Using Red Light / Green Light to Understand Resiliency and Manage Risk in Complex Systems

Threat 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, the National Aeronautics and Space Administration (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.