Accident analysis and hazard analysis for human and organizational factors

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, February 2011."October 2010." Cataloged from PDF version of thesis.Includes bibliographical references (p. 275-283).Pressures and incentives to operate complex socio-technical aerospace systems in a high-risk state are ever present. Without consideration of the role humans and organizations play in system safety during the development of these systems, accidents will occur. Safe design of the "socio" parts of the sociotechnical system is challenging. Even if the system, including the human and organizational aspects of the system, are designed to be safe for anticipated system needs and operating environments, without consideration of pressures for increased performance and efficiency and shifting system goals, the system will migrate to a high-risk operating regime and safety can be compromised. Accident analysis is conducted to discover the reasons why an accident occurred and to prevent future accidents. Safety professionals have attributed 70-80% of aviation accidents to human error. Investigators have long known that the human and organizational aspects of systems are key contributors to accidents, yet they lack a rigorous approach for analyzing their impacts. Many safety engineers strive for blame-free reports that will foster reflection and learning from the accident, but struggle with methods that require direct technical causality, do not consider systemic factors, and seem to leave individuals looking culpable. An accident analysis method is needed that will guide the work, aid in the analysis of the role of human and organizations in accidents and promote blame-free accounting of accidents that will support learning from the events. Current hazard analysis methods, adapted from traditional accident models, are not able to evaluate the potential for risk migration, or comprehensively identify accident scenarios involving humans and organizations. Thus, system engineers are not able to design systems that prevent loss events related to human error or organizational factors. State of the art methods for human and organization hazard analysis are, at best, elaborate event-based classification schemes for potential errors. Current human and organization hazard analysis methods are not suitable for use as part of the system engineering process. Systems must be analyzed with methods that identify all human and organization related hazards during the design process, so that this information can be used to change the design so that human error and organization errors do not occur. Errors must be more than classified and categorized, errors must be prevented in design. A new type of hazard analysis method that identifies hazardous scenarios involving humans and organizations is needed for both systems in conception and those already in the field. This thesis contains novel new approaches to accident analysis and hazard analysis. Both methods are based on principles found in the Human Factors, Organizational Safety and System Safety literature. It is hoped that the accident analysis method should aid engineers in understanding how human actions and decisions are connected to the accident and aid in the development of blame-free reports that encourage learning from accidents. The goal for the hazard analysis method is that it will be useful in: 1) designing systems to be safe; 2) diagnosing policies or pressures and identifying design flaws that contribute to high-risk operations; 3) identifying designs that are resistant to pressures that increase risk; and 4) allowing system decision-makers to predict how proposed or current policies will affect safety. To assess the accident analysis method, a comparison with state of the art methods is conducted. To demonstrate the feasibility of the method applied to hazard analysis; it is applied to several systems in various domains.by Margaret V. Stringfellow.Ph.D

Fourth Annual Workshop on Space Operations Applications and Research (SOAR 90)

The papers from the symposium are presented. Emphasis is placed on human factors engineering and space environment interactions. The technical areas covered in the human factors section include: satellite monitoring and control, man-computer interfaces, expert systems, AI/robotics interfaces, crew system dynamics, and display devices. The space environment interactions section presents the following topics: space plasma interaction, spacecraft contamination, space debris, and atomic oxygen interaction with materials. Some of the above topics are discussed in relation to the space station and space shuttle

Twelfth Annual Conference on Manual Control

Main topics discussed cover multi-task decision making, attention allocation and workload measurement, displays and controls, nonvisual displays, tracking and other psychomotor tasks, automobile driving, handling qualities and pilot ratings, remote manipulation, system identification, control models, and motion and visual cues. Sixty-five papers are included with presentations on results of analytical studies to develop and evaluate human operator models for a range of control task, vehicle dynamics and display situations; results of tests of physiological control systems and applications to medical problems; and on results of simulator and flight tests to determine display, control and dynamics effects on operator performance and workload for aircraft, automobile, and remote control systems

Fault Detection and Isolation Expert System and Kernel Smoothing Techniques to Monitor the Continuous Automated Vault Inventory System (CAVIS)

The Continuous Automated Vault Inventory System (CAVIS™) is a system designed to continually monitor the status of special nuclear materials (SNM) at the Oak Ridge based Y-12 facility. CAVIS consists of an integrated package of low-cost sensors used to continuously monitor weight and radiation attributes of the stored items. The CAVIS system detects “change-in-state” of the special nuclear material and generates an appropriate alarm. Unfortunately, the CAVIS system is susceptible to false alarms that do not coincide with the removal of special nuclear material. These false alarms may be due to the random stochastic nature of the measurements, due to failing components, or due to external sources in the vicinity or the facility. The response to a false alarm may be an inventory check, which entails the physical verification of the attributes of the SNM. Thus, it is desirable to limit this costly response. This thesis presents the development of a monitoring system for CAVIS to eliminate the costly responses caused by false alarms. The system merges advanced statistical algorithms, such as the sequential probability ratio test (SPRT), to extract features related to changes in the CAVIS sensors with an expert system that forms a hypothesis on the root cause of any anomaly. In addition, kernel-averaging techniques have been developed as a regional anomaly-monitoring module. This thesis presents the development of the expert system and the kernel-averaging techniques features in the fault detection and isolation system. The implementation of these techniques will enable the monitoring of the CAVIS system and develop alternative hypothesis of the root cause of spurious CAVIS alarms. These alternative hypotheses can be investigated prior to any inventory check, thus reducing cost and lessening radiation exposures

