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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.

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NASA NTRS1932

Statistics of the Bureau Veritas

Statistics are indispensable factors for the amelioration of safety. Through the reconciliation of accidents which may appear isolated to interested parties, they permit tracking of typical causes of accidents; conversely, they can prevent, after a serious accident due to some fortuitous cause, the taking of incautious measures under the pressure of public opinion, which always inclines to gauge the gravity of the causes by that of the results. Lastly, they permit appraisal of the efficacy of rules in force. We should add that statistics provide an agency of prevention for future accidents. A careful inspection of all signs of malfunction of material quite often prevents the occurrence of an accident. In this respect, many pilot's report, perfectly normal in every way as far as operation is concerned, can reveal much more interesting technical data than an accident, although it does not diminish the importance of statistics. Therefore, from the inception of its aeronautical service, at the end of 1922, the Bureau Veritas has kept annual statistics of all accidents which occurred in French civil aviation. In order to correctly perform their proper function, the statistics must be exact and sufficiently explicit and complete. To be exact, they must bear on all pertinent events, and on these alone. It is a matter then, first of all, defining the accident in such a way that no sinister detail bearing on the definition may escape control. The consideration of accidents to personnel only has appeared too limited. One of the essential qualities of statistics is to permit the taking of averages and in consequence to apply them ot a sufficiently large number; such is happily not the case in accidents to personnel.

Volmerange, Andre↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Three

The Columbia Accident Investigation Board's (CAIB) independent investigation into the February 1, 2003 destruction of the Space Shuttle Columbia produced a six volume report. This is Volume III of the report. Volume III contains other technical documents produced by NASA and other organizations, which were provided to the CAIB in support of its inquiry into the tragedy. Technical documents included in the report are: Appendix E.1 CoFR Endorsements; Appendix E.2 STS-107 Image Analysis Team Final Report; Appendix E.3 An Assessment of Potential Material Candidates for the 'Flight Day 2', Radar Object Observed during the NASA Mission STS-107; Appendix E.4 Columbia Early Sighting Assessment Team Final Report.

STS-107↗
NASA NTRS2014

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗
NASA NTRS1974

Control Characteristics of Alcohol-Impaired Operators

Although the operation of vehicles like airplanes, cars, and bicycles involves a complex array of perceptual, decision and control activities, most accident statistics clearly show that intoxicated operators are a dominant cause of accidents, and not the difficulty of the task itself. This paper summarizes some recent research on the nature of the impairment of operator control under blood alcohol concentrations (BAC) up to above 0.16 percent. Alcohol toxicity is shown to be quite specific with respect to visual-motor functions involved in control of a vehicle, and experiments with a generalized workload task and special driving simulator show how these are reflected in terms of changes in operator control parameters such as response latency, gains, stability margins, and coherency.

Jex, Henry R.↗
NASA NTRS1971

The practical application of mishap data in Army aircraft system safety programs

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

James T. Darrah, Jr↗
NASA NTRS2007

An Application of CICCT Accident Categories to Aviation Accidents in 1988-2004

Interventions or technologies developed to improve aviation safety often focus on specific causes or accident categories. Evaluation of the potential effectiveness of those interventions is dependent upon mapping the historical aviation accidents into those same accident categories. To that end, the United States civil aviation accidents occurring between 1988 and 2004 (n=26,117) were assigned accident categories based upon the taxonomy developed by the CAST/ICAO Common Taxonomy Team (CICTT). Results are presented separately for four main categories of flight rules: Part 121 (large commercial air carriers), Scheduled Part 135 (commuter airlines), Non-Scheduled Part 135 (on-demand air taxi) and Part 91 (general aviation). Injuries and aircraft damage are summarized by year and by accident category.

Evans, Joni K.↗
NASA NTRS2009

Software Health Management: A Short Review of Challenges and Existing Techniques

Modern spacecraft (as well as most other complex mechanisms like aircraft, automobiles, and chemical plants) rely more and more on software, to a point where software failures have caused severe accidents and loss of missions. Software failures during a manned mission can cause loss of life, so there are severe requirements to make the software as safe and reliable as possible. Typically, verification and validation (V&V) has the task of making sure that all software errors are found before the software is deployed and that it always conforms to the requirements. Experience, however, shows that this gold standard of error-free software cannot be reached in practice. Even if the software alone is free of glitches, its interoperation with the hardware (e.g., with sensors or actuators) can cause problems. Unexpected operational conditions or changes in the environment may ultimately cause a software system to fail. Is there a way to surmount this problem? In most modern aircraft and many automobiles, hardware such as central electrical, mechanical, and hydraulic components are monitored by IVHM (Integrated Vehicle Health Management) systems. These systems can recognize, isolate, and identify faults and failures, both those that already occurred as well as imminent ones. With the help of diagnostics and prognostics, appropriate mitigation strategies can be selected (replacement or repair, switch to redundant systems, etc.). In this short paper, we discuss some challenges and promising techniques for software health management (SWHM). In particular, we identify unique challenges for preventing software failure in systems which involve both software and hardware components. We then present our classifications of techniques related to SWHM. These classifications are performed based on dimensions of interest to both developers and users of the techniques, and hopefully provide a map for dealing with software faults and failures.

