Results for “ACCIDENT INVESTIGATIONS” — Page 19

NASA NTRS1995

Piloted simulation tests of propulsion control as backup to loss of primary flight controls for a mid-size jet transport

Failures of aircraft primary flight-control systems to aircraft during flight have led to catastrophic accidents with subsequent loss of lives (e.g. , DC-1O crash, B-747 crash, C-5 crash, B-52 crash, and others). Dryden Flight Research Center (DFRC) investigated the use of engine thrust for emergency flight control of several airplanes, including the B-720, Lear 24, F-15, C-402, and B-747. A series of three piloted simulation tests have been conducted at Ames Research Center to investigate propulsion control for safely landing a medium size jet transport which has experienced a total primary flight-control failure. The first series of tests was completed in July 1992 and defined the best interface for the pilot commands to drive the engines. The second series of tests was completed in August 1994 and investigated propulsion controlled aircraft (PCA) display requirements and various command modes. The third series of tests was completed in May 1995 and investigated PCA full-flight envelope capabilities. This report describes the concept of a PCA, discusses pilot controls, displays, and procedures; and presents the results of piloted simulation evaluations of the concept by a cross-section of air transport pilots.

Bull, John↗

NASA NTRS2000

Analysis of Complexity Evolution Management and Human Performance Issues in Commercial Aircraft Automation Systems

Autoflight systems in the current generation of aircraft have been implicated in several recent incidents and accidents. A contributory aspect to these incidents may be the manner in which aircraft transition between differing behaviours or 'modes.' The current state of aircraft automation was investigated and the incremental development of the autoflight system was tracked through a set of aircraft to gain insight into how these systems developed. This process appears to have resulted in a system without a consistent global representation. In order to evaluate and examine autoflight systems, a 'Hybrid Automation Representation' (HAR) was developed. This representation was used to examine several specific problems known to exist in aircraft systems. Cyclomatic complexity is an analysis tool from computer science which counts the number of linearly independent paths through a program graph. This approach was extended to examine autoflight mode transitions modelled with the HAR. A survey was conducted of pilots to identify those autoflight mode transitions which airline pilots find difficult. The transitions identified in this survey were analyzed using cyclomatic complexity to gain insight into the apparent complexity of the autoflight system from the perspective of the pilot. Mode transitions which had been identified as complex by pilots were found to have a high cyclomatic complexity. Further examination was made into a set of specific problems identified in aircraft: the lack of a consistent representation of automation, concern regarding appropriate feedback from the automation, and the implications of physical limitations on the autoflight systems. Mode transitions involved in changing to and leveling at a new altitude were identified across multiple aircraft by numerous pilots. Where possible, evaluation and verification of the behaviour of these autoflight mode transitions was investigated via aircraft-specific high fidelity simulators. Three solution approaches to concerns regarding autoflight systems, and mode transitions in particular, are presented in this thesis. The first is to use training to modify pilot behaviours, or procedures to work around known problems. The second approach is to mitigate problems by enhancing feedback. The third approach is to modify the process by which automation is designed. The Operator Directed Process forces the consideration and creation of an automation model early in the design process for use as the basis of the software specification and training.

Vakil, Sanjay S.↗

NASA NTRS2009

Measurement Variability of Vertical Scanning Interferometry Tool Used for Orbiter Window Defect Assessment

The ability to sufficiently measure orbiter window defects to allow for window recertification has been an ongoing challenge for the orbiter vehicle program. The recent Columbia accident has forced even tighter constraints on the criteria that must be met in order to recertify windows for flight. As a result, new techniques are being investigated to improve the reliability, accuracy and resolution of the defect detection process. The methodology devised in this work, which is based on the utilization of a vertical scanning interferometric (VSI) tool, shows great promise for meeting the ever increasing requirements for defect detection. This methodology has the potential of a 10-100 fold greater resolution of the true defect depth than can be obtained from the currently employed micrometer based methodology. An added benefit is that it also produces a digital elevation map of the defect, thereby providing information about the defect morphology which can be utilized to ascertain the type of debris that induced the damage. However, in order to successfully implement such a tool, a greater understanding of the resolution capability and measurement repeatability must be obtained. This work focused on assessing the variability of the VSI-based measurement methodology and revealed that the VSI measurement tool was more repeatable and more precise than the current micrometer based approach, even in situations where operator variation could affect the measurement. The analysis also showed that the VSI technique was relatively insensitive to the hardware and software settings employed, making the technique extremely robust and desirable

