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Weather Information Communications (WINCOMM) Project: Dissemination of Weather Information for the Reduction of Aviation Weather-Related Accident Causal Factors

Weather Information Communications (WINCOMM) is part of the Weather Accident Prevention (WxAP) Project, which is part of the NASA's Aviation Safety and Security Program. The goals of WINCOMM are to facilitate the exchange of tactical and strategic weather information between air and ground. This viewgraph presentation provides information on data link decision factors, architectures, validation goals. WINCOMM is capable of providing en-route communication air-to-ground, ground-to-air, and air-to-air, even on international or intercontinental flights. The presentation also includes information on the capacity, cost, and development of data links.

Jarrell, Michael↗

Application of Electron Microscopy Techniques to the Investigation of Space Shuttle Columbia Accident

This viewgraph presentation gives an overview of the investigation into the breakup of the Space Shuttle Columbia, and addresses the importance of a failure analysis strategy for the investigation of the Columbia accident. The main focus of the presentation is on the usefulness of electron microscopy for analyzing slag deposits from the tiles and reinforced carbon-carbon (RCC) wing panels of the Columbia orbiter.

Shah, Sandeep↗

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.↗

Overview of the Aerothermodynamics Analysis Conducted in Support of the STS-107 Accident Investigation

A graphic presentation of the aerothermodynamics analysis conducted in support of the STS-107 accident investigation. Investigation efforts were conducted as part of an integrated AATS team (Aero, Aerothermal, Thermal, Stress) directed by OVEWG. Graphics presented are: STS-107 Entry trajectory and timeline (1st off-nominal event to Post-LOS); Indications from OI telemetry data; Aero/aerothermo/thermal analysis process; Selected STS-107 side fuselage/OMS pod off-nominal temperatures; Leading edge structural subsystem; Relevant forensics evidence; External aerothermal environments; STS-107 Pre-entry EOM3 heating profile; Surface heating and temperatures; Orbiter wing leading edge damage survey; Internal aerothermal environments; Orbiter wing CAD model; Aerodynamic flight reconstruction; Chronology of aerodynamic/aerothermoydynamic contributions; Acreage TPS tile damage; Larger OML perturbations; Missing RCC panel(s); Localized damage to RCC panel/missing T-seal; RCC breach with flow ingestion; and Aero-aerothermal closure. NAIT served as the interface between the CAIB and NASA investigation teams; and CAIB requests for study were addressed.

Campbell, Charles H.↗

New Technologies for Reducing Aviation Weather-Related Accidents

The National Aeronautics and Space Administration (NASA) has developed technologies to reduce aviation weather-related accidents. New technologies are presented for data-link and display of weather information to aircraft in flight, for detection of turbulence ahead of aircraft in flight, and for automated insitu reporting of atmospheric conditions from aircraft.

Stough, H. Paul, III↗

Aeromedical Lessons from the Space Shuttle Columbia Accident Investigation

This paper presents the aeromedical lessons learned from the Space Shuttle Columbia Accident Investigation. The contents include: 1) Introduction and Mission Response Team (MRT); 2) Primary Disaster Field Office (DFO); 3) Mishap Investigation Team (MIT); 4) Kennedy Space Center (KSC) Mishap Response Plan; 5) Armed Forces Institute of Pathology (AFIP); and 6) STS-107 Crew Surgeon.

Pool, Sam L.↗

Aircraft Loss-of-Control Accident Prevention: Switching Control of the GTM Aircraft with Elevator Jam Failures

Switching control, servomechanism, and H2 control theory are used to provide a practical and easy-to-implement solution for the actuator jam problem. A jammed actuator not only causes a reduction of control authority, but also creates a persistent disturbance with uncertain amplitude. The longitudinal dynamics model of the NASA GTM UAV is employed to demonstrate that a single fixed reconfigured controller design based on the proposed approach is capable of accommodating an elevator jam failure with arbitrary jam position as long as the thrust control has enough control authority. This paper is a first step towards solving a more comprehensive in-flight loss-of-control accident prevention problem that involves multiple actuator failures, structure damages, unanticipated faults, and nonlinear upset regime recovery, etc.