Pipatsrisawat, Knot↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Two

Volume II of the Report contains appendices that were cited in Volume I. The Columbia Accident Investigation Board produced many of these appendices as working papers during the investigation into the February 1, 2003 destruction of the Space Shuttle Columbia. Other appendices were produced by other organizations (mainly NASA) in support of the Board investigation. In the case of documents that have been published by others, they are included here in the interest of establishing a complete record, but often at less than full page size. Contents include: CAIB Technical Documents Cited in the Report: Reader's Guide to Volume II; Appendix D. a Supplement to the Report; Appendix D.b Corrections to Volume I of the Report; Appendix D.1 STS-107 Training Investigation; Appendix D.2 Payload Operations Checklist 3; Appendix D.3 Fault Tree Closure Summary; Appendix D.4 Fault Tree Elements - Not Closed; Appendix D.5 Space Weather Conditions; Appendix D.6 Payload and Payload Integration; Appendix D.7 Working Scenario; Appendix D.8 Debris Transport Analysis; Appendix D.9 Data Review and Timeline Reconstruction Report; Appendix D.10 Debris Recovery; Appendix D.11 STS-107 Columbia Reconstruction Report; Appendix D.12 Impact Modeling; Appendix D.13 STS-107 In-Flight Options Assessment; Appendix D.14 Orbiter Major Modification (OMM) Review; Appendix D.15 Maintenance, Material, and Management Inputs; Appendix D.16 Public Safety Analysis; Appendix D.17 MER Manager's Tiger Team Checklist; Appendix D.18 Past Reports Review; Appendix D.19 Qualification and Interpretation of Sensor Data from STS-107; Appendix D.20 Bolt Catcher Debris Analysis.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Six

In the course of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia, the Columbia Accident Investigation Board conducted a series of public hearings at Houston, Texas; Cape Canaveral, Florida; and Washington, DC. Testimony from these hearings was recorded and then transcribed. This appendix, Volume VI of the Report, is a compilation of those transcripts. Contents: Transcripts of Board Public Hearings; Appendix H.1 March 6, 2003 Houston, Texas; Appendix H.2 March 17, 2003 Houston, Texas; Appendix H.3 March 18, 2003 Houston, Texas; Appendix H. 4 March 25, 2003 Cape Canaveral, Florida; Appendix H.5 March 26, 2003 Cape Canaveral, Florida; Appendix H.6 April 7, 2003 Houston, Texas; Appendix H.7 April 8, 2003 Houston, Texas; Appendix H.8 April 23, 2003 Houston, Texas; Appendix H.9 May 6, 2003 Houston, Texas; Appendix H.10 June 12, 2003 Washington, DC.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS1996

Early Warning: Development of Confidential Incident Reporting Systems

Accidents hardly ever happen without warning. The combination, or sequence, of failures and mistakes that cause an accident may indeed be unique but the individual failures and mistakes rarely are. In the USA in 1974 the crews on two different aircraft misunderstood the same aeronautical chart and descended towards their destination dangerously early towards a mountain. The first crew were in good weather conditions and could see the mountain and resolved their misinterpretation of the chart. The second crew six weeks later were not so lucky. In cloud they had no clues to point out their mistake nor the presence of the mountain. The resulting crash and the ensuing inquiry, which brought to light the previous incident, shocked the country but gave it the impetus to instigate a safety reporting system. This system eventually became the NASA's Aviation Safety Reporting System (ASRS). The programme collects incident reports from pilots, controllers, mechanics, cabin attendants and many others involved in aviation operations. By disseminating this safety information the ASRS has helped enormously to give US airlines and airspace the highest safety standards. Accident prevention is a goal sought by everyone in the aviation industry and establishing effective incident reporting programmes can go a long way toward achieving that goal. This article will describe the steps and issues required to establish an incident reporting system. The authors summarize the lessons learned from the ASRS, now in its twentieth year of operation and from the Confidential Human Factors Reporting (HER) Programme run by British Airways, an airline that is a recognized world leader in safety reporting and analysis. The differences between government and airline operation of confidential safety reporting systems will be addressed.

