Search NASA⌕ Search

SEARCH · Search NASA

Results for “mishaps”

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.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 73 records · Page 4
All sourcesNASA NTRSDOE OSTI
NASA NTRS2017

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

human error↗
NASA NTRS2017

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

mishaps↗
NASA NTRS2018

Results of a Manned Over Pressurization Event in the Extravehicular Mobility Unit Space Suit Assembly

The Neutral Buoyancy Laboratory (NBL) is a 102 x 202 x 40-foot-deep tank holding over 6 million gallons of water used to simulate weightlessness for Astronaut training. The maxim "Train Like You Fly" refers to the desire to have the suit perform, during training, as close as possible to how it performs during an Extra-Vehicular Activity (EVA), particularly with respect to mobility. Therefore, the Space Suit Assembly (SSA) used in the NBL is a downgraded hardware version of the flight SSA; it is not designed for the NBL environment or operations. A classification system defines the flight Space Suit Assembly hardware as Class I, and the NBL training hardware SSA as Class IIIW. On July 20, 2017, during a manned training event in the NBL, the SSA was inadvertently over-pressurized to 22 psid; normal operating pressure being 4.3 psid. The suit subject was removed from the suit with no injury. The event was investigated by a NASA Mishap Team. The Team investigated common causes and differences between the Class I and Class IIIW Extra-vehicular Mobility Unit (EMU). The investigation determined that the event was limited to Class IIIW hardware and its external flow-controlled open loop ventilation systems. The flight EMU is a pressure regulated closed loop ventilation system. This paper will examine the differences between the Class I and Class IIIW SSA hardware and provide details of the Mishap Investigation. Corrective actions taken to mitigate risk with hardware, operations, and hazard documentation will be discussed.

Spacesuit↗
NASA NTRS1972

Manned Space Programs Accident/Incident Summaries (1970 - 1971)

A compilation of 223 mishaps assembled from company and NASA records covering the Accident/Incident experience in 1970-1971 in the Manned Space Flight Programs is presented. It is the companion volume to NASA-CR-120998 which covered the years 1963-1969. The objectives of this summary is to make available to Government agencies and industrial firms the lessons learned from these mishaps. Each accident/incident summary has been reviewed by description, cause and recommended preventive action. The summaries have been categorized by the following ten systems: (1) Cryogenic; (2) Electrical; (3) Facility/GSE; (4) Fuel and Propellant; (5) Life Support; (6) Ordnance; (7) Pressure; (8) Propulsion; (9) Structural; and (10) Transport/Handling.

Source record↗
NASA NTRS1974

Review of hydrogen accidents and incidents in NASA operations

A number of the accidents/incidents with hydrogen in NASA operations are reviewed. The cause factors for the mishaps are reviewed and show that although few accidents occurred, the number could have been further reduced if the established NASA rules and regulations had been followed. Requirements for effective safety codes and areas of study for hydrogen safety information are included. The report concludes with a compilation of 96 hydrogen mishaps; a description of the accidents and their causes.

Ordin, P. M.↗
NASA NTRS2000

U.S. Civil Rotorcraft Accidents, 1963 Through 1997

Narrative summary data produced by the U.S. National Transportation Safety Board (NTSB) has been obtained and analyzed for all 8,436 U.S. civil registered rotorcraft accidents which occurred from mid-1963 through 1997. This analysis was based on the NTSB's assignment of each mishap into one of 21 "first event" categories. The number of U.S. civil registered rotorcraft as recorded by the Federal Aviation Administration (FAA) for the same period has also been obtained. Taken together, these data indicate the civil rotorcraft accident rate (on a per 1,000 registered rotorcraft basis) has decreased by almost a factor of 10 (i.e., from 130 accidents per 1,000 rotorcraft in 1964 to 13.4 per 1,000 in 1997). Analysis of the mishap data indicates over 70% of the rotorcraft accidents were associated with one of the following four NTSB "first event" categories: 2408 Loss of engine power (28.5%); 1,322 In-flight collisions with objects (15.7%); 1,114 Loss of control (13.2%); 1,083 Airframe/component/system failure or malfunction (12.8%).

Harris, Franklin D.↗
NASA NTRS2004

Review of X-43A Return to Flight Activities and Current Status

This paper provides an overview and status of the return to flight activities for the X-43A scramjet flight demonstrator after the first flight mishap. The first flight was attempted on June 2, 2001 and resulted in vehicle destruction by range safety when the booster went out of control early in the flight. In the time since the mishap much work has been done to examine the causes of the failure and make modifications to the booster to insure that the boost for the second flight will be successful. In addition, all other aspects of the flight have been examined to maximize the probability of a successful flight.