Padula, Santo, II↗

NASA NTRS1982

Antimisting kerosene atomization and flammability

Various parameters found to affect the flammability of antimisting kerosene (Jet A + polymer additive) are investigated. Digital image processing was integrated into a technique for measurement of fuel spray characteristics. This technique was developed to avoid many of the error sources inherent to other spray assessment techniques and was applied to the study of engine fuel nozzle atomization performance with Jet A and antimisting fuel. Aircraft accident fuel spill and ignition dynamics were modeled in a steady state simulator allowing flammability to be measured as a function of airspeed, fuel flow rate, fuel jet Reynolds number and polymer concentration. The digital imaging technique was employed to measure spray characteristics in this simulation and these results were related to flammability test results. Scaling relationships were investigated through correlation of experimental results with characteristic dimensions spanning more than two orders of magnitude.

Fleeter, R.↗

NASA NTRS2002

Synthetic Vision Systems in GA Cockpit-Evaluation of Basic Maneuvers Performed by Low Time GA Pilots During Transition from VMC to IMC

An experimental investigation was conducted to study the effectiveness of modern flight displays in general aviation cockpits for mitigating Low Visibility Loss of Control and the Controlled Flight Into Terrain accidents. A total of 18 General Aviation (GA) pilots with private pilot, single engine land rating, with no additional instrument training beyond private pilot license requirements, were recruited to evaluate three different display concepts in a fixed-based flight simulator at the NASA Langley Research Center's General Aviation Work Station. Evaluation pilots were asked to continue flight from Visual Meteorological Conditions (VMC) into Instrument Meteorological Conditions (IMC) while performing a series of 4 basic precision maneuvers. During the experiment, relevant pilot/vehicle performance variables, pilot control inputs and physiological data were recorded. Human factors questionnaires and interviews were administered after each scenario. Qualitative and quantitative data have been analyzed and the results are presented here. Pilot performance deviations from the established target values (errors) were computed and compared with the FAA Practical Test Standards. Results of the quantitative data indicate that evaluation pilots committed substantially fewer errors when using the Synthetic Vision Systems (SVS) displays than when they were using conventional instruments. Results of the qualitative data indicate that evaluation pilots perceived themselves to have a much higher level of situation awareness while using the SVS display concept.

Takallu, M. A.↗

NASA NTRS2004

Symbology Development for General Aviation Synthetic Vision Primary Flight Displays for the Approach and Missed-Approach Modes of Flight

Spatial disorientation induced by inadvertent flight into instrument meteorological conditions (IMC) continues to be a leading cause of fatal accidents in general aviation. The Synthetic Vision Systems General Aviation (SVS-GA) research element, an integral part of NASA s Aviation Safety and Security Program (AvSSP), is investigating a revolutionary display technology designed to mitigate low visibility events such as controlled flight into terrain (CFIT) and low-visibility loss of control (LVLoC). The integrated SVS Primary Flight Display (SVS-PFD) utilizes computer generated 3-dimensional imagery of the surrounding terrain augmented with flight path guidance symbology. This unique combination will provide GA pilots with an accurate representation of their environment and projection of their flight path, regardless of time of day or out-the-window (OTW) visibility. The initial Symbology Development for Head-Down Displays (SD-HDD) simulation experiment examined 16 display configurations on a centrally located high-resolution PFD installed in NASA s General Aviation Work Station (GAWS) flight simulator. The results of the experiment indicate that situation awareness (SA) can be enhanced without having a negative impact on flight technical error (FTE), by providing a general aviation pilot with an integrated SVS display to use when OTW visibility is obscured.

