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National Transportation Safety Board Aircraft Accident Investigation Supported

The main purpose of this investigation was for NASA to help the National Transportation Safety Board (NTSB) gain better understanding of the events that led to the loss of Comair Flight 3272 over Monroe, Michigan, on January 9, 1997. In-flight icing was suspected as being the primary cause of this accident. Of particular interest to the Safety Board was what NASA could learn about the potential performance degradation of the wing of the Embraer EMB-120 twin-turboprop commuter aircraft with various levels of ice contamination. NASA agreed to undertake (1) ice-accretion prediction computations with NASA s LEWICE program to bound the kind of contaminations that the vehicle may have developed, (2) testing in the NASA Lewis Research Center's Icing Research Tunnel to verify and refine the ice shapes developed by LEWICE, (3) a two-dimensional Navier- Stokes analysis to determine the performance degradation that those ice shapes could have caused, and (4) an examination using three-dimensional Navier-Stokes codes to study the three-dimensional effects of ice contamination.

Reehorst, Andrew L.↗

Transformational Phenomena as Predictors of Aircraft Accidents: What Goes Around Comes Around

Flight crew confusion, excessive stressworkload, and ineffective Crew Resource Management among other issues arising from dependence on automated systems on the flight deck have been identified as major causal factors in multiple fatal accidents, significant incidents and near misses. Many Loss of Control events have been traced to display of erroneous flight data and auto-flight system mode status to the crew. Safety was compromised by not having sufficiently obvious and unambiguous information available in order to permit quick diagnosis of aircraft status and then appropriate action to regain control of the aircraft energy state or trajectory. Continually evolving training and operational requirements related to aircraft automation have also presented critical challenges to commercial aviation. During times of high demand and low supply of experienced pilots (which is today the case in South-East Asia, for instance), basic training in manual flight may be minimal and as low as a few hundred flight hours on light aircraft before beginning training on advanced, highly automated aircraft. Predominant use of automation may cause aircrew trained in this way to have trouble performing traditionally simple operations such as manually switching to other runways or overriding the autopilot in tight situations. Inadequate crew training andor experience coupled with attempted manual flight in highly automated airplanes may more easily lead to loss of aircraft control in unusual situations such as high-altitude stallsupsets, traffic avoidance or maneuvering. Loss of basic piloting skills through increasing dependence on automation may exacerbate this problem. Finally, design changes by nature take a long time and are very costly. Incorporating novel automated functionality into new aircraft designs is technically feasible and desirable. However, it may take many years for these changes to have a significant impact on tomorrows fleet, given the time it takes to develop a new aircraft and for these aircraft to become a significant fraction of the fleet. This paper will review and summarize the findings and recommendations from a 2004 study of the topic, Increasing reliance on flight deck automation conducted by the Future Aviation Safety Team at the behest of the Joint Safety Strategy Initiative (JSSI) within the Joint Aviation Authorities (JAA) organization that existed at the time. Although this study was conducted more than ten years ago, its findings and recommendations are as relevant now as then and into the future.

safety↗

Model predictions of wind and turbulence profiles associated with an ensemble of aircraft accidents

The feasibility of predicting conditions under which wind/turbulence environments hazardous to aviation operations exist is studied by examining a number of different accidents in detail. A model of turbulent flow in the atmospheric boundary layer is used to reconstruct wind and turbulence profiles which may have existed at low altitudes at the time of the accidents. The predictions are consistent with available flight recorder data, but neither the input boundary conditions nor the flight recorder observations are sufficiently precise for these studies to be interpreted as verification tests of the model predictions.

Williamson, G. G.↗

The engineering investigation of aircraft accidents

The organization and plan for an investigation, procedures used at the scene of the accident, engineering aspects covered in the main investigation, use of special analytical techniques and simulation tools, and use of flight recorder data are discussed. Examples of investigations are used to illustrate the processes used.

Anderson, S. B.↗

The use of flight test techniques in aircraft accident investigations

Wind shear is a serious safety hazard to commercial aviation. Low level wind shear (downburst) was the cause of the takeoff accident in New Orleans, July 9, 1982, and the landing accident in Dallas, Aug. 2, 1985. Shear layer instability is a common cause of clear air turbulence (CAT) at cruising altitudes. A number of encounters with severe CAT, in which passengers were injured, have recently occurred (Hannibal, MO, April 1981; Morton, WY, July 1982; etc.). Improved accident investigation techniques can lead to a better understanding of the nature of the wind environment associated with downbursts and CAT and to better detection and avoidance procedures. For the past several years, NASA-Ames has worked closely with the National Transportation Safety Board in the investigation of wind related accidents.

