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NASA NTRS2004

Distribution of Causes in Selected US Aviation Accident Reports Between 1996 and 2003

This paper describes the results of an independent analysis of the probable and contributory causes of selected aviation accidents in the United States between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a variety of causal factors in the reporting of these adverse events. Although our results show that more of these high consequence accidents were attributed to human error than to any other single factor, a large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These wider issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗

NASA NTRS2005

Structural Analysis for the American Airlines Flight 587 Accident Investigation: Global Analysis

NASA Langley Research Center (LaRC) supported the National Transportation Safety Board (NTSB) in the American Airlines Flight 587 accident investigation due to LaRC's expertise in high-fidelity structural analysis and testing of composite structures and materials. A Global Analysis Team from LaRC reviewed the manufacturer s design and certification procedures, developed finite element models and conducted structural analyses, and participated jointly with the NTSB and Airbus in subcomponent tests conducted at Airbus in Hamburg, Germany. The Global Analysis Team identified no significant or obvious deficiencies in the Airbus certification and design methods. Analysis results from the LaRC team indicated that the most-likely failure scenario was failure initiation at the right rear main attachment fitting (lug), followed by an unstable progression of failure of all fin-to-fuselage attachments and separation of the VTP from the aircraft. Additionally, analysis results indicated that failure initiates at the final observed maximum fin loading condition in the accident, when the VTP was subjected to loads that were at minimum 1.92 times the design limit load condition for certification. For certification, the VTP is only required to support loads of 1.5 times design limit load without catastrophic failure. The maximum loading during the accident was shown to significantly exceed the certification requirement. Thus, the structure appeared to perform in a manner consistent with its design and certification, and failure is attributed to VTP loads greater than expected.

Young, Richard D.↗

NASA NTRS2006

Why System Safety Professionals Should Read Accident Reports

System safety professionals, both researchers and practitioners, who regularly read accident reports reap important benefits. These benefits include an improved ability to separate myths from reality, including both myths about specific accidents and ones concerning accidents in general; an increased understanding of the consequences of unlikely events, which can help inform future designs; a greater recognition of the limits of mathematical models; and guidance on potentially relevant research directions that may contribute to safety improvements in future systems.

Holloway, C. M.↗

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 NTRS2010

Causal Factors and Adverse Conditions of Aviation Accidents and Incidents Related to Integrated Resilient Aircraft Control

The causal factors of accidents from the National Transportation Safety Board (NTSB) database and incidents from the Federal Aviation Administration (FAA) database associated with loss of control (LOC) were examined for four types of operations (i.e., Federal Aviation Regulation Part 121, Part 135 Scheduled, Part 135 Nonscheduled, and Part 91) for the years 1988 to 2004. In-flight LOC is a serious aviation problem. Well over half of the LOC accidents included at least one fatality (80 percent in Part 121), and roughly half of all aviation fatalities in the studied time period occurred in conjunction with LOC. An adverse events table was updated to provide focus to the technology validation strategy of the Integrated Resilient Aircraft Control (IRAC) Project. The table contains three types of adverse conditions: failure, damage, and upset. Thirteen different adverse condition subtypes were gleaned from the Aviation Safety Reporting System (ASRS), the FAA Accident and Incident database, and the NTSB database. The severity and frequency of the damage conditions, initial test conditions, and milestones references are also provided.

Reveley, Mary S.↗

NASA NTRS2011

Aeromedical Lessons Learned from the Space Shuttle Columbia Accident Investigation

This slide presentation provides an update on the Columbia accident response presented in 2005 with additional information that was not available at that time. It will provide information on the following topics: (1) medical response and Search and Rescue, (2) medico-legal issues associated with the accident, (3) the Spacecraft Crew Survival Integrated Investigation Team Report published in 2008, and (4) future NASA flight surgeon spacecraft accident response training.

