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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.↗

Directory of aerospace safety specialized information sources

Directory aids safety specialists in locating information sources and individual experts in engineering-related fields. Lists 170 organizations and approximately 300 individuals who can provide safety-related technical information in form of documentation, data, and consulting expertise. Information on hazard and failure cause identification, accident analysis, and materials characteristics are covered.

Fullerton, E. A.↗

Directory of aerospace safety specialized information sources

A directory is presented to make available to the aerospace safety community a handbook of organizations and experts in specific, well-defined areas of safety technology. It is designed for the safety specialist as an aid for locating both information sources and individual points of contact (experts) in engineering related fields. The file covers sources of data in aerospace design, tests, as well as information in hazard and failure cause identification, accident analysis, materials characteristics, and other related subject areas. These 171 organizations and their staff members, hopefully, should provide technical information in the form of documentation, data and consulting expertise. These will be sources that have assembled and collated their information, so that it will be useful in the solution of engineering problems. One of the goals of the project in the United States that have and are willing to share data of value to the aerospace safety community.

Fullerton, E. A.↗

Directory of aerospace safety specialized information sources, volume 2

A handbook of organizations and experts in specific and well-defined areas of safety technology is presented. It is designed for the safety specialist as an aid for locating both information sources and individual points of contact (experts) in engineering related fields. The file covers sources of data in aerospace design, tests, and operations, as well as information on hazard and failure cause identification, accident analysis, and materials characteristics. Other related areas include the handling and transportation of hazardous chemicals, radioactive isotopes, and liquified natural gases.

Rubinstein, R. I.↗

Wind shear detection using measurement of aircraft total energy change

Encounters with wind shears are of concern and have caused major accidents, particularly during landing approaches. Changes in the longitudinal component of the wind affect the aircraft by changing its kinetic energy with respect to the air. It is shown that an instrument which will measure and display the rate of change of total energy of the aircraft with respect to the air will give a leading indication of wind shear problems. The concept is outlined and some instrumentation and display considerations are discussed.

Joppa, R. G.↗

Wind shear and vortex wake research in UK, 1982

A wind shear and vortex wake and their impact on aircraft were investigated. The systems and advice to help pilots, and rational scientific methods to assist in advising certification authorities and those interested in improving flight safety were developed. Wind Shear and Vortex Wakes are related, they are both invisible enemies of aircraft in the form of large disturbances in the atmosphere, both cause major accidents. Problems of building wakes at airports are is considered. Research on wind shear was initiated by the American FAA following the Boston, New York and Denver accidents to civil airliners. This resulted in: useful advice to pilots about wind shear; better attempts by the meteorologists at forecasting wind shear conditions; and useful ideas for wind shear measurement and warning systems. Three major research tasks are outstanding: (1) Worldwide measurements to give reliable estimates of probability and details of the forms of large wind shears; (2) Developments of real time wind shear measuring systems for ground or airborne use; and (3) Establishing relationships between measured wind shear and the potential hazard to an aircraft, or class of aircraft.

Alan A. Woodfield↗

Fusion energy from the Moon for the twenty-first century

It is shown in this paper that the D-He-3 fusion fuel cycle is not only credible from a physics standpoint, but that its breakeven and ignition characteristics could be developed on roughly the same time schedule as the DT cycle. It was also shown that the extremely low fraction of power in neutrons, the lack of significant radioactivity in the reactants, and the potential for very high conversion efficiencies, can result in definite advantages for the D-He-3 cycle with respect to DT fusion and fission reactors in the twenty-first century. More specifically, the D-He-3 cycle can accomplish the following: (1) eliminate the need for deep geologic waste burial facilities and the wastes can qualify for Class A, near-surface land burial; (2) allow 'inherently safe' reactors to be built that, under the worst conceivable accident, cannot cause a civilian fatality or result in a significant (greater than 100 mrem) exposure to a member of the public; (3) reduce the radiation damage levels to a point where no scheduled replacement of reactor structural components is required, i.e., full reactor lifetimes (approximately 30 FPY) can be credibly claimed; (4) increase the reliability and availability of fusion reactors compared to DT systems because of the greatly reduced radioactivity, the low neutron damage, and the elimination of T breeding; and (5) greatly reduce the capital costs of fusion power plants (compared to DT systems) by as much as 50 percent and present the potential for a significant reduction on the COE. The concepts presented in this paper tie together two of the most ambitious high-technology endeavors of the twentieth century: the development of controlled thermonuclear fusion for civilian power applications and the utilization of outer space for the benefit of mankind on Earth.

