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NASA NTRSDate not supplied

On the Use of Resilience Models as Digital Twins for Operational Support and In time Decision Making

Human error is a major contributor to accidents and performance losses in complex engineered systems. If one examines these human error caused failures further, a specific cause, the lack of situation awareness, has dominated as a major cause of human errors that instigate latent or catastrophic failures in complex systems. Studies of aviation accidents involving major air carriers revealed that situation awareness was the root cause of around 90% of accidents involving pilot error. Another study explored offshore drilling accidents involving human error and found that 40% of accidents were directly attributed to the loss of situation awareness. Studies of human errors in other domains such as nuclear power, air traffic control, process industry, and advanced driving show that loss of SA was a root cause in a majority of the events. Situation awareness-related failures are not only common but also costly and fatal (e.g., Bhopal Gas Leak, Air France 447 Flight Crash). Thus, the concept of situation awareness has emerged as an important construct in human factors, resulting in numerous models and measurement methods to aid in promoting appropriate levels of situation awareness.

Lukman Irshad↗

NASA NTRS1994

Shared Problem Models and Crew Decision Making

The importance of crew decision making to aviation safety has been well established through NTSB accident analyses: Crew judgment and decision making have been cited as causes or contributing factors in over half of all accidents in commercial air transport, general aviation, and military aviation. Yet the bulk of research on decision making has not proven helpful in improving the quality of decisions in the cockpit. One reason is that traditional analytic decision models are inappropriate to the dynamic complex nature of cockpit decision making and do not accurately describe what expert human decision makers do when they make decisions. A new model of dynamic naturalistic decision making is offered that may prove more useful for training or aiding cockpit decision making. Based on analyses of crew performance in full-mission simulation and National Transportation Safety Board accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation and reflect the crew's metacognitive skill. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that all crew members have essential information, but it also regulates and coordinates crew actions and is the medium of collective thinking in response to a problem. This presentation will examine the relation between communication that serves to build performance. Implications of these findings for crew training will be discussed.

Orasanu, Judith↗

DOE OSTI2020

Evaluation of the Performance of the SAVY Container Subjected to Various Impact Events using Finite Element Methods

The SAVY container is a Safety Class Design Feature utilized both inside engineered features and outside engineered features (e.g. gloveboxes) at TA-55 Plutonium Facility Building 4. These containers were certified as low damage ratio containers by demonstrating their ability to retain material after exposure to impacts and elevated temperatures resulting from a design basis seismic event. Original testing of the SAVY did not evaluate the effects of various facility specific insults to the SAVY while within a DOT Type A Container, caused either by design basis accident or an operational mishap. These insults include: 1. Impact of a structural I-beam (drum upright & drum on side); 2. Impact of a section of Positive Pressure Chilled Water Pipe (PPCWS); 3. Forklift fork tine impact; 4. Fuel truck impact. Abaqus Explicit Dynamics Finite Element Analysis was performed on a nested SAVY/DOT Type 7A container configuration to assess the structural integrity of the SAVY under the accident conditions listed.

98 NUCLEAR DISARMAMENT, SAFEGUARDS, AND PHYSICAL P↗

DOE OSTI2020

Fast Evaluation of Aircraft Icing Severity Using Machine Learning Based on XGBoost

Aircraft icing represents a serious hazard in aviation which has caused a number of fatal accidents over the years. In addition, it can lead to substantial increase in drag and weight, thus reducing the aerodynamics performance of the airplane. The process of ice accretion on a solid surface is a complex interaction of aerodynamic and environmental variables. The complex relationship makes machine learning-based methods an attractive alternative to traditional numerical simulation-based approaches. In this study, we introduce a purely data-driven approach to find the complex pattern between different flight conditions and aircraft icing severity prediction. The supervised learning algorithm Extreme Gradient Boosting (XGBoost) is applied to establish the prediction framework which makes prediction based on any set of observations. The input flight conditions for the proposed prediction framework are liquid water content, droplet diameter and exposure time. The proposed approach is demonstrated in three cases: maximum ice thickness prediction, icing area prediction and icing severity level evaluation. Performance comparison studies and error analysis are also conducted to verify the effectiveness and performance of the proposed method. Results show that the proposed method has reasonable capability in evaluating aircraft icing severity.

