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At least 37 records · Page 2

Qualitative Future Safety Risk Identification an Update

The purpose of this report is to document the results of a high-level qualitative study that was conducted to identify future aviation safety risks and to assess the potential impacts to the National Airspace System (NAS) of NASA Aviation Safety research on these risks. Multiple external sources (for example, the National Transportation Safety Board, the Flight Safety Foundation, the National Research Council, and the Joint Planning and Development Office) were used to develop a compilation of future safety issues risks, also referred to as future tall poles. The primary criterion used to identify the most critical future safety risk issues was that the issue must be cited in several of these sources as a safety area of concern. The tall poles in future safety risk, in no particular order of importance, are as follows: Runway Safety, Loss of Control In Flight, Icing Ice Detection, Loss of Separation, Near Midair Collision Human Fatigue, Increasing Complexity and Reliance on Automation, Vulnerability Discovery, Data Sharing and Dissemination, and Enhanced Survivability in the Event of an Accident.

future aviation safety risk↗

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

Reveley, Mary S.↗

Identification of Safety Metrics for Airport Surface Operations

A large fraction of safety incidents occurs on the ground during airport surface operations. Although these incidents are mostly non-fatal with a few exceptions, they are high profile incidents that remain a source of concern for the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), major airlines, and other stakeholders of the National Airspace System (NAS). These incidents have historically been mitigated by implementing changes to regulations, policies, and procedures over time. This approach has minimized but not eliminated the risk of occurrences. It is thus important to develop integrated techniques to assess, model, and prevent these incidents by analyzing the risk and likelihood of occurrence and communicating results of the analysis to decision-making personnel who can mitigate and prevent incidents in real time. The research presented in this report builds on prior work of researchers at the NASA Ames Research Center who developed an automated framework, Real-Time Safety Monitoring (RTSM), to enable monitoring and prediction of the safety of the NAS. In the RTSM framework, hazards to flight are translated to safety metrics such as wake vortex encounters or loss of separation, that can be modeled and analyzed offline and also predicted and monitored in real time (online). The intent of this report is to integrate predictable incidents that occur during surface and ground operations into the safety portfolio of the RTSM project by (i) identifying suitable information sources from which ground incidents can be studied, (ii) developing safety metrics correlated with surface operations, and (iii) recommending suitable data sources that can be quantified and used for the computation of pertinent safety metrics.

ground operations↗

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↗

NASA spinoffs to public service

The National Aeronautics and Space Administration (NASA) Technology Utilization (TU) Division of the Office of Commercial Programs has been quite successful in directing the transfer to technology into the public sector. NASA developments of particular interest have been those in the areas of aerodynamics and aviation transport, safety, sensors, electronics and computing, and satellites and remote sensing. NASA technology has helped law enforcement, firefighting, public transportation, education, search and rescue, and practically every other sector of activity serving the U.S. public. NASA works closely with public service agencies and associations, especially those serving local needs of citizens, to expedite technology transfer benefits. A number of examples exist to demonstrate the technology transfer method and opportunities of NASA spinoffs to public service.

Ault, L. A.↗

Railroad safety program, volume 1

Since 1981, the Federal Railroad Administration (FRA) has annually prepared a National Inspection Plan (NIP) whose purpose is to summarize regional efforts to improve railroad transportation safety. The research concluded on the following tasks including the problems, conclusions and recommendations associated with these tasks is summarized: (1) the preparation of the 1983 NIP, with recommended procedures for improving future NIPs; (2) the development of an outline for the 1984 NIP, including a methodology for the allocation of inspection resources and other specialized regional activities; (3) the management and development of the 1984 NIP; and (4) the development of an instruction manual to be used in the preparation of future NIPs.