Reubush, David E.↗
NASA NTRS2004

Ontology Development and Evolution in the Accident Investigation Domain

InvestiigationOrganizer (IO) is a collaborative semantic web system designed to support the conduct of mishap investigations. IO provides a common repository for a wide range of mishap related information, allowing investigators to integrate evidence, causal models, and investigation results. IO has been used to support investigations ranging from a small property damage case to the loss of the Space Shuttle Columbia. Through IO'S use in these investigations, we have learned significant lessons? about the application of ontologies and semantic systems to solving real-world problems. This paper will describe the development of the ontology within IO, from the initial development, its growth in response to user requests during use in investigations, and the recent work that was done to control the results of that growth. This paper will also describe the lessons learned from this experience and how they may apply to the implementaton of future ontologies and semantic systems.

Carvalho, Robert↗
NASA NTRS2005

Contingency Operations Support to NASA Johnson Space Center Medical Operations Division

The Wyle Laboratories Contingency Operations Group provides support to the NASA Johnson Space Center (JSC) Medical Operations Division in the event of a space flight vehicle accident or JSC mishap. Support includes development of Emergency Medical System (EMS) requirements, procedures, training briefings and real-time support of mishap investigations. The Contingency Operations Group is compliant with NASA documentation that provides guidance in these areas and maintains contact with the United States Department of Defense (DOD) to remain current on military plans to support NASA. The contingency group also participates in Space Operations Medical Support Training Courses (SOMSTC) and represents the NASA JSC Medical Operations Division at contingency exercises conducted worldwide by the DOD or NASA. The events of September 11, 2001 have changed how this country prepares and protects itself from possible terrorist attacks on high-profile targets. As a result, JSC is now considered a high-profile target and thus, must prepare for and develop a response to a Weapons of Mass Destruction (WMD) incident. The Wyle Laboratories Contingency Operations Group supports this plan, specifically the medical response, by providing expertise and manpower.

Stepaniak, Philip↗
NASA NTRS2005

Aeromedical Lessons from the Space Shuttle Columbia Accident Investigation

This paper presents the aeromedical lessons learned from the Space Shuttle Columbia Accident Investigation. The contents include: 1) Introduction and Mission Response Team (MRT); 2) Primary Disaster Field Office (DFO); 3) Mishap Investigation Team (MIT); 4) Kennedy Space Center (KSC) Mishap Response Plan; 5) Armed Forces Institute of Pathology (AFIP); and 6) STS-107 Crew Surgeon.

Pool, Sam L.↗
NASA NTRS2010

NASA Headquarters Space Operations Center: Providing Situational Awareness for Spaceflight Contingency Response

This paper discusses the NASA Headquarters mishap response process for the Space Shuttle and International Space Station programs, and how the process has evolved based on lessons learned from the Space Shuttle Challenger and Columbia accidents. It also describes the NASA Headquarters Space Operations Center (SOC) and its special role in facilitating senior management's overall situational awareness of critical spaceflight operations, before, during, and after a mishap, to ensure a timely and effective contingency response.

Maxwell, Theresa G.↗
NASA NTRS2010

Medical Response, Search and Recovery during the Space Shuttle Columbia Accident Investigation

On February 1, 2003, the Space Shuttle Columbia broke apart during atmospheric re-entry on mission STS-107. After an event such as this, with high visibility and international interest, the operational challenge of recovering the crewmembers could not be underestimated. The Space Shuttle Program is organized to respond to a vehicle mishap using the resources of the Mishap Investigation Team (MIT). On the afternoon of Feb. 1, 2003, the MIT deployed to Barksdale Air Force Base (AFB), Louisiana. This location became the investigative center and interim storage location for crewmembers received from the Lufkin, Texas Disaster Field Office (DFO). The Lufkin DFO served as the primary area for all operations, including staging assets and deploying field teams for search, recovery and security of crewmember remains. More than 2,000 people from numerous organizations were involved with the recovery of the crew. All seven crewmembers of STS-107 were recovered and ceremonial last rights were administered. Astronaut and military personnel escorted the crew with honor to the MIT at Barksdale AFB, Louisiana. At Barksdale AFB a temporary morgue was established in an aircraft hangar and operated for approximately two weeks during which time coordination with the DFO field recovery teams, Armed Forces Institute of Pathology (AFIP) medical personnel, and the crew surgeons was on going. Families of crewmembers and NASA management were notified daily of the current findings. Working under the leadership of the MIT Lead, the medical team developed and executed a short-term plan to identify and relocate the crew with a military honor guard and protocol to the medical examiner at the Armed Forces Port Mortuary, Dover AFB, Delaware. After operations at Barksdale AFB were concluded the medical team transitioned back to Houston and a long-term plan was developed and implemented which involved the Air Force Mortuary Affairs at Randolph AFB, Texas. This plan was coordinated with search teams in the field, Barksdale AFB Mortuary Affairs, KSC security, AFIP, and the crew surgeons at JSC.

