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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
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.
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.
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.
A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. From the analyses conducted and presented in this paper, the following conclusions were drawn. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985-certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003- subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs. I.
One of the lessons learned from the Fukushima Daiichi nuclear power plant (NPP) accident is strengthening the station blackout (SBO) mitigation capabilities by enhancing defense in depth for all existing and new NPPs. One of the possible remedies is diverse and flexible coping strategies (FLEX). The objective of this study is to address the benefits of FLEX in various accident scenarios in terms of both risk and cost. FLEX was originally devised against SBO accidents. In this research, we investigate the fundamental plant responses against accidents considering two fundamentally different cases: accidents that lead to high pressure on the primary side and accidents that lead to low pressure on the primary side. Several uncertainties are associated with the characteristics of the FLEX portable equipment. Specifically, the time for FLEX deployment may depend on several factors such as type of accident, point of injection, availability of safety systems, battery backup timings, and human actions. This study utilizes a dynamic risk assessment framework to analyze accident scenarios and suggests a novel importance measure, which is a cumulative distribution function– based importance metric that characterizes the influence of input distribution on complete output distribution. The importance of the existing and newly developed FLEX strategy based on risk significance is illustrated with examples. The suggested measure provides clear insight into how FLEX affects risk of the whole system and additional risk margins thanks to new safety systems.
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.
A description and analysis of each of the 208 civil helicopter wire strike accidents reported to the National Transportation Safety Board (NTSB) for the ten year period 1970-1979 is given. The accident analysis briefs were based on pilot reports, FAA investigation reports, and such accident photographs as were made available. Briefs were grouped by year and, within year, by NTSB accident report number.
In an experimental study to obtain detailed heating data over the Space Shuttle Orbiter, CUBRC has completed an extensive matrix of experiments using three distinct models and two unique hypervelocity wind tunnel facilities. This detailed data will be employed to assess heating augmentation due to boundary layer transition on the Orbiter wing leading edge and wind side acreage with comparisons to computational methods and flight data obtained during the Orbiter Entry Boundary Layer Flight Experiment and HYTHIRM during STS-119 reentry. These comparisons will facilitate critical updates to be made to the engineering tools employed to make assessments about natural and tripped boundary layer transition during Orbiter reentry. To achieve the goals of this study data was obtained over a range of Mach numbers from 10 to 18, with flight scaled Reynolds numbers and model attitudes representing key points on the Orbiter reentry trajectory. The first of these studies were performed as an integral part of Return to Flight activities following the accident that occurred during the reentry of the Space Shuttle Columbia (STS-107) in February of 2003. This accident was caused by debris, which originated from the foam covering the external tank bipod fitting ramps, striking and damaging critical wing leading edge heating tiles that reside in the Orbiter bow shock/wing interaction region. During investigation of the accident aeroheating team members discovered that only a limited amount of experimental wing leading edge data existed in this critical peak heating area and a need arose to acquire a detailed dataset of heating in this region. This new dataset was acquired in three phases consisting of a risk mitigation phase employing a 1.8% scale Orbiter model with special temperature sensitive paint covering the wing leading edge, a 0.9% scale Orbiter model with high resolution thin-film instrumentation in the span direction, and the primary 1.8% scale Orbiter model with detailed thin-film resolution in both the span and chord direction in the area of peak heating. Additional objectives of this first study included: obtaining natural or tripped turbulent wing leading edge heating levels, assessing the effectiveness of protuberances and cavities placed at specified locations on the orbiter over a range of Mach numbers and Reynolds numbers to evaluate and compare to existing engineering and computational tools, obtaining cavity floor heating to aid in the verification of cavity heating correlations, acquiring control surface deflection heating data on both the main body flap and elevons, and obtain high speed schlieren videos of the interaction of the orbiter nose bow shock with the wing leading edge. To support these objectives, the stainless steel 1.8% scale orbiter model in addition to the sensors on the wing leading edge was instrumented down the windward centerline, over the wing acreage on the port side, and painted with temperature sensitive paint on the starboard side wing acreage. In all, the stainless steel 1.8% scale Orbiter model was instrumented with over three-hundred highly sensitive thin-film heating sensors, two-hundred of which were located in the wing leading edge shock interaction region. Further experimental studies will also be performed following the successful acquisition of flight data during the Orbiter Entry Boundary Layer Flight Experiment and HYTHIRM on STS-119 at specific data points simulating flight conditions and geometries. Additional instrumentation and a protuberance matching the layout present during the STS-119 boundary layer transition flight experiment were added with testing performed at Mach number and Reynolds number conditions simulating conditions experienced in flight. In addition to the experimental studies, CUBRC also performed a large amount of CFD analysis to confirm and validate not only the tunnel freestream conditions, but also 3D flows over the orbiter acreage, wing leading edge, and controlurfaces to assess data quality, shock interaction locations, and control surface separation regions. This analysis is a standard part of any experimental program at CUBRC, and this information was of key importance for post-test data quality analysis and understanding particular phenomena seen in the data. All work during this effort was sponsored and paid for by the NASA Space Shuttle Program Office at the Johnson Space Center in Houston, Texas.
Presentation to introduce a number of university-led NEUP projects on the subject of thermal-hydraulic behavior of accident tolerant fuel materials for the 2020 AFC Annual Review Meeting.
