RAM. Unfortunately, these changes are vulnerable to being wiped during a SBC initialization/reset, when the RAM is overwritten by the EEPROM. Although the EEPROM loads the default FSW configurations, the process to command non-default individual table and application changes is very cumbersome and time consuming. This consequentially increases the time until the spacecraft is back into nominal Mission Science Mode (MSM) drastically. The GPM Power-On Reset (POR) Expedited Recovery Process (PERP) Design introduces a method of consolidating commands into a single file load which the SBC can process independently of the ground - decreasing recovery time, the level of TDRS support reliance, and human error. This tested design can be implemented across many other missions that utilize a similar core Flight Executive (cFE) platform; hence providing an easy-to-follow, safe, and efficient process that can be applied across the board.

recovery↗

NASA NTRS2006

An Efficient Approach for the Reliability Analysis of Phased-Mission Systems with Dependent Failures

We consider the reliability analysis of phased-mission systems with common-cause failures in this paper. Phased-mission systems (PMS) are systems supporting missions characterized by multiple, consecutive, and nonoverlapping phases of operation. System components may be subject to different stresses as well as different reliability requirements throughout the course of the mission. As a result, component behavior and relationships may need to be modeled differently from phase to phase when performing a system-level reliability analysis. This consideration poses unique challenges to existing analysis methods. The challenges increase when common-cause failures (CCF) are incorporated in the model. CCF are multiple dependent component failures within a system that are a direct result of a shared root cause, such as sabotage, flood, earthquake, power outage, or human errors. It has been shown by many reliability studies that CCF tend to increase a system's joint failure probabilities and thus contribute significantly to the overall unreliability of systems subject to CCF.We propose a separable phase-modular approach to the reliability analysis of phased-mission systems with dependent common-cause failures as one way to meet the above challenges in an efficient and elegant manner. Our methodology is twofold: first, we separate the effects of CCF from the PMS analysis using the total probability theorem and the common-cause event space developed based on the elementary common-causes; next, we apply an efficient phase-modular approach to analyze the reliability of the PMS. The phase-modular approach employs both combinatorial binary decision diagram and Markov-chain solution methods as appropriate. We provide an example of a reliability analysis of a PMS with both static and dynamic phases as well as CCF as an illustration of our proposed approach. The example is based on information extracted from a Mars orbiter project. The reliability model for this orbiter considers the various phases of Launch, Cruise, Mars Orbit Insertion, and Orbit. Some of the CCF for the orbiter in this mission include environmental effects, such as micrometeoroids, human operator errors, and software errors.

reliability analysis↗

NASA NTRS2013

Modeling Longitudinal Data Containing Non-Normal Within Subject Errors

The mission of the National Aeronautics and Space Administration’s (NASA) human research program is to advance safe human spaceflight. This involves conducting experiments, collecting data, and analyzing data. The data are longitudinal and result from a relatively few number of subjects; typically 10 – 20. A longitudinal study refers to an investigation where participant outcomes and possibly treatments are collected at multiple follow-up times. Standard statistical designs such as mean regression with random effects and mixed–effects regression are inadequate for such data because the population is typically not approximately normally distributed. Hence, more advanced data analysis methods are necessary. This research focuses on four such methods for longitudinal data analysis: the recently proposed linear quantile mixed models (lqmm) by Geraci and Bottai (2013), quantile regression, multilevel mixed–effects linear regression, and robust regression. This research also provides computational algorithms for longitudinal data that scientists can directly use for human spaceflight and other longitudinal data applications, then presents statistical evidence that verifies which method is best for specific situations. This advances the study of longitudinal data in a broad range of applications including applications in the sciences, technology, engineering and mathematics fields.

Feiveson, Alan↗

NASA NTRS2013

A Satellite Mortality Study to Support Space Systems Lifetime Prediction

Estimating the operational lifetime of satellites and spacecraft is a complex process. Operational lifetime can differ from mission design lifetime for a variety of reasons. Unexpected mortality can occur due to human errors in design and fabrication, to human errors in launch and operations, to random anomalies of hardware and software or even satellite function degradation or technology change, leading to unrealized economic or mission return. This study focuses on data collection of public information using, for the first time, a large, publically available dataset, and preliminary analysis of satellite lifetimes, both operational lifetime and design lifetime. The objective of this study is the illustration of the relationship of design life to actual lifetime for some representative classes of satellites and spacecraft. First, a Weibull and Exponential lifetime analysis comparison is performed on the ratio of mission operating lifetime to design life, accounting for terminated and ongoing missions. Next a Kaplan-Meier survivor function, standard practice for clinical trials analysis, is estimated from operating lifetime. Bootstrap resampling is used to provide uncertainty estimates of selected survival probabilities. This study highlights the need for more detailed databases and engineering reliability models of satellite lifetime that include satellite systems and subsystems, operations procedures and environmental characteristics to support the design of complex, multi-generation, long-lived space systems in Earth orbit.

Fox, George↗

NASA NTRS2013

HRA Aerospace Challenges

Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.

DeMott, Diana↗