Document
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).
Future work
• Take home: Resilient performance descriptions even in
reports intended to describe something that went
wrong.