Chang, Bor-Chin↗

Aircraft Accident Prevention: Loss-of-Control Analysis

The majority of fatal aircraft accidents are associated with loss-of-control . Yet the notion of loss-of-control is not well-defined in terms suitable for rigorous control systems analysis. Loss-of-control is generally associated with flight outside of the normal flight envelope, with nonlinear influences, and with an inability of the pilot to control the aircraft. The two primary sources of nonlinearity are the intrinsic nonlinear dynamics of the aircraft and the state and control constraints within which the aircraft must operate. In this paper we examine how these nonlinearities affect the ability to control the aircraft and how they may contribute to loss-of-control. Examples are provided using NASA s Generic Transport Model.

Kwatny, Harry G.↗

Development of NASA's Accident Precursor Analysis Process Through Application on the Space Shuttle Orbiter

Accident Precursor Analysis (APA) serves as the bridge between existing risk modeling activities, which are often based on historical or generic failure statistics, and system anomalies, which provide crucial information about the failure mechanisms that are actually operative in the system. APA docs more than simply track experience: it systematically evaluates experience, looking for under-appreciated risks that may warrant changes to design or operational practice. This paper presents the pilot application of the NASA APA process to Space Shuttle Orbiter systems. In this effort, the working sessions conducted at Johnson Space Center (JSC) piloted the APA process developed by Information Systems Laboratories (ISL) over the last two years under the auspices of NASA's Office of Safety & Mission Assurance, with the assistance of the Safety & Mission Assurance (S&MA) Shuttle & Exploration Analysis Branch. This process is built around facilitated working sessions involving diverse system experts. One important aspect of this particular APA process is its focus on understanding the physical mechanism responsible for an operational anomaly, followed by evaluation of the risk significance of the observed anomaly as well as consideration of generalizations of the underlying mechanism to other contexts. Model completeness will probably always be an issue, but this process tries to leverage operating experience to the extent possible in order to address completeness issues before a catastrophe occurs.

Maggio, Gaspare↗

Cavity Heating Experiments Supporting Shuttle Columbia Accident Investigation

The two-color thermographic phosphor method has been used to map the local heating augmentation of scaled idealized cavities at conditions simulating the windward surface of the Shuttle Orbiter Columbia during flight STS-107. Two experiments initiated in support of the Columbia Accident Investigation were conducted in the Langley 20-Inch Mach 6 Tunnel. Generally, the first test series evaluated open (length-to-depth less than 10) rectangular cavity geometries proposed as possible damage scenarios resulting from foam and ice impact during launch at several discrete locations on the vehicle windward surface, though some closed (length-to-depth greater than 13) geometries were briefly examined. The second test series was designed to parametrically evaluate heating augmentation in closed rectangular cavities. The tests were conducted under laminar cavity entry conditions over a range of local boundary layer edge-flow parameters typical of re-entry. Cavity design parameters were developed using laminar computational predictions, while the experimental boundary layer state conditions were inferred from the heating measurements. An analysis of the aeroheating caused by cavities allowed exclusion of non-breeching damage from the possible loss scenarios being considered during the investigation.

Everhart, Joel L.↗

The Space Shuttle Columbia Accident Investigation and Reconstruction: Two Years Later

The Space Shuttle Columbia was lost during re-entry over two years ago. Since the release of the official materials-related findings in August of 2003, additional testing and analysis of select pieces of debris has continued. Microanalytical techniques, including EMPA, ESCA, and x-ray elemental dot mapping, were employed during the initial investigation; the results related the microstructural characteristics of deposit layers to the breach location in the leading edge of the left wing. Such characteristics included deposition order, composition, and distribution. Subsequent to the original efforts, new analytical data and information, not available at the time of the primary investigation, has been generated. This data was obtained via a low-vacuum SEM, fitted not only with a light-element EDS detector, but an XRF tube as well. Essentially, for elements up to sodium, classic EDS was utilized; above sodium, XRF was used. Predominantly, the elements of interest were aluminum, titanium, chromium, iron, nickel, and copper. The findings of both old and new data are compared, and their application to the overall accident investigation detailed.

