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At least 55 records · Page 3

The Role of Alerting System Failures in Loss of Control Accidents CAST SE-210 Output 2

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane's energy state or attitude and enters an upset condition. In a report by the Commercial Aviation Safety Team, an analysis of accidents and incidents related to loss of airplane state awareness determined that hazard alerting was not effective in producing the appropriate pilot response to a hazard (CAST, 2014). In the current report, we take a detailed look at 28 airplane state awareness accidents and incidents to determine how well the hazard alerting worked. We describe a five-step integrated alerting-to-recovery sequence that prescribes how hazard alerting should lead to effective flight crew actions for managing the hazard. Then, for each hazard in each of the 28 events, we determine if that sequence failed and, if so, how it failed. The results show that there was an alerting failure in every one of the 28 safety events, and that the most frequent failure (20/28) was tied to the flight crew not orienting to (not being aware of) the hazard. The discussion section summarizes findings and identifies alerting issues that are being addressed and issues that are not currently being addressed. We identify a few recent upgrades that have addressed certain alerting failures. Two of these upgrades address alerting design, but one response to the safety events is to upgrade training for approach to stall and stall recovery. We also describe issues that are not being addressed adequately: better alert integration for flight path management types of hazards, airplanes in the fleet that do not meet the current alerting regulations, a lack of innovation for addressing cases of channelized attention, and existing vulnerabilities in managing data validity.

aviation safety

Analytical redundancy and the design of robust failure detection systems

The Failure Detection and Identification (FDI) process is viewed as consisting of two stages: residual generation and decision making. It is argued that a robust FDI system can be achieved by designing a robust residual generation process. Analytical redundancy, the basis for residual generation, is characterized in terms of a parity space. Using the concept of parity relations, residuals can be generated in a number of ways and the design of a robust residual generation process can be formulated as a minimax optimization problem. An example is included to illustrate this design methodology. Previously announcedd in STAR as N83-20653

Chow, E. Y.

A system for early warning of bearing failure

System for detecting incipient failure in ball bearings is described. Ultrasonic equipment detects bearing system resonance and provides warning signal through electronic circuitry. Detector can be used to evaluate performance of newly installed bearings. Schematic diagram is provided to show components.

Broderick, J. J.

Empirically based analysis of failures in software systems

An empirical analysis of software-system failures is used to study several specific issues in software testing, reliability analysis, and reuse. Failure data from a large software manufacturer and a NASA production environment were collected and analyzed. The systems ranged in size from 30,000 to over 100,000 lines. The results show that (1) the first 15 percent of the test cases detected 67 percent of the high-severity failures and 50 percent of all failures; (2) multiple fault-detection and testing phases may result in a significant increase in reliability or none at all; (3) composite measures of system reliability did not adequately reflect reliability at the function or component level; (4) developers were biased toward portions of systems that would be heavily tested; (5) fault-proneness of reused or modified components was 74 percent less than that of newly developed components; and (6) systems with more reused software had lower component development effort, but not lower component fault-proneness.

Selby, Richard W.

Failure detection and identification for a reconfigurable flight control system

Failure detection and identification logic for a fault-tolerant longitudinal control system were investigated. Aircraft dynamics were based upon the cruise condition for a hypothetical transonic business jet transport configuration. The fault-tolerant control system consists of conventional control and estimation plus a new outer loop containing failure detection, identification, and reconfiguration (FDIR) logic. It is assumed that the additional logic has access to all measurements, as well as to the outputs of the control and estimation logic. The pilot may also command the FDIR logic to perform special tests.

Dallery, Francois

Automatic patient respiration failure detection system with wireless transmission

Automatic respiration failure detection system detects respiration failure in patients with a surgically implanted tracheostomy tube, and actuates an audible and/or visual alarm. The system incorporates a miniature radio transmitter so that the patient is unencumbered by wires yet can be monitored from a remote location.

Dimeff, J.

Starr - An expert system for failure diagnosis in a space based power system

Starr, a prototype expert system, is designed to monitor and model a space power system, recognize problem states, identify the failure, and recommend the proper action to be taken. The system was modeled on the autonomously managed power system (AMPS) breadboard at NASA-Marshall. An object-oriented approach was used for the Starr model.

Walls, Bryan

Matrix Failure Modes and Effects Analysis as a Knowledge Base for a Real Time Automated Diagnosis Expert System

Failure Modes and Effects Analysis contain a wealth of information that can be used to create the knowledge base required for building automated diagnostic Expert systems. A real time monitoring and diagnosis expert system based on an actual NASA project's matrix failure modes and effects analysis was developed. This Expert system Was developed at NASA Ames Research Center. This system was first used as a case study to monitor the Research Animal Holding Facility (RAHF), a Space Shuttle payload that is used to house and monitor animals in orbit so the effects of space flight and microgravity can be studied. The techniques developed for the RAHF monitoring and diagnosis Expert system are general enough to be used for monitoring and diagnosis of a variety of other systems that undergo a Matrix FMEA. This automated diagnosis system was successfully used on-line and validated on the Space Shuttle flight STS-58, mission SLS-2 in October 1993.

Herrin, Stephanie

Evaluation of Fuzzy Rulemaking for Expert Systems for Failure Detection

Computer aids in expert systems were proposed to diagnose failures in complex systems. It is shown that the fuzzy set theory of Zadeh offers a new perspective for modeling for humans thinking and language use. It is assumed that real expert human operators of aircraft, power plants and other systems do not think of their control tasks or failure diagnosis tasks in terms of control laws in differential equation form, but rather keep in mind a set of rules of thumb in fuzzy form. Fuzzy set experiments are described.

Laritz, F.

A solenoid failure detection system for cold gas attitude control jet valves

The development of a solenoid valve failure detection system is described. The technique requires the addition of a radioactive gas to the propellant of a cold gas jet attitude control system. Solenoid failure is detected with an avalanche radiation detector located in the jet nozzle which senses the radiation emitted by the leaking radioactive gas. Measurements of carbon monoxide leakage rates through a Mariner type solenoid valve are presented as a function of gas activity and detector configuration. A cylindrical avalanche detector with a factor of 40 improvement in leak sensitivity is proposed for flight systems because it allows the quantity of radioactive gas that must be added to the propellant to be reduced to a practical level.

Johnston, P. A.

Generating parity relations for detecting and identifying control system component failures

The monitoring of control system sensors and actuators for failures is presently undertaken by means of an exceptionally simple form of generalized parity relations based on a discrete-time model of the dynamics of linear, time-invariant systems. These generalized parity relations are constructed by recourse to a transfer matrix-description of the system that is additionally useful in the interpretation of their properties. Attention is given to a novel method for constructing the parity relation of minimum length that depends on the output of only a single sensor.

Vander Velder, Wallace E.