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Analyzing human errors in flight mission operationsA long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.
Document ID
19940007062
Acquisition Source
Legacy CDMS
Document Type
Conference Paper
Authors
Bruno, Kristin J.
(Jet Propulsion Lab., California Inst. of Tech. Pasadena, CA, United States)
Welz, Linda L.
(Jet Propulsion Lab., California Inst. of Tech. Pasadena, CA, United States)
Barnes, G. Michael
(California State Univ. Northridge., United States)
Sherif, Josef
(Jet Propulsion Lab., California Inst. of Tech. Pasadena, CA, United States)
Date Acquired
September 6, 2013
Publication Date
February 1, 1993
Publication Information
Publication: NASA. Johnson Space Center, Sixth Annual Workshop on Space Operations Applications and Research (SOAR 1992), Volume 2
Subject Category
Behavioral Sciences
Accession Number
94N11534
Distribution Limits
Public
Copyright
Work of the US Gov. Public Use Permitted.
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