McDanels, Steven J.↗

Microscopic and Metallurgical Aspects of the Space Shuttle Columbia Accident Investigation and Reconstruction

The Space Shuttle Columbia was descending for a landing at the Kennedy Space Center (KSC) on February 1, 2003. Approximately 20 minutes prior to touchdown, the Columbia began disintegrating over the western United States; the majority of debris eventually impacted in eastern Texas and western Louisiana. A monumental effort eventually recovered approximately 84,000 pieces of debris, approximately 38% of the Orbiter's original dry weight. The debris was transported to KSC, where the items were catalogued and evaluated. Critical areas of interest, such as the left and right leading edge surfaces and the underside of the ship, were placed upon a grid to aid in the reconstruction. Items of interest included metallic structures, reinforced carbon-carbon composites, and ceramic heat insulation tiles. Many of the leading edge elements had re-solidified metallic deposits spattered on them. These deposits became known as slag and were one of the main focuses of the investigation. In order to help determine the sequence of events inside the left wing during the accident, the slag's composition, layering order, and directionality of deposition were studied. A myriad of analytical tests were performed in an attempt to ascertain the compositional and depositional characteristics of selected slag deposits, including the ordering of deposited layers within each individual slag deposit harvested. Initially, Scanning Electron Microscopy and Energy Dispersive X-Ray Spectroscopy (SEM/EDX) were performed to quickly characterize the overall composition of individual slag deposits: SEM utilizes a narrowlyfocused high-energy electron beam impinging upon a specimen. The incident beam excites and liberates lower energy secondary electrons, which are detected and analyzed, providing a visual representation of the sample's surface topography. EDX also relies on an incident electron beam, except an EDX unit measures X-ray energies generated by the impinging beam. Each element generates a unique X-ray signature; the EDX detector measures these discreet energies. EDX actually penetrates approximately 2 microns into the bulk of the sample. However, random examination of various portions of slag, coupled with the semiquantitative nature of the SEM/EDX analysis, did not yield convincingly pertinent data. Therefore, X-ray dot mapping was conducted, which provided more understandable data, both in terms of slag layering and composition. An X-ray dot map is generated by performing numerous EDX scans for individual elements, then compiling the scans in a visual representation. Eventually, specimens consisting of not only the slag, but of the adjacent RCC substrate as well were cross-sectioned. X-Ray dot mapping of the materialographicallymounted and -polished cross- sections provided a visual representation of both the layering sequence and compositional characteristics of the slag. Contemporaneously, Electron Spectroscopy for Chemical Analysis/X-Ray Photoelectron Spectroscopy (ESCA/XPS) and powdered X-Ray Diffraction (XRD) were performed to further characterize the deposits and to attempt to identify what, if any, compounds were present. The ESCA/XPS analysis allowed the analyst to "sputter" into the sample with an electron gun, aiding in the identification of the layering sequence. XPS uses photons, rather than electrons, which impinge upon the surface of the sample. XPS measures the electrons emitted from within the first 5 nm of the sample's surface. The XRD measures the scatter angles of incident X-rays; the angle and intensity of scatter depend upon the crystalline structure of the pulverized sample. XRD is considered a qualitative rather than quantitative technique. ESCA/XPS revealed that the final layer to deposit was predominantly carbonaceous. XRD was successful in identifying specific compounds, such as Al 2O3, Al and/or Al3 21SiO47, mullite (3(Al2)O3 -SiO2), and nickel-aluminides. Eventually, Electron MicroProbe Analysis (EMPA) was conducted on the marialographically-prepared cross- sections of selected slag deposits. Microprobe combines SEM and Wavelength Dispersive X-Ray Spectroscopy (WDS), and, like EDX, uses a narrowly-focused high-energy electron beam impinging upon a specimen to elicit, in the case of EPMA, characteristic X-rays with specific wavelengths. This quantitative, analytical tool proved the most useful in determining depositional layering and composition of the slag deposits. This information was utilized in verifying the location of the breach in the left leading edge of the wing of the Columbia.