Source record↗

The Role of Spatial Disorientation in Fatal General Aviation Accidents

In-flight Spatial Disorientation (SD) in pilots is a serious threat to aviation safety. Indeed, SD may play a much larger role in aviation accidents than the approximate 6-8% reported by the National Transportation Safety Board (NTSB) each year, because some accidents coded by the NTSB as aircraft control-not maintained (ACNM) may actually result from SD. The purpose of this study is to determine whether SD is underestimated as a cause of fatal general aviation (GA) accidents in the NTSB database. Fatal GA airplane accidents occurring between January 1995 and December 1999 were reviewed from the NTSB aviation accident database. Cases coded as ACNM or SD as the probable cause were selected for review by a panel of aerospace medicine specialists. Using a rating scale, each rater was instructed to determine if SD was the probable cause of the accident. Agreement between the raters and agreement between the raters and the NTSB were evaluated by Kappa statistics. The raters agreed that 11 out of 20 (55%) accidents coded by the NTSB as ACNM were probably caused by SD (p less than 0.05). Agreement between the raters and the NTSB did not reach significance (p greater than 0.05). The 95% C.I. for the sampling population estimated that between 33-77% of cases that the NTSB identified as ACNM could be identified by aerospace medicine experts as SD. Aerospace medicine specialists agreed that some cases coded by the NTSB as ACNM were probably caused by SD. Consequently, a larger number of accidents may be caused by the pilot succumbing to SD than indicated in the NTSB database. This new information should encourage regulating agencies to insure that pilots receive SD recognition training, enabling them to take appropriate corrective actions during flight. This could lead to new training standards, ultimately saving lives among GA airplane pilots.

Scheuring, RIchard↗

Pilot Fatigue and Circadian Desynchronosis

Pilot fatigue and circadian desynchronosis, its significance to air transport safety, and research approaches, were examined. There is a need for better data on sleep, activity, and other pertinent factors from pilots flying a variety of demanding schedules. Simulation studies of flight crew performance should be utilized to determine the degree of fatigue induced by demanding schedules and to delineate more precisely the factors responsible for performance decrements in flight and to test solutions proposed to resolve problems induced by fatigue and desynchronosis. It was concluded that there is a safety problem of uncertain magnitude due to transmeridian flying and a potential problem due to fatigue associated with various factors found in air transport operations.

Source record↗

Systems Analysis of NASA Aviation Safety Program: Final Report

A three-month study (February to April 2010) of the NASA Aviation Safety (AvSafe) program was conducted. This study comprised three components: (1) a statistical analysis of currently available civilian subsonic aircraft data from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system to identify any significant or overlooked aviation safety issues; (2) a high-level qualitative identification of future safety risks, with an assessment of the potential impact of the NASA AvSafe research on the National Airspace System (NAS) based on these risks; and (3) a detailed, top-down analysis of the NASA AvSafe program using an established and peer-reviewed systems analysis methodology. The statistical analysis identified the top aviation "tall poles" based on NTSB accident and FAA incident data from 1997 to 2006. A separate examination of medical helicopter accidents in the United States was also conducted. Multiple external sources were used to develop a compilation of ten "tall poles" in future safety issues/risks. The top-down analysis of the AvSafe was conducted by using a modification of the Gibson methodology. Of the 17 challenging safety issues that were identified, 11 were directly addressed by the AvSafe program research portfolio.

Jones, Sharon M.↗

An Analysis of U.S. Civil Rotorcraft Accidents by Cost and Injury (1990-1996)

A study of rotorcraft accidents was conducted to identify safety issues and research areas that might lead to a reduction in rotorcraft accidents and fatalities. The primary source of data was summaries of National Transportation Safety Board (NTSB) accident reports. From 1990 to 1996, the NTSB documented 1396 civil rotorcraft accidents in the United States in which 491 people were killed. The rotorcraft data were compared to airline and general aviation data to determine the relative safety of rotorcraft compared to other segments of the aviation industry. In depth analysis of the rotorcraft data addressed demographics, mission, and operational factors. Rotorcraft were found to have an accident rate about ten times that of commercial airliners and about the same as that of general aviation. The likelihood that an accident would be fatal was about equal for all three classes of operation. The most dramatic division in rotorcraft accidents is between flights flown by private pilots versus professional pilots. Private pilots, flying low cost aircraft in benign environments, have accidents that are due, in large part, to their own errors. Professional pilots, in contrast, are more likely to have accidents that are a result of exacting missions or use of specialized equipment. For both groups judgement error is more likely to lead to a fatal accident than are other types of causes. Several approaches to improving the rotorcraft accident rate are recommended. These mostly address improvement in the training of new pilots and improving the safety awareness of private pilots.

