THERMAL RUNAWAY OF NITRIC ACID-SOAKED KITTY LITTER IN TRANSURANIC WASTE
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Hobbs, Michael L.↗
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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.↗
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.↗
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.
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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.↗
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.↗
'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.↗
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↗
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.↗
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.↗
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.
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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.↗
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↗
Handling qualities related to stall/spin accidents of supersonic fighter aircraft
This paper reviews the handling qualities which influence the high angle of attack (AOA) behavior of supersonic fighter aircraft in order to obtain a clearer understanding of the causes of stall/spin accidents. The results show that, because modern fighters suffer more serious consequences when control is lost, good handling qualities are essential for safe operation at high AOA. Relaxed static stability used on some fighter aircraft can result in control problems at high AOA owing to inertia coupling and the difficulty of a recovery from a deep stall. Indications are that the use of departure/spin resistance and an automatic spin prevention system will greatly improve the safety record for modern supersonic fighters.
Anderson, S. B.↗
Columbia Accident Investigation Board Report
The Columbia Accident Investigation Board's independent investigation into the tragic February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months and involved 13 Board members, approximately 120 Board investigators, and thousands of NASA and support personnel. Because the events that initiated the accident were not apparent for some time, the investigation's depth and breadth were unprecedented in NASA history. Further, the Board determined early in the investigation that it intended to put this accident into context. We considered it unlikely that the accident was a random event; rather, it was likely related in some degree to NASA's budgets, history, and program culture, as well as to the politics, compromises, and changing priorities of the democratic process. We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing. The Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASA's Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry. Findings and recommendations are in the relevant chapters and all recommendations are compiled in Chapter 11. Volume I is organized into four parts: The Accident; Why the Accident Occurred; A Look Ahead; and various appendices. To put this accident in context, