Search NASA⌕ Search

SEARCH · Search NASA

Results for “ACCIDENT CAUSES”

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 289 records · Page 16

Ocular hazards of light

The eye is protected against bright light by the natural aversion response to viewing bright light sources. The aversion response normally protects the eye against injury from viewing bright light sources such as the sun, arc lamps and welding arcs, since this aversion limits the duration of exposure to a fraction of a second (about 0.25 s). The principal retinal hazard resulting from viewing bright light sources is photoretinitis, e.g., solar retinitis with an accompanying scotoma which results from staring at the sun. Solar retinitis was once referred to as 'eclipse blindness' and associated 'retinal burn'. Only in recent years has it become clear that photoretinitis results from a photochemical injury mechanism following exposure of the retina to shorter wavelengths in the visible spectrum, i.e., violet and blue light. Prior to conclusive animal experiments at that time, it was thought to be a thermal injury mechanism. However, it has been shown conclusively that an intense exposure to short-wavelength light (hereafter referred to as 'blue light') can cause retinal injury. The product of the dose-rate and the exposure duration always must result in the same exposure dose (in joules-per-square centimeter at the retina) to produce a threshold injury. Blue-light retinal injury (photoretinitis) can result from viewing either an extremely bright light for a short time, or a less bright light for longer exposure periods. This characteristic of photochemical injury mechanisms is termed reciprocity and helps to distinguish these effects from thermal burns, where heat conduction requires a very intense exposure within seconds to cause a retinal coagulation otherwise, surrounding tissue conducts the heat away from the retinal image. Injury thresholds for acute injury in experimental animals for both corneal and retinal effects have been corroborated for the human eye from accident data. Occupational safety limits for exposure to UVR and bright light are based upon this knowledge. As with any photochemical injury mechanism must consider the action spectrum, which describes the relative effectiveness of different wavelengths in causing a photobiological effect. The action spectrum for photochemical retinal injury peaks at approximately 440 nm.

Sliney, David H.↗

The Challenger tragedy was caused by an Apollo mistake, terminating risk analysis

NASA’s view of risk changed between early Apollo and the Space Shuttle. Risk was a known serious problem at the beginning of Apollo and the risk estimates were disturbingly high. To avoid public concern, risk analysis was discontinued. Risk analysis was avoided in Shuttle, leading to an unnecessarily risky design. The immediate cause of the Challenger tragedy was the mistaken decision to launch in cold weather. The fundamental cause was the high risk of the Shuttle design. Before Challenger, management thought and testified that the probability of an accident was 1 in 100,000. After Challenger, Probabilistic Risk Analysis (PRA) found a roughly 1 in 100 chance of a Shuttle failure. The recent Orion design uses the safer Apollo approach, with a hardened capsule, launch abort escape, and the crew placed above the rocket tanks and engines. During Apollo it was estimated that, “assuming all elements from propulsion to rendezvous and life support were done as well or better than ever before, that 30 astronauts would be lost before 3 were returned safely to the Earth.” The chance of astronaut survival was only 10%. After the Apollo 1 tragedy, the awareness of risk led to an intense focus on achieving safety. “The only possible explanation for the astonishing success – no losses in space and on time – was that every participant at every level in every area far exceeded the norm of human capabilities.” During Apollo, a NASA PRA found that the chance of success was “less than 5 percent.” The NASA Administrator felt that “the numbers could do irreparable harm,” and discontinued numerical risk assessment. This led to decreasing understanding of risk. The head of Apollo reliability and safety decided, “Statistics don’t count for anything,” and that risk is reduced by “attention taken in design.” The great and initially unexpected success of Apollo appeared to validate the neglect of PRA. Continuing to neglect the mathematical estimation of risk led Shuttle into a high risk design that produced tragic results. The initial design of the Shuttle emphasized increasing capability and reducing cost without analysis or even mention of risk. A retired NASA official stated, “some NASA people began to confuse desire with reality. … One result was to assess risk in terms of what was thought acceptable without regard for verifying the assessment. … Note that under such circumstances real risk management is shut out.” Not computing risk led to removing launch abort, removing crew escape, selecting less reliable Solid Rocket Boosters, placing the crew compartment next to the rocket boosters, and accepting more stressed shielding tile designs. Accepting these specific risks directly caused the shuttle disasters. The Challenger tragedy is frequently taught as a case of management failure. The focus is on the Challenger launch decision hours before, which is a dramatic example of bad management. However, the true cause of the Challenger disaster occurred decades earlier in the Apollo era. When the easily predictable failures occurred, failure investigations focused on how they might have been avoided. The Shuttle was cancelled after the space station was completed because of its high risk. The ultimate cause of the Shuttle tragedies was the choice by the Apollo-era NASA administrator to avoid a negative public reaction to realistic risk analysis.

Harry W. Jones↗

Improving Dose Modeling With Dynamic Modeling Tools [Slides]

Utilities aiming for higher fuel enrichment for power uprates or extended operation times before refueling must conduct a new dose analysis. Current conservative dose estimation standards may cause utilities to exceed regulatory limits for proposed increased fuel enrichment. A more accurate modeling of doses from reactor accidents can lower these conservative assumptions. Prescott et al. (2022) demonstrated that the Event Modeling Risk Assessment using Linked Diagrams (EMRALD) software tool, developed at Idaho National Laboratory (INL), can be coupled with the Modular Accident Analysis Program (MAAP5) for dynamic accident analysis in reactor plants. EMRALD forms models of potential accident scenarios, while MAAP5 simulates the accident progression and dose consequences. By integrating these software tools with utility-specific data, a more precise estimation of dose consequences from plant accidents can be achieved. Preliminary findings indicate that EMRALD provides accurate mean core damage frequencies for generalized accident scenarios. Future work includes expanding the model to account for plant-specific data and mitigation factors.

97 - MATHEMATICS AND COMPUTING↗

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.↗

Structural analysis of a thermal insulation retainer assembly

In January 1989 an accident occurred in the National Transonic Facility wind tunnel at NASA Langley Research Center that was believed to be caused by the failure of a thermal insulation retainer. A structural analysis of this retainer assembly was performed in order to understand the possible failure mechanisms. Two loading conditions are important and were considered in the analysis. The first is the centrifugal force due to the fact that this retainer is located on the fan drive shaft. The second loading is a differential temperature between the retainer assembly and the underlying shaft. Geometrically nonlinear analysis is required to predict the stiffness of this component and to account for varying contact regions between various components in the assembly. High, local stresses develop in the band part of the assembly near discontinuities under both the centrifugal and thermal loadings. The presence of an aluminum ring during a portion of the part's operating life was found to increase the stresses in other regions of the band. Under the centrifugal load, high bending stresses develop near the intersection of the band with joints in the assembly. These high bending stresses are believed to be the most likely cause for failure of the assembly.

Greene, William H.↗

Collision in space

On June 25, 1997, the Russian supply spacecraft Progress 234 collided with the Mir space station, rupturing Mir's pressure hull, throwing it into an uncontrolled attitude drift, and nearly forcing evacuation of the station. Like many high-profile accidents, this collision was the consequence of a chain of events leading to the final piloting errors that were its immediate cause. The discussion in this article does not resolve the relative contributions of the actions and decisions in this chain. Neither does it suggest corrective measures, many of which are straightforward and have already been implemented by the National Aeronautics and Space Administration (NASA) and the Russian Space Agency. Rather, its purpose is to identify the human factors that played a pervasive role in the incident. Workplace stress, fatigue, and sleep deprivation were identified by NASA as contributory factors in the Mir-Progress collision (Culbertson, 1997; NASA, forthcoming), but other contributing factors, such as requiring crew to perform difficult tasks for which their training is not current, could potentially become important factors in future situations.

Mir Project↗

A Summary of the Space Shuttle Columbia Tragedy and the Use of LS Dyna in the Accident Investigation and Return to Flight Efforts

On February 1, 2003, the Space Shuttle Columbia broke apart during reentry resulting in loss of 7 crewmembers and craft. For the next several months an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA concluded in August, 2003 that the cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the missions launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing which ultimately led to the breakup of the orbiter. In order to gain a better understanding the foam impact on the orbiters RCC wing leading edge, a multi-center team of NASA and Boeing impact experts was formed to characterize the foam and RCC materials for impact analysis using LS Dyna. Dyna predictions were validated with sub-component and full scale tests. LS Dyna proved to be a valuable asset in supporting both the Columbia Accident Investigation and NASA s return to flight efforts. This paper summarizes Columbia Accident and the nearly seven month long investigation that followed. The use of LS-DYNA in this effort is highlighted. Contributions to the investigation and return to flight efforts of the multicenter team consisting of members from NASA Glenn, NASA Langley, and Boeing Philadelphia are introduced and covered in detail in papers to follow in these proceedings.

Melis, Matthew↗

Emergency egress requirements for Space Station Freedom

An objective was to determine if the pressurized elements and hatchways of the Space Station Freedom support the emergency egress of crewmembers during operation of the station at the stage of Permanently Manned Capacity. Emergency egress was defined as the exit from a pressurized element when an event occurs which makes that element uninhabitable. The possible egress paths for four emergency scenarios considered were: (1) accident occurs in a module and crewmembers translate to the attached node; (2) accident occurs at a node and crewmembers translate through it to the safe node; (3) accident occurs at a module close to a node and crewmembers are not able to translate through the affected area; and (4) accident occurs at a node and crewmembers cannot translate through it. The structural design of the pressurized elements and the hatches studied is adequate for the emergence egress translation requirement. The current location of a few racks may cause some obstruction for egress to the orbiter. The egress time required in the worst situation is estimated to be about 3 mins. There is a chance of getting crewmembers trapped in a module in case of a severe accident. Aids are needed for emergency egress translation.

Ray, Paul S.↗

Crush Gun Impact of Lightly Confined Explosive with Rounded Projectiles at Nominal Velocity 35 m/s

Blunt, crushing impact of high explosives can cause internal shear heating sufficient to ignite a deflagration. Low-velocity impact of this sort is plausible in handling accident scenarios, e.g. if a charge is dropped or an object is dropped onto a charge. This mechanism can also be activated during sub-shock fragment impact. Efforts to model this viscous shear heating mechanism are currently being developed and refined. The Crush Gun apparatus was created to provide a controlled low-velocity impact stimuli to explosive samples. Infrared thermography captures temporal- and spatially-resolved heating that occurs during the impact event.

45 MILITARY TECHNOLOGY, WEAPONRY, AND NATIONAL DEF↗

Evaluation of micron size carbon fibers released from burning graphite composites

Quantitative estimates were developed of micron carbon fibers released during the burning of graphite composites. Evidence was found of fibrillated particles which were the predominant source of the micron fiber data obtained from large pool fire tests. The fibrillation phenomena were attributed to fiber oxidation effects caused by the fire environment. Analysis of propane burn test records indicated that wind sources can cause considerable carbon fiber oxidation. Criteria estimates were determined for the number of micron carbon fibers released during an aircraft accident. An extreme case analysis indicated that the upper limit of the micron carbon fiber concentration level was only about half the permissible asbestos ceiling concentration level.

Sussholz, B.↗

Detailed Studies on the Structure and Dynamics of Reacting Dusty Flows at Normal and Microgravity

Two-phase reacting flows are substantially less understood compared to gas phase flows. While extensive work has been done on sprays, less attention has been given to the details of dusty reacting flows. Dusty flows are of particular interest for a wide range of applications. Particles can be present in a gas intentionally or unintentionally, and they can be inert or reacting. Inert particles can be also present in an otherwise reacting gas flow, and that can lead to flame cooling and modification of the extinction limits of a combustible mixture. Reacting solid particles can release substantial amounts of heat upon oxidation, and can be used either for propulsion (e.g. Al, B, Mg) or power generation (coal). Furthermore, accidents can occur when a reacting dust accumulates in air and which, in the presence of an ignition source, can cause explosion. Such explosions can occur during lumber milling, in grain elevators, and in mine galleries.

Egolfopoulos, Fokion N.↗

Five Years of NASA Research on ISS: A Continuing Saga

The first NASA experiments reached ISS in September 2000, a very modest beginning to what later became a more robust, diverse and overall highly successful research program, continuing essentially uninterrupted since March 2001. Along the way, several major challenges had to be overcome. First, there were delays in the initial construction of the station. Second, maintenance of the station exceeded earlier assumptions resulting in less crew time being available for research. Third, the lengthy interruption of Shuttle flights after the Columbia accident significantly, but temporarily, reduced the research traffic to and from ISS. And fourth, the Vision of Space Exploration as caused a refocusing of NASA's research efforts on ISS from a multi-disciplinary basic and applied science program to one dedicated to solving the critical questions to enable exploration missions. The principal factors that allowed these challenges to be overcome have been flexibility and cooperation. Flexibility on the part of the ISS Program to minimize impacts to research from delays and resource bottlenecks, flexibility on the part of researchers to adapt their research to changing environments, and flexibility to be able to use existing and planned facilities not only for their original basic science purpose but also for new applications. And cooperation not only between the ISS Program and the research community, but also among NASA and its International Partners to continually strive to optimize the research conducted aboard ISS. Once the challenges were overcome, the research program has been remarkably successful, with an expanding on-orbit capability. Over 80 investigations have been completed, many resulting in publications.

