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NASA NTRS1996

Evaluating Fatigue in Operational Settings: The NASA Ames Fatigue Countermeasures Program

In response to a 1980 Congressional request, NASA Ames initiated a program to examine fatigue in flight operations. The Program objectives are to examine fatigue, sleep loss, and circadian disruption in flight operations, determine the effects of these factors on flight crew performance, and the development of fatigue countermeasures. The NASA Ames Fatigue Countermeasures Program conducts controlled laboratory experiments, full-mission flight simulations, and field studies. A range of subjective, behavioral, performance, physiological, and environmental measures are used depending on study objectives. The Program has developed substantial expertise in gathering data during actual flight operations and in other work settings. This has required the development of ambulatory and other measures that can be carried throughout the world and used at 41,000 feet in aircraft cockpits. The NASA Ames Fatigue Countermeasures Program has examined fatigue in shorthaul, longhaul, overnight cargo, and helicopter operations. A recent study of planned cockpit rest periods demonstrated the effectiveness of a brief inflight nap to improve pilot performance and alertness. This study involved inflight reaction time/vigilance performance testing and EEG/EOG measures of physiological alertness. The NASA Ames Fatigue Countermeasures Program has applied scientific findings to the development of education and training materials on fatigue countermeasures, input to federal regulatory activities on pilot flight, duty, and rest requirements, and support of National Transportation Safety Board accident investigations. Current activities are examining fatigue in nonaugmented longhaul flights, regional/commuter flight operations, corporate/business aviation, and psychophysiological variables related to performance.

Rosekind, Mark R.↗

NASA NTRS1998

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Orasanu, Judith↗

NASA NTRS1998

U.S. Civil Rotorcraft Accidents, 1963 through 1997

The U.S. National Transportation Safety Board (NTSB) has recorded 8,436 rotorcraft accidents during the period mid - 1963 through the end of 1997. Review and analysis of the NTSB summary narrative for each accident has been completed. In addition, FAA (Federal Aviation Administration) counts of the growing registered rotorcraft fleet over this period has obtained. Taken together, a large and informative data base is now available, which indicates that the accident rate (on a per airframe basis) has changed very little since the mid 1970s. The data base, even in the summary form provided by this paper, offers suggestions for safer designs and improved flight operations. For analysis purposes, each accident has been placed in one of 21 top level categories as defined by the NTSB. Analysis of this grouping shows that 70 percent of rotorcraft accidents are associated with four categories. The accident count in these top four categories are: (1) 2,408 Loss of engine power (2) 1,322 In flight collision with object (3) 1,114 Loss of control (4) 1,083 Airframe/component/system failure or malfunction. Single engine rotorcraft dominate these accident statistics because of their sheer numbers over the study period. One-third of the loss of engine power accidents with these aircraft is fuel/air mixture related and fuel exhaustion is a common event. This appears to be the case whether a piston or turbine engine is installed. This paper provides similar study results in the other major mishap categories. It shows that both minor and major design and flight operations changes can -- and should -- be made to reduce rotorcraft accidents in the future. The paper outlines these changes and suggests how they may be made.

Harris, Franklin D.↗

NASA NTRS2002

Crew Factors in Flight Operations XIV: Alertness Management in Regional Flight Operations Education Module

Regional operations encompass a broad range of pilots and equipment. This module is intended to help all those involved in regional aviation, including pilots, schedulers, dispatchers, maintenance technicians, policy makers, and others, to understand the physiological factors underlying fatigue, how flight operations affect fatigue, and what can be done to counteract fatigue and maximize alertness and performance in their operations. The overall purpose of this module is to promote aviation safety, performance, and productivity. It is intended to meet three specific objectives: (1) to explain the current state of knowledge about the physiological mechanisms underlying fatigue; (2) to demonstrate how this knowledge can be applied to improving flight crew sleep, performance, and alertness; and (3) to offer strategies for alertness management. Aviation Safety Reporting System (ASRS) and National Transportation Safety Board (NISH) reports are used throughout this module to demonstrate that fatigue is a safety issue in the regional operations community. The appendices at the end of this module include the ASRS reports used for the examples contained in this publication, brief introductions to sleep disorders and relaxation techniques, summaries of relevant NASA publications, and a list of general readings on sleep, sleep disorders, and circadian rhythms.

