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This report is a revision of NACA-TR-357. It was prepared by the Committee on Aircraft Accidents. The purpose of this report is to provide a basis for the classification and comparison of aircraft accidents, both civil and military.
This paper analyzes a NASA Convair 990 (CV-990) accident with emphasis on rejected-takeoff (RTO) decision making, training, procedures, and accident statistics. The NASA Aircraft Accident Investigation Board was somewhat perplexed that an aircraft could be destroyed as a result of blown tires during the takeoff roll. To provide a better understanding of tire failure RTO's, The Board obtained accident reports, Federal Aviation Administration (FAA) studies, and other pertinent information related to the elements of this accident. This material enhanced the analysis process and convinced the Accident Board that high-speed RTO's in transport aircraft should be given more emphasis during pilot training. Pilots should be made aware of various RTO situations and statistics with emphasis on failed-tire RTO's. This background information could enhance the split-second decision-making process that is required prior to initiating an RTO.
Human crash studies, impact studies, acceleration stress, automobile and aircraft accidents, safety devices
In connection with the occurrence of aircraft accidents and the evolution of the air-travel system, questions arise regarding the computer's potential for making fundamental contributions to improving the safety and reliability of air travel. An important result of an analysis of the causes of aircraft accidents is the conclusion that humans - 'pilots and other personnel' - are implicated in well over half of the accidents which occur. Over 70 percent of the incident reports contain evidence of human error. In addition, almost 75 percent show evidence of an 'information-transfer' problem. Thus, the question arises whether improvements in air safety could be achieved by removing humans from control situations. In an attempt to answer this question, it is important to take into account also certain advantages which humans have in comparison to computers. Attention is given to human error and the effects of technology, the motivation to automate, aircraft automation at the crossroads, the evolution of cockpit automation, and pilot factors.
The burn and burn/explode effects on aircraft structures were examined in a series of fifteen outdoor tests conducted to verify the results obtained in previous burn and explode tests of carbon/graphite composite samples conducted in a closed chamber, and to simulate aircraft accident scenarios in which carbon/graphite fibers would be released. The primary effects that were to be investigaged in these tests were the amount and size distribution of the conductive fibers released from the composite structures, and how these various sizes of fibers transported downwind. The structures included plates, barrels, aircraft spoilers and a cockpit. The heat sources included a propane gas burner and 20 ft by 20 ft and 40 ft by 60 ft JP-5 pool fires. The larger pool fire was selected to simulate an aircraft accident incident. The passive instrumentation included sticky paper and sticky bridal veil over an area 6000 ft downwind and 3000 ft crosswind. The active instrumentation included instrumented meteorological towers, movies, infrared imaging cameras, LADAR, high voltage ball gages, light emitting diode gages, microwave gages and flame velocimeter.
The aviation community is faced with reducing the fatal aircraft accident rate by 80 percent within 10 years. This must be achieved even with ever increasing, traffic and a changing National Airspace System. This is not just an altruistic goal, but a real necessity, if our growing level of commerce is to continue. Honeywell Technology Center's topical study, "Weather Avoidance Using Route Optimization as a Decision Aid", addresses these pressing needs. The goal of this program is to use route optimization and user interface technologies to develop a prototype decision aid for dispatchers and pilots. This decision aid will suggest possible diversions through single or multiple weather hazards and present weather information with a human-centered design. At the conclusion of the program, we will have a laptop prototype decision aid that will be used to demonstrate concepts to industry for integration into commercialized products for dispatchers and/or pilots. With weather a factor in 30% of aircraft accidents, our program will prevent accidents by strategically avoiding weather hazards in flight. By supplying more relevant weather information in a human-centered format along with the tools to generate flight plans around weather, aircraft exposure to weather hazards can be reduced. Our program directly addresses the NASA's five year investment areas of Strategic Weather Information and Weather Operations (simulation/hazard characterization and crew/dispatch/ATChazard monitoring, display, and decision support) (NASA Aeronautics Safety Investment Strategy: Weather Investment Recommendations, April 15, 1997). This program is comprised of two phases, Phase I concluded December 31, 1998. This first phase defined weather data requirements, lateral routing algorithms, an conceptual displays for a user-centered design. Phase II runs from January 1999 through September 1999. The second phase integrates vertical routing into the lateral optimizer and combines the user interface into a prototype software testbed. Phase II concludes with a dispatcher and pilot evaluation of the route optimizer decision aid. This document describes work completed in Phase I in contract with NASA Langley August 1998 - December 1998. This report includes: (1) Discuss how weather hazards were identified in partnership with experts, and how weather hazards were prioritized; (2) Static representations of display layouts for integrated planning function (3) Cost function for the 2D route optimizer; (4) Discussion of the method for obtaining, access to raw data of, and the results of the flight deck user information requirements definition; (5) Itemized display format requirements identified for representing weather hazards in a route planning aid.