Li, Sibo (ORCID:000000021705844X)↗

NASA NTRS1990

Terminal weather information management

Since the mid-1960's, microburst/windshear events have caused at least 30 aircraft accidents and incidents and have killed more than 600 people in the United States alone. This study evaluated alternative means of alerting an airline crew to the presence of microburst/windshear events in the terminal area. Of particular interest was the relative effectiveness of conventional and data link ground-to-air transmissions of ground-based radar and low-level windshear sensing information on microburst/windshear avoidance. The Advanced Concepts Flight Simulator located at Ames Research Center was employed in a line oriented simulation of a scheduled round-trip airline flight from Salt Lake City to Denver Stapleton Airport. Actual weather en route and in the terminal area was simulated using recorded data. The microburst/windshear incident of July 11, 1988 was re-created for the Denver area operations. Six experienced airline crews currently flying scheduled routes were employed as test subjects for each of three groups: (1) A baseline group which received alerts via conventional air traffic control (ATC) tower transmissions; (2) An experimental group which received alerts/events displayed visually and aurally in the cockpit six miles (approx. 2 min.) from the microburst event; and (3) An additional experimental group received displayed alerts/events 23 linear miles (approx. 7 min.) from the microburst event. Analyses of crew communications and decision times showed a marked improvement in both situation awareness and decision-making with visually displayed ground-based radar information. Substantial reductions in the variability of decision times among crews in the visual display groups were also found. These findings suggest that crew performance will be enhanced and individual differences among crews due to differences in training and prior experience are significantly reduced by providing real-time, graphic display of terminal weather hazards.

Lee, Alfred T.↗

NASA NTRS1991

Philosophy, policies, and procedures - The three P's of flight-deck operations

Standard operating procedures are drafted and provided to flightcrews to dictate the manner in which tasks are carried out. Failure to conform to Standard Operating Procedures (SOP) is frequently listed as the cause of violations, incidents, and accidents. However, procedures are often designed piecemeal, rather than being based on a sound philosophy of operations and policies that follow from such a philosophy. A framework of philosophy, policies, and procedures is proposed.

Degani, Asaf↗

NASA NTRS1999

An Experimental and Numerical Study of Icing Effects on the Performance and Controllability of a Twin Engine Aircraft

In September 1997 the National Transportation Safety Board (NTSB) requested assistance from the NASA Lewis Research Center (LeRC) Icing Branch in the investigation of an aircraft accident that was suspected of being caused by ice contamination. In response to the request NASA agreed to perform an experimental and computational study. The main activities that NASA performed were LERC Icing Research Tunnel (IRT) testing to define ice shapes and 2-D Navier-Stokes analysis to determine the performance degradation that those ice shapes would have caused. An IRT test was conducted in January 1998. Most conditions for the test were based upon raw and derived data from the Flight Data Recorder (FDR) recovered from the accident and upon the current understanding of the Meteorological conditions near the accident. Using a two-dimensional Navier-Stokes code, the flow field and resultant lift and drag were calculated for the wing section with various ice shapes accreted in the IRT test. Before the final calculations could be performed extensive examinations of geometry smoothing and turbulence were conducted. The most significant finding of this effort is that several of the five-minute ice accretions generated in the IRT were found by the Navier-Stokes analysis to produce severe lift and drag degradation. The information generated by this study suggests a possible scenario for the kind of control upset recorded in the accident. Secondary findings were that the ice shapes accreted in the IRT were mostly limited to the protected pneumatic boot region of the wing and that during testing, activation of the pneumatic boots cleared most of the ice.

