Results for “criticality accident” — Page 12

NASA NTRS1993

Cockpit checklists - Concepts, design, and use

Although the aircraft checklist has long been regarded as a foundation of pilot standardization and cockpit safety, it has escaped the scrutiny of the human factors profession. The improper use, or nonuse, of the normal checklist by flight crews is often cited as a major contributing factor to aircraft accidents. This paper reports the results of a field study of flight deck checklists and examines this seemingly mundane yet critical device from several perspectives: its functions, format, design, length, and usage, and the limitations of the humans who must interact with it. Certain sociotechnical factors, such as the airline 'culture', cockpit resource management, and production pressures that influence the design and use of this device, are also discussed. Finally, a list of design guidelines for normal checklists is provided. Although the focus of this paper is on the air transport industry, most of the principles discussed apply equally well to other high-risk industries, such as maritime transportation, power production, weapons systems, space flight, and medical care.

Degani, Asaf↗

DOE OSTI2022

Critical review and analysis of hydrogen safety data collection tools

The wider adoption of hydrogen in multiple sectors of the economy requires that safety and risk issues be rigorously investigated. Quantitative Risk Assessment (QRA) is an important tool for enabling safe deployment of hydrogen fueling stations and is increasingly embedded in the permitting process. QRA requires reliability data, and currently hydrogen QRA is limited by the lack of hydrogen specific reliability data, thereby hindering the development of necessary safety codes and standards [1]. Four tools have been identified that collect hydrogen system safety data: H2Tools Lessons Learned, Hydrogen Incidents and Accidents Database (HIAD), National Renewable Energy Lab's (NREL) Composite Data Products (CDPs), and the Center for Hydrogen Safety (CHS) Equipment and Component Failure Rate Data Submission Form. This work critically reviews and analyzes these tools for their quality and usability in QRA. It is determined that these tools lay a good foundation, however, the data collected by these tools needs improvement for use in QRA. Areas in which these tools can be improved are highlighted, and can be used to develop a path towards adequate reliability data collection for hydrogen systems.

08 HYDROGEN↗

DOE OSTI2025

Accident Progression and Source Term Demonstration Calculations for the Advanced Burner Test Reactor (ABTR)

As advanced reactor designers approach broad deployment of new reactor technologies and the associated applications, a critical milestone on this path includes licensing or authorization of these designs in the current regulatory environment. Commercial licensing and DOE authorization both consist of numerous aspects to not only certify the designed plant will operate as intended, but also related to confirmation of the safe operation of these facilities that comply with specific standards and requirements. To that end, domestic industry and regulators require toolsets and methods which can be used to confirm that advanced reactor designs not only align with expected performance during normal operation, but also a series of transient scenarios. These codes require a satisfactory validation basis, and in the absence of such a basis, code-to-code comparisons are often utilized as a surrogate to confirm model adequacy. To support this need for fast reactor technologies, a series of analyses using SAS4A/SASSYS- 1 and the Simplified Radionuclide Transport (SRT) code have been conducted for the Advanced Burner Test Reactor (ABTR). These analyses are expected to not only provide a baseline for transient and source term analyses of ABTR, but to also provide context for the key physics that determine evolution of specific transient scenarios in a sodium-cooled fast reactor (SFR). These codes are utilized for this work given their adoption in the SFR industry and by key SFR stakeholders.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

NASA NTRS1974

The deadly triad

The contributions of a design deficiency, supervisory shortcoming, and pilot error to the occurrence of a major accident involving a mechanically intact fighter aircraft during VFR weather are analyzed. The need for physiologically oriented flight surgeons to exercise critical judgment about the adequacy of the man-machine interface is pointed out.