Kulcinski, G. L.↗

Columbia Accident Investigation Board Report. Volume Four

This is Volume Four of a set of six reports produced by NASA and other organizations which were provided to the Columbia Accident Investigation Board (CAIB) in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia. The Technical Documents included in this volume are: Appendix F.1 Water Absorption by Foam; Appendix F.2 Follow the TPS; Appendix F.3 MADS Sensor Data; Appendix F.4 ET Cryoinsulation; Appendix F.5 Space Shuttle STS-107 Columbia Accident Investigation, and External Tank Working Group Final Report - Volume 1.

CRYOINSULATION↗

Characterization of Space Shuttle External Tank Thermal Protection System (TPS) Materials in Support of the Columbia Accident Investigation

NASA suffered the loss of the seven-member crew of the Space Shuttle Columbia on February 1, 2003 when the vehicle broke apart upon re-entry to the Earth's atmosphere. The final report of the Columbia Accident Investigation Board (CAIB) determined that the accident was caused by a launch ascent incident-a suitcase-sized chunk of insulating foam on the Shuttle's External Tank (ET) broke off, and moving at almost 500 mph, struck an area of the leading edge of the Shuttle s left wing. As a result, one or more of the protective Reinforced Carbon-Carbon (RCC) panels on the wing leading edge were damaged. Upon re-entry, superheated air approaching 3,000 F breached the wing damage and caused the vehicle breakup and loss of crew. The large chunk of insulating foam that broke off during the Columbia launch was determined to come from the so-called bipod ramp area where the Shuttle s orbiter (containing crew) is attached to the ET. Underneath the foam in the bipod ramp area is a layer of TPS that is a cork-filled silicone rubber composite. In March 2003, the NASA Marshall Space Flight Center (MSFC) in Huntsville, Alabama received cured samples of the foam and composite for testing from the Michoud Assembly Facility (MAF) in New Orleans, Louisiana. The MAF is where the Shuttle's ET is manufactured. The foam and composite TPS materials for the ET have been well characterized for mechanical property data at the super-cold temperatures of the liquid oxygen and hydrogen fuels used in the ET. However, modulus data on these materials is not as well characterized. The TA Instruments 2980 Dynamic Mechanical Analyzer (DMA) was used to determine the modulus of the two TPS materials over a range of -145 to 95 C in the dual cantilever bending mode. Multi-strain, fixed frequency DMA tests were followed by multi-frequency, fixed strain tests to determine the approximate bounds of linear viscoelastic behavior for the two materials. Additional information is included in the original extended abstract.

Wingard, Charles D.↗

Renewed Commitment to Excellence: An Assessment of the NASA Agency-Wide Applicability of the Columbia Accident Investigation Board Report

The Space Shuttle fleet has been grounded since the Columbia accident. As a result, 'Return to Flight' has become not just a phrase but a program and the global of virtually everyone associated with NASA. Even those who are not affiliated with the Shuttle Program are looking forward to the safe and successful completion of the next Shuttle mission. In this recovery process, NASA will be guided by the Report of the Columbia Accident Investigation Board (CAIB). The CAIB was an investigating body, convened by NASA Administrator O'Keefe the day of the Columbia accident, according to procedures established after the loss of Space Challenger.

SPACE SHUTTLE COLUMBIA↗

Air Safety Spinoffs

Weight saving-even a matter of a few pounds-is an important consideration in airplane design and . construction. Boeing saved 200 pounds simply by substituting a new type of compressed gas cylinder on their 747 commercial airliners. For quickly evacuating passengers in the event of a ground emergency the 747 escape chutes allow ' passengers to slide to safety from the two-story height of the cabin deck. The chutes pop out of exitways and are automatically inflated in seconds by compressed air stored in pressure vessels. Boeing's weight saving resulted from a recent changeover to a new type of pressure vessel built by Structural Composites Industries Inc. of Azusa, Cal. The company employs technology originally developed for rocket motor casings; the cylinders are constructed by winding fibers around an aluminum liner. This technique offers high strength for very low weight-in this case 60 percent less than the pressure vessels earlier used on the 747. Another contribution to improved air safety is an underwater locator device. Called the "Pinger," it uses sonar techniques to locate aircraft crashed in water-or, more specifically, to recover the flight recorder aboard the airplane. Its recovery provides clues as to what caused the accident and suggests measures to prevent similar future occurrences. Until recently, there was no way to recover flight recorders aboard aircraft lost in water crashes. The Pinger, now serving 95 percent of the airline industry, provides an answer. Key element of the Pinger system is a small, battery-powered transmitter, or homing beacon, included as part of the recorder package. For as long as 30 days, the transmitter sends out an acoustic signal from water depths up to 20,000 feet. The other element of the system is a receiver, used by search crews to home in on the transmitter's signal. Originating as a U.S. Navy project, this device was refined and further developed by NASA's Langley Research Center to retrieve submerged nose cones from research rockets. NASA's contractor for the transmitter portion of the system was Dukane Corp., St. Charles, Ill. who subsequently developed the commercial version.

