Presentation
Using Red Light / Green Light to Understand Resiliency and Manage Risk in Complex Systems
Event Type
Lecture
Virtual Program Session
Safety
TimeThursday, October 13th8:45am - 9:00am EDT
LocationA707
DescriptionThreat and error management in complex systems has historically centered around failures rather than successes. This has led to an unbalanced view of risk within organizations in that information regarding resiliency within the system (those factors which help to negate failure) are typically ignored. Currently, NASA employs the Human Factors Analysis and Classification System (HFACS) to both identify human error involved in mishaps and assess those events which prevented more serious consequences from occurring. This paper demonstrates a Red Light/Green Light analysis of a case study, EVA 23 to outline an incident in which an astronaut came dangerously close to drowning in space due to the collection of water in his helmet.