Barry, W. E.↗

DOE OSTI2021

Full core LOCA safety analysis for a PWR containing high burnup fuel

For economic reasons, the US nuclear industry is renewing efforts to build a technical basis to extend peak rod average burnup limits above the current regulatory burnup limit of 62 GWd/MTU. The primary driver of these efforts is to economically increase pressurized water reactor (PWR) cycle lengths to 24 months, reduce the number of fresh fuel assemblies, increase time online, thereby reducing number of outages and their associated cost, higher fuel utilization, and possibly reduce core design constraints. In order for US nuclear utilities to leverage these economic efficiencies, the US Nuclear Regulatory Commission (NRC) will likely require nuclear power plants (NPPs) to analyze a number of potential operational occurrences and their potential consequences with each new core design prior to resuming normal operation. Potential operational occurrences can be divided into three primary regimes: (1) normal operation, (2) anticipated operation occurrences (AOOs), and (3) design basis accidents (DBAs). Normal plant operation is an operating regime in which the plant operates within specified operational limits until the end of the cycle, whereas AOOs are events that result in the NPP deviating outside the normal operating regime. A key attribute of an AOO is that the occurrence should be expected. However, by definition, the occurrence of an AOO does not result in significant impact to critical safety functions. The last potential operational occurrence is a DBA. From the fuel performance point-of-view, DBAs can be subdivided into two bounding categories: (1) loss of coolant accidents (LOCAs), and (2) reactivity insertion accidents (RIAs). Unlike AOOs, DBAs may result in fuel rod failure. The NRC imposes fundamental acceptance criteria to minimize radiological consequences to the public and onsite staff. Furthermore, safety criteria are typically linked to the fulfillment of other acceptance criteria related to reactor safety equipment designed to mitigate DBAs.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

DOE OSTI2021

Demonstration of CFD to support the coupled analysis of a reactor pressure vessel subjected to pressurized thermal shock

The structural components that comprise nuclear reactors and their supporting structures are subjected to harsh operating environments that can challenge their integrity, especially after exposure for extended duration or under accident condition. As one of the most significant components of a reactor, the Reactor Pressure Vessel (RPV) is exposed to an aggressive environment during the operation time (e.g. more than 40 years). Aging degradation mechanisms (e.g. thermo-fatigue) could grow initial defects up to a critical size, increasing the susceptibility to failure in the RPV. The conventional methods are mostly based on simple crack and structure geometries. Very limited studies consider the real conditions of the RPV subjected to a thermal shock due to a Loss of Coolant Accident (LOCA). During a LOCA event, the most severe conditions take place when the emergency core cooling (ECC) water is injected inside the cold legs filled initially with hotter water and/or steam. The rapid cooling of the down-comer and the internal RPV surface followed probably by re-pressurization of the RPV causes large temperature gradients and variation of pressure which induces thermal-mechanical stresses. In order to develop the model for integrity assessment of a reactor pressure vessel (RPV) subjected to pressurized thermal shock (PTS), a multi-physics simulation, which includes the thermo-hydraulic, thermo-mechanical and fracture mechanics analyses is necessary. The prediction of the temperature field is achieved by using computational fluid dynamics (CFD) simulation. In this report, a demonstration CFD standalone simulation is performed to support coupled analysis for Reactor Pressure Vessel (RPV) subjected to Pressurized Thermal Shock (PTS). The study use a simplified computational domain to represents a real RPV. The purpose of the study is to demonstrate the transient temperature response of RPV to ECC injection. The CFD model is built in a robust and efficient way for further coupled calculation. The next steps of this work, including the coupled thermal and tensor mechanics capabilities using Cardinal are expected to be complete by the end of FY21 for the demo problem. After this, into FY22, the capability will be demonstrated for a realistic RPV.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2023

Simulation and Analysis on Reactor Pressure Vessel (RPV) subjected to Pressurized Thermal Shock (PTS) under SBLOCA scenario by using Cardinal to support the fracture mechanics analyses