Reehorst, A.↗

NASA NTRS2004

Context-Aware Intelligent Assistant Approach to Improving Pilot's Situational Awareness

Faulty decision making due to inaccurate or incomplete awareness of the situation tends to be the prevailing cause of fatal general aviation accidents. Of these accidents, loss of weather situational awareness accounts for the largest number of fatalities. We describe a method for improving weather situational awareness through the support of a contextaware,domain and task knowledgeable, personalized and adaptive assistant. The assistant automatically monitors weather reports for the pilot's route of flight and warns her of detected anomalies. When and how warnings are issued is determined by phase of flight, the pilot s definition of acceptable weather conditions, and the pilot's preferences for automatic notification. In addition to automatic warnings, the pilot is able to verbally query for weather and airport information. By noting the requests she makes during the approach phase of flight, our system learns to provide the information without explicit requests on subsequent flights with similar conditions. We show that our weather assistant decreases the effort required to maintain situational awareness by more than 5.5 times when compared to the conventional method of in-flight weather briefings.

Spirkovska, Lilly↗

NASA NTRS1995

Aircraft Ice Accretion Due to Large-Droplet Icing Clouds

Studies of aircraft icing due to clouds consisting of individual droplets 10 times larger than those normally found in icing conditions are being carried out by members of the NASA Lewis Research Center's Icing Technology Branch. When encountered by an aircraft in freezing conditions, clouds consisting of large water droplets have a significantly different effect than those with normal droplets. A large-water-droplet cloud has been suggested as the cause of a commuter airplane accident in the late fall of 1994. As a result, studies of what happens to aircraft flying in these rare, but potentially very hazardous, conditions have been reemphasized.

Source record↗

NASA NTRS1978

Single pilot IFR operating problems determined from accidental data analysis

The accident reports examined were restricted to instrument rated pilots flying in IFR weather. A brief examination was made of accidents which occurred during all phases of flight and which were due to all causes. A detailed examination was made of those accidents which involved a single pilot which occurred during the landing phases of flight, and were due to pilot error. Problem areas found include: (1) landing phase operations especially final approach, (2) pilot weather briefings, (3) night approaches in low IFR weather, (4) below minimum approaches, (5) aircraft icing, (6) imprecise navigation, (7) descending below minimum IFR altitudes, (8) fuel mismanagement, (9) pilot overconfidence, and (10) high pilot workload especially in twins. Some suggested areas of research included: (1) low cost deicing systems, (2) standardized navigation displays, (3) low cost low-altitude warning systems, (4) improved fuel management systems, (5) improved ATC communications, (6) more effective pilot training and experience acquisition methods, and (7) better weather data dissemination techniques.

Forsyth, D. L.↗

DOE OSTI2021

MACCS Theory Manual

This report describes the models of the MACCS computer code as presented in MACCS Version 3.10.0. The purpose of MACCS is to simulate the impact of severe accidents at nuclear power plants on the surrounding environment. MACCS has been developed by Sandia National Laboratories for the U.S. Nuclear Regulatory Commission. From a given release of radioactive material into the atmosphere, MACCS estimates the extent and magnitude of radiological contamination, offsite doses, protective actions, socioeconomic impacts and costs, and health effects. Since the weather at the time of an accident is not predictable, MACCS supports various sampling options to run a representative set of simulations to evaluate weather variability. MACCS simulates atmospheric transport with a straight-line Gaussian plume segment model. From the estimated air and ground concentrations, MACCS models dose projections through several dose exposure pathways. These exposures can be offset by protective actions during the emergency response and long-term recovery of the accident. MACCS users directly specify the evacuation and sheltering area, while other protective actions (e.g., relocation, farmland restrictions, decontamination) are based on user-specified dose or concentration limits. While protective actions help reduce dose accumulation, they also cause social and economic impacts. MACCS models the extent of displaced individuals and land contamination, and the cost of offsite property damage, economic disruptions, and various accident expenditures caused by protective actions. Finally, from the dose accumulation, MACCS estimates early and stochastic health effects according to dose-response models. The purpose of consequence analyses is to be able to understand and estimate the impact of nuclear accidents. Consequence analysis is an essential tool to inform determinations of adequate protection of the public, to understand nuclear power hazards, to measure the value of regulations, and to help us appreciate the importance of nuclear safety. As such, MACCS has a variety of regulatory uses including environmental analyses (10 CFR 51.53, 52.47), regulatory cost-benefit analyses, backfit analyses (10 CFR 50.109), consequence analysis studies such as SOARCA (NUREG-1935), Level 3 PRA studies, and risk-informing of emergency planning (10 CFR 50 App. E and 50.47). This report updates the previous MACCS theory manual (NUREG/CR-4691 Vol. 2; Chanin, Sprung, Ritchie, & Jow, 1990) and accompanies the MACCS User's Guide (SAND-2021-1588) that describes the use and input requirements of the graphical user interface of MACCS known as WinMACCS. The MACCS User's Guide is also a reference guide that describes data input file formats, describes various software components in the MACCS code suite, and provides a set of example tutorials for running WinMACCS. Also, soon to be published is a MACCS input parameter guidance report (NUREG/CR-7270) that provides technical bases for commonly used MACCS input values. This page left blank