Chandler, Mike↗

NASA NTRS2005

Techniques and Tools of NASA's Space Shuttle Columbia Accident Investigation

The Space Shuttle Columbia accident investigation was a fusion of many disciplines into a single effort. From the recovery and reconstruction of the debris, Figure 1, to the analysis, both destructive and nondestructive, of chemical and metallurgical samples, Figure 2, a multitude of analytical techniques and tools were employed. Destructive and non-destructive testing were utilized in tandem to determine if a breach in the left wing of the Orbiter had occurred, and if so, the path of the resultant high temperature plasma flow. Nondestructive analysis included topometric scanning, laser mapping, and real-time radiography. These techniques were useful in constructing a three dimensional virtual representation of the reconstruction project, specifically the left wing leading edge reinforced carbon/carbon heat protectant panels. Similarly, they were beneficial in determining where sampling should be performed on the debris. Analytic testing included such techniques as Energy Dispersive Electron Microprobe Analysis (EMPA), Electron Spectroscopy Chemical Analysis (ESCA), and X-Ray dot mapping; these techniques related the characteristics of intermetallics deposited on the leading edge of the left wing adjacent to the location of a suspected plasma breach during reentry. The methods and results of the various analyses, along with their implications into the accident, are discussed, along with the findings and recommendations of the Columbia Accident Investigation Board. Likewise, NASA's Return To Flight efforts are highlighted.

McDanels, Steve J.↗

NASA NTRS2012

Object-Oriented Bayesian Networks (OOBN) for Aviation Accident Modeling and Technology Portfolio Impact Assessment

The concern for reducing aviation safety risk is rising as the National Airspace System in the United States transforms to the Next Generation Air Transportation System (NextGen). The NASA Aviation Safety Program is committed to developing an effective aviation safety technology portfolio to meet the challenges of this transformation and to mitigate relevant safety risks. The paper focuses on the reasoning of selecting Object-Oriented Bayesian Networks (OOBN) as the technique and commercial software for the accident modeling and portfolio assessment. To illustrate the benefits of OOBN in a large and complex aviation accident model, the in-flight Loss-of-Control Accident Framework (LOCAF) constructed as an influence diagram is presented. An OOBN approach not only simplifies construction and maintenance of complex causal networks for the modelers, but also offers a well-organized hierarchical network that is easier for decision makers to exploit the model examining the effectiveness of risk mitigation strategies through technology insertions.

Shih, Ann T.↗

NASA NTRS2014

A Comprehensive Analysis of the X-15 Flight 3-65 Accident

The November 15, 1967, loss of X-15 Flight 3-65-97 (hereafter referred to as Flight 3-65) was a unique incident in that it was the first and only aerospace flight accident involving loss of crew on a vehicle with an adaptive flight control system (AFCS). In addition, Flight 3-65 remains the only incidence of a single-pilot departure from controlled flight of a manned entry vehicle in a hypersonic flight regime. To mitigate risk to emerging aerospace systems, the NASA Engineering and Safety Center (NESC) proposed a comprehensive review of this accident. The goal of the assessment was to resolve lingering questions regarding the failure modes of the aircraft systems (including the AFCS) and thoroughly analyze the interactions among the human agents and autonomous systems that contributed to the loss of the pilot and aircraft. This document contains the outcome of the accident review.

Dennehy, Cornelius J.↗

DOE OSTI2023

Criticality Accident Alarm System Modeling for the Uranium Processing Facility

The Criticality Accident Alarm System (CAAS) for the Uranium Processing Facility (UPF) provides coverage for two primary processing facilities. For UPF, detailed documentation and drawings of the design are readily available. While this design information allows for some CAAS modeling features to match the actual design with a high level of accuracy, assumptions and simplifications are necessary as it is unrealistic and unnecessary to replicate many aspects of the design. A set of modeling guidelines and techniques were used to develop consistency between the MCNP6 models. While ensuring conservatism, overly conservative choices must be avoided to demonstrate the minimum accident of concern can be detected. To ensure proper modeling choices were made for the final models, a group of parametric studies were performed to evaluate the impact on the dose rates detected at the individual detectors. Some of these modeling choices and/or associated parametric studies include: - Modeling the grid steel area above the detectors as homogeneous stainless steel and determining the impact on detectability with an increasing density. - Modeling the presence of equipment in close proximity to the CAAS detectors. - Determining an appropriate material density to represent miscellaneous items not specifically modeled. - Evaluating the impact of sprinkler activation. The results of UPF CAAS analyses show that the modeling assumptions made based on the detailed design and parametric studies are appropriate and demonstrate accurate yet conservative models have been developed for detecting minimum accident of concern within the UPF.