Parks, E. K.↗

German aircraft accident statistics, 1930

The investigation of all serious accidents, involving technical defects in the airplane or engine, is undertaken by the D.V.L. in conjunction with the imperial traffic minister and other interested parties. All accidents not clearly explained in the reports are subsequently cleared up.

Weitzmann, Ludwig↗

Advanced risk assessment of the effects of graphite fibers on electronic and electric equipment

An assessment of the risk associated with accidents involving aircraft with carbon fiber composite structural components is examined. The individual fiber segments cause electrical and electronic equipment to fail under certain operating conditions. A Monte Carlo simulation model was used to computer the risk. Aircraft accidents with fire, release of carbon fiber material, entrainment of carbon fibers in a smoke plume transport of fibers downwind, transfer of some fibers/into the the interior of buildings, failures of electrical and electronic equipment, and economic impact of failures are discussed. Risk profiles were prepared for individual airports and the Nation. The vulnerability of electrical transmission equipment to carbon fiber incursion and aircraft accident total costs is investigated.

Pocinki, L.↗

Accident investigation

Aircraft accident investigations are discussed with emphasis on those accidents that involved weather as a contributing factor. The organization of the accident investigation board for air carrier accidents is described along with the hearings, and formal report preparation. Statistical summaries of the investigations of general aviation accidents are provided.

Brunstein, A. I.↗

Aircraft Loss-of-Control: Analysis and Requirements for Future Safety-Critical Systems and Their Validation

Loss of control remains one of the largest contributors to fatal aircraft accidents worldwide. Aircraft loss-of-control accidents are complex, resulting from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. This paper summarizes recent analysis results in identifying worst-case combinations of loss-of-control accident precursors and their time sequences, a holistic approach to preventing loss-of-control accidents in the future, and key requirements for validating the associated technologies.

Belcastro, Christine M.↗

Methods Developed by the Tools for Engine Diagnostics Task to Monitor and Predict Rotor Damage in Real Time

Tools for Engine Diagnostics is a major task in the Propulsion System Health Management area of the Single Aircraft Accident Prevention project under NASA s Aviation Safety Program. The major goal of the Aviation Safety Program is to reduce fatal aircraft accidents by 80 percent within 10 years and by 90 percent within 25 years. The goal of the Propulsion System Health Management area is to eliminate propulsion system malfunctions as a primary or contributing factor to the cause of aircraft accidents. The purpose of Tools for Engine Diagnostics, a 2-yr-old task, is to establish and improve tools for engine diagnostics and prognostics that measure the deformation and damage of rotating engine components at the ground level and that perform intermittent or continuous monitoring on the engine wing. In this work, nondestructive-evaluation- (NDE-) based technology is combined with model-dependent disk spin experimental simulation systems, like finite element modeling (FEM) and modal norms, to monitor and predict rotor damage in real time. Fracture mechanics time-dependent fatigue crack growth and damage-mechanics-based life estimation are being developed, and their potential use investigated. In addition, wireless eddy current and advanced acoustics are being developed for on-wing and just-in-time NDE engine inspection to provide deeper access and higher sensitivity to extend on-wing capabilities and improve inspection readiness. In the long run, these methods could establish a base for prognostic sensing while an engine is running, without any overt actions, like inspections. This damage-detection strategy includes experimentally acquired vibration-, eddy-current- and capacitance-based displacement measurements and analytically computed FEM-, modal norms-, and conventional rotordynamics-based models of well-defined damages and critical mass imbalances in rotating disks and rotors.

Baaklini, George Y.↗

Single pilot IFR accident data analysis

The aircraft accident data recorded and maintained by the National Transportation Safety Board for 1964 to 1979 were analyzed to determine what problems exist in the general aviation single pilot instrument flight rules environment. A previous study conducted in 1978 for the years 1964 to 1975 provided a basis for comparison. The purpose was to determine what changes, if any, have occurred in trends and cause-effect relationships reported in the earlier study. The increasing numbers have been tied to measures of activity to produce accident rates which in turn were analyzed in terms of change. Where anomalies or unusually high accident rates were encountered, further analysis was conducted to isolate pertinent patterns of cause factors and/or experience levels of involved pilots. The bulk of the effort addresses accidents in the landing phase of operations. A detailed analysis was performed on controlled/uncontrolled collisions and their unique attributes delineated. Estimates of day vs. night general aviation activity and accident rates were obtained.