Cr-coated zirconium alloys represent a modern approach to enhance cladding safety during accident scenarios. Two high-power impulse magnetron sputtered Cr-coated Zry-4 systems were subjected to simulated loss-of-coolant accident conditions to investigate cladding performance. The first Cr-coating (4.8 µm thick) was deposited onto Zry-4 cladding and exhibited through-thickness cracking while the second Cr-coating (6.8 µm thick) was deposited with improved deposition parameters onto polished Zry-4 and exhibited no cracking. During burst testing, the coating with a higher density of defects failed to consistently reduce oxidation and exhibited similar burst behavior as Zry-4. In contrast, the second Cr-coating reduced ZrO 2 formation through formation of Cr 2 O 3 and displayed enhanced burst temperatures by ~80 °C compared to Zry-4. Utilizing an empirical relation for burst behavior of zirconium alloys, the 6.8 µm Cr/Zry-4 system displayed enhanced burst temperatures equivalent to an effective 0.464 mm increase in Zry-4 wall thickness, highlighting the value of continuous Cr coatings for accident scenarios.
Terry steam turbines are employed in the safety systems of many nuclear Boiling Water Reactors to drive pumps and provide cooling water to the nuclear reactor core. While the turbine efficiency is low, the more important feature is high reliability under off-normal conditions. An important aspect of reliability is the ability to function with two-phase steam-water injection into the turbine, as most likely occurred in the Fukushima Dai-ichi nuclear accidents. This study investigates the characteristics of a Terry turbine during air-water injection with gas mass fractions ranging from 1 (dry gas) to 0.05 (wet gas), to better understand the Terry turbine’s true operational capabilities and provide justification for extended Terry turbine use for reactor safety. Other parameters investigated are the inlet pressure, the exhaust backpressure and the turbine’s rotational speed. The turbine performance is presented in terms of dynamometer loading and pump performance change as functions of the gas mass fraction.
The range of managerial, technical, and procedural initiatives implemented by NASA's post-Challenger safety program is reviewed. The recommendations made by the Rogers Commission, the NASA post-Challenger review of Shuttle design, the Congressional investigation of the accident, the National Research Council, the Aerospace Safety Advisory Panel, and NASA internal advisory panels and studies are summarized. NASA safety initiatives regarding improved organizational accountability for safety, upgraded analytical techniques and methodologies for risk assessment and management, procedural initiatives in problem reporting and corrective-action tracking, ground processing, maintenance documentation, and improved technologies are discussed. Safety issues relevant to the planned Space Station are examined.
An autobiography, of a noted aeronautical engineer, W. Hewitt Phillips, whose career spanned 58 years (1940-1998) at NASA Langley is presented. This work covers his early years to the Sputnik launch. His interests have been in research in aeronautics and in the related problems of spaceflight. After an introduction, his early life through the college years is reviewed, and his early interest in model airplanes is described. The first assignment for the National Advisory Committee for Aeronautics (NACA), which would later become NASA, was with the Flight Research Division. His early work involved "Flying Qualities", i.e., the stability and control characteristics of an airplane. The next chapter describes his early analytical studies. His work during World War II in the design of military airplanes, and the other effects of the war on research activities, is covered in the next two chapters. This research was involved in such innovations and refinements as the swept wing, the flettner tabs, servo tabs, spring tabs and whirlerons. The rest of the work covers the research which Mr. Hewitt was involved in, after the war until the Sputnik launch. These areas include unsteady lift, measurements of turbulence in the atmosphere, gust alleviation, and lateral response to random turbulence. He was also involved in several investigations of airplane accidents. The last two chapters cover the administration of the Langley Research Center, and the dawn of the Space Age. A complete bibliography of reports written by Mr. Hewitt, is included.
Externally-imposed tasks frequently interrupt ongoing task performance in the commercial flight deck. While normally managed without consequence, basic research as well as aviation accident and incident investigations show that interruptions can negatively affect performance and safety. This research investigates the influence of interruption and interrupted task modality on pilot performance in a simulated commercial flight deck. Fourteen current commercial airline pilots performed approach scenarios in a fixed-base flight simulator. Air traffic control instructions, conveyed either aurally or visually (via a data link system) interrupted a visual task (obtaining information from the Flight Management System) and an auditory task (listening to the automated terminal information service recording). Some results confirm the hypothesized performance advantage of cross-modality conditions, more compelling nature of auditory interruptions, and interruption-resistance of auditory ongoing tasks. However, taken together, results suggest the four interaction conditions had different effects on pilot performance. These results have implications for the design of data link systems, and for facilitating interruption management through interface design, aiding, and training programs.
We provide a description of work at the National Aeronautics and Space Administration (NASA) on building system based on semantic-web concepts and technologies. NASA has been one of the early adopters of semantic-web technologies for practical applications. Indeed there are several ongoing 0 endeavors on building semantics based systems for use in diverse NASA domains ranging from collaborative scientific activity to accident and mishap investigation to enterprise search to scientific information gathering and integration to aviation safety decision support We provide a brief overview of many applications and ongoing work with the goal of informing the external community of these NASA endeavors.
The first major structural component failure of a composite part on a commercial airplane occurred during the crash of American Airlines Flight 587. The fractured composite lugs that attached the vertical stabilizer to the aircraft tail and the fractured composite honeycomb rudder were examined as part of the National Transportation Safety Board investigation of the accident. In this paper the composite fractures are described and the resulting clues to the failure events are discussed.