Rosekind, Mark R.↗

NASA NTRS2002

Crew Factors in Flight Operations XV: Alertness Management in General Aviation Education Module

Rosekind, Mark R.↗

NASA NTRS2002

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↗

NASA NTRS2005

Fractographic Examination of the Vertical Stabilizer and Rudder from American Airlines Flight 587

The first major structural component failure of a composite part on a commercial airplane occurred during the crash of American Airlines Flight 587. The fractured composite lugs that attached the vertical stabilizer to the aircraft tail and the fractured composite honeycomb rudder were examined as part of the National Transportation Safety Board investigation of the accident. In this paper the composite fractures are described and the resulting clues to the failure events are discussed.

Fox, Matthew R.↗

NASA NTRS2005

NASA Structural Analysis Report on the American Airlines Flight 587 Accident - Local Analysis of the Right Rear Lug

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. From the analyses conducted and presented in this paper, the following conclusions were drawn. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985-certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003- subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs. I.

Raju, Ivatury S↗

NASA NTRS2005

Structural Analysis for the American Airlines Flight 587 Accident Investigation: Global Analysis

NASA Langley Research Center (LaRC) supported the National Transportation Safety Board (NTSB) in the American Airlines Flight 587 accident investigation due to LaRC's expertise in high-fidelity structural analysis and testing of composite structures and materials. A Global Analysis Team from LaRC reviewed the manufacturer s design and certification procedures, developed finite element models and conducted structural analyses, and participated jointly with the NTSB and Airbus in subcomponent tests conducted at Airbus in Hamburg, Germany. The Global Analysis Team identified no significant or obvious deficiencies in the Airbus certification and design methods. Analysis results from the LaRC team indicated that the most-likely failure scenario was failure initiation at the right rear main attachment fitting (lug), followed by an unstable progression of failure of all fin-to-fuselage attachments and separation of the VTP from the aircraft. Additionally, analysis results indicated that failure initiates at the final observed maximum fin loading condition in the accident, when the VTP was subjected to loads that were at minimum 1.92 times the design limit load condition for certification. For certification, the VTP is only required to support loads of 1.5 times design limit load without catastrophic failure. The maximum loading during the accident was shown to significantly exceed the certification requirement. Thus, the structure appeared to perform in a manner consistent with its design and certification, and failure is attributed to VTP loads greater than expected.

Young, Richard D.↗

NASA NTRS2005

Materials Examination of the Vertical Stabilizer from American Airlines Flight 587

The first in-flight failure of a primary structural component made from composite material on a commercial airplane led to the crash of American Airlines Flight 587. As part of the National Transportation Safety Board investigation of the accident, the composite materials of the vertical stabilizer were tested, microstructure was analyzed, and fractured composite lugs that attached the vertical stabilizer to the aircraft tail were examined. In this paper the materials testing and analysis is presented, composite fractures are described, and the resulting clues to the failure events are discussed.

Fox, Matthew R.↗

NASA NTRS2006

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↗

NASA NTRS1998

Evaluation of Cabin Crew Technical Knowledge

Accident and incident reports have indicated that flight attendants have numerous opportunities to provide the flight-deck crew with operational information that may prevent or essen the severity of a potential problem. Additionally, as carrier fleets transition from three person to two person flight-deck crews, the reliance upon the cabin crew for the transfer of this information may increase further. Recent research (Chute & Wiener, 1996) indicates that light attendants do not feel confident in their ability to describe mechanical parts or malfunctions of the aircraft, and the lack of flight attendant technical training has been referenced in a number of recent reports (National Transportation Safety Board, 1992; Transportation Safety Board of Canada, 1995; Chute & Wiener, 1996). The present study explored both flight attendant technical knowledge and flight attendant and dot expectations of flight attendant technical knowledge. To assess the technical knowledge if cabin crewmembers, 177 current flight attendants from two U.S. carriers voluntarily :ompleted a 13-item technical quiz. To investigate expectations of flight attendant technical knowledge, 181 pilots and a second sample of 96 flight attendants, from the same two airlines, completed surveys designed to capture each group's expectations of operational knowledge required of flight attendants. Analyses revealed several discrepancies between the present level of flight attendants.