The structural components that comprise nuclear reactors and their supporting structures are subjected to harsh operating environments that can challenge their integrity, especially after exposure for extended durations or under accident condition. As one of the most significant components of a Reactor, the Reactor Pressure Vessel (RPV) is exposed to an aggressive environment during the operation time (e.g. more than 40 years). Ageing degradation mechanisms (e.g. thermos-fatigue) could grow initial defects up to a critical size, increasing the susceptibility to failure in the RPV. The conventional methods are mostly based on simple crack and structure geometries. Very limited studies consider the real conditions of the RPV subjected to a thermal shock due to a Loss of Coolant Accident (LOCA). During a LOCA event, the most severe conditions take place when the emergency core cooling (ECC) water is injected inside the cold legs filled initially with hotter water and/or steam. The rapid cooling of the down-comer and the internal RPV surface followed probably by re-pressurization of the RPV causes large temperature gradients and variation of pressure which induces thermal-mechanical stresses. In order to develop the model for integrity assessment of a reactor pressure vessel (RPV) subjected to pressurized thermal shock (PTS), a multi-physics simulation, which includes the thermo-hydraulic, thermo-mechanical and fracture mechanics analyses is necessary. The multi-physics simulations are performed using Cardinal, a wrapping of the GPU-oriented spectral element Computational Fluid Dynamics (CFD) code NekRS and other multi-physics sub-modules within the MOOSE framework. Cardinal now fully supports MOOSE stochastic perturbations of NekRS models with varying boundary conditions, initial conditions, material properties, and any other quantity which is defined by a kernel (such as coefficients in a momentum source model). The implementation is designed in a flexible manner so that scalar values are sent from MOOSE into a user scratch space in NekRS, which can then be applied for any purpose within the NekRS case files (both on the host and device). When modeling PTS, several factors can impact the results significantly. In this report, the impacts of the geometry of the model, Reynolds number and buoyancy effect are investigated. Two geometry, i.e., a simplified model and a realistic RPV model, with both laminar and turbulent flow condition are adopted for the PTS simulation with and without buoyancy effect. The purpose of the investigation is to understand the impact of these factors on the prediction of temperature history of RPV. The accurate prediction on the temperature evolution, which will be exported to Grizzly code for further analyses on the progression of aging mechanisms and their effects on the integrity of RPV structures, is very crucial. Based on the understanding of these factors, a more sophisticated model is built to analysis the PTS under SBLOCA scenario. A literature survey is conducted to pick the SBLOCA scenario for the multi-physics simulation. The analysis helps to explain the form and the transformation of the cold plum when the ECC is activated under SBLOCA. This model can be can be applied to study the PTS effect for different RPV configurations. The results can help to assess structural component degradation for advanced reactors.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2022

Multi physics simulation on Reactor Pressure Vessel (RPV) subjected to Pressurized Thermal Shock (PTS) by using Cardinal

The structural components that comprise nuclear reactors and their supporting structures are subjected to harsh operating environments that can challenge their integrity, especially after exposure for extended durations or under accident condition. As one of the most significant components of a Reactor, the Reactor Pressure Vessel (RPV) is exposed to an aggressive environment during the operation time (e.g. more than 40 years). Ageing degradation mechanisms (e.g. thermo-fatigue) could grow initial defects up to a critical size, increasing the susceptibility to failure in the RPV. The conventional methods are mostly based on simple crack and structure geometries. Very limited studies consider the real conditions of the RPV subjected to a thermal shock due to a Loss of Coolant Accident (LOCA). During a LOCA event, the most severe conditions take place when the emergency core cooling (ECC) water is injected inside the cold legs filled initially with hotter water and/or steam. The rapid cooling of the down-comer and the internal RPV surface followed probably by re-pressurization of the RPV causes large temperature gradients and variation of pressure which induces thermal-mechanical stresses. In order to develop the model for integrity assessment of a reactor pressure vessel (RPV) subjected to pressurized thermal shock (PTS), a multi-physics simulation, which includes the thermo-hydraulic, thermo-mechanical and fracture mechanics analyses is necessary.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