OLeary, Mike J.↗
NASA NTRS2007

Image Analysis Based on Soft Computing and Applied on Space Shuttle During the Liftoff Process

Imaging techniques based on Soft Computing (SC) and developed at Kennedy Space Center (KSC) have been implemented on a variety of prototype applications related to the safety operation of the Space Shuttle during the liftoff process. These SC-based prototype applications include detection and tracking of moving Foreign Objects Debris (FOD) during the Space Shuttle liftoff, visual anomaly detection on slidewires used in the emergency egress system for the Space Shuttle at the laJlIlch pad, and visual detection of distant birds approaching the Space Shuttle launch pad. This SC-based image analysis capability developed at KSC was also used to analyze images acquired during the accident of the Space Shuttle Columbia and estimate the trajectory and velocity of the foam that caused the accident.

Dominquez, Jesus A.↗
NASA NTRS1984

Design of wind shear filters

A number of aircraft accidents are caused by the effects of wind shear. In connection with efforts to eliminate or reduce hazards leading to such accidents, the possibility was considered to improve aircraft control systems. However, the effective implementation of the considered approaches will only be possible if suitable filters can be designed for a separation of gusts, which involve higher frequencies from low-frequency wind shear components. Filters of appropriate design should be suited for an employment in connection with all flight conditions. Feasible approaches for obtaining such filters are discussed. A survey is provided regarding the order of magnitude of the improvements which can be achieved, taking into account the performance characteristics of the A300 controller.

Joerck, H.↗
NASA NTRS1980

Emergency relief venting of the infrared telescope liquid helium dewar

An analysis is made of the emergency relief venting of the liquid helium dewar of the Spacelab 2 infrared telescope experiment in the event of a massive failure of the dewar guard vacuum. Such a failure, resulting from a major accident, could cause rapid heating and pressurization of the liquid helium in the dewar and lead to relief venting through the emergency relief system. The heat input from an accident is estimated for various fluid conditions in the dewar and the relief process as it takes place through one or both of the emergency relief paths is considered. It is shown that under all reasonable circumstances the dewar will safely relieve itself, and the pressure will not exceed 85 percent of the proof pressure or 63 percent of the burst pressure.

Urban, E. W.↗
NASA NTRS1981

Emergency relief venting of the infrared telescope liquid helium dewar, second edition

An updated analysis is made of the emergency relief venting of the liquid helium dewar of the Spacelab 2 Infrared Telescope experiment in the event of a massive failure of the dewar guard vacuum. Such a failure, resulting from a major accident, could cause rapid heating and pressurization of the liquid helium in the dewar and lead to relief venting through the emergency relief system. The heat input from an accident is estimated for various fluid conditions in the dewar and the relief process considered as it takes place through one or both of the emergency relief paths. It was previously assumed that the burst diaphragms in the dewar relief paths would rupture at a pressure of 65 psi differential or 4.4 atmospheres. In fact, it has proved necessary to use burst diaphragms in the dewar which rupture at 115 psid or 7.8 atmospheres. An analysis of this case was carried out and shows that when the high pressure diaphragm rupture occurs, the dewar pressure falls within 8 s to below the 4.4 atmospheres for which the original analysis was performed, and thereafter it remains below that level.

Urban, E. W.↗
NASA NTRS2009

Orbiter Payload Bay Bucket Hoist Mishap...An Accident We Should Never Forget

This slide presentation reviews the accident that occurred in 1985 when a bay bucket hoist fell from its stowed position. This accident damaged the orbiter, injured a technician, and delayed the launch. The accident was investigated, and the cause of the accident was determined to be the practice of two-blocking. Two-blocking is the result of hoisting beyond the intended safe upper limit of hook travel to the point of solid contact between the load block and the upper block or hoist/trolley structure. The usual result is immediate failure of the wire rope, due to the ropes being cut by the grooves of the drum or sheaves. The design of the hoist, the inspection, and the operator training were all in part responsible for this failure.

Lytle, Bradford P.↗
NASA NTRS2010

Experimental Space Shuttle Orbiter Studies to Acquire Data for Code and Flight Heating Model Validation

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.

Wadhams, T. P.↗
NASA NTRS2015

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilots taking direct control of the reaction control system. The analysis described here suggests that all of the events that caused the accident occurred well before the moment when the pilot switched to direct control. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

accident investigation↗