Bartolone, Anthony P.↗

NASA NTRS2015

Investigation of Asymmetric Thrust Detection with Demonstration in a Real-Time Simulation Testbed

The purpose of this effort is to develop, demonstrate, and evaluate three asymmetric thrust detection approaches to aid in the reduction of asymmetric thrust-induced aviation accidents. This paper presents the results from that effort and their evaluation in simulation studies, including those from a real-time flight simulation testbed. Asymmetric thrust is recognized as a contributing factor in several Propulsion System Malfunction plus Inappropriate Crew Response (PSM+ICR) aviation accidents. As an improvement over the state-of-the-art, providing annunciation of asymmetric thrust to alert the crew may hold safety benefits. For this, the reliable detection and confirmation of asymmetric thrust conditions is required. For this work, three asymmetric thrust detection methods are presented along with their results obtained through simulation studies. Representative asymmetric thrust conditions are modeled in simulation based on failure scenarios similar to those reported in aviation incident and accident descriptions. These simulated asymmetric thrust scenarios, combined with actual aircraft operational flight data, are then used to conduct a sensitivity study regarding the detection capabilities of the three methods. Additional evaluation results are presented based on pilot-in-the-loop simulation studies conducted in the NASA Glenn Research Center (GRC) flight simulation testbed. Data obtained from this flight simulation facility are used to further evaluate the effectiveness and accuracy of the asymmetric thrust detection approaches. Generally, the asymmetric thrust conditions are correctly detected and confirmed.

aircraft safety↗

NASA NTRS2015

Investigation of Asymmetric Thrust Detection with Demonstration in a Real-Time Simulation Testbed

The purpose of this effort is to develop, demonstrate, and evaluate three asymmetric thrust detection approaches to aid in the reduction of asymmetric thrust-induced aviation accidents. This paper presents the results from that effort and their evaluation in simulation studies, including those from a real-time flight simulation testbed. Asymmetric thrust is recognized as a contributing factor in several Propulsion System Malfunction plus Inappropriate Crew Response (PSM+ICR) aviation accidents. As an improvement over the state-of-the-art, providing annunciation of asymmetric thrust to alert the crew may hold safety benefits. For this, the reliable detection and confirmation of asymmetric thrust conditions is required. For this work, three asymmetric thrust detection methods are presented along with their results obtained through simulation studies. Representative asymmetric thrust conditions are modeled in simulation based on failure scenarios similar to those reported in aviation incident and accident descriptions. These simulated asymmetric thrust scenarios, combined with actual aircraft operational flight data, are then used to conduct a sensitivity study regarding the detection capabilities of the three methods. Additional evaluation results are presented based on pilot-in-the-loop simulation studies conducted in the NASA Glenn Research Center (GRC) flight simulation testbed. Data obtained from this flight simulation facility are used to further evaluate the effectiveness and accuracy of the asymmetric thrust detection approaches. Generally, the asymmetric thrust conditions are correctly detected and confirmed.

gas turbine engines↗

NASA NTRS2016

Investigation of Asymmetric Thrust Detection with Demonstration in a Real-Time Simulation Testbed

The purpose of this effort is to develop, demonstrate, and evaluate three asymmetric thrust detection approaches to aid in the reduction of asymmetric thrust-induced aviation accidents. This paper presents the results from that effort and their evaluation in simulation studies, including those from a real-time flight simulation testbed. Asymmetric thrust is recognized as a contributing factor in several Propulsion System Malfunction plus Inappropriate Crew Response (PSM+ICR) aviation accidents. As an improvement over the state-of-the-art, providing annunciation of asymmetric thrust to alert the crew may hold safety benefits. For this, the reliable detection and confirmation of asymmetric thrust conditions is required. For this work, three asymmetric thrust detection methods are presented along with their results obtained through simulation studies. Representative asymmetric thrust conditions are modeled in simulation based on failure scenarios similar to those reported in aviation incident and accident descriptions. These simulated asymmetric thrust scenarios, combined with actual aircraft operational flight data, are then used to conduct a sensitivity study regarding the detection capabilities of the three methods. Additional evaluation results are presented based on pilot-in-the-loop simulation studies conducted in the NASA Glenn Research Center (GRC) flight simulation testbed. Data obtained from this flight simulation facility are used to further evaluate the effectiveness and accuracy of the asymmetric thrust detection approaches. Generally, the asymmetric thrust conditions are correctly detected and confirmed.

propulsion system performance↗

NASA NTRS1987

AC-67 Press Conference

On March 26, 1987, after the launch of an Atlas/Centaur rocket with a payload of a Navy Communications Satellite, a problem developed and the rocket was lost. This videotape is a press conference held to review the incident. Mr. John Gibb, the Atlas-Centaur Program Manager at Lewis Research Center, opens the press conference with a statement that reviews the situation, and what is known about the accident. He reviews the constraints to launch and explains that to the best of his knowledge there was no violation of these constraints. He further states that a review panel will investigate the circumstances and make recommendations. The press conference is then opened up to questions. Most of the questions concern the weather conditions and the existence of lightning in the area. The Air Force representative, Colonel John Albrook, is asked if the loss of the satellite would pose any problems. He answers that there were several satellites performing the role for which this satellite was slated, and that these were still healthy, and capable of continuing for a considerable length of time.