61 RADIATION PROTECTION AND DOSIMETRY↗

DOE OSTI2023

Application of the ANSI/ANS-8.3-2022 Minimum Accident to Tube Vault Storage

In support of planned site activities, the existing basis for criticality safety in nuclear facilities is being revisited. One such technical basis is the demonstration of Criticality Accident Alarm System (CAAS) coverage in tube vaults at Y-12 National Security Complex. The configuration of the vaults places significant shielding between the source and the detector stations and is dissimilar to drum storage or other processes. This paper describes tube vault storage at Y-12, describes the basis for the application of the 2022 minimum accident for system design (MASD) to the analysis, and presents how the accident is implemented in the analysis.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

DOE OSTI2022

BISON validation of FeCrAl cladding mechanical failure during simulated reactivity-initiated accident conditions*

Here, a reactivity-initiated accident (RIA) is a postulated design basis accident in light water reactors (LWRs) in which a rapid reactivity insertion induces a fission rate increase and a fuel pellet temperature rise. During RIA, the fuel pellet thermally expands and may cause pellet-cladding mechanical interaction (PCMI). Separate effects PCMI tests were performed on C26M FeCrAl cladding tube samples, introducing biaxial stress via a well understood modified burst test (MBT) system. A high-speed camera in the MBT system captured the projections, covering a 360° view of the cladding deformation and enabling a digital image correlation (DIC) method to quantify the surface strains with high fidelity. Representative hot zero-power RIA mechanical loading conditions were applied to the sample, and the test duration ranged from 20 to 500 ms at an average temperature of 573 K. BISON finite element–based fuel performance code modeling was performed against the high-fidelity DIC data produced from the MBTs. Validation calculations were conducted with 2D models and systematically compared with test data of the burst time, burst pressure, burst hoop strains, and hoop strain rates. Based on the behaviors from the separate effects test, BISON calculations satisfactorily predicted the cladding deformation behaviors. Sensitivity analysis was conducted to identify highly influential mechanical properties responsible for the cladding failure behavior during the MBT experiments. The results highlight the significance of the cladding's mechanical strength in governing cladding strain, followed by the significance of the mechanical interactions between the pellet and the cladding.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

DOE OSTI2025

The impact of chromium coatings on Zircaloy cladding deformation behavior under reactivity-initiated accident-like mechanical loading conditions

A reactivity-initiated accident (RIA) occurs when a control rod ejection or control blade drop causes an increase in the fission rate. The injection of energy results in an increase in fuel temperature which in turn causes rapid thermal expansion of the fuel pellet. This thermal expansion may result in pellet-cladding mechanical interaction (PCMI) in which the fuel imparts a mechanical strain to the cladding. PCMI may cause the cladding to fail, and thus, the mechanical response of cladding due to PCMI must be investigated when characterizing new cladding materials. Chromium-coated Zircaloy-4 is a near-term accident-tolerant fuel cladding that exhibits improved high-temperature oxidation resistance. Modified burst testing was utilized to experimentally simulate the effects of PCMI on both uncoated and chromium-coated Zircaloy cladding samples at hot zero power conditions. Samples were coated using either cold spraying or physical vapor deposition to understand the differences in behavior that the coating application method may cause. Digital image correlation was used to analyze images of the deforming specimens to extract the in-situ strain behavior of the cladding. The uncoated specimens burst at hoop strains ranging from 8.8 % to 17.2 %. The cold-spray chromium-coated Zircaloy specimens burst at hoop strains of 7.0 % to 11.0 %. The physical vapor deposition coated tubes burst at hoop strains of 9.1 % to 11.5 %. These results indicate that the chromium coating causes a loss in the ductility of the cladding. Furthermore, the higher burst hoop strains of the physical vapor deposition-coated samples relative to the cold-spray samples indicate that the cold-spraying technique causes more of a loss in ductility than physical vapor deposition. All samples burst at higher hoop strains than those expected to occur in an RIA for fresh cladding.