French research on impact and crash - human tolerance, aircraft accidents, ejection seats
The progressive introduction of modern, high performance aircraft, coupled with a significant increase in the complexity of the operational environment, has highlighted crew co-operation as a critical factor in aircraft safety. Investigation into recent MAC aircraft accidents supports the conclusion reached by NASA and other U.S. research institutions that a positive training program is required to improve resource management in the cockpit and prevent a breakdown under stress of the crew process. Past training and regulation has concentrated on the attainment of individual flying skills, but group skills have been neglected through lack of knowledge and understanding of the group process. This long-standing deficiency is now being addressed in the U.S. by the progressive and widespread introduction of theoretical and practical training programs to improve crew co-operation. The RAF should provide similar training for its aircrews through the adaptation and development of existing training resources. Better crew co-operation would not only reduce the number of RAF aircraft accidents but also improve the morale of the Service.
Faa impact research - aviation medicine, human tolerance, acceleration stress, aircraft accidents
Impact damage to internal organs - automobile and aircraft accidents
In-flight loss of control (LOC) is currently the leading cause of fatal accidents based on various commercial aircraft accident statistics. As the Next Generation Air Transportation System (NextGen) emerges, new contributing factors leading to LOC are anticipated. The NASA Aviation Safety Program (AvSP), along with other aviation agencies and communities are actively developing safety products to mitigate the LOC risk. This paper discusses the approach used to construct a generic integrated LOC accident framework (LOCAF) model based on a detailed review of LOC accidents over the past two decades. The LOCAF model is comprised of causal factors from the domain of human factors, aircraft system component failures, and atmospheric environment. The multiple interdependent causal factors are expressed in an Object-Oriented Bayesian belief network. In addition to predicting the likelihood of LOC accident occurrence, the system-level integrated LOCAF model is able to evaluate the impact of new safety technology products developed in AvSP. This provides valuable information to decision makers in strategizing NASA's aviation safety technology portfolio. The focus of this paper is on the analysis of human causal factors in the model, including the contributions from flight crew and maintenance workers. The Human Factors Analysis and Classification System (HFACS) taxonomy was used to develop human related causal factors. The preliminary results from the baseline LOCAF model are also presented.
Loss of control (LOC) remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft LOC accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. Research is underway at the National Aeronautics and Space Administration (NASA) in the development of advanced onboard system technologies for preventing or recovering from loss of vehicle control and for assuring safe operation under off-nominal conditions associated with aircraft LOC accidents. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V&V) and ultimate certification. The V&V of complex integrated systems poses highly significant technical challenges and is the subject of a parallel research effort at NASA. This chapter summarizes the V&V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft LOC accidents. A summary of recent research accomplishments in this effort is referenced.