97 MATHEMATICS AND COMPUTING↗

NASA NTRS2007

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Johnson, C. W.↗

NASA NTRS1987

Structural analysis of a bolted joint concept for the space shuttle's solid rocket motor casing

The Space Shuttle Challenger accident is thought to have been caused by the failure of one of the tang-clevis joints joining together the casing segments of the Solid Rocket Motors (SRM). Excessive displacement between the tang and clevis, possibly unseating the O-ring seals, may have initiated the resulting accident. An effort was made at NASA Langley Research Center to design an alternative concept for mating the casing segments. A bolted flange joint concept was designed and analyzed to determine if the concept would effectively maintain a seal while minimizing joint weight and controlling stress levels. It is shown that under the loading conditions analyzed the seal area of the joint remains seated. The only potential stress problem is a stress concentration in the flange at the edge of the bolt hole, which is highly localized. While heavier than the existing joint, this concept does have some advantages making the bolted joint an attractive alternative.

Lindell, Michael C.↗

NASA NTRS1987

Structural analysis of a bolted joint concept for the Space Shuttle's solid rocket motor casing

The Space Shuttle Challenger accident is thought to have been caused by the failure of one of the tang-clevis joints which join together the casing segments of the Solid Rocket Motors (SRM). Excessive displacement between the tang and clevis, possibly unseating the O-ring seals, may have initiated the resulting accident. An effort was undertaken at NASA's Langley Research Center to design an alternative concept for mating the casing segments. A bolted flanged joint concept was designed and analyzed to determine if the concept would effectively maintain a seal while minimizing joint weight and controlling stress levels. It is shown that under the loading condition analyzed the seal area of the joint remains seated. The only potential stress problem is a stress concentration in the flange at the edge of the bolt hole, which is highly localized. While heavier than the existing joint, this concept does have some advantages which make the bolted joint an attractive alternative.

Lindell, Michael C.↗

NASA NTRS2017

NASA Weather Support 2017

In the mid to late 1980's, as NASA was studying ways to improve weather forecasting capabilities to reduce excessive weather launch delays and to reduce excessive weather Launch Commit Criteria (LCC) waivers, the Challenger Accident occurred and the AC-67 Mishap occurred.[1] NASA and USAF weather personnel had advance knowledge of extremely high levels of weather hazards that ultimately caused or contributed to both of these accidents. In both cases, key knowledge of the risks posed by violations of weather LCC was not in the possession of final decision makers on the launch teams. In addition to convening the mishap boards for these two lost missions, NASA convened expert meteorological boards focusing on weather support. These meteorological boards recommended the development of a dedicated organization with the highest levels of weather expertise and influence to support all of American spaceflight. NASA immediately established the Weather Support Office (WSO) in the Office of Space Flight (OSF), and in coordination with the United Stated Air Force (USAF), initiated an overhaul of the organization and an improvement in technology used for weather support as recommended. Soon after, the USAF established a senior civilian Launch Weather Officer (LWO) position to provide meteorological support and continuity of weather expertise and knowledge over time. The Applied Meteorology Unit (AMU) was established by NASA, USAF, and the National Weather Service to support initiatives to place new tools and methods into an operational status. At the end of the Shuttle Program, after several weather office reorganizations, the WSO function had been assigned to a weather branch at Kennedy Space Center (KSC). This branch was dismantled in steps due to further reorganization, loss of key personnel, and loss of budget line authority. NASA is facing the loss of sufficient expertise and leadership required to provide current levels of weather support. The recommendation proposed herein is to re-establish the WSO under a high level office, with funding set at about the same levels as today, with a revitalized charter and focus to allow for the WSO to operate as originally intended.