NASA NTRS2006

Orbiter Return-To-Flight Entry Aeroheating

The Columbia accident on February 1, 2003 began an unprecedented level of effort within the hypersonic aerothermodynamic community to support the Space Shuttle Program. During the approximately six month time frame of the primary Columbia Accident Investigation Board activity, many technical disciplines were involved in a concerted effort to reconstruct the last moments of the Columbia and her crew, and understand the critical events that led to that loss. Significant contributions to the CAIB activity were made by the hypersonic aerothermodynamic community(REF CAIB) in understanding the re-entry environments that led to the propagation of an ascent foam induced wing leading edge damage to a subsequent breech of the wing spar of Columbia, and the subsequent breakup of the vehicle. A core of the NASA hypersonic aerothermodynamics team that was involved in the CAIB investigation has been combined with the United Space Alliance and Boeing Orbiter engineering team in order to position the Space Shuttle Program with a process to perform in-flight Thermal Protection System damage assessments. This damage assessment process is now part of the baselined plan for Shuttle support, and is a direct out-growth of the Columbia accident and NASAs response. Multiple re-entry aeroheating tools are involved in this damage assessment process, many of which have been developed during the Return To Flight activity. In addition, because these aeroheating tools are part of an overall damage assessment process that also involves the thermal and stress analyses community, in addition to a much broader mission support team, an integrated process for performing the damage assessment activities has been developed by the Space Shuttle Program and the Orbiter engineering community. Several subsets of activity in the Orbiter aeroheating communities support to the Return To Flight effort have been described in previous publications (CFD?, Cavity Heating? Any BLT? Grid Generation?). This work will provide a description of the integrated process utilized to perform Orbiter tile damage assessment, and in particular will seek to provide a description of the integrated aeroheating tools utilized to perform these assessments. Individual aeroheating tools will be described which provide the nominal re-entry heating environment characterization for the Orbiter, the heating environments for tile damage, heating effects due to exposed Thermal Protection System substrates, the application of Computational Fluid Dynamics for the description of tile cavity heating, and boundary layer transition prediction. This paper is meant to provide an overall view of the integrated aeroheating assessment process for tile damage assessment as one of a sequence of papers on the development of the boundary layer transition prediction capability in support of Space Shuttle Return To Flight efforts.

Campbell, Charles H.↗

NASA NTRS1993

The influence of ATC message length and timing on pilot communication

Pilot-controller communication is critical to safe and efficient flight. It is often a challenging component of piloting, which is reflected in the number of incidents and accidents involving miscommunication. Our previous field study identified communication problems that disrupt routine communication between pilots and controllers. The present part-task simulation study followed up the field results with a more controlled investigation of communication problems. Pilots flew a simulation in which they were frequently vectored by Air Traffic Control (ATC), requiring intensive communication with the controller. While flying, pilots also performed a secondary visual monitoring task. We examined the influence of message length (one message with four commands vs. two messages with two commands each) and noncommunication workload on communication accuracy and length. Longer ATC messages appeared to overload pilot working memory, resulting in more incorrect or partial readbacks, as well as more requests to repeat the message. The timing between the two short messages also influenced communication. The second message interfered with memory for or response to the first short message when it was delivered too soon after the first message. Performing the secondary monitoring task did not influence communication. Instead, communication reduced monitoring accuracy.

Morrow, Daniel↗

NASA NTRS1995

Safety in the operating theatre--part 1: interpersonal relationships and team performance

The authors examine the application of interpersonal human factors training on operating room (OR) personnel. Mortality studies of OR deaths and critical incident studies of anesthesia are examined to determine the role of human error in OR incidents. Theoretical models of system vulnerability to accidents are presented with emphasis on a systems approach to OR performance. Input, process, and outcome factors are discussed in detail.

