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Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

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At least 73 records · Page 4
All sourcesNASA NTRSDOE OSTI
NASA NTRS1967

Report of Apollo 204 Review Board

The Nation's space program requires that man and machine achieve the highest capability to pursue the exploration of space. The Apollo 204 Review Board was charged with the responsibility of reviewing the circumstances surrounding the accident, reporting its findings relating to the cause of the accident, and formulating recommendations so that inherent hazards are reduced to a minimum. The Board is very concerned that its description of the defects in the Apollo Program that led to the condition existing at the time of the Apollo 204 accident will be interpreted as an indictment of the entire manned space flight program and a castigation of the many people associated with that program. This report, rather than presenting a total picture of that program, is concerned with the deficiencies uncovered.

Source record↗
NASA NTRS2012

The Analysis of the Contribution of Human Factors to the In-Flight Loss of Control 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.

Ancel, Ersin↗
NASA NTRS2003

Columbia Accident Investigation Board. Volume One

The Columbia Accident Investigation Board's independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Board's 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecraft's debris. In the process, Columbia's tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident. This report concludes with recommendations, some of which are specifically identified and prefaced as 'before return to flight.' These recommendations are largely related to the physical cause of the accident, and include preventing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protection System. The remaining recommendations, for the most part, stem from the Board's findings on organizational cause factors. While they are not 'before return to flight' recommendations, they can be viewed as 'continuing to fly' recommendations, as they capture the Board's thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term. These recommendations reflect both the Board's strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board's conviction that operation of the Space Shuttle, and all human space-flight, is a developmental activity with high inherent risks.

SPACE SHUTTLE COLUMBIA↗
NASA NTRS1928

A dangerous seaplane landing condition

A peculiar phenomena in seaplane landing is observed and reported. The seaplane having executed a normal fast landing at low incidence, a forward movement of the control stick effected an unusual condition in that the seaplane left the water suddenly in an abnormal attitude. The observations describing this phenomena are offered as a warning against possible accident and as a conjectural cause of seaplane landing accidents of a certain kind.

PRESSURE DISTRIBUTION - FLOAT BOTTOMS↗
NASA NTRS2012

Software Programs Derive Measurements from Photographs

Even under the most unfortunate circumstances, NASA continues on a path of innovation. After the Space Shuttle Columbia reentered the atmosphere on February 1, 2003, it experienced a catastrophic failure, and the entire crew and vehicle were lost. For the two weeks prior to the accident, Columbia STS-107 was on a mission to perform physical, life, and space sciences research in the unique environment of microgravity. Following the accident, the remaining shuttles - Endeavor, Atlantis, and Discovery - were grounded, and an intense investigation ensued. The Columbia Accident Investigation Board spent nearly 7 months examining the cause of the accident and determining what would ensure a safe return to flight. To this end, investigators performed an extensive review down five analytic paths: aerodynamic, thermodynamic, sensor data timeline, debris reconstruction, and imaging. As part of the evaluation of all the available imagery from Columbia's ascent, orbit, and entry, investigators needed a new method for analyzing still video images to determine the size of the material that fell from Columbia, as well as the distance that the material traveled. John Lane, a scientist at Kennedy Space Center, devised a software program to calculate the unknown dimension of the material in the images, and soon after the investigation was complete, continued to enhance the technology. Eventually, the program that assisted in the Columbia investigation became available for licensing.

Source record↗
NASA NTRS1987

The classification of wind shears from the point of view of aerodynamics and flight mechanics

A study of international statistical data shows that in about three quarters of all serious accidents which occurred with jet propelled airliners wind shear was either one of the main causes of the accident or represented a major contributory cause. Wind shear related problems are examined. The necessity of a use of different concepts, definitions, and divisions is explained, and the concepts and definitions required for the division of wind and wind shear into different categories is discussed. A description of the context between meteorological and aerodynamics-flight mechanics concepts, definitions, and divisions is also provided. Attention is given to wind and wind components, general characteristics of wind shear and the meteorological terms, the basic types of wind shear for aerodynamics-flight mechanics investigations, special types of wind shear for aerodynamics-flight mechanics investigations, and possibilities regarding a change of the wind component.

Seidler, Fritz↗
NASA NTRS2007

Pressing the Approach: A NASA Study of 19 Recent Accidents Yields a New Perspective on Pilot Error

This article begins with a review of two sample airplane accidents that were caused by pilot error. The analysis of these and 17 other accidents suggested that almost all experienced pilot operating in the same environment in which the accident crews were operating and knowing only what the accident crews knew at each moment of the flight, would be vulnerable to making a similar decision and similar errors. Whether a particular crew in a given situation makes errors depends on somewhat random interaction of factors. Two themes that seem to be prevalent in these cases are: Plan Continuation Bias, and Snowballing Workload.