Source record↗

Measuring Positions of Objects using Two or More Cameras

An improved method of computing positions of objects from digitized images acquired by two or more cameras (see figure) has been developed for use in tracking debris shed by a spacecraft during and shortly after launch. The method is also readily adaptable to such applications as (1) tracking moving and possibly interacting objects in other settings in order to determine causes of accidents and (2) measuring positions of stationary objects, as in surveying. Images acquired by cameras fixed to the ground and/or cameras mounted on tracking telescopes can be used in this method. In this method, processing of image data starts with creation of detailed computer- aided design (CAD) models of the objects to be tracked. By rotating, translating, resizing, and overlaying the models with digitized camera images, parameters that characterize the position and orientation of the camera can be determined. The final position error depends on how well the centroids of the objects in the images are measured; how accurately the centroids are interpolated for synchronization of cameras; and how effectively matches are made to determine rotation, scaling, and translation parameters. The method involves use of the perspective camera model (also denoted the point camera model), which is one of several mathematical models developed over the years to represent the relationships between external coordinates of objects and the coordinates of the objects as they appear on the image plane in a camera. The method also involves extensive use of the affine camera model, in which the distance from the camera to an object (or to a small feature on an object) is assumed to be much greater than the size of the object (or feature), resulting in a truly two-dimensional image. The affine camera model does not require advance knowledge of the positions and orientations of the cameras. This is because ultimately, positions and orientations of the cameras and of all objects are computed in a coordinate system attached to one object as defined in its CAD model.

Klinko, Steve↗

Lessons Learned From The EMU Fire and How It Impacts CxP Suit Element Development and Testing

During testing a Space Shuttle Extravehicular Mobility Unit (EMU) pressure garment and life-support backpack was destroyed in a flash fire in the Johnson Space Center's Crew systems laboratory. This slide presentation reviews the accident, probable causes, the lessons learned and the effect this has on the testing and the environment for testing of the Space Suit for the Constellation Program.

Metts, Jonathan↗

High Speed Mobility Through On-Demand Aviation

Game changing advances come about by the introduction of new technologies at a time when societal needs create the opportunity for new market solutions. A unique opportunity exists for NASA to bring about such a mobility revolution in General Aviation, extendable to other aviation markets, to maintain leadership in aviation by the United States. This report outlines the research carried out so far under NASA's leadership towards developing a new mobility choice, called Zip Aviation1,2,3. The feasibility, technology and system gaps that need to be addressed, and pathways for successful implementation have been investigated to guide future investment. The past decade indicates exciting trends in transportation technologies, which are quickly evolving. Automobiles are embracing automation to ease driver tasks as well as to completely control the vehicle with added safety (Figure 1). Electric propulsion is providing zero tail-pipe emission vehicles with dramatically lower energy and maintenance costs. These technologies have not yet been applied to aviation, yet offer compelling potential benefits across all aviation markets, and in particular to General Aviation (GA) as an early adopter market. The benefits of such an adoption are applicable in the following areas: 􀁸 Safety: The GA market experiences accident rates that are substantially higher than automobiles or commercial airlines, with 7.5 fatal accidents per 100 million vehicle miles compared to 1.3 for automobiles and.068 for airlines. Approximately 80% of these accidents are caused by some form of pilot error, with another 13% caused by single point propulsion system failure. 􀁸 Emissions: Environmental constraints are pushing for the elimination of 100Low Lead (LL) fuel used in most GA aircraft, with aviation fuel the #1 source of lead emissions into the environment. Aircraft also have no emission control systems (i.e. no catalytic converters etc.), so they are gross hydrocarbon polluters compared to automobiles. 􀁸 Community Noise: Hub and smaller GA airports are facing increasing noise restrictions, and while commercial airliners have dramatically decreased their community noise footprint over the past 30 years, GA aircraft noise has essentially remained same, and moreover, is located in closer proximity to neighborhoods and businesses. 􀁸 Operating Costs: GA operating costs have risen dramatically due to average fuel costs of over $6 per gallon, which has constrained the market over the past decade and resulted in more than 50% lower sales and 35% less yearly operations. Infusion of autonomy and electric propulsion technologies can accomplish not only a transformation of the GA market, but also provide a technology enablement bridge for both larger aircraft and the emerging civil Unmanned Aerial Systems (UAS) markets. The NASA Advanced General Aviation Transport Experiments (AGATE) project successfully used a similar approach to enable the introduction of primary composite structures and flat panel displays in the 1990s, establishing both the technology and certification standardization to permit quick adoption through partnerships with industry, academia, and the Federal Aviation Administration (FAA). Regional and airliner markets are experiencing constant pressure to achieve decreasing levels of community emissions and noise, while lowering operating costs and improving safety. But to what degree can these new technology frontiers impact aircraft safety, the environment, operations, cost, and performance? Are the benefits transformational enough to fundamentally alter aircraft competiveness and productivity to permit much greater aviation use for high speed and On-Demand Mobility (ODM)? These questions were asked in a Zip aviation system study named after the Zip Car, an emerging car-sharing business model. Zip Aviation investigates the potential to enable new emergent markets for aviation that offer "more flexibility than the existing transportation solutions." These studies indicate that autonomy and electric propulsion technology infusions offer a unique opportunity to provide breakthrough capabilities for new high speed, on-demand travel alternatives that can leapfrog the need for future expensive ground-based infrastructure investment. At the same time, such investments offer a method of laying the foundation for these technologies to be incubated for commercial aviation at lower cost, and with lower initial certification thresholds due to the relatively poor capabilities of GA aircraft to permit early adoption and private market capitalization by rapid technology accelerations, as depicted in Figure 2.