Iseler, Laura↗

Evaluation of Synthetic Vision Display Concepts for Improved Awareness in Unusual Attitude Recovery Scenarios

A recent study conducted by the Commercial Aviation Safety Team (CAST) determined 40 percent of all fixed-wing fatal accidents, between 2001 and 2011, were caused by Loss-of-Control (LOC) in flight (National Transportation Safety Board, 2015). Based on their findings, CAST recommended manufacturers develop and implement virtual day-visual meteorological conditions (VMC) display systems, such as synthetic vision or equivalent systems (CAST, 2016). In a 2015 simulation study conducted at NASA Langley Research Center (LaRC), researchers gathered to test and evaluate virtual day-VMC displays under realistic flight operation scenarios capable of inducing reduced attention states in pilots. Each display concept was evaluated to determine its efficacy to improve attitude awareness. During the experiment, Evaluation Pilots (EPs) were shown the following three display concepts on the Primary Flight Display (PFD): Baseline, Synthetic Vision (SV) with color gradient, and SV with texture. The baseline configuration was a standard, conventional 'blue over brown' display. Experiment scenarios were simulated over water to evaluate Unusual Attitude (UA) recovery over 'featureless terrain' environments. Thus, the SV with color gradient configuration presented a 'blue over blue' display with a linear blue color progression, to differentiate attitude changes between sky and ocean. The SV with texture configuration presented a 'blue over blue' display with a black checkerboard texture atop a synthetic ocean. These displays were paired with a Background Attitude Indicator (BAI) concept. The BAI was presented across all four Head-Down Displays (HDDs), displaying a wide field-of-view blue-over-blue attitude indicator. The BAI aligned with the PFD and showed through the background of the navigation displays with opaque transparency. Each EP participated in a two-part experiment series with a total seventy-five trial runs: Part I included a set of twenty-five Unusual Attitude Recovery (UAR) scenarios; Part II included a set of fifty Attitude Memory Recall Tasks (AMRT). At the conclusion of each trial, EPs were asked to complete a set post-run questionnaires. Quantitative results showed that there were no significant statistical effects on UA recovery times when utilizing SV with or without the presence of a BAI. Qualitative results show the SV displays (color, texture) with BAI On are most preferred for both UA recognition and recovery when compared with the baseline display. When only comparing SV display concepts, EPs performed better when using the SV with texture, BAI On, than any other display configuration. This is an interesting find considering most EPs noted their preference towards the SV with color gradient when the BAI was on.

Nicholas, Stephanie↗

Space transportation system payload safety policy

A brief description of the Space Transportation System (STS) is given, and the evolution of a payload safety policy for it is described. The policy adopted in June, 1976, minimizes STS involvement in the payload design process while maintaining the assurance of a safe operation. The payload developer is responsible for assurance of safety and verification of compliance with the requirements. The STS will exercise reviews to ensure that interaction between payloads does not create hazards.

Scheller, J. A.↗

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↗

Another Approach to Enhance Airline Safety: Using Management Safety Tools

The ultimate goal of conducting an accident investigation is to prevent similar accidents from happening again and to make operations safer system-wide. Based on the findings extracted from the investigation, the "lesson learned" becomes a genuine part of the safety database making risk management available to safety analysts. The airline industry is no exception. In the US, the FAA has advocated the usage of the System Safety concept in enhancing safety since 2000. Yet, in today s usage of System Safety, the airline industry mainly focuses on risk management, which is a reactive process of the System Safety discipline. In order to extend the merit of System Safety and to prevent accidents beforehand, a specific System Safety tool needs to be applied; so a model of hazard prediction can be formed. To do so, the authors initiated this study by reviewing 189 final accident reports from the National Transportation Safety Board (NTSB) covering FAR Part 121 scheduled operations. The discovered accident causes (direct hazards) were categorized into 10 groups Flight Operations, Ground Crew, Turbulence, Maintenance, Foreign Object Damage (FOD), Flight Attendant, Air Traffic Control, Manufacturer, Passenger, and Federal Aviation Administration. These direct hazards were associated with 36 root factors prepared for an error-elimination model using Fault Tree Analysis (FTA), a leading tool for System Safety experts. An FTA block-diagram model was created, followed by a probability simulation of accidents. Five case studies and reports were provided in order to fully demonstrate the usefulness of System Safety tools in promoting airline safety.