Non-NASA Center↗

NASA NTRSDate not supplied

Revisiting the Soyuz-1 Parachute Failure in the Context of Safety in the Modern Era

The Soyuz‑1 accident remains one of the most consequential parachute related failures in human spaceflight history and provides enduring lessons for modern Entry, Descent, and Landing (EDL) system design. Occurring during the height of the Cold War and the Space Race, the mission unfolded under extraordinary political and schedule pressure as the Soviet Union sought to maintain its early leadership in space achievements following the death of chief designer Sergei Korolev. Despite unresolved propulsion, electrical, and parachute system deficiencies, Soyuz‑1 proceeded to launch and immediately encountered critical inflight anomalies, including a failed solar panel deployment, attitude control issues, and communication dropouts. Upon reentry, a malfunction in the parachute system, driven by a primary main canopy that failed to deploy, and subsequent entanglement of the reserve main canopy with the primary drogue parachute, resulted in insufficient deceleration and the fatal crash of cosmonaut Vladimir Komarov. Subsequent investigations revealed deep rooted cultural and organizational issues within the Soviet space program, including inadequate testing, suppression of dissent, undocumented last minute design changes, and the absence of integrated parachute system verification. More than 200 design flaws were identified after the accident, and firsthand accounts, including those from Yuri Gagarin, highlighted widespread concern prior to launch. Over time, the Soviet program implemented substantial reforms: systematic design corrections, rigorous process documentation, and an extensive series of drop tests that ultimately transformed the Soyuz system into one of the world’s most reliable human-rated return vehicles. This paper examines the technical architecture of the Soyuz‑1 parachute system, reconstructs the likely deployment sequence and failure mechanism, and analyzes the cultural contributors that shaped the accident. The study draws parallels to modern spacecraft parachute development, emphasizing the critical importance of integrated system testing, transparent engineering culture, and continuous hardware surveillance. These lessons remain directly relevant to today’s NASA and Commercial Crew Programs (CCP), where the Government continues to refine its understanding of aggregate risk and strengthen overall astronaut safety in the face of increasingly complex parachute systems.

Aaron L Morris↗

NASA NTRS2013

Self Diagnostic Accelerometer Ground Testing on a C-17 Aircraft Engine

The self diagnostic accelerometer (SDA) developed by the NASA Glenn Research Center was tested for the first time in an aircraft engine environment as part of the Vehicle Integrated Propulsion Research (VIPR) program. The VIPR program includes testing multiple critical flight sensor technologies. One such sensor, the accelerometer, measures vibrations to detect faults in the engine. In order to rely upon the accelerometer, the health of the accelerometer must be ensured. Sensor system malfunction is a significant contributor to propulsion in flight shutdowns (IFSD) which can lead to aircraft accidents when the issue is compounded with an inappropriate crew response. The development of the SDA is important for both reducing the IFSD rate, and hence reducing the rate at which this component failure type can put an aircraft in jeopardy, and also as a critical enabling technology for future automated malfunction diagnostic systems. The SDA is a sensor system designed to actively determine the accelerometer structural health and attachment condition, in addition to making vibration measurements. The SDA uses a signal conditioning unit that sends an electrical chirp to the accelerometer and recognizes changes in the response due to changes in the accelerometer health and attachment condition. In an effort toward demonstrating the SDAs flight worthiness and robustness, multiple SDAs were mounted and tested on a C-17 aircraft engine. The engine test conditions varied from engine off, to idle, to maximum power. The two SDA attachment conditions used were fully tight and loose. The newly developed SDA health algorithm described herein uses cross correlation pattern recognition to discriminate a healthy from a faulty SDA. The VIPR test results demonstrate for the first time the robustness of the SDA in an engine environment characterized by high vibration levels.

Tokars, Roger P.↗

NASA NTRS1990

Weather data dissemination to aircraft

Documentation exists that shows weather to be responsible for approximately 40 percent of all general aviation accidents with fatalities. Weather data products available on the ground are becoming more sophisticated and greater in number. Although many of these data are critical to aircraft safety, they currently must be transmitted verbally to the aircraft. This process is labor intensive and provides a low rate of information transfer. Consequently, the pilot is often forced to make life-critical decisions based on incomplete and outdated information. Automated transmission of weather data from the ground to the aircraft can provide the aircrew with accurate data in near-real time. The current National Airspace System Plan calls for such an uplink capability to be provided by the Mode S Beacon System data link. Although this system has a very advanced data link capability, it will not be capable of providing adequate weather data to all airspace users in its planned configuration. This paper delineates some of the important weather data uplink system requirements, and describes a system which is capable of meeting these requirements. The proposed system utilizes a run-length coding technique for image data compression and a hybrid phase and amplitude modulation technique for the transmission of both voice and weather data on existing aeronautical Very High Frequency (VHF) voice communication channels.