Uri, John J.↗

Planetary Protection Bioburden Analysis Program

This program is a Microsoft Access program that performed statistical analysis of the colony counts from assays performed on the Mars Science Laboratory (MSL) spacecraft to determine the bioburden density, 3-sigma biodensity, and the total bioburdens required for the MSL prelaunch reports. It also contains numerous tools that report the data in various ways to simplify the reports required. The program performs all the calculations directly in the MS Access program. Prior to this development, the data was exported to large Excel files that had to be cut and pasted to provide the desired results. The program contains a main menu and a number of submenus. Analyses can be performed by using either all the assays, or only the accountable assays that will be used in the final analysis. There are three options on the first menu: either calculate using (1) the old MER (Mars Exploration Rover) statistics, (2) the MSL statistics for all the assays, or This software implements penetration limit equations for common micrometeoroid and orbital debris (MMOD) shield configurations, windows, and thermal protection systems. Allowable MMOD risk is formulated in terms of the probability of penetration (PNP) of the spacecraft pressure hull. For calculating the risk, spacecraft geometry models, mission profiles, debris environment models, and penetration limit equations for installed shielding configurations are required. Risk assessment software such as NASA's BUMPERII is used to calculate mission PNP; however, they are unsuitable for use in shield design and preliminary analysis studies. The software defines a single equation for the design and performance evaluation of common MMOD shielding configurations, windows, and thermal protection systems, along with a description of their validity range and guidelines for their application. Recommendations are based on preliminary reviews of fundamental assumptions, and accuracy in predicting experimental impact test results. The software is programmed in Visual Basic for Applications for installation as a simple add-in for Microsoft Excel. The user is directed to a graphical user interface (GUI) that requires user inputs and provides solutions directly in Microsoft Excel workbooks. This work was done by Shannon Ryan of the USRA Lunar and Planetary Institute for Johnson Space Center. Further information is contained in a TSP (see page 1). MSC- 24582-1 Micrometeoroid and Orbital Debris (MMOD) Shield Ballistic Limit Analysis Program Lyndon B. Johnson Space Center, Houston, Texas Commercially, because it is so generic, Enigma can be used for almost any project that requires engineering visualization, model building, or animation. Models in Enigma can be exported to many other formats for use in other applications as well. Educationally, Enigma is being used to allow university students to visualize robotic algorithms in a simulation mode before using them with actual hardware. This work was done by David Shores and Sharon P. Goza of Johnson Space Center; Cheyenne McKeegan, Rick Easley, Janet Way, and Shonn Everett of MEI Technologies; Mark Manning of PTI; and Mark Guerra, Ray Kraesig, and William Leu of Tietronix Software, Inc. For further information, contact the JSC Innovation Partnerships Office at (281) 483-3809. MSC-24211-1 Spitzer Telemetry Processing System NASA's Jet Propulsion Laboratory, Pasadena, California The Spitzer Telemetry Processing System (SirtfTlmProc) was designed to address objectives of JPL's Multi-mission Image Processing Lab (MIPL) in processing spacecraft telemetry and distributing the resulting data to the science community. To minimize costs and maximize operability, the software design focused on automated error recovery, performance, and information management. The system processes telemetry from the Spitzer spacecraft and delivers Level 0 products to the Spitzer Science Center. SirtfTlmProc is a unique system with automated error notification and recovery, with a real-time continuous service that can go quiescent after periods of inactivity. The software can process 2 GB of telemetry and deliver Level 0 science products to the end user in four hours. It provides analysis tools so the operator can manage the system and troubleshoot problems. It automates telemetry processing in order to reduce staffing costs. This work was done by Alice Stanboli, Elmain M. Martinez, and James M. McAuley of Caltech for NASA's Jet Propulsion Laboratory. For more information, contact iaoffice @jpl.nasa.gov. This software is available for commercial licensing. Please contact Dan Broderick at Daniel.F. Broderick@jpl.nasa.gov. Refer to NPO-47803. NASA Tech Briefs, September 2013 29 This rapid response computer program predicts Orbiter Wing Leading Edge (WLE) damage caused by ice or foam impact during a Space Shuttle launch (Program "IMPACT2"). The program was developed after the Columbia accident in order to assess quickly WLE damage due to ice, foam, or metal impact (if any) during a Shuttle launch. IMPACT2 simulates an impact event in a few minutes for foam impactors, and in seconds for ice and metal impactors. The damage criterion is derived from results obtained from one sophisticated commercial program, which requires hours to carry out simulations of the same impact events. The program was designed to run much faster than the commercial program with prediction of projectile threshold velocities within 10 to 15% of commercial-program values. The mathematical model involves coupling of Orbiter wing normal modes of vibration to nonlinear or linear springmass models. IMPACT2 solves nonlinear or linear impact problems using classical normal modes of vibration of a target, and nonlinear/ linear time-domain equations for the projectile. Impact loads and stresses developed in the target are computed as functions of time. This model is novel because of its speed of execution. A typical model of foam, or other projectile characterized by material nonlinearities, impacting an RCC panel is executed in minutes instead of hours needed by the commercial programs. Target damage due to impact can be assessed quickly, provided that target vibration modes and allowable stress are known. This work was done by Robert Clark, Jr., Paul Cotter, and Constantine Michalopoulos of The Boeing Company for Johnson Space Center. For further information, contact the JSC Innovation Partnerships Office at (281) 483-3809. MSC-24988-1 Wing Leading Edge RCC Rapid Response Damage Prediction Tool (IMPACT2) Lyndon B. Johnson Space Center, Houston, Texas (3) the MSL statistics for only the accountable assays. Other options on the main menu include a data editing form and utility programs that produce various reports requested by the microbiologists and the project, and tools to generate the groupings for the final analyses. The analyses can be carried out in three ways: Each assay can be treated separately, the assays can be collectively treated for the whole zone as a group, or the assays can be collected in groups designated by the JPL Planetary Protection Manager. The latter approach was used to generate the final report because assays on the same equipment or similar equipment can be assumed to have been exposed to the same environment and cleaning. Thus, the statistics are improved by having a larger population, thereby reducing the standard deviation by the square root of N. For each method mentioned above, three reports are available. The first is a detailed report including all the data. This version was very useful in verifying the calculations. The second is a brief report that is similar to the full detailed report, but does not print out the data. The third is a grand total and summary report in which each assay requires only one line. For the first and second reports, most of the calculations are performed in the report section itself. For the third, all the calculations are performed directly in the query bound to the report. All the numerical results were verified by comparing them with Excel templates, then exporting the data from the Planetary Protection Analysis program to Excel.

