Reports of Resilient Performance: Investigating Operators' Descriptions of Safety-producing Behaviors in the Aviation Safety Reporting System

NASA (NTRS) · 2021

Open the PDFPublic domain · NASA (NTRS)Technical Reports

Overview

While many existing taxonomies and frameworks provide a common vocabulary for describing how human operators fail in the context of sociotechnical systems, at present, there is no common vocabulary to describe how humans succeed. Such a framework would facilitate systematically collecting and…

Pages: 9

Key points

The document investigates how operators describe safety-producing behaviors in the Aviation Safety Reporting System (ASRS).
ASRS reports are confidential, voluntary, and de-identified, providing insights into resilience behaviors in aviation operations.
The study utilizes Erik Hollnagel's framework, which includes anticipating, monitoring, responding, and learning as key components of resilience.
Examples from ASRS highlight the importance of communication and situational awareness in maintaining safety during operations.
Future work will focus on analyzing the context of events to better understand the opportunities for resilient performance.

Frequently asked questions

What is the purpose of the report?

The purpose is to learn about how operators talk about safety-producing behaviors and to identify where to focus safety training efforts.

What is the Aviation Safety Reporting System (ASRS)?

The ASRS is a database that collects confidential and voluntary reports from aviation operators, providing insights into safety behaviors.

What framework is used in the analysis of ASRS reports?

The analysis uses Erik Hollnagel's framework, which includes the concepts of anticipating, monitoring, responding, and learning.

What challenges are mentioned regarding resilience in ASRS reports?

Challenges include the implicit nature of descriptions, overlapping categories, and the need for context to judge actions appropriately.

What will future work focus on?

Future work will analyze the context of events and explore who or what created opportunities for resilient performance.

National Aeronautics and Space Administration Reports of Resilient Performance:

Investigating Operators’ Descriptions of Safety - Producing

Behaviors in the Aviation Safety Reporting System

Jolene Feldman, SJSU Research Foundation Immanuel Barshi , NASA Ames Research Center Brian Smith, NASA Ames Research Center Bryan Matthews, KBR Wyle Services st This is a prerecorded presentation for the 21 International Symposium on Aviation Psychology

Purpose

• To learn about how operators’ talk about safety -

producing behaviors

• Different ways of thinking about safety • No way to collect information when things go right, no common vocabulary

• Learn how safety is produced and where to focus

safety training efforts

Aviation Safety Reporting System Database (ASRS)

• What, who, when & why?

• De - identified, confidential, and voluntary • Where: https://asrs.arc.nasa.gov ASRS Search page ASRS narrative submission section ASRS Main page

Approach & Methodology

• Every ASRS report is an example of resilience behavior • Resilience is… (in everyday operations) described in ASRS reports • Database search & level of analysis • Coding strategies • Erik Hollnagel’s framework ( Hollnagel , 2015) ! Anticipate: knowing what to expect ! Monitor: knowing what to look for ! Respond: knowing what to do ! Learn: knowing what happened • Holbrook et al. (2019) – Resilient Performance Strategies • Turning points and triggers

Example from ASRS & Challenge

Example #1 (ASRS #1516535) “…FO had checked ATIS and noted that Runway 23 was in use. He also mentioned at that time that since Runway 23 is on the ATIS we would most likely get that runway from our direction. So FMC was planned with Runway 23 during cruise…” • The First Officer (FO) shared his knowledge with the Captain (CA), compared his experience to the current situation, and the plan was modified.

• The FO knew what to expect (Anticipate) and learned from his experience (Learn), and knew what to do (Respond) Challenge : resilience that is not specifically named with key words/phrases

Example from ASRS & Challenges

Example #2 (ASRS #1516535) “Approach saw our problem and said nicely, I'm going to spin you around and get you back on a heading to intercept localizer for 23.” • The CA describes that ATC knew what to look for (Monitor), knew what to expect (Anticipate), and knew what to do (Respond).

Challenges : definitions, overlapping of categories, not mutually exclusive, interdependencies of the potentials

Example from ASRS & Challenges

Example #3 (ASRS #1741671) “…I called for a Go Around… the Go Around was done to look at a problem…Captain decided to keep Flaps 1 .. to avoid a potential emergency gear extension procedure…Crew Established and Communicated a plan....We communicated our intentions with flight attendants and advised passengers and Dispatch. We requested delay vectors to run the required QRH Decent Checklist…” • The CA knew what to look for (Monitor), and knew what to do (Respond) in a rapidly changing situation, and called for a go - around • Described their motivation, processes – explicit description Challenges : Descriptions may be implicit – need the context. Actions judged on the outcome. A go - around appropriate in one situation but may not be in the next (but capabilities can contribute to resilient performance).