Berman, Benjamin A.↗
NASA NTRS2014

Preliminary Analysis of Aircraft Loss of Control Accidents: Worst Case Precursor Combinations and Temporal Sequencing

Aircraft loss of control (LOC) is a leading cause of fatal accidents across all transport airplane and operational classes, and can result from a wide spectrum of hazards, often occurring in combination. Technologies developed for LOC prevention and recovery must therefore be effective under a wide variety of conditions and uncertainties, including multiple hazards, and their validation must provide a means of assessing system effectiveness and coverage of these hazards. This requires the definition of a comprehensive set of LOC test scenarios based on accident and incident data as well as future risks. This paper defines a comprehensive set of accidents and incidents over a recent 15 year period, and presents preliminary analysis results to identify worst-case combinations of causal and contributing factors (i.e., accident precursors) and how they sequence in time. Such analyses can provide insight in developing effective solutions for LOC, and form the basis for developing test scenarios that can be used in evaluating them. Preliminary findings based on the results of this paper indicate that system failures or malfunctions, crew actions or inactions, vehicle impairment conditions, and vehicle upsets contributed the most to accidents and fatalities, followed by inclement weather or atmospheric disturbances and poor visibility. Follow-on research will include finalizing the analysis through a team consensus process, defining future risks, and developing a comprehensive set of test scenarios with correlation to the accidents, incidents, and future risks. Since enhanced engineering simulations are required for batch and piloted evaluations under realistic LOC precursor conditions, these test scenarios can also serve as a high-level requirement for defining the engineering simulation enhancements needed for generating them.

Belcastro, Christine M.↗
NASA NTRS2008

Influence Map Methodology for Evaluating Systemic Safety Issues

"Raising the bar" in safety performance is a critical challenge for many organizations, including Kennedy Space Center. Contributing-factor taxonomies organize information about the reasons accidents occur and therefore are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This project successfully addressed the following two problems: (1) methods and metrics to support the design of effective taxonomies are limited and (2) influence relationships among contributing factors are not explicitly modeled within a taxonomy.

Source record↗
NASA NTRS2012

Comparing the Identification of Recommendations by Different Accident Investigators Using a Common Methodology

Accident reports play a key role in the safety of complex systems. These reports present the recommendations that are intended to help avoid any recurrence of past failures. However, the value of these findings depends upon the causal analysis that helps to identify the reasons why an accident occurred. Various techniques have been developed to help investigators distinguish root causes from contributory factors and contextual information. This paper presents the results from a study into the individual differences that can arise when a group of investigators independently apply the same technique to identify the causes of an accident. This work is important if we are to increase the consistency and coherence of investigations following major accidents.

Johnson, Chris W.↗
NASA NTRS1972

Fatigue failure of metal components as a factor in civil aircraft accidents

A review of records maintained by the National Transportation Safety Board showed that 16,054 civil aviation accidents occurred in the United States during the 3-year period ending December 31, 1969. Material failure was an important factor in the cause of 942 of these accidents. Fatigue was identified as the mode of the material failures associated with the cause of 155 accidents and in many other accidents the records indicated that fatigue failures might have been involved. There were 27 fatal accidents and 157 fatalities in accidents in which fatigue failures of metal components were definitely identified. Fatigue failures associated with accidents occurred most frequently in landing-gear components, followed in order by powerplant, propeller, and structural components in fixed-wing aircraft and tail-rotor and main-rotor components in rotorcraft. In a study of 230 laboratory reports on failed components associated with the cause of accidents, fatigue was identified as the mode of failure in more than 60 percent of the failed components. The most frequently identified cause of fatigue, as well as most other types of material failures, was improper maintenance (including inadequate inspection). Fabrication defects, design deficiencies, defective material, and abnormal service damage also caused many fatigue failures. Four case histories of major accidents are included in the paper as illustrations of some of the factors invovled in fatigue failures of aircraft components.

Holshouser, W. L.↗
NASA NTRS2004

'Systemic Failures' and 'Human Error' in Canadian TSB Aviation Reports Between 1996 and 2002

This paper describes the results of an independent analysis of the primary and contributory causes of aviation accidents in Canada between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of these adverse events. Our results suggest that the majority of these high consequence accidents were attributed to human error. A large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗
NASA NTRS1921

Airplane crashes: engine troubles : a possible explanation

The aim was to bring attention to what might be the cause of some aircraft accidents for which there was no satisfactory explanation. The author notes that in testing aircraft accidents at the Bureau of Standards, it happened frequently that the engine performance became erratic when the temperature of the air entering the carburetor was between 0 C and 20 C. Investigation revealed the trouble to have been caused by the formation and collection of snow somewhere between the entrance to the carburetor and the manifold, probably at the throttle. Proof scarcely less convincing was obtained during engine tests. The results of such engine tests are described. Granting that the loss of power and the sudden increases in power were caused by the condensation of moisture from the air and the subsequent formation of snow, two solutions proved effective. The removal of the moisture or an increase in temperature cured the problem.