Mcfarland, Richard H.↗

NASA NTRS2010

NASA Headquarters Space Operations Center: Providing Situational Awareness for Spaceflight Contingency Response

This paper discusses the NASA Headquarters mishap response process for the Space Shuttle and International Space Station programs, and how the process has evolved based on lessons learned from the Space Shuttle Challenger and Columbia accidents. It also describes the NASA Headquarters Space Operations Center (SOC) and its special role in facilitating senior management's overall situational awareness of critical spaceflight operations, before, during, and after a mishap, to ensure a timely and effective contingency response.

Maxwell, Theresa G.↗

NASA NTRS2022

Maintenance Human Factors and Flight Safety

This chapter will chronicle the journey of the community of operators, regulators, and researchers who embarked upon the task of identifying critical human factors of maintenance and inspection, establishing a database and research tools, developing practical strategies for reducing the risks of maintenance and inspection errors, and understanding its critical role in preserving flight safety. We will take a historical perspective, developing a timeline that is largely driven by key events such as accidents and regulatory/government actions and initiatives. Part 1 focuses on how the field of maintenance human factors was built, beginning in the late 1980’s. Part 2 describes the development of methods and tools for meeting the maintenance human factors challenges identified. Finally, Part 3 updates the original chapter by focusing on issues that have persisted or emerged since 2010.

maintenance↗

DOE OSTI2021

Design, Manufacturing and Performance Considerations in Reactor System, Components and Materials

Idaho National Laboratory (INL) is the national and global leader of the Department of Energy (DOE) ’s nuclear energy research, development, and demonstration programs. Developing critical design criteria of new advanced reactor systems, components and materials requires an understanding of fabrication and the irradiation environment during normal operating and accident conditions. Next generation researchers and designers, are, therefore challenged not only by demands for ever improved performance but must also work to shorten the development and commercialization lifecycle for new nuclear reactors and systems to remain competitive. This provides unique and exciting opportunities for all contributors to this field of study. This presentation will offer a strategic overview of the competitively funded R&D awards by the Advanced Methods for Manufacturing (AMM) program of the DOE’s office of Nuclear Energy (NE). This program conducts research and development (R&D) to accelerate innovations by reducing the cost and schedule of constructing new nuclear plants and to make fabrication of nuclear power plant components faster, cheaper, and more reliable. By evaluating state-of-the-art practices found in other large manufacturing industries, the nuclear community has identified six major areas of innovation to reach the objectives of this DOE-NE program. Additionally, typical research case studies performed at INL, will be presented, showing the vast variety of opportunities for which, the next generation of researchers can seek solutions.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

NASA NTRS2010

Passing the Baton: An Experimental Study of Shift Handover

Shift handovers occur in many safety-critical environments, including aviation maintenance, medicine, air traffic control, and mission control for space shuttle and space station operations. Shift handovers are associated with increased risk of communication failures and human error. In dynamic industries, errors and accidents occur disproportionately after shift handover. Typical shift handovers involve transferring information from an outgoing shift to an incoming shift via written logs, or in some cases, face-to-face briefings. The current study explores the possibility of improving written communication with the support modalities of audio and video recordings, as well as face-to-face briefings. Fifty participants participated in an experimental task which mimicked some of the critical challenges involved in transferring information between shifts in industrial settings. All three support modalities, face-to-face, video, and audio recordings, reduced task errors significantly over written communication alone. The support modality most preferred by participants was face-to-face communication; the least preferred was written communication alone.

Parke, Bonny↗