Moore, Mark D.↗

Space Biology and Medicine: Space and Its Exploration - Volume I

Perhaps one of the greatest gifts that has been given to the people of the world in the last few hundred years has been an emerging sense of the place of our planet and its inhabitants within the context of the vast universe. Our knowledge of the rest of the universe has not come quickly, nor was the process of attaining it only recently begun; however, the unprecedented acceleration of that process has benefitted from a fundamental new aspect of our species that has only manifested itself in the last 30 years or so, the ability to travel in space. Before the space age, the Universe was studied only through observations from the Earth. All that has changed with the beginning of the space age. Machines built by humans have flown to all but one of the nine planets that revolve around our Sun, have ventured billions of miles from the Earth and looked back, and have landed on three other worlds. Spacecraft in orbit around the Earth have viewed the sky at a vast number of electromagnetic wavelengths, detecting the shape of the galaxy and the universe, and even measuring the remnants of the universe's beginning. Human explorers have ventured forth, first for short stays in orbit, then, later, walking upon the Moon and living for long periods in space. As they did so, billions of people on the Earth came to view the Earth in a fundamentally different way, not just as the familiar day to- day backdrop for their lives, but as a small oasis suspended in the night sky above an alien landscape. It is this new view of the Earth that is the true gift of space exploration. Space exploration has at once given us a new perspective on the value of our world, and a new perspective from which to understand how it operates. It has shown us that the Earth is by far the most precious place in the solar system in terms of supporting human life, while revealing that other destinations may still be compelling. The exploration of space has at once become a challenge for humanity to overcome and a path to our common future. But for humanity to embark on this path, we need to understand ourselves in a new environment. As such, an understanding of the biological consequences of and opportunities in space flight is essential. In this, the first volume of a joint U.S./Russian series on space biology and medicine, we describe the current status of our understanding of space and present general information that will prove useful when reading subsequent volumes. Since we are witnesses to the beginning of a new era of interplanetary travel, a significant portion of the first volume will concentrate on the physical and ecological conditions that exist in near and outer space, as well as heavenly bodies from the smallest ones to the giant planets and stars. While space exploration is a comparatively recent endeavor, its foundations were laid much more than 30 years ago, and its history has been an eventful one. In the first part of this volume, Rauschenbach, Sokolskiy, and Gurjian address the "Historical Aspects of Space Exploration" from its beginnings to a present-day view of the events of the space age. The nature of space itself and its features is the focus of the second section of the volume. In the first chapter of the part, "Stars and Interstellar Space," the origin and evolution of stars, and the nature of the portions of space most distant from Earth are described by Galeev and Marochnik. In Chapter 2, Pisarenko, Logachev, and Kurt in "The Sun and Interplanetary Space" bring us to the vicinity of our own solar system and provide a description and discussion of the nearest star and its influence on the space environment that our Earth and the other planets inhabit. In our solar system there are many fascinating objects, remnants of the formation of a rather ordinary star in a rather obscure portion of the galaxy. Historical accident has caused us to be much more curious (and knowledgeable) about "The Inner Planets of the Solar System" than about any of these other objects. In Chapter 3, Marov describes the planets Mercury, Venus, Earth, and Mars, their history and origin, and their environmental conditions, and in Chapter 4 Owen provides similar information about Jupiter, Saturn, Uranus, Neptune, and Pluto, "The Outer Planets of the Solar System." Morrison provides a thorough discussion of "Asteroids, Comets, and Other Small Bodies" in Chapter 5. The understanding of these relics of the formation of the solar system may form the center of our ability to understand the origin of solar systems in general, and of the critical role that the beginning of the solar system had on the prospects for the origin of life and its continued survival and evolution in the face of their recurrent impacts on Earth. In Chapter 6, the first chapter of the third part, Rummel describes the area of "Exobiology," the study of the origin, evolution, and distribution of life in the context of the origin and evolution of the universe. The same processes that have given rise to life on Earth may have given rise to life elsewhere. In Chapter 7, the "Earth and the Biosphere," the nature and function of the Earth are discussed as a specific instance of planetary and biological evolution. The effects of biological processes on the Earth under the influence of human activities are also addressed by Moore and Bartlett in Chapter 7. The final chapter in this section concerns the prospects that life in the universe may be widespread; "SETI," the Search for Extraterrestrial Intelligence, by Billingham and Tarter, presents the arguments for conducting a search for evidence of life elsewhere in the galaxy, and describes the various methods proposed for conducting such a search. While SETI has a distinctly exploration al character, more direct means are available for exploring the solar system around us. The fourth part of the volume addresses this subject of space exploration. Considering the prospects for research on space biology and medicine, the means of providing "Access to Space" are described by Feoktistov and Briggs in Chapter 9. This chapter addresses carriers and launch systems, the unmanned and manned spacecraft that they loft into space, and the task of mission operations by which these precious vessels are monitored, navigated, and controlled. Despite the successes of the past and the capabilities of the present, it is clear that the study of space biology and medicine will be even more rewarding in the future than it has been to date. The work of the next few years that will be undertaken by the U.S. and Russia, both independently and jointly, will focus first on enabling greater capabilities in the exploration of space, and then on using the unique characteristics of the space environment to provide insight and greater understanding into biological systems, their behavior, development, and origin. The chapters of the first volume were written by leaders in their fields from the U.S. and Russia. The material presented summarizes our current understanding of space and its exploration. We understand that the first volume will be of interest not only to medical personnel and biologists, but also to general readers who want information about space beyond their own particular fields of expertise.