Factors external to the aircraft are often a significant causal factor in loss of control (LOC) accidents. In today s aviation world, very few accidents stem from a single cause and typically have a number of causal factors that culminate in a LOC accident. Very often the "trigger" that initiates an accident sequence is an external environment factor. In a recent NASA statistical analysis of LOC accidents, aircraft icing was shown to be the most common external environmental LOC causal factor for scheduled operations. When investigating LOC accident or incidents aircraft icing causal factors can be categorized into groups of 1) in-flight encounter with super-cooled liquid water clouds, 2) take-off with ice contamination, or 3) in-flight encounter with high concentrations of ice crystals. As with other flight hazards, icing induced LOC accidents can be prevented through avoidance, detection, and recovery mitigations. For icing hazards, avoidance can take the form of avoiding flight into icing conditions or avoiding the hazard of icing by making the aircraft tolerant to icing conditions. Icing detection mitigations can take the form of detecting icing conditions or detecting early performance degradation caused by icing. Recovery from icing induced LOC requires flight crew or automated systems capable of accounting for reduced aircraft performance and degraded control authority during the recovery maneuvers. In this report we review the icing induced LOC accident mitigations defined in a recent LOC study and for each mitigation describe a research topic required to enable or strengthen the mitigation. Many of these research topics are already included in ongoing or planned NASA icing research activities or are being addressed by members of the icing research community. These research activities are described and the status of the ongoing or planned research to address the technology needs is discussed
The Emergency Local Transmitter (ELT) is a radio transmitter with a self-contained power source designed to provide notification of and homing to aircraft accident sites. The Crash Research Institute has monitored general aviation fixed-wing accidents in the United States and in Canada and has found that: (1) the ELT was destroyed in approximately 25% of all fatal accidents; (2) the ELT activated in about 62% of the fatal accidents, 69% of the fatal with survivors accidents, almost 80% of the serious accidents and about 57% of the minor accidents; (3) in fatal accidents the aircraft sections least likely to be destroyed are the vertical and horizontal tail surfaces; (4) antenna cable disconnection and antenna breakage caused failure to transmit usable signals; and (5) initial alerting control occurred in nearly half of the situations where the ELT aided in search.
Army impact studies - human tolerance, acceleration stress, aircraft accidents, aviation medicine
Crew decision making and response have long been leading causal and contributing factors associated with aircraft accidents. Further, it is anticipated that future aircraft and operational environments will increase exposure to risks related to these factors if proactive steps are not taken to account for ever-increasing complexity. A flight simulation study was designed to collect data to help in understanding how complexity can, or may, be manifest. More specifically, an experimental apparatus was constructed that allowed for manipulation of information complexity and uncertainty, while also manipulating operational complexity and uncertainty. Through these manipulations, and the aid of experienced airline pilots, several issues have been discovered, related most prominently to the influence of information content, quality, and management. Flight crews were immersed in an environment that included new operational complexities suggested for the future air transportation system as well as new technological complexities (e.g. electronic flight bags, expanded data link services, synthetic and enhanced vision systems, and interval management automation). In addition, a set of off-nominal situations were emulated. These included, for example, adverse weather conditions, traffic deviations, equipment failures, poor data quality, communication errors, and unexpected clearances, or changes to flight plans. Each situation was based on one or more reference events from past accidents or incidents, or on a similar case that had been used in previous developmental tests or studies. Over the course of the study, 10 twopilot airline crews participated, completing over 230 flights. Each flight consisted of an approach beginning at 10,000 ft. Based on the recorded data and pilot and research observations, preliminary results are presented regarding decision-making issues in the presence of the operational and technological complexities encountered during the flights.
A number of aircraft accidents are caused by the effects of wind shear. In connection with efforts to eliminate or reduce hazards leading to such accidents, the possibility was considered to improve aircraft control systems. However, the effective implementation of the considered approaches will only be possible if suitable filters can be designed for a separation of gusts, which involve higher frequencies from low-frequency wind shear components. Filters of appropriate design should be suited for an employment in connection with all flight conditions. Feasible approaches for obtaining such filters are discussed. A survey is provided regarding the order of magnitude of the improvements which can be achieved, taking into account the performance characteristics of the A300 controller.
In order to estimate the potential risks due to carbon fibers (CF) released from aircraft accidents, it was necessary to quantify the probability of an accident or incident at a major hub airport. This probability was contingent upon various conditions surrounding the incident including the phase of operation, aircraft type, and the weather conditions. The type of accident predicted was categorized according to its location relative to the runway and the severity of damage sustained. The methodology utilized to estimate the probability of a specific type of accident is outlined and the various models that were developed in the course of this work are described.