ENGINE TROUBLE↗
NASA NTRS2004

A Formal Methods Approach to the Analysis of Mode Confusion

The goal of the new NASA Aviation Safety Program (AvSP) is to reduce the civil aviation fatal accident rate by 80% in ten years and 90% in twenty years. This program is being driven by the accident data with a focus on the most recent history. Pilot error is the most commonly cited cause for fatal accidents (up to 70%) and obviously must be given major consideration in this program. While the greatest source of pilot error is the loss of situation awareness , mode confusion is increasingly becoming a major contributor as well. The January 30, 1995 issue of Aviation Week lists 184 incidents and accidents involving mode awareness including the Bangalore A320 crash 2/14/90, the Strasbourg A320 crash 1/20/92, the Mulhouse-Habsheim A320 crash 6/26/88, and the Toulouse A330 crash 6/30/94. These incidents and accidents reveal that pilots sometimes become confused about what the cockpit automation is doing. Consequently, human factors research is an obvious investment area. However, even a cursory look at the accident data reveals that the mode confusion problem is much deeper than just training deficiencies and a lack of human-oriented design. This is readily acknowledged by human factors experts. It seems that further progress in human factors must come through a deeper scrutiny of the internals of the automation. It is in this arena that formal methods can contribute. Formal methods refers to the use of techniques from logic and discrete mathematics in the specification, design, and verification of computer systems, both hardware and software. The fundamental goal of formal methods is to capture requirements, designs and implementations in a mathematically based model that can be analyzed in a rigorous manner. Research in formal methods is aimed at automating this analysis as much as possible. By capturing the internal behavior of a flight deck in a rigorous and detailed formal model, the dark corners of a design can be analyzed. This paper will explore how formal models and analyses can be used to help eliminate mode confusion from flight deck designs and at the same time increase our confidence in the safety of the implementation. The paper is based upon interim results from a new project involving NASA Langley and Rockwell Collins in applying formal methods to a realistic business jet Flight Guidance System (FGS).

Butler, Ricky W.↗
NASA NTRS1980

Decision-problem state analysis methodology

A methodology for analyzing a decision-problem state is presented. The methodology is based on the analysis of an incident in terms of the set of decision-problem conditions encountered. By decomposing the events that preceded an unwanted outcome, such as an accident, into the set of decision-problem conditions that were resolved, a more comprehensive understanding is possible. All human-error accidents are not caused by faulty decision-problem resolutions, but it appears to be one of the major areas of accidents cited in the literature. A three-phase methodology is presented which accommodates a wide spectrum of events. It allows for a systems content analysis of the available data to establish: (1) the resolutions made, (2) alternatives not considered, (3) resolutions missed, and (4) possible conditions not considered. The product is a map of the decision-problem conditions that were encountered as well as a projected, assumed set of conditions that should have been considered. The application of this methodology introduces a systematic approach to decomposing the events that transpired prior to the accident. The initial emphasis is on decision and problem resolution. The technique allows for a standardized method of accident into a scenario which may used for review or the development of a training simulation.

Dieterly, D. L.↗
NASA NTRS1986

Investigation of the Challenger Accident

The work of the Presidential Commission on the Space Shuttle Challenger Accident (hereafter referred to as the Rogers Commission) and the work of the National Aeronautics and Space Administration in investigating the causes of the accident were reviewed. In addition to reviewing the five volumes of the Rogers Commission, the entire direct on-line Rogers Commission data base, which included full-text and document retrieval capability was also reviewed. The findings and recommendations contained also include materials submitted for the record, staff investigations, interviews, and trips.

