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At least 37 records · Page 2

Civil helicopter wire strike assessment study. Volume 2: Accident analysis briefs

A description and analysis of each of the 208 civil helicopter wire strike accidents reported to the National Transportation Safety Board (NTSB) for the ten year period 1970-1979 is given. The accident analysis briefs were based on pilot reports, FAA investigation reports, and such accident photographs as were made available. Briefs were grouped by year and, within year, by NTSB accident report number.

Tuomela, C. H.↗

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.↗

A summary and integration of research concerning single pilot IFR operational problems

A review of seven research studies pertaining to Single Pilot IFR (SPIFR) operations was performed. Two studies were based on questionnaire surveys; two based on National Transportation Safety Board (NTSB) reports; two were based on Aviation Safety Reporting System (ASRS) incident reports, and one report used event analysis and statistics to forecast problems. The results obtained in each study were extracted and integrated. Results were synthesized and key issues pertaining to SPIFR operations problems were identified. The research that was recommended by the studies and that addressed the key issues is catalogued for each key issue.

Chapman, G. C.↗

A summary and integration of research concerning single pilot IFR operational problems

A review of seven research studies pertaining to Single Pilot IFR (SPIFR) operations was performed. Two studies were based on questionnaire surveys, two were based on National Transportation Safety Board (NTSB) reports, two were based on Aviation Safety Reporting System (ASRS) incident reports, and one report used event analysis and statistics to forecast problems. The results obtained in each study were extracted and integrated. Results were synthesized and key issues pertaining to SPIFR operations problems were identified. The research that was recommended by the studies and that addressed the key issues is cataloged for each key issue.

Chapman, G. C.↗

Identification of vortex-induced clear-air turbulence using airline flight records

The nature and cause of clear-air turbulence is being investigated, in cooperation with the National Transportation Safety Board, using the flight records available from airline encounters with severe turbulence. This paper presents two case studies of severe turbulence which indicate that the airplanes involved encountered vortex arrays which were generated by destabilized wind-shear layers near the tropopause. In order to identify and analyze vortex patterns (i.e., vortex strength, size, and spacings), potential-flow models of vortex arrays were developed that describe reasonably well the wind patterns derived from the airliner flight records. The results of this analysis indicate that in the two cases studied, the vortex cores had diameters in the range of 900 to 1,200 ft with tangential velocities in the range of 70 to 85 ft/sec. This study presents the first identification and analysis of vortex arrays from airline flight data. The results are compared with theoretical predictions and previous observations.

Parks, E. K.↗

Analysis of the nature and cause of turbulence upset using airline flight records

The development and application of methods for determining aircraft motions and related winds, using data normally recorded during airline flight operations, are described. The methods are being developed, in cooperation with the National Transportation Safety Board, to aid in the analysis and understanding of circumstances associated with aircraft accidents or incidents. Data from a recent DC-10 encounter with severe, high-altitude turbulence are used to illustrate the methods. The analysis of this encounter shows the turbulence to be a series of equally spaced horizontal swirls known as 'cat's eyes' vortices. The use of flight-data analysis methods to identify this type of turbulence phenomenon is presented for the first time.

Parks, E. K.↗

Angle-of-attack estimation for analysis of CAT encounters

Recent studies of clear-air turbulence (CAT) encounters involving wide-body airliners have been based upon flight-path wind estimates made by analyzing digital flight-data-recorder (DFDR) records and radar records. Such estimates require a time history of the aircraft angle of attack, a record that is not usually included in the DFDR measurement set. This paper describes a method for reconstructing angle of attack that utilizes available flight record and aircraft-specific information associated with an aerodynamic model of the lift coefficient. Results from two wide-body incidents in which vane measurements of angle of attack were recorded show good agreement between measured and calculated time histories. This research has been performed in cooperation with the National Transportation Safety Board to provide a better understanding of the CAT phenomenon.

Bach, R. E., Jr.↗

Accident investigation

The National Transportation Safety Board (NTSB) has attributed wind shear as a cause or contributing factor in 15 accidents involving transport-categroy airplanes since 1970. Nine of these were nonfatal; but the other six accounted for 440 lives. Five of the fatal accidents and seven of the nonfatal accidents involved encounters with convective downbursts or microbursts. Of other accidents, two which were nonfatal were encounters with a frontal system shear, and one which was fatal was the result of a terrain induced wind shear. These accidents are discussed with reference to helping the aircraft to avoid the wind shear or if impossible to help the pilot to get through the wind shear.

