Search NASA⌕ Search

SEARCH · Search NASA

Results for “ACCIDENT INVESTIGATIONS”

Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 235 records · Page 13

NASA Medical Response to Human Spacecraft Accidents

Manned space flight is risky business. Accidents have occurred and may occur in the future. NASA's manned space flight programs, with all their successes, have had three fatal accidents, one at the launch pad and two in flight. The Apollo fire and the Challenger and Columbia accidents resulted in a loss of seventeen crewmembers. Russia's manned space flight programs have had three fatal accidents, one ground-based and two in flight. These accidents resulted in the loss of five crewmembers. Additionally, manned spacecraft have encountered numerous close calls with potential for disaster. The NASA Johnson Space Center Flight Safety Office has documented more than 70 spacecraft incidents, many of which could have become serious accidents. At the Johnson Space Center (JSC), medical contingency personnel are assigned to a Mishap Investigation Team. The team deploys to the accident site to gather and preserve evidence for the Accident Investigation Board. The JSC Medical Operations Branch has developed a flight surgeon accident response training class to capture the lessons learned from the Columbia accident. This presentation will address the NASA Mishap Investigation Team's medical objectives, planned response, and potential issues that could arise subsequent to a manned spacecraft accident. Educational Objectives are to understand the medical objectives and issues confronting the Mishap Investigation Team medical personnel subsequent to a human space flight accident.

Patlach, Robert↗

Preliminary Effect of Synthetic Vision Systems Displays to Reduce Low-Visibility Loss of Control and Controlled Flight Into Terrain Accidents

An experimental investigation was conducted to study the effectiveness of Synthetic Vision Systems (SVS) flight displays as a means of eliminating Low Visibility Loss of Control (LVLOC) and Controlled Flight Into Terrain (CFIT) accidents by low time general aviation (GA) pilots. A series of basic maneuvers were performed by 18 subject pilots during transition from Visual Meteorological Conditions (VMC) to Instrument Meteorological Conditions (IMC), with continued flight into IMC, employing a fixed-based flight simulator. A total of three display concepts were employed for this evaluation. One display concept, referred to as the Attitude Indicator (AI) replicated instrumentation common in today's General Aviation (GA) aircraft. The second display concept, referred to as the Electronic Attitude Indicator (EAI), featured an enlarged attitude indicator that was more representative of a glass display that also included advanced flight symbology, such as a velocity vector. The third concept, referred to as the SVS display, was identical to the EAI except that computer-generated terrain imagery replaced the conventional blue-sky/brown-ground of the EAI. Pilot performance parameters, pilot control inputs and physiological data were recorded for post-test analysis. Situation awareness (SA) and qualitative pilot comments were obtained through questionnaires and free-form interviews administered immediately after the experimental session. Initial pilot performance data were obtained by instructor pilot observations. Physiological data (skin temperature, heart rate, and muscle flexure) were also recorded. Preliminary results indicate that far less errors were committed when using the EAI and SVS displays than when using conventional instruments. The specific data example examined in this report illustrates the benefit from SVS displays to avoid massive loss of SA conditions. All pilots acknowledged the enhanced situation awareness provided by the SVS display concept. Levels of pilot stress appear to be correlated with skin temperature measurements.

Glaab, Louis J.↗

Photogrammetry Tool for Forensic Analysis

A system allows crime scene and accident scene investigators the ability to acquire visual scene data using cameras for processing at a later time. This system uses a COTS digital camera, a photogrammetry calibration cube, and 3D photogrammetry processing software. In a previous instrument developed by NASA, the laser scaling device made use of parallel laser beams to provide a photogrammetry solution in 2D. This device and associated software work well under certain conditions. In order to make use of a full 3D photogrammetry system, a different approach was needed. When using multiple cubes, whose locations relative to each other are unknown, a procedure that would merge the data from each cube would be as follows: 1. One marks a reference point on cube 1, then marks points on cube 2 as unknowns. This locates cube 2 in cube 1 s coordinate system. 2. One marks reference points on cube 2, then marks points on cube 1 as unknowns. This locates cube 1 in cube 2 s coordinate system. 3. This procedure is continued for all combinations of cubes. 4. The coordinate of all of the found coordinate systems is then merged into a single global coordinate system. In order to achieve maximum accuracy, measurements are done in one of two ways, depending on scale: when measuring the size of objects, the coordinate system corresponding to the nearest cube is used, or when measuring the location of objects relative to a global coordinate system, a merged coordinate system is used. Presently, traffic accident analysis is time-consuming and not very accurate. Using cubes with differential GPS would give absolute positions of cubes in the accident area, so that individual cubes would provide local photogrammetry calibration to objects near a cube.

Lane, John↗

The Apollo spacecraft: A chronology volume 4, 21 January 1966 - 13 July 1974

This final volume of the chronology is divided into three parts: (1) preparation for flight, the accident, and investigation; (2) recovery, spacecraft redefinition, and the first manned flight; and (3) man circles the moon, the Eagle lands, and manned space exploration. Congressional documents, official correspondence, government and contractor reports, memoranda, working papers, and minutes of meetings were used as primary sources. A relatively few entries are based on press releases and newspaper and magazine articles.