McDaniels, Steven J.↗

The Role of Materials Degradation and Analysis in the Space Shuttle Columbia Accident Investigation

The efforts following the loss of the Space Shuttle Columbia included debris recovery, reconstruction, and analysis. The debris was subjected to myriad quantitative and semiquantitative chemical analysis techniques, ranging from examination via the scanning electron microscope (SEM) with energy dispersive spectrometer (EDS) to X-Ray diffraction (XRD) and electron probe micro-analysis (EPMA). The results from the work with the debris helped the investigators determine the location where a breach likely occurred in the leading edge of the left wing during lift off of the Orbiter from the Kennedy Space Center. Likewise, the information evidenced by the debris was also crucial in ascertaining the path of impinging plasma flow once it had breached the wing. After the Columbia Accident Investigation Board (CAIB) issued its findings, the major portion of the investigation was concluded. However, additional work remained to be done on many pieces of debris from portions of the Orbiter which were not directly related to the initial impact during ascent. This subsequent work was not only performed in the laboratory, but was also performed with portable equipment, including examination via portable X-Ray fluorescence (XRF) and Fourier transform infrared spectroscopy (FTIR). Likewise, acetate and silicon-rubber replicas of various fracture surfaces were obtained for later macroscopic and fractographic examination. This paper will detail the efforts and findings from the initial investigation, as well as present results obtained by the later examination and analysis of debris from the Orbiter including its windows, bulkhead structures, and other components which had not been examined during the primary investigation.

McDanels, Steven J.↗

NASA-ONERA Collaboration on Human Factors in Aviation Accidents and Incidents

This is the first annual report jointly prepared by NASA and ONERA on the work performed under the agreement to collaborate on a study of the human factors entailed in aviation accidents and incidents, particularly focused on the consequences of decreases in human performance associated with fatigue. The objective of this agreement is to generate reliable, automated procedures that improve understanding of the levels and characteristics of flight-crew fatigue factors whose confluence will likely result in unacceptable crew performance. This study entails the analyses of numerical and textual data collected during operational flights. NASA and ONERA are collaborating on the development and assessment of automated capabilities for extracting operationally significant information from very large, diverse (textual and numerical) databases; much larger than can be handled practically by human experts.

Srivastava, Ashok N.↗

First Annual Report: NASA-ONERA Collaboration on Human Factors in Aviation Accidents and Incidents

This is the first annual report jointly prepared by NASA and ONERA on the work performed under the agreement to collaborate on a study of the human factors entailed in aviation accidents and incidents particularly focused on consequences of decreases in human performance associated with fatigue. The objective of this Agreement is to generate reliable, automated procedures that improve understanding of the levels and characteristics of flight-crew fatigue factors whose confluence will likely result in unacceptable crew performance. This study entails the analyses of numerical and textual data collected during operational flights. NASA and ONERA are collaborating on the development and assessment of automated capabilities for extracting operationally significant information from very large, diverse (textual and numerical) databases much larger than can be handled practically by human experts. This report presents the approach that is currently expected to be used in processing and analyzing the data for identifying decrements in aircraft performance and examining their relationships to decrements in crewmember performance due to fatigue. The decisions on the approach were based on samples of both the numerical and textual data that will be collected during the four studies planned under the Human Factors Monitoring Program (HFMP). Results of preliminary analyses of these sample data are presented in this report.

Srivastava, Ashok↗

Human Factors in Accidents Involving Remotely Piloted Aircraft

This presentation examines human factors that contribute to RPA mishaps and provides analysis of lessons learned. RPA accident data from U.S. military and government agencies were reviewed and analyzed to identify human factors issues. Common contributors to RPA mishaps fell into several major categories: cognitive factors (pilot workload), physiological factors (fatigue and stress), environmental factors (situational awareness), staffing factors (training and crew coordination), and design factors (human machine interface).

Merlin, Peter William↗

Accident Case Study of Organizational Silence Communication Breakdown: Shuttle Columbia, Mission STS-107

This report has been developed by the National Aeronautics and Space Administration (NASA) ESMD Risk and Knowledge Management team. This document provides a point-in-time, cumulative, summary of key lessons learned derived from the official Columbia Accident Investigation Board (CAIB). Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document. This report is accompanied by a video that will be sent at request

Lessons Learned↗