Laynor, William G. Bud↗

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.↗

Pre-flight risk assessment in Emergency Medical Service (EMS) helicopters

The Emergency Medical Service (EMS) industry has been the subject of several television and newspaper articles (Harvey and Jensen, 1987) which emphasized the negative aspects, (e.g., fatalities and high accident rates), rather than the life saving services performed. Until recently, the accident rate of the EMS industry has been five times as high as that of other civil helicopters. This high accident rate has been coupled with the dramatic rise in the number of programs. The industry has built from a single service at its inception in 1972, to over 180 in 1987 (Spray, 1987), to the point that 93 percent of the contiguous U.S. is now covered by some type of EMS service. These factors prompted the National Transportation Safety Board (NTSB) to study the accidents that occurred between May 11, 1978 and December 3, 1986 (NTSB, 1988). The NTSB report concluded that 'Sound pilot judgment is central to safe flight operations.' They further stated that '... factors unique to EMS helicopter operations--such as the influence of the mission itself, program competition, and EMS program management perspectives--can drastically influence pilot judgment during the EMS mission.' One of the most difficult decisions that a pilot must make is whether to accept or decline a mission. A pre-flight risk assessment system (SAFE) was developed at NASA-Ames Research Center for civil EMS operations to aid pilots in making this decision objectively. The ability of the SAFE system to predict mission risk profiles was tested at an EMS facility. The results of this field study demonstrated that the usefulness of SAFE was highly dependent on the type of mission flown. SAFE is now being modified so that it can 'learn' with each mission flown. For example, after flying a mission to a particular site, an EMS pilot would input information about this mission into the system, such as new buildings, wires, or approach procedures. Then, the next time a pilot flew a similar mission or one to the same area, this additional information would be taken into account in computing a risk assessment.

Shively, R. J.↗

Piloted Simulation Tests of Propulsion Control as Backup to Loss of Primary Flight Controls for a B747-400 Jet Transport

Partial failures of aircraft primary flight control systems and structural damages to aircraft during flight have led to catastrophic accidents with subsequent loss of lives (e.g. DC-10, B-747, C-5, B-52, and others). Following the DC-10 accident at Sioux City, Iowa in 1989, the National Transportation Safety Board recommended 'Encourage research and development of backup flight control systems for newly certified wide-body airplanes that utilize an alternate source of motive power separate from that source used for the conventional control system.' This report describes the concept of a propulsion controlled aircraft (PCA), discusses pilot controls, displays, and procedures; and presents the results of a PCA piloted simulation test and evaluation of the B747-400 airplane conducted at NASA Ames Research Center in December, 1996. The purpose of the test was to develop and evaluate propulsion control throughout the full flight envelope of the B747-400 including worst case scenarios of engine failures and out of trim moments. Pilot ratings of PCA performance ranged from adequate to satisfactory. PCA performed well in unusual attitude recoveries at 35,000 ft altitude, performed well in fully coupled ILS approaches, performed well in single engine failures, and performed well at aft cg. PCA performance was primarily limited by out-of-trim moments.

Bull, John↗

Research Lasers and Air Traffic Safety: Issues, Concerns and Responsibilities of the Research Community

The subject of outdoor use of lasers relative to air traffic has become a diverse and dynamic topic. During the past several decades, the use of lasers in outdoor research activities have increased significantly. Increases in the outdoor use of lasers and increases in air traffic densities have changed the levels of risk involved. To date there have been no documented incidents of air traffic interference from research lasers; however, incidents involving display lasers have shown a marked increase. As a result of the national response to these incidents, new concerns over lasers have arisen. Through the efforts of the SAE G-10T Laser Safety Hazards Subcommittee and the ANSI Z136.6 development committee, potential detrimental effects to air traffic beyond the traditional eye damage concerns have been identified. An increased emphasis from the Federal Aviation Administration (FAA), the Center for Devices and Radiological Hazards (CDRH), and the National Transportation Safety Board (NTSB) along with increased concern by the public have resulted in focused scrutiny of potential hazards presented by lasers. The research community needs to rethink the traditional methods of risk evaluation and application of protective measures. The best current approach to assure adequate protection of air traffic is the application of viable hazard and risk analysis and the use of validated protective measures. Standards making efforts and regulatory development must be supported by the research community to assure that reasonable measures are developed. Without input, standards and regulations can be developed that are not compatible with the needs of the research community. Finally, support is needed for the continued development and validation of protective measures.

Nessler, Phillip J., Jr.↗

An Experimental and Numerical Study of Icing Effects on the Performance and Controllability of a Twin Engine Aircraft

In September 1997 the National Transportation Safety Board (NTSB) requested assistance from the NASA Lewis Research Center (LeRC) Icing Branch in the investigation of an aircraft accident that was suspected of being caused by ice contamination. In response to the request NASA agreed to perform an experimental and computational study. The main activities that NASA performed were LERC Icing Research Tunnel (IRT) testing to define ice shapes and 2-D Navier-Stokes analysis to determine the performance degradation that those ice shapes would have caused. An IRT test was conducted in January 1998. Most conditions for the test were based upon raw and derived data from the Flight Data Recorder (FDR) recovered from the accident and upon the current understanding of the Meteorological conditions near the accident. Using a two-dimensional Navier-Stokes code, the flow field and resultant lift and drag were calculated for the wing section with various ice shapes accreted in the IRT test. Before the final calculations could be performed extensive examinations of geometry smoothing and turbulence were conducted. The most significant finding of this effort is that several of the five-minute ice accretions generated in the IRT were found by the Navier-Stokes analysis to produce severe lift and drag degradation. The information generated by this study suggests a possible scenario for the kind of control upset recorded in the accident. Secondary findings were that the ice shapes accreted in the IRT were mostly limited to the protected pneumatic boot region of the wing and that during testing, activation of the pneumatic boots cleared most of the ice.