Nicogossian, Arnauld E.↗

Piloted Simulator Evaluation Results of Flight Physics Based Stall Recovery Guidance

In recent studies, it has been observed that loss of control in flight is the most frequent primary cause of accidents. A significant share of accidents in this category can be remedied by upset prevention if possible, and by upset recovery if necessary, in this order of priorities. One of the most important upsets to be recovered from is stall. Recent accidents have shown that a correct stall recovery maneuver remains a big challenge in civil aviation, partly due to a lack of pilot training. A possible strategy to support the flight crew in this demanding context is calculating a recovery guidance signal, and showing this signal in an intuitive way on one of the cockpit displays, for example by means of the flight director. Different methods for calculating the recovery signal, one based on fast model predictive control and another using an energy based approach, have been evaluated in four relevant operational scenarios by experienced commercial as well as test pilots in the Vertical Motion Simulator at NASA Ames Research Center. Evaluation results show that this approach could be able to assist the pilots in executing a correct stall recovery maneuver.

Lombaerts, Thomas↗

Creating Formal Characterizations of Routine Contingency Management in Commercial Aviation

The identification, modelling, and analysis of root causes of accidents and incidents dominate conventional safety management approaches. However, the effect of humans’ safety-producing behavior on the overall resilience of the system is often neglected. Additionally, emerging aviation markets are giving rise to concepts of operation, such as urban air mobility and optionally piloted air cargo operations, that are leading to a shift in locus of control between humans and automation. Without an understanding of the human contribution to safety, it is difficult to assess the effects of these novel role allocations on overall system safety. In this work, safety-producing behaviors are identified and abstracted into resilient performance strategies. Production rules that encapsulate these strategies are then generated and classified in the Soar cognitive architecture. The strategies are then applied to a remotely-operated air cargo example to demonstrate how safe learning is facilitated. The learned rules and strategies are then formally verified.

Safety Critical Systems↗

How Humans Contribute to Safety

We have all heard, and much too often, how human error is the leading cause of accidents. What we haven’t been hearing is how humans produce safety far more often than reduce safety. Before we embark on developing technologies to replace the error-prone human, it behooves us to understand how humans produce safety lest we lose that primary source of resilience in our aviation system.

safety↗