Harris, D. F.↗

Single pilot IFR accident data analysis

The aircraft accident data recorded by the National Transportation and Safety Board (NTSR) for 1964-1979 were analyzed to determine what problems exist in the general aviation (GA) single pilot instrument flight rule (SPIFR) environment. A previous study conducted in 1978 for the years 1964-1975 provided a basis for comparison. This effort was generally limited to SPIFR pilot error landing phase accidents but includes some SPIFR takeoff and enroute accident analysis as well as some dual pilot IFR accident analysis for comparison. Analysis was performed for 554 accidents of which 39% (216) occurred during the years 1976-1979.

Harris, D. F.↗

The NASA Aviation Safety Program: Overview

In 1997, the United States set a national goal to reduce the fatal accident rate for aviation by 80% within ten years based on the recommendations by the Presidential Commission on Aviation Safety and Security. Achieving this goal will require the combined efforts of government, industry, and academia in the areas of technology research and development, implementation, and operations. To respond to the national goal, the National Aeronautics and Space Administration (NASA) has developed a program that will focus resources over a five year period on performing research and developing technologies that will enable improvements in many areas of aviation safety. The NASA Aviation Safety Program (AvSP) is organized into six research areas: Aviation System Modeling and Monitoring, System Wide Accident Prevention, Single Aircraft Accident Prevention, Weather Accident Prevention, Accident Mitigation, and Synthetic Vision. Specific project areas include Turbulence Detection and Mitigation, Aviation Weather Information, Weather Information Communications, Propulsion Systems Health Management, Control Upset Management, Human Error Modeling, Maintenance Human Factors, Fire Prevention, and Synthetic Vision Systems for Commercial, Business, and General Aviation aircraft. Research will be performed at all four NASA aeronautics centers and will be closely coordinated with Federal Aviation Administration (FAA) and other government agencies, industry, academia, as well as the aviation user community. This paper provides an overview of the NASA Aviation Safety Program goals, structure, and integration with the rest of the aviation community.

Shin, Jaiwon↗

Equations for determining aircraft motions for accident data

Procedures for determining a comprehensive accident scenario from a limited data set are reported. The analysis techniques accept and process data from either an Air Traffic Control radar tracking system or a foil flight data recorder. Local meteorological information at the time of the accident and aircraft performance data are also utilized. Equations for the desired aircraft motions and forces are given in terms of elements of the measurement set and certain of their time derivatives. The principal assumption made is that aircraft side force and side-slip angle are negligible. An estimation procedure is outlined for use with each data source. For the foil case, a discussion of exploiting measurement redundancy is given. Since either formulation requires estimates of measurement time derivatives, an algorithm for least squares smoothing is provided.

Bach, R. E., Jr.↗

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

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

Accident Investigation↗

Airplane crashes: engine troubles : a possible explanation

The aim was to bring attention to what might be the cause of some aircraft accidents for which there was no satisfactory explanation. The author notes that in testing aircraft accidents at the Bureau of Standards, it happened frequently that the engine performance became erratic when the temperature of the air entering the carburetor was between 0 C and 20 C. Investigation revealed the trouble to have been caused by the formation and collection of snow somewhere between the entrance to the carburetor and the manifold, probably at the throttle. Proof scarcely less convincing was obtained during engine tests. The results of such engine tests are described. Granting that the loss of power and the sudden increases in power were caused by the condensation of moisture from the air and the subsequent formation of snow, two solutions proved effective. The removal of the moisture or an increase in temperature cured the problem.

ENGINE TROUBLE↗

The effect of heavy rain on windshear attributed accidents

In recent years several commercial aircraft accidents have occurred as an aircraft attempted landing in a thunderstorm cell. The horizontal and vertical windshear associated with the cell have been identified as the factors responsible for the accident. In addition to the wind shear encounter, several of these aircraft simultaneously penetrated a heavy rain cell. Heavy rain affects the aircraft by imparting a momentum penalty, and a drag penalty, due to the rain roughening of the airfoil. These penalties have been evaluated by a computer model that, when incorporated with a landing simulation program, was used to assess the relative influence of heavy rain versus wind shear. Using this model, an assessment was made of the influence of heavy rain on several wind shear attributed accidents.

Luers, J. K.↗