Reehorst, A.↗

Navier-Stokes Analysis of the Flowfield Characteristics of an Ice Contaminated Aircraft Wing

An analytical study was performed as part of the NASA Lewis support of a National Transportation Safety Board (NTSB) aircraft accident investigation. The study was focused on the performance degradation associated with ice contamination on the wing of a commercial turbo-prop-powered aircraft. Based upon the results of an earlier numerical study conducted by the authors, a prominent ridged-ice formation on the subject aircraft wing was selected for detailed flow analysis using 2-dimensional (2-D), as well as, 3-dimensional (3-D) Navier-Stokes computations. This configuration was selected because it caused the largest lift decrease and drag increase among all the ice shapes investigated in the earlier study. A grid sensitivity test was performed to find out the influence of grid spacing on the lift, drag, and associated angle-of-attack for the maximum lift (C(sub lmax)). This study showed that grid resolution is important and a sensitivity analysis is an essential element of the process in order to assure that the final solution is independent of the grid. The 2-D results suggested that a severe stability and control difficulty could have occurred at a slightly higher angle-of-attack (AOA) than the one recorded by the Flight Data Recorder (FDR). This stability and control problem was thought to have resulted from a decreased differential lift on the wings with respect to the normal loading for the configuration. The analysis also indicated that this stability and control problem could have occurred whether or not natural ice shedding took place. Numerical results using an assumed 3-D ice shape showed an increase of the angle at which this phenomena occurred of about 4 degrees. As it occurred with the 2-D case, the trailing edge separation was observed but started only when the AOA was very close to the angle at which the maximum lift occurred.

Chung, J.↗

Investigation of Electromagnetic Field Threat to Fuel Tank Wiring of a Transport Aircraft

National Transportation Safety Board investigators have questioned whether an electrical discharge in the Fuel Quantity Indication System (FQIS) may have initiated the TWA-800 center wing tank explosion. Because the FQIS was designed to be incapable of producing such a discharge on its own, attention has been directed to mechanisms of outside electromagnetic influence. To support the investigation, the NASA Langley Research Center was tasked to study the potential for radiated electromagnetic fields from external radio frequency (RF) transmitters and passenger carried portable electronic devices (PEDs) to excite the FQIS enough to cause arcing, sparking or excessive heating within the fuel tank.

Ely, Jay J.↗

U.S. Civil Rotorcraft Accidents, 1963 Through 1997

Narrative summary data produced by the U.S. National Transportation Safety Board (NTSB) has been obtained and analyzed for all 8,436 U.S. civil registered rotorcraft accidents which occurred from mid-1963 through 1997. This analysis was based on the NTSB's assignment of each mishap into one of 21 "first event" categories. The number of U.S. civil registered rotorcraft as recorded by the Federal Aviation Administration (FAA) for the same period has also been obtained. Taken together, these data indicate the civil rotorcraft accident rate (on a per 1,000 registered rotorcraft basis) has decreased by almost a factor of 10 (i.e., from 130 accidents per 1,000 rotorcraft in 1964 to 13.4 per 1,000 in 1997). Analysis of the mishap data indicates over 70% of the rotorcraft accidents were associated with one of the following four NTSB "first event" categories: 2408 Loss of engine power (28.5%); 1,322 In-flight collisions with objects (15.7%); 1,114 Loss of control (13.2%); 1,083 Airframe/component/system failure or malfunction (12.8%).

Harris, Franklin D.↗

Shared Problem Models and Crew Decision Making

The importance of crew decision making to aviation safety has been well established through NTSB accident analyses: Crew judgment and decision making have been cited as causes or contributing factors in over half of all accidents in commercial air transport, general aviation, and military aviation. Yet the bulk of research on decision making has not proven helpful in improving the quality of decisions in the cockpit. One reason is that traditional analytic decision models are inappropriate to the dynamic complex nature of cockpit decision making and do not accurately describe what expert human decision makers do when they make decisions. A new model of dynamic naturalistic decision making is offered that may prove more useful for training or aiding cockpit decision making. Based on analyses of crew performance in full-mission simulation and National Transportation Safety Board accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation and reflect the crew's metacognitive skill. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that all crew members have essential information, but it also regulates and coordinates crew actions and is the medium of collective thinking in response to a problem. This presentation will examine the relation between communication that serves to build performance. Implications of these findings for crew training will be discussed.

Orasanu, Judith↗

Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation Accident

Flight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.

Rosekind, Mark R.↗