Source record↗

NASA NTRS2005

External Tank CIL Closed Loop Verification System

Lockheed Martin was requested to develop a closed loop CIL system following the Challenger accident. The system that was developed has proven to be very robust with minimal problems since implementation, having zero escapes in the last 7 years (27 External Tanks). We are currently investigating expansion of the CIL Closed Loop system to include "MI" CILs.

Hartley, Eugene A., Jr.↗

NASA NTRS2024

Nonlinear Dynamic Analyses of STS-1 Forward RCS Oxidizer Tank Structural Failure

At liftoff of the first Space Shuttle mission, a strong ignition overpressure pulse excited the stack. The frequency of the experienced pressure wave exceeded pre-launch predictions, and resulted in high, alternating normal accelerations along the length of the vehicle. As result of this unexpected loading, an oxidizer tank support strut in the orbiter’s forward reaction control system module failed in buckling under axial compression, which could have led to loss of the mission, crew, and vehicle. This incident is investigated in more detail using linear and nonlinear finite element analyses, complementing previous analyses with classical structural mechanics. The results of these analyses are examined to provide additional insight into the accident and to better inform future design decisions for modern space vehicle systems and structures.

Space Shuttle↗

NASA NTRS2024

Nonlinear Dynamic Analyses of STS-1 Forward RCS Oxidizer Tank Structural Failure

At liftoff of the first Space Shuttle mission, a strong ignition overpressure pulse excited the stack. The frequency of the experienced pressure wave exceeded pre-launch predictions, and resulted in high, alternating normal accelerations along the length of the vehicle. As result of this unexpected loading, an oxidizer tank support strut in the orbiter’s forward reaction control system module failed in buckling under axial compression, which could have led to loss of the mission, crew, and vehicle. This incident is investigated in more detail using linear and nonlinear finite element analyses, complementing previous analyses with classical structural mechanics. The results of these analyses are examined to provide additional insight into the accident and to better inform future design decisions for modern space vehicle systems and structures.

Space Shuttle↗

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 NTRS2010

Pion Production Data Needed for Space Radiation

A recent discovery concerning the importance of hadron production in space radiation is that pions can contribute up to twenty percent of the dose from galactic cosmic ray interactions (S. Aghara, S. Blattnig, J. Norbury, R. Singleterry, Nuclear Instruments and Methods, Vol. 267, 2009, p. 1115). Although the contribution for dose equivalent will be smaller, the dose contribution could be important for fluence based radiation models. Pion production cross sections will be an essential ingredient to such models, and it is of interest to investigate the adequacy of the pion production experimental data base for energies relevant to space radiation. The pion production threshold in nucleon - nucleon reactions is at 280 MeV and, in an interesting accident of nature, this lies near the peak of the galactic cosmic ray proton spectrum. Therefore, pion production data are needed from threshold up to energies around 50 GeV/nucleon, where the galactic cosmic ray fluence is of decreasing importance. Total and differential cross section data for pion production in this energy range will be reviewed. The availability and accuracy of theoretical models will also be discussed. It will be shown that there are a significant lack of data in this important energy range and that theoretical models still need improvement.

Norbury, John W.↗

NASA NTRS1929

Fire prevention on airplanes. Part I

Various methods for preventing fires in airplanes are presented with most efforts centering around prevention of backfires, new engine and carburetor designs, as well as investigations on different types of fuels.

EXHAUST GASES - FIRE PREVENTION↗

NASA NTRS1985

Power Plant Construction

Stone & Webster Engineering Corporation utilized TAP-A, a COSMIC program originally developed as part of a NASA investigation into the potential of nuclear power for space launch vehicles. It is useful in nuclear power plant design to qualify safety-related equipment at the temperatures it would experience should an accident occur. The program is easy to use, produces accurate results, and is inexpensive to run.

Source record↗

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↗