Beaudet, Robert A.↗

Wing Leading Edge RCC Rapid Response Damage Prediction Tool (IMPACT2)

This rapid response computer program predicts Orbiter Wing Leading Edge (WLE) damage caused by ice or foam impact during a Space Shuttle launch (Program "IMPACT2"). The program was developed after the Columbia accident in order to assess quickly WLE damage due to ice, foam, or metal impact (if any) during a Shuttle launch. IMPACT2 simulates an impact event in a few minutes for foam impactors, and in seconds for ice and metal impactors. The damage criterion is derived from results obtained from one sophisticated commercial program, which requires hours to carry out simulations of the same impact events. The program was designed to run much faster than the commercial program with prediction of projectile threshold velocities within 10 to 15% of commercial-program values. The mathematical model involves coupling of Orbiter wing normal modes of vibration to nonlinear or linear springmass models. IMPACT2 solves nonlinear or linear impact problems using classical normal modes of vibration of a target, and nonlinear/ linear time-domain equations for the projectile. Impact loads and stresses developed in the target are computed as functions of time. This model is novel because of its speed of execution. A typical model of foam, or other projectile characterized by material nonlinearities, impacting an RCC panel is executed in minutes instead of hours needed by the commercial programs. Target damage due to impact can be assessed quickly, provided that target vibration modes and allowable stress are known.

Clark, Robert↗

Human Performance Contributions to Safety in Commercial Aviation

Every day in aviation, pilots, air traffic controllers, and other front-line personnel perform countless correct judgments and actions in a variety of operational environments. These judgments and actions are often the difference between an accident and a non-event. Ironically, data on these behaviors are rarely collected or analyzed. Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence how decision makers characterize problems and identify solutions. Large volumes of data are collected on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that result in routine successful outcomes, safety management and system design decisions are based on a small sample of nonrepresentative safety data. This assessment aimed to find and document “safety successes” made possible by human operators. With many Aeronautics Research Mission Directorate (ARMD) Programs and Projects focusing on increased automation and autonomy and decreased human involvement, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant risk — a risk that has not been recognized to date. Without understanding how humans contribute to safety, any estimate of predicted safety of autonomous capabilities is incomplete and inherently suspect. Furthermore, understanding the ways in which humans contribute to safety can promote strategic interactions among safety technologies, functions, procedures and the people using them. Without this understanding, the full benefits of an integrated, optimized human/technology or autonomous system will not be realized. Historically, safety has been consistently defined in terms of the occurrence of accidents or recognized risks (i.e., in terms of things that go wrong). These adverse outcomes are explained by identifying their causes, and safety is restored by eliminating or mitigating these causes. An alternative to this approach is to focus on what goes right and identify how to replicate that process. Focusing on the rare cases of failures attributed to “human error” provides little information about why human performance routinely prevents adverse events. Hollnagel has proposed that things go right because people continuously adjust their work to match their operating conditions. These adjustments become increasingly important as systems continue to grow in complexity. Thus, the definition of safety should reflect not only “avoiding things that go wrong” but “ensuring that things go right.” The basis for safety management requires developing an understanding of everyday activities. However, few mechanisms to monitor everyday work exist in the aviation domain, which limits opportunities to learn how designs function in reality. This concept of safety thinking and safety management is reflected in the emerging field of resilience engineering. According to Hollnagel, a system is resilient if it can sustain required operations under expected and unexpected conditions by adjusting its functioning prior to, during, or following changes, disturbances, and opportunities. To explore “positive” behaviors that contribute to resilient performance in commercial aviation, the assessment team examined a range of existing sources of data about pilot and air traffic control (ATC) tower controller performance, including subjective interviews with domain experts and objective aircraft flight data records. These data were used to identify strategies that support resilient performance, methods for exploring and refining those strategies in existing data, and proposed methods for capturing and analyzing new data.