Proceedings of the NASA Conference on Space Telerobotics, volume 2

These proceedings contain papers presented at the NASA Conference on Space Telerobotics held in Pasadena, January 31 to February 2, 1989. The theme of the Conference was man-machine collaboration in space. The Conference provided a forum for researchers and engineers to exchange ideas on the research and development required for application of telerobotics technology to the space systems planned for the 1990s and beyond. The Conference: (1) provided a view of current NASA telerobotic research and development; (2) stimulated technical exchange on man-machine systems, manipulator control, machine sensing, machine intelligence, concurrent computation, and system architectures; and (3) identified important unsolved problems of current interest which can be dealt with by future research

Decision uncertainty minimization and autonomous information gathering

Thesis: Ph. D., Massachusetts Institute of Technology, Department of Aeronautics and Astronautics, 2013.Cataloged from PDF version of thesis.Includes bibliographical references (pages 272-283).Over the past several decades, technologies for remote sensing and exploration have become increasingly powerful but continue to face limitations in the areas of information gathering and analysis. These limitations affect technologies that use autonomous agents, which are devices that can make routine decisions independent of operator instructions. Bandwidth and other communications limitation require that autonomous differentiate between relevant and irrelevant information in a computationally efficient manner. This thesis presents a novel approach to this problem by framing it as an adaptive sensing problem. Adaptive sensing allows agents to modify their information collection strategies in response to the information gathered in real time. We developed and tested optimization algorithms that apply information guides to Monte Carlo planners. Information guides provide a mechanism by which the algorithms may blend online (realtime) and offline (previously simulated) planning in order to incorporate uncertainty into the decisionmaking process. This greatly reduces computational operations as well as decisional and communications overhead. We begin by introducing a 3-level hierarchy that visualizes adaptive sensing at synoptic (global), mesocale (intermediate) and microscale (close-up) levels (a spatial hierarchy). We then introduce new algorithms for decision uncertainty minimization (DUM) and representational uncertainty minimization (RUM). Finally, we demonstrate the utility of this approach to real-world sensing problems, including bathymetric mapping and disaster relief. We also examine its potential in space exploration tasks by describing its use in a hypothetical aerial exploration of Mars. Our ultimate goal is to facilitate future large-scale missions to extraterrestrial objects for the purposes of scientific advancement and human exploration.by Lawrence A. M. Bush.Ph. D

Proceedings of the NASA Conference on Space Telerobotics, volume 3

The theme of the Conference was man-machine collaboration in space. The Conference provided a forum for researchers and engineers to exchange ideas on the research and development required for application of telerobotics technology to the space systems planned for the 1990s and beyond. The Conference: (1) provided a view of current NASA telerobotic research and development; (2) stimulated technical exchange on man-machine systems, manipulator control, machine sensing, machine intelligence, concurrent computation, and system architectures; and (3) identified important unsolved problems of current interest which can be dealt with by future research

Second Conference on Artificial Intelligence for Space Applications

The proceedings of the conference are presented. This second conference on Artificial Intelligence for Space Applications brings together a diversity of scientific and engineering work and is intended to provide an opportunity for those who employ AI methods in space applications to identify common goals and to discuss issues of general interest in the AI community

Proceedings of the NASA Conference on Space Telerobotics, volume 4

Papers presented at the NASA Conference on Space Telerobotics are compiled. The theme of the conference was man-machine collaboration in space. The conference provided a forum for researchers and engineers to exchange ideas on the research and development required for the application of telerobotic technology to the space systems planned for the 1990's and beyond. Volume 4 contains papers related to the following subject areas: manipulator control; telemanipulation; flight experiments (systems and simulators); sensor-based planning; robot kinematics, dynamics, and control; robot task planning and assembly; and research activities at the NASA Langley Research Center

Technology 2003: The Fourth National Technology Transfer Conference and Exposition, volume 2

Proceedings from symposia of the Technology 2003 Conference and Exposition, Dec. 7-9, 1993, Anaheim, CA, are presented. Volume 2 features papers on artificial intelligence, CAD&E, computer hardware, computer software, information management, photonics, robotics, test and measurement, video and imaging, and virtual reality/simulation