Stepaniak, Philip C.↗
NASA NTRS2011

NASA Medical Response to Human Spacecraft Accidents

This slide presentation reviews NASA's role in the response to spacecraft accidents that involve human fatalities or injuries. Particular attention is given to the work of the Mishap Investigation Team (MIT), the first response to the accidents and the interface to the accident investigation board. The MIT does not investigate the accident, but the objective of the MIT is to gather, guard, preserve and document the evidence. The primary medical objectives of the MIT is to receive, analyze, identify, and transport human remains, provide assistance in the recovery effort, and to provide family Casualty Coordinators with latest recovery information. The MIT while it does not determine the cause of the accident, it acts as the fact gathering arm of the Mishap Investigation Board (MIB), which when it is activated may chose to continue to use the MIT as its field investigation resource. The MIT membership and the specific responsibilities and tasks of the flight surgeon is reviewed. The current law establishing the process is also reviewed.

Patlach, Robert↗
NASA NTRS2006

A Silent Safety Program

NASA's Columbia Accident Investigation Board (CAIB) referred 8 times to the NASA "Silent Safety Program." This term, "Silent Safety Program" was not an original observation but first appeared in the Rogers Commission's Investigation of the Challenger Mishap. The CAIB on page 183 of its report in the paragraph titled 'Encouraging Minority Opinion,' stated "The Naval Reactor Program encourages minority opinions and "bad news." Leaders continually emphasize that when no minority opinions are present, the responsibility for a thorough and critical examination falls to management. . . Board interviews revealed that it is difficult for minority and dissenting opinions to percolate up through the agency's hierarchy. . ." The first question and perhaps the only question is - what is a silent safety program? Well, a silent safety program may be the same as the dog that didn't bark in Sherlock Holmes' "Adventure of the Silver Blaze" because system safety should behave as a devil's advocate for the program barking on every occasion to insure a critical review inclusion. This paper evaluates the NASA safety program and provides suggestions to prevent the recurrence of the silent safety program alluded to in the Challenger Mishap Investigation. Specifically targeted in the CAM report, "The checks and balances the safety system was meant to provide were not working." A silent system safety program is not unique to NASA but could emerge in any and every organization. Principles developed by Irving Janis in his book, Groupthink, listed criteria used to evaluate an organization's cultural attributes that allows a silent safety program to evolve. If evidence validates Jams's criteria, then Jams's recommendations for preventing groupthink can also be used to improve a critical evaluation and thus prevent the development of a silent safety program.

Goodin, James Ronald↗
NASA NTRS2013

Human Factors in Accidents Involving Remotely Piloted Aircraft

This presentation examines human factors that contribute to RPA mishaps and provides analysis of lessons learned. RPA accident data from U.S. military and government agencies were reviewed and analyzed to identify human factors issues. Common contributors to RPA mishaps fell into several major categories: cognitive factors (pilot workload), physiological factors (fatigue and stress), environmental factors (situational awareness), staffing factors (training and crew coordination), and design factors (human machine interface).

Merlin, Peter William↗
NASA NTRS2016

Tailoring a Human Reliability Analysis to Your Industry Needs

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

DeMott, D. L.↗
NASA NTRS2017

NASA Weather Support 2017

In the mid to late 1980's, as NASA was studying ways to improve weather forecasting capabilities to reduce excessive weather launch delays and to reduce excessive weather Launch Commit Criteria (LCC) waivers, the Challenger Accident occurred and the AC-67 Mishap occurred.[1] NASA and USAF weather personnel had advance knowledge of extremely high levels of weather hazards that ultimately caused or contributed to both of these accidents. In both cases, key knowledge of the risks posed by violations of weather LCC was not in the possession of final decision makers on the launch teams. In addition to convening the mishap boards for these two lost missions, NASA convened expert meteorological boards focusing on weather support. These meteorological boards recommended the development of a dedicated organization with the highest levels of weather expertise and influence to support all of American spaceflight. NASA immediately established the Weather Support Office (WSO) in the Office of Space Flight (OSF), and in coordination with the United Stated Air Force (USAF), initiated an overhaul of the organization and an improvement in technology used for weather support as recommended. Soon after, the USAF established a senior civilian Launch Weather Officer (LWO) position to provide meteorological support and continuity of weather expertise and knowledge over time. The Applied Meteorology Unit (AMU) was established by NASA, USAF, and the National Weather Service to support initiatives to place new tools and methods into an operational status. At the end of the Shuttle Program, after several weather office reorganizations, the WSO function had been assigned to a weather branch at Kennedy Space Center (KSC). This branch was dismantled in steps due to further reorganization, loss of key personnel, and loss of budget line authority. NASA is facing the loss of sufficient expertise and leadership required to provide current levels of weather support. The recommendation proposed herein is to re-establish the WSO under a high level office, with funding set at about the same levels as today, with a revitalized charter and focus to allow for the WSO to operate as originally intended.

lessons learned↗
NASA NTRS2018

Understanding Risk Tolerance and Building an Effective Safety Culture

Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

Loyd, David↗