Null, Cynthia H.↗

The Challenger disaster was caused by an Apollo decision

NASA’s view of risk changed between early Apollo and the Space Shuttle. Risk was a known serious problem at the beginning of Apollo and the risk estimates were disturbingly high. To avoid public concern, risk analysis was discontinued. Risk analysis was avoided in Shuttle, leading to an unnecessarily risky design. The immediate cause of the Challenger tragedy was the mistaken decision to launch in cold weather. The fundamental cause was the high risk of the Shuttle design. Before Challenger, management thought and testified that the probability of an accident was 1 in 100,000. After Challenger, Probabilistic Risk Analysis (PRA) found a roughly 1 in 100 chance of a Shuttle failure. The recent Orion design uses the safer Apollo approach, with a hardened capsule, launch abort escape, and the crew placed above the rocket tanks and engines. During Apollo it was estimated that, “assuming all elements from propulsion to rendezvous and life support were done as well or better than ever before, that 30 astronauts would be lost before 3 were returned safely to the Earth.” The chance of astronaut survival was only 10%. After the Apollo 1 tragedy, the awareness of risk led to an intense focus on achieving safety. “The only possible explanation for the astonishing success – no losses in space and on time – was that every participant at every level in every area far exceeded the norm of human capabilities.” During Apollo, a NASA PRA found that the chance of success was “less than 5 percent.” The NASA Administrator felt that “the numbers could do irreparable harm,” and discontinued numerical risk assessment.

Harry W Jones↗

The Columbia Accident Investigation and The NASA Glenn Ballistic Impact Laboratory Contributions Supporting NASA's Return to Flight

On February 1, 2003, the Space Shuttle Columbia broke apart during reentry, resulting in loss of the vehicle and its seven crewmembers. For the next several months, an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA, concluded in August, 2003 that the most likely cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the mission's launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing, which ultimately led to the breakup of the orbiter. The findings of the CAIB were supported by ballistic impact tests, which simulated the physics of External Tank Foam impact on the RCC wing leading edge material. These tests ranged from fundamental material characterization tests to full-scale Orbiter Wing Leading Edge tests. Following the accident investigation, NASA spent the next 18 months focused on returning the shuttle safely to flight. In order to fully evaluate all potential impact threats from the many debris sources on the Space Shuttle during ascent, NASA instituted a significant impact testing program. The results from these tests led to the validation of high-fidelity computer models, capable of predicting actual or potential Shuttle impact events, were used in the certification of STS-114, NASA s Return to Flight Mission, as safe to fly. This presentation will provide a look into the inner workings of the Space Shuttle and a behind the scenes perspective on the impact analysis and testing done for the Columbia Accident Investigation and NASA's Return to Flight programs. In addition, highlights from recent Shuttle missions are presented.

Melis, Matthew E.↗

Aircraft Loss-of-Control Accident Prevention: Switching Control of the GTM Aircraft with Elevator Jam Failures

Switching control, servomechanism, and H2 control theory are used to provide a practical and easy-to-implement solution for the actuator jam problem. A jammed actuator not only causes a reduction of control authority, but also creates a persistent disturbance with uncertain amplitude. The longitudinal dynamics model of the NASA GTM UAV is employed to demonstrate that a single fixed reconfigured controller design based on the proposed approach is capable of accommodating an elevator jam failure with arbitrary jam position as long as the thrust control has enough control authority. This paper is a first step towards solving a more comprehensive in-flight loss-of-control accident prevention problem that involves multiple actuator failures, structure damages, unanticipated faults, and nonlinear upset regime recovery, etc.

Chang, Bor-Chin↗