Accident-tolerant fuel↗

DOE OSTI2025

Recrystallization driven softening and heating rate dependencies of FeCrAl nuclear fuel cladding during accident transients

A refined understanding of FeCrAl cladding behavior during rapid transients is critical for its potential deployment in light-water reactors. Current assessments focus on transient burst testing metrics such as balloon geometry, burst temperature, and hoop stress, often used as proxies for simpler conventional tensile properties. However, directly correlating isothermal tensile and creep data with accident transient scenarios remains a challenge, although it is essential for high fidelity model development. Recent modeling based on tensile tests up to 800 °C, conducted with both immediate loading and a 10-minute soak, showed that immediate loading better predicts experimental burst temperatures, indicating a thermal softening effect. Building upon this observation, the current study connects transient performance, microstructural evolution, and high-temperature tensile properties by leveraging results from C26M claddings burst tests performed at heating rates of 1–50 °C/s and hoop stresses from 25 to 100 MPa. At 25 MPa, rupture temperatures varied by only 6 °C, but at 100 MPa, the difference reached 116 °C, with faster heating yielding higher burst temperatures. Microstructural analysis identified recrystallization as the primary cause of heating rate-dependent softening, eliminating prior cold-working. In-situ thermomechanical data linked ballooning onset to localized instabilities, similar to ultimate tensile strength behavior in conventional tensile tests. High heating rates correlated with immediate loading tensile data, while lower rates matched soaked data. Furthermore, by linking burst performance to microstructural evolution and tensile properties, this work provides a foundation for more accurate modeling of FeCrAl claddings and potentially other Fe-based materials under accident conditions.

11 - NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

DOE OSTI2024

Source term analysis of FeCrAl accident tolerant fuel using MELCOR

It has been established that incremental improvements in beyond design basis accident performance can be achieved through accident tolerant fuel (ATF). However, they have the potential to recover margin with respect to conventional fuel and therefore enhance plant economics through uprate or cycle length increase. To realize this potential, it is necessary to quantify the reduction in source term due to use of ATF, and correspondingly how this is affected by increasing the cycle length and/or burnup. This requires development of a risk informed analysis methodology for ATF under high burnup conditions, which is being developed within LWRS. To this end, a MELCOR simulation of FeCrAl ATF in a recovered Large Break LOCA (LBLOCA) scenario has been developed, using a model based on the Zion Pressurized Water Reactor (PWR). The new user defined material capability, along with the inclusion of detailed neutronics- and depletion-derived parameters such as core power distribution, decay heat behavior, and fission product inventories, allows a more detailed simulation of FeCrAl clad material properties and behavior than has previously been possible using MELCOR. These detailed FeCrAl results were compared with a zircaloy clad model to investigate the differences between the two clad types and quantify the benefits of FeCrAl ATF with an 18-month cycle. Next, the fuel cycle with ATF was extended to 24 months, to determine whether any additional safety margin provided by FeCrAl ATF could be leveraged to implement high burnup FeCrAl-clad fuel while retaining the same operating and safety limits as current zircaloy-clad fuel. For the particular scenario analyzed, the delay to fuel failure from using ATF was of the same order as the LOCA recovery time, and hence significant in reducing fission product release, with the 24-month FeCrAl core performing better than the 18-month zircaloy core. It is noted that for other transients, the reduction in release due to using FeCrAl may be less significant. Furthermore, the material model developed here can be used in such further studies in support of determining the overall source term.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

DOE OSTI2020

Innovative accident tolerant fuel concept enabled through direct manufacturing technology