Ertel, I. D.↗

A theory of human error

Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Mcruer, D. T.↗

A parametric shell analysis of the shuttle 51-L SRB AFT field joint

Following the Shuttle 51-L accident, an investigation was conducted to determine the cause of the failure. Investigators at the Langley Research Center focused attention on the structural behavior of the field joints with O-ring seals in the steel solid rocket booster (SRB) cases. The shell-of-revolution computer program BOSOR4 was used to model the aft field joint of the solid rocket booster case. The shell model consisted of the SRB wall and joint geometry present during the Shuttle 51-L flight. A parametric study of the joint was performed on the geometry, including joint clearances, contact between the joint components, and on the loads, induced and applied. In addition combinations of geometry and loads were evaluated. The analytical results from the parametric study showed that contact between the joint components was a primary contributor to allowing hot gases to blow by the O-rings. Based upon understanding the original joint behavior, various proposed joint modifications are shown and analyzed in order to provide additional insight and information. Finally, experimental results from a hydro-static pressurization of a test rocket booster case to study joint motion are presented and verified analytically.

Davis, Randall C.↗

Sizing Up the Situation

Hailstorm damage to the Space Shuttle's External Tank inspired a NASA innovation with extensive photography applications. In order to measure the defects caused by the storm, Kennedy Space Center used telephoto lenses to zoom in on the tank and view the damage clearly. However, since there was no reference object in the image, the engineers could not determine the scale of the damage. In photographic situations similar to this, an object, such as a ruler, is placed within the field of view. This allows a person to look at a photograph and have a visual indication of the scale of the objects in it. In the External Tank situation, however, this procedure was not possible. As a solution, Kennedy developed the Scaling and Measurement Device for Photographic Images, which provides a non-intrusive means of adding a scale to a photograph. In addition to meeting Kennedy's needs, scaling images is extremely important in crime and accident scene investigations, oil and chemical tank monitoring, and aerial photography. The innovation consists of a tool that attaches directly to a camera or charge coupled device using a standard screw. Two lasers fitted to the device provide parallel beams that are set 1 inch apart. These lasers enable the device to project a pattern into the field of view. When a photograph is taken, the image of the laser pattern appears, along with the image of the object under investigation, allowing the viewer quantifiable information as to the size of the object. The laser beams are accurate to approximately 200 feet. Windows-based software was developed to work with the scaling device tool. The software provides further techniques to measure objects in photographs and digital images. By using the software, any object in the image can be measured diagonally, vertically, and horizontally. The device and its software enable the user to determine two-dimensional measurements within a photograph.

Source record↗

Aeronautics and Space Report of the President, Fiscal Year 2002 Activities

Fiscal Year (FY) 2002 brought advances on many fronts in support of NASAs new vision, announced by Administrator Sean OKeefe on April 12, to improve life here, to extend life to there, to find life beyond. NASA successfully carried out four Space Shuttle missions, including three to the International Space Station (ISS) and one servicing mission to the Hubble Space Telescope (HST). By the end of the fiscal year, humans had occupied the ISS continuously for 2 years. NASA also managed five expendable launch vehicle (ELV) missions and participated in eight international cooperative ELV launches. In the area of space science, two of the Great Observatories, the Hubble Space Telescope and the Chandra X-Ray Observatory, continued to make spectacular observations. The Mars Global Surveyor and Mars Odyssey carried out their mapping missions of the red planet in unprecedented detail. Among other achievements, the Near Earth Asteroid Rendezvous (NEAR) Shoemaker spacecraft made the first soft landing on an asteroid, and the Solar and Heliospheric Observatory (SOHO) monitored a variety of solar activity, including the largest sunspot observed in 10 years. The education and public outreach program stemming from NASAs space science missions continues to grow. In the area of Earth science, attention focused on completing the first Earth Observing Satellite series. Four spacecraft were successfully launched. The goal is to understand our home planet as a system, as well as how the global environment responds to change.

Aeronautics↗

Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents. CRM/HF Conference, Held in Denver, Colorado on April 16-17, 2006

Reviewed NTSB reports of the 19 U.S. airline accidents between 1991-2000 attributed primarily to crew error. Asked: Why might any airline crew in situation of accident crew--knowing only what they knew--be vulnerable. Can never know with certainty why accident crew made specific errors but can determine why the population of pilots is vulnerable. Considers variability of expert performance as function of interplay of multiple factors.

Aviation accidents↗

The X-15 3-65 Accident: An Aircraft Systems and Flight Control Perspective

Despite the NASA X-15 program's outstanding success in developing and operating the first manned hypersonic research platform, the program suffered a fatal accident on November 15, 1967, when X-15-3, the only aircraft outfitted with advanced pilot displays and an adaptive flight control system, was lost after entering uncontrolled flight at an altitude of 230,000 feet and a velocity near Mach 5. The pilot, Major Michael J. Adams, was incapacitated by the aircraft accelerations and was killed either during the ensuing breakup or upon ground impact. In light of mitigating risk to current and emerging manned aerospace vehicles, a comprehensive systems level analysis of the accident is presented with a focus on the electrical power, flight control, and instrumentation failures that affected not only the vehicle dynamics but substantially impacted the pilot decisions that led to an inevitable loss of control. Insights based on reconstructed flight data as well as analysis and simulation of the X-15's unique adaptive control system, yield new conclusions about the reasons for the control systems anomalous behavior and the system-level interactions and human-machine interface design oversights that led to the accident.