lessons learned↗

NASA NTRS2006

Questioning the Role of Requirements Engineering in the Causes of Safety-Critical Software Failures

Many software failures stem from inadequate requirements engineering. This view has been supported both by detailed accident investigations and by a number of empirical studies; however, such investigations can be misleading. It is often difficult to distinguish between failures in requirements engineering and problems elsewhere in the software development lifecycle. Further pitfalls arise from the assumption that inadequate requirements engineering is a cause of all software related accidents for which the system fails to meet its requirements. This paper identifies some of the problems that have arisen from an undue focus on the role of requirements engineering in the causes of major accidents. The intention is to provoke further debate within the emerging field of forensic software engineering.

Johnson, C. W.↗

DOE OSTI1995

Nuclear Safety [Vol. 36, No. 2, July-December 1995]

Nuclear Safety is a journal that covers significant issues in the field of nuclear safety. Its primary scope is safety in the design, construction, operation, and decommissioning of nuclear power reactors worldwide and the research and analysis activities that promote this goal, but it also encompasses the safety aspects of the entire nuclear fuel cycle, including fuel fabrication, spent-fuel processing and handling, and nuclear waste disposal, the handling of fissionable materials and radioisotopes, and the environmental effects of all these activities. Table of Contents for this issue follows. THE CHORNOBYL ACCIDENT: 195 The Chornobyl Accident Revisited, Part III: Chernobyl Source Term Release Dynamics and Reconstruction of Events During the Active Phase, A. R. Sich; GENERAL SAFETY CONSIDERATIONS: 218 Second ANS Workshop on the Safety of Soviet-Designed Nuclear Power Plants, R. A. Bari; 234 Elements of a Nuclear Criticality Safety Program, C. M. Hopper; 243 Rickover, Excellence, and Criticality Safety Programs, R. E. Wilson; ACCIDENT ANALYSIS: 249 Transient Analysis of the PIUS Advanced Reactor Design with the TRAC-PF1/MOD2 Code, B. E. Boyack, J. L Steiner, S. C. Harmony, H. J. Stumpf, and J. F. Lime; 278 The Hierarchy-By-Interval Approach to Identifying Important Models that Need Improvement in Severe-Accident Simulation Codes, T. J. Heames, M. Khatib-Rahbar, J. E. Kelly, R. P. Jenks-Johnson, and Y.-S. Chen; 290 RELAP5/MOD3 Code Coupling Model, R. P. Martin; 299 Missiles Caused by Severe Pressurized-Water Reactor Accidents, R. Krieg; DESIGN FEATURES: 310 Validation of COMMIX with Westinghouse AP-600 PCCS Test Data, J. G. Sun, T. H. Chien, J. Ding, and W T. Sha; ENVIRONMENTAL EFFECTS: 321 Spent Nuclear Fuel Characterization for a Bounding Reference Assembly for the Receiving Basin for Off-Site Fuel, S. D. Kahook, R. L. Garrett, L. R. Canas, and M J. Beckum; OPERATING EXPERIENCES: 332 Reactor Shutdown Experience, Compiled by J. W. Cletcher; U.S. NUCLEAR REGULATORY COMMISSION INFORMATION AND ANALYSES: 335 Reactor Coolant System Blowdown at Wolf Creek on September 17, 1994, J. V. Kauffman and S. L. Israel; RECENT DEVELOPMENTS: 344 Reports, Standards, and Safety Guides, D. S. Oueener; 349 Proposed Rule Changes as of June 30, 1995; ANNOUNCEMENTS: 320 Symposium on Acceptability of Risk From Radiation—Application to Manned Space Flight; 320 24th DOE/NRC Nuclear Air Cleaning and Treatment Conference; 361 Radiation Biology and Radiation Protection— Modern Developments and Tendencies in Radiation Biology; 362 1997 IEEE Sixth Conference on Human Factors and Power Plants; 354 The Authors; 360 Reviewers of Nuclear Safety, Vol. 36.

05 NUCLEAR FUELS↗

DOE OSTI1995

Nuclear Safety [Vol. 36, No. 2, July-December 1995]

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