Nuclear energy is one of the largest sources of carbon-free electricity in the world. Some countries are looking at new ways to support and revitalize the nuclear sector since the Fukushima disaster. The accident tolerant fuel program is geared toward improving the safety of nuclear energy by investigating materials that can replace or modify the current uranium-dioxide nuclear fuel and zirconium-based cladding. This research program is being supported by all major nuclear countries since 2011. The practical limitations on allowable uranium enrichment has taken the focus away from the most promising fuels with high radioactivity retention such as tristructural isotropic particle fuel. To overcome such enrichment limitation, a new fuel concept is proposed using advanced ceramic direct manufacturing with laser-induced chemical vapor deposition. The fuel-as-fiber concept is an accident-tolerant fuel design that features high thermal conductivity, strong capability of radioactivity retention and most importantly requires reasonable enrichment levels with uranium nitride as the fuel. In this work, the initial fabrication of uranium-based fuel with laser-induced chemical vapor deposition technology is demonstrated. Then an advanced multi-physics guided modeling approach based on finite element analysis codes and informed by the manufacturing capabilities is developed to accelerate the advancement of fuel-as-fiber concept for use in current light-water reactor technology. The detailed thermomechanical analysis showed promising results for viability of the innovative fuel-as-fiber concept. The predicted stresses in the fuel structural materials were similar to the case of tristructural isotropic particle fuel experience base that has shown excellent reliability in retention of fuel radioactivity at high temperatures.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

DOE OSTI2021

Steam oxidation of chromium corrosion barrier coatings for sic-based accident tolerant fuel cladding

SiC-based materials are currently being considered for accident tolerant fuel (ATF) cladding, however, there are concerns regarding hydrothermal corrosion rates and hermeticity. These issues may be addressed with the utilization of a Cr corrosion barrier coating (CBC) but the interaction of Cr with SiC under loss of coolant accident (LOCA) conditions needs to be investigated. In the present work, Cr coatings were deposited onto chemically vapor deposited (CVD) SiC with either high power impulse magnetron sputtering (HiPIMS), cathodic arc (CA), or a combination of both. Annealing and steam thermogravimetric analysis (TGA) was used to study reaction product formation with and without oxidation. Additionally, after 1200 °C annealing, formation of a Cr x C y carbide layer at the ambient interface and a Cr x Si y C z silicide layer at the SiC interface was observed. After 1200 °C TGA exposure, similar carbide and silicide layers were observed but with a Cr 2 O 3 outer reaction layer and a Si and O rich interfacial layer forming between the carbide and silicide layers. Initial mass gain of the coatings during the 1200 °C TGA exposure was parabolic and were similar to reported rates of chromia formation. Mass gain behavior and observed transitions in chromia microstructure indicate that metallic Cr may be consumed within the first ~1 h at 1200 °C and that subsequent chromia formation occurs at the expense of the underlying Cr carbide layer. Overall, the results show no detrimental impact of Cr coatings on the steam oxidation resistance of SiC up to 4 h at 1200 °C.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

DOE OSTI2023

Accident event progression, gaps, and key performance indicators for steam generator tube rupture events in water-cooled SMRs: A review

According to historical records of reactor-related incidents, a steam generator tube rupture (SGTR) is one of the most common occurrences at operating pressurized water reactors (PWRs). Such design-basis accidents (DBAs) could lead to a direct path for radionuclides to be released to the atmosphere via the safety and relief valves, making assessments of radionuclide discharge from operating nuclear power plants (NPPs) into the environment crucial for ensuring safety. In such analyses, the primary focus has been on the extent of radioactive release, not the potential damage to the core. Moreover, significant and timely intervention by operators is needed during the initial stages of SGTRs in order to avert overfilling of the SGs, as well as to restrict the dissemination of radioactive materials. Determining the event sequence and phases that occur during an SGTR incident in an advanced passive (e.g., AP1000) water-cooled nuclear reactor is crucial for implementing effective passive safety systems (PSSs) for a specific water-cooled small modular reactor (SMR) design. Here this study provides a comprehensive review of the accident event progression, associated physical phenomena, knowledge gaps, and key performance indicators that must be evaluated and assessed in thermal-hydraulics models, based on relevant test data, respectively.

21 SPECIFIC NUCLEAR REACTORS AND ASSOCIATED PLANTS↗