Dunbar, Melisa G.↗

NASA NTRS2005

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↗

NASA NTRS2007

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Johnson, C. W.↗

NASA NTRS2001

Runway Incursion Prevention: A Technology Solution

A runway incursion occurs any time an airplane, vehicle, person or object on the ground creates a collision hazard with an airplane that is taking off or landing at an airport under the supervision of Air Traffic Control (ATC). Despite the best efforts of the Federal Aviation Administration (FAA), runway incursions continue to occur more frequently. The number of incursions reported in the U.S. rose from 186 in 1993 to 431 in 2000, an increase of 132 percent. Recently, the National Transportation Safety Board (NTSB) has made specific recommendations for reducing runway incursions including a recommendation that the FAA require, at all airports with scheduled passenger service, a ground movement safety system that will prevent runway incursions; the system should provide a direct warning capability to flight crews. To this end, NASA and its industry partners have developed an advanced surface movement guidance and control system (A-SMGCS) architecture and operational concept that are designed to prevent runway incursions while also improving operational capability. This operational concept and system design have been tested in both full-mission simulation and operational flight test experiments at major airport facilities. Anecdotal, qualitative, and specific quantitative results will be presented along with an assessment of technology readiness with respect to equipage.

Young, Steven D.↗

NASA NTRS2006

Structural Analysis of the Right Rear Lug of American Airlines Flight 587

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985- certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003-subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs.

Raju, Ivatury S.↗

NASA NTRS2005

Introduction and Mission Response Team (MRT)

On February 1, 2003 the Space Shuttle Columbia, returning to Earth with a crew of seven astronauts, disintegrated along a track extending from California to Louisiana. Observers on the ground filmed breakup of the spacecraft. Debris fell along a 567 statute mile track from Littlefield, Texas to Fort Polk, Louisiana; the largest ever recorded debris field. At the time of the accident the National Aeronautics and Space Administration (NASA) flight surgeon on-duty at the Mission Control Center (MCC) in Houston, Texas initiated the medical contingency response. The DOD surgeon at Patrick Air Force Base was notified, NASA medical personnel were recalled and the services of Armed Forces Institute of Pathology (AFIP) were requested. Subsequent to the accident the NASA flight surgeons that had supported the crew on orbit now provided medical support to the crewmember s families. Federal Emergency Management Agency (FEMA), the National Transportation Safety Board (NTSB), the Federal Bureau of Investigation (FBI) and numerous other federal, state and local agencies along with the citizens of Texas and Louisiana responded to the disaster. Search and recovery was managed from a Disaster Field Office (DFO) established in Lufkin, Texas. Mishap Investigation Team (MIT) medical operations were managed from Barksdale Air Force Base, Louisiana. Accident investigation teams (Columbia Accident Investigation Task Force (CAITF) and Columbia Accident Investigation Board (CAIB)) appointed immediately after the disaster included current and former authorities in space medicine. In August 2003, the CAIB concluded its investigation and released its findings in a report published in February 2004.

Pool, Sam↗

NASA NTRS2010

Causal Factors and Adverse Conditions of Aviation Accidents and Incidents Related to Integrated Resilient Aircraft Control

The causal factors of accidents from the National Transportation Safety Board (NTSB) database and incidents from the Federal Aviation Administration (FAA) database associated with loss of control (LOC) were examined for four types of operations (i.e., Federal Aviation Regulation Part 121, Part 135 Scheduled, Part 135 Nonscheduled, and Part 91) for the years 1988 to 2004. In-flight LOC is a serious aviation problem. Well over half of the LOC accidents included at least one fatality (80 percent in Part 121), and roughly half of all aviation fatalities in the studied time period occurred in conjunction with LOC. An adverse events table was updated to provide focus to the technology validation strategy of the Integrated Resilient Aircraft Control (IRAC) Project. The table contains three types of adverse conditions: failure, damage, and upset. Thirteen different adverse condition subtypes were gleaned from the Aviation Safety Reporting System (ASRS), the FAA Accident and Incident database, and the NTSB database. The severity and frequency of the damage conditions, initial test conditions, and milestones references are also provided.

Reveley, Mary S.↗