[SystemSafety] HC2AS - Human Contribution to Aviation Safety
Robert P. Schaefer
rps at mit.edu
Wed Jun 6 18:33:02 CEST 2018
Brian,
If you haven’t read John Downer on human error in aviation accidents and accident analysis, I recommend his reports highly.
I have several of his papers in my filing cabinet and can make a list for this group, if its wanted.
bob s.
Research Engineer
MIT Haystack Observatory
On Jun 6, 2018, at 12:06 PM, Smith, Brian E. (ARC-TH) <brian.e.smith at nasa.gov<mailto:brian.e.smith at nasa.gov>> wrote:
Hey everyone, I’d appreciate the insights of you safety elders (and youngers!) on this topic…
Hypothesis: While it is variously cited that human error is a causal factor in 40 to 70% of fatal aviation accidents, there are so few such fatal events that consequential human error is actually quite rare. We are currently enjoying a record level of safety in Western commercial aviation. Human actors (flight crew, ATC, airline operations centers, maintenance, etc.) with their real-time problem solving ability and resilience are a major reason today’s aviation system is as safe as it is. Granted, the role of advanced, reliable technology such as modern high-bypass ratio jet engines and “automation” avionics is not to be underestimated.
Question #1: By what mechanism(s) can we quantify the human contribution to aviation safety?
Textual analysis of narrative incident reports can produce word counts of phrases that are indicative of, say, flight-crew problem solving. The ASRS - Aviation Safety Reporting System - NASA<https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwj4_8fArb_bAhVCtlMKHSNSD3cQFggpMAA&url=https%3A%2F%2Fasrs.arc.nasa.gov%2F&usg=AOvVaw0W-4li6cnnAwT4lnj-PV3_> has a so-called “positive taxonomy” that can be used to code reports for the good actions that were reported that keep an incident from turning into a smoking hole. Other instruments such as the Normal Operations Safety Survey (NOSS) | Eurocontrol<https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwjL66zNrb_bAhUJ4VMKHQkxCiIQFgg1MAA&url=http%3A%2F%2Fwww.eurocontrol.int%2Farticles%2Fnormal-operations-safety-survey-noss&usg=AOvVaw2qaUd3clwQZhlWsrz1hoVv> are based on a threat and error model "the underlying principles of which claim that routine threats to the safety integrity of the system are constantly being managed by the system before they lead to serious outcomes.”
It is hoped that perhaps buried in digital Flight Operations Quality Assurance – FOQA<https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0ahUKEwjboI-Grr_bAhVOylMKHRuxASYQFghFMAI&url=http%3A%2F%2Ffoqa.com%2F&usg=AOvVaw3hFTKFpayhMIQlbaUvnD0_> – data or similar are telltale signatures of successful intervention by humans in adverse events.
Question #2: Have any of you examples from other industries in which human problem solving ability has been quantified in novel ways?
Inasmuch as humans are a key component of the Software – Hardware – Environment – Liveware/Liveware (SHELL) organizational model, it would be great to have hard evidence of the human contribution to safety of operations within this framework. Such evidence would be of great value in designing and testing the advanced technologies, functions, and procedures of future aviation systems.
Thanks in advance for your insights!
Brian Smith, Human Systems Integration Division, NASA Ames Research Center
* "Computers in the future may weigh no more than 1.5 tons." - Popular Mechanics, forecasting the relentless march of science, 1949.
* "I have traveled the length and breadth of this country and talked with the best people, and I can assure you that data processing is a fad that won't last out the year." - Editor in charge of business books for Prentice Hall, 1957.
* There is no reason anyone would want a computer in their home." - Ken Olson, founder of Digital Equipment Corp., 1977.
* "The concept is interesting and well-formed, but in order to earn better than a 'C,' the idea must be feasible." - A Yale University management professor in response to Fred Smith's paper proposing reliable overnight delivery service. Smith went on to found Federal Express.
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