Source record↗
NASA NTRS2004

Understanding Columbia's Reentry Problems

Soon after the Space Shuttle Columbia accident occurred last year, a group of CFD analysts from NASA centers and private industry was organized to help determine the cause of the accident. This group was under the direction of the Applied Aeroscience and CFD Branch of the Aeroscience and Flight Mechanics Division at the Johnson Space Center. For external flow simulations, noncommercial CFD codes that specialize in hypersonic or high Mach number flows were used. These tools were used to determine heating rates, pressures, and temperatures for a large number of vehicle damage scenarios. Lockheed Martin Space Operations was called upon to provide CFD support in the area of internal flows within the shuttle wing cavity, and or these simulations, FLUENT 6.1 was chosen. Two large-scale, simplified models were run to understand the flow patterns once a breach of the internal wing cavity was initiated. The results were primarily used to visualize flow patterns within the wing cavity. The first CFD model included the entire left wing without the wheel. well cavity. The purpose of the first model, which did not include the reinforced carbon-carbon (RCC) cavity along the wing leading edge, was to visualize the flow field within the wing cavity immediately after the leading edge spar breach, This model assumed that the flow coming into the wing cavity was nom1 to the spar. It included all o f the primary vents that allow for flow between the main cavities of the wing. A six-inch diameter hole was modeled in the spar at the approximate location where the spar breach was judged to have occurred, which was between RCC panels 8 and 9. The results of the modeling showed that at this location, the high temperature, high velocity gas stream entering the wing cavity impinged on the outboard wheel well cavity. Instrumentation in the Shuttle wheel well cavity registered abnormal temperatures during reentry, so the FLUENT results helped support the conclusion of the accident investigation team that the spar breach was in the RCC panel 8-9 area, and that the initial spar breach was likely entering the wing cavity normal to the spar. This model also showed that the flow entering the wing cavity tended to swirl within the cavity just outboard of the wheel well, and did not initially penetrate further into the rear cavities of the wing. The second CFD model was a 2-D simulation of the left wing cavity and the RCC cavity. It was used to visualize the flow through the RCC breach, through the wing spar breach, and into the wing cavity directly outboard of the wheel well. The purpose of this model was to verify whether or not it was possible for the flow to come into the wing cavity normal to the leading edge spar. The results from this 2-D model showed that the internal structure behind the RCC panels probably deflected the flow entering the RCC cavity so that it impinged normal to the spar. As in the 3-D model, this deflected flow stream was found to impinge on the wheel well outer wall. This model again supported the conclusions regarding the location of the spar breach and how the flow behaved inside the wing cavity.

Paul, Thomas H.↗
NASA NTRS2006

Understanding Columbia's Reentry Problems

Soon after the Space Shuttle Columbia accident occurred last year, a group of CFD analysts from NASA centers and private industry was organized to help determine the cause of the accident. This group was under the direction of the Applied Aeroscience and CFD Branch of the Aeroscience and Flight Mechanics Division at the Johnson Space Center. For external flow simulations, noncommercia2 CFD codes that specialize in hypersonic or high Mach number flows were used. These tools were used to determine heating rates, pressures, and temperatures for a large number of vehicle damage scenarios. Lockheed Martin Space Operations was called upon to provide CFD support in the area of internal flows within the shuttle wing cavity, and for these simulations, FLUENT 6.1 was chosen. Two large-scale, simplified models were m to understand the flow patterns once a breach of the internal wing cavity was initiated. The results were primarily used to visualize flow patterns within the wing cavity. The first CFD model included the entire lee wing without the wheel well cavity. The purpose of the first model, which did not include the reinforced carbon-carbon (RCC) cavity along the wing leading edge, was to visualize the flow field within the wing cavity immediately after the leading edge spar breach, This model assumed that the flow coming into the wing cavity was normal to the spar. It included all of the primary vents that allow for flow between the main cavities of the wing. A six-inch diameter hole was modeled in the spar at the approximate location where the spar breach was judged to have occurred, which was between RCC panels 8 and 9. The results of the modeling showed that at this location, the high temperature, high velocity gas stream entering the wing cavity impinged on the outboard wheel well cavity. Instrumentation in the Shuttle wheel well cavity registered abnormal temperatures during reentry, so the FLUENT results helped support the conclusion of the accident investigation team that the spar breach was in the RCC panel 8-9 area, and that the initial spar breach was likely entering the wing cavity normal to the spar. This model also showed that the flow entering the wing cavity tended to swirl within the cavity just outboard of the wheel well, and did not initially penetrate further into the rear cavities of the wing. The second CFD model was a 2-D simulation of the left wing cavity and the RCC cavity. It was used to visualize the flow through the RCC breach, through the wing spar breach, and into the wing cavity directly outboard of the wheel well. The purpose of this model was to verify whether or not it was possible for the flow to come into the wing cavity normal to the leading edge spar. The results from this 2-D model showed that the internal structure behind the RCC panels probably deflected the flow entering the RCC cavity so that it impinged normal to the spar. As in the 3-D model, this deflected flow stream was Found to impinge on the wheel well outer wall. This model again supported the conclusions regarding the location of the spar breach and how the flow behaved inside the wing cavity.

Paul, Thomas↗