Lu, Chien-tsug↗

Aviation Trends Related to Atmospheric Environment Safety Technologies Project Technical Challenges

Current and future aviation safety trends related to the National Aeronautics and Space Administration's Atmospheric Environment Safety Technologies Project's three technical challenges (engine icing characterization and simulation capability; airframe icing simulation and engineering tool capability; and atmospheric hazard sensing and mitigation technology capability) were assessed by examining the National Transportation Safety Board (NTSB) accident database (1989 to 2008), incidents from the Federal Aviation Administration (FAA) accident/incident database (1989 to 2006), and literature from various industry and government sources. The accident and incident data were examined for events involving fixed-wing airplanes operating under Federal Aviation Regulation (FAR) Parts 121, 135, and 91 for atmospheric conditions related to airframe icing, ice-crystal engine icing, turbulence, clear air turbulence, wake vortex, lightning, and low visibility (fog, low ceiling, clouds, precipitation, and low lighting). Five future aviation safety risk areas associated with the three AEST technical challenges were identified after an exhaustive survey of a variety of sources and include: approach and landing accident reduction, icing/ice detection, loss of control in flight, super density operations, and runway safety.

Reveley, Mary S.↗

Identification of Crew-Systems Interactions and Decision Related Trends

NASA Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified technical challenges. Statistical data and published safety priority lists from academic, industry and other government agencies were reviewed and analyzed by NASA Aviation Safety Program (AvSP) systems analysis personnel to identify issues and future research needs related to one of VSST's technical challenges, Crew Decision Making (CDM). The data examined in the study were obtained from the National Transportation Safety Board (NTSB) Aviation Accident and Incident Data System, Federal Aviation Administration (FAA) Accident/Incident Data System and the NASA Aviation Safety Reporting System (ASRS). In addition, this report contains the results of a review of safety priority lists, information databases and other documented references pertaining to aviation crew systems issues and future research needs. The specific sources examined were: Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementation (SERFIs), Flight Deck Automation Issues (FDAI) and NTSB Most Wanted List and Open Recommendations. Various automation issues taxonomies and priority lists pertaining to human factors, automation and flight design were combined to create a list of automation issues related to CDM.

Jones, Sharon Monica↗

Stabilized Approach Criteria: Bridging the Gap Between Theory and Practice

Approach and landing is the most common phase of flight for aviation accidents, accounting annually for approximately 65 percent of all accidents. A Flight Safety Foundation study of 16 years of runway excursions determined that 83 percent could have been avoided with a decision to go around. In other words, 54 percent of all accidents could potentially be prevented by going around. A critical industry policy designed to help prevent such accidents is the go-around policy. However, the collective industry performance of complying with go-around policies is extremely poor and only about three percent of unstable approaches result in a go-around. Improving the go-around compliance rate holds tremendous potential in reducing approach and landing accidents. There are many reasons for flight crews ignoring go-around policies related to pilot judgement and company policies. Examples are the collective industry norm to accept the noncompliance of go-around policies, management being disengaged from go-around noncompliance, and pilot fatigue and lack of situational awareness. One of the biggest factors is that pilots see current stabilized-approach criteria as too complex and restrictive for the operational environment. Following the American Airlines 1420 accident (Little Rock, 1999), where the aircraft overran the runway upon landing and crashed, the National Transportation Safety Board (NTSB) recommended that the Federal Aviation Administration (FAA) define detailed parameters for a stabilized approach, and develop detailed criteria indicating when a go-around should be performed. The experiment discussed in this presentation is the first step towards developing these go-around criteria for commercial transport aircraft.

pilot performance↗