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- Title
- INFLUENCE MAP METHODOLOGY FOR EVALUATING SYSTEMIC SAFETY ISSUES.
- Creator
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Barth, Timothy, Pet-Armacost, Julia, University of Central Florida
- Abstract / Description
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"Raising the bar" in safety performance is a critical challenge for many organizations. Contributing factor taxonomies organize information on why accidents occur. Therefore, they are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This research successfully addressed two problems: (1)...
Show more"Raising the bar" in safety performance is a critical challenge for many organizations. Contributing factor taxonomies organize information on why accidents occur. Therefore, they are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This research successfully addressed two problems: (1) limited methods and metrics exist to support the design of effective taxonomies, and (2) influence relationships between contributing factors are not explicitly modeled within a taxonomy. The primary result of the taxonomic relationship modeling efforts was an innovative "dual role" contributing factor taxonomy with significant improvements in comprehensiveness and diagnosticity over existing taxonomies. The influence map methodology was the result of a unique graphical and analytical combination of the dual role taxonomy and influence relationship models. Influence maps were developed for several safety incidents at Kennedy Space Center. An independent assessment was conducted by a team of experts using the new dual role taxonomy and influence chain methodology to evaluate the accuracy and completeness of contributing factors identified during the formal incident investigations. One hundred and sixteen contributing factors were identified using the influence map methodology. Only 16% of these contributing factors were accurately identified with traditional tools, and over half of the 116 contributing factors were completely unaddressed by the findings and recommendations of the formal incident reports. The new methodology is being applied to improve spaceport operations and enhance designs of future NASA launch systems.
Show less - Date Issued
- 2006
- Identifier
- CFE0001274, ucf:46928
- Format
- Document (PDF)
- PURL
- http://purl.flvc.org/ucf/fd/CFE0001274
- Title
- A Systems Approach to Assessing, Interpreting and Applying Human Error Mishap Data to Mitigate Risk of Future Incidents in a Space Exploration Ground Processing Operations Environment.
- Creator
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Alexander, Tiffaney, McCauley, Pamela, Rabelo, Luis, Karwowski, Waldemar, Nunez, Jose, University of Central Florida
- Abstract / Description
-
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. Although many existing incident report systems have been beneficial for identifying engineering failures, most of them are not designed around a theoretical framework of human error, thus failing to address core issues and causes of the mishaps. Therefore, it is imperative to develop a human error assessment framework to identify these causes. This research...
Show moreResearch results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. Although many existing incident report systems have been beneficial for identifying engineering failures, most of them are not designed around a theoretical framework of human error, thus failing to address core issues and causes of the mishaps. Therefore, it is imperative to develop a human error assessment framework to identify these causes. This research focused on identifying causes of human error and leading contributors to historical Launch Vehicle Ground Processing Operations mishaps based on past mishaps, near mishaps, and close calls. Three hypotheses were discussed. The first hypothesis addressed the impact Human Factor Analysis and Classification System (HFACS) contributing factors (unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and/or organizational influences) have on human error events (i.e. mishaps, close calls, incident or accidents) in NASA Ground Processing Operations. The second hypothesis focused on determining if the HFACS framework conceptual model could be proven to be a viable analysis and classification system to help classify both latent and active underlying contributors and causes of human error in ground processing operations. Lastly, the third hypothesis focused on determining if the development of a model using the Human Error Assessment and Reduction Technique (HEART) could be used as a tool to help determine the probability of human error occurrence in ground processing operations. A model to analyze and classify contributing factors to mishaps or incidents, and generate predicted Human Error Probabilities (HEPs) of future occurrence was developed using the HEART and HFACS tools. The research methodology was applied (retrospectively) to six Ground Processing Operations (GPO) Scenarios and 30 years of Launch Vehicle Related Mishap Data. Surveys were used to provide Subject Matter Experts' (SMEs) subjective assessments of the impact Error Producing Conditions (EPC) had on specific tasks. In this research a Logistic Binary Regression model, which identified the four most significant contributing HFACS human error factors was generated. This model provided predicted probabilities of future occurrence of mishaps when these contributing factors are present. The results showed that the HEART and HFACS methods, when modified, can be used as an analysis tool to identify contributing factors, their impact on human error events, and predict the potential probability of future human error occurrence. This methodology and framework was validated through consistency and comparison to other related research. A contribution methodology for other space operations and similar complex operations to follow was provided from this research. Future research should involve broadening the scope to explore and identify other existing models of human error management systems to integrate into complex space systems beyond what was conducted in this research.
Show less - Date Issued
- 2016
- Identifier
- CFE0006829, ucf:51795
- Format
- Document (PDF)
- PURL
- http://purl.flvc.org/ucf/fd/CFE0006829