Accident Investigation↗

Honeywell Enhancing Airplane State Awareness (EASA) Project: Final Report on Refinement and Evaluation of Candidate Solutions for Airplane System State Awareness

The loss of pilot airplane state awareness (ASA) has been implicated as a factor in several aviation accidents identified by the Commercial Aviation Safety Team (CAST). These accidents were investigated to identify precursors to the loss of ASA and develop technologies to address the loss of ASA. Based on a gap analysis, two technologies were prototyped and assessed with a formative pilot-in-the-loop evaluation in NASA Langley’s full-motion Research Flight Deck. The technologies address: 1) data source anomaly detection in real-time, and 2) intelligent monitoring aids to provide nominal and predictive awareness of situations to be monitored and a mission timeline to visualize events of interest. The evaluation results indicated favorable impressions of both technologies for mitigating the loss of ASA in terms of operational utility, workload, acceptability, complexity, and usability. The team concludes that there is a feasible retrofit solution for improving ASA that would minimize certification risk, integration costs, and training impact.

Whitlow, Stephen D.↗

The Multi-Dimensional Nature of Wind Shear Investigations

The impact of air carrier accidents has lead to investigations into the wind shear phenomenon. This report includes such topics as wind shear characterization, aircraft pilot performance in shear conditions, terminology and language development, wind shear forecasting, ground and flight wind shear displays, wind shear data collection and dissemination, and pilot factors associated with wind shear encounters. Some areas which show promise for short term solutions to the wind shear hazards includes: (1) improved gust front warning through ground based sensors; (2) greater pilot awareness of wind shear through improved training; and (3) airborne displays based on groundspeed/airspeed comparisons.

Cox, W. J.↗

Challenger and Columbia Lessons Learned

The Space Shuttle Challenger and Columbia accidents resulted in tragic loss of life and national assets, and investigations into both accidents produced important lessons to prevent future accidents

Hoffman, William C., III↗

Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation

Advances in technology and new levels of automation on commercial jet transports has had many effects. There have been positive effects from both an economic and a safety point of view. The technology changes on the flight deck also have had reverberating effects on many other aspects of the aviation system and different aspects of human performance. Operational experience, research investigations, incidents, and occasionally accidents have shown that new and sometimes surprising problems have arisen as well. What are these problems with cockpit automation, and what should we learn from them? Do they represent over-automation or human error? Or instead perhaps there is a third possibility - they represent coordination breakdowns between operators and the automation? Are the problems just a series of small independent glitches revealed by specific accidents or near misses? Do these glitches represent a few small areas where there are cracks to be patched in what is otherwise a record of outstanding designs and systems? Or do these problems provide us with evidence about deeper factors that we need to address if we are to maintain and improve aviation safety in a changing world? How do the reverberations of technology change on the flight deck provide insight into generic issues about developing human-centered technologies and systems (Winograd and Woods, 1997)? Based on a series of investigations of pilot interaction with cockpit automation (Sarter and Woods, 1992; 1994; 1995; 1997a, 1997 b), supplemented by surveys, operational experience and incident data from other studies (e.g., Degani et al., 1995; Eldredge et al., 1991; Tenney et al., 1995; Wiener, 1989), we too have found that the problems that surround crew interaction with automation are more than a series of individual glitches. These difficulties are symptoms that indicate deeper patterns and phenomena concerning human-machine cooperation and paths towards disaster. In addition, we find the same kinds of patterns behind results from studies of physician interaction with computer-based systems in critical care medicine (e.g., Moll van Charante et al., 1993; Obradovich and Woods, 1996; Cook and Woods, 1996). Many of the results and implications of this kind of research are synthesized and discussed in two comprehensive volumes, Billings (1996) and Woods et al. (1994). This paper summarizes the pattern that has emerged from our research, related research, incident reports, and accident investigations. It uses this new understanding of why problems arise to point to new investment strategies that can help us deal with the perceived "human error" problem, make automation more of a team player, and maintain and improve safety.

Woods, David D.↗

Archetypes for Organisational Safety

We propose a framework using system dynamics to model the dynamic behavior of organizations in accident analysis. Most current accident analysis techniques are event-based and do not adequately capture the dynamic complexity and non-linear interactions that characterize accidents in complex systems. In this paper we propose a set of system safety archetypes that model common safety culture flaws in organizations, i.e., the dynamic behaviour of organizations that often leads to accidents. As accident analysis and investigation tools, the archetypes can be used to develop dynamic models that describe the systemic and organizational factors contributing to the accident. The archetypes help clarify why safety-related decisions do not always result in the desired behavior, and how independent decisions in different parts of the organization can combine to impact safety.

Marais, Karen↗

Investigation of technology needs for avoiding helicopter pilot error related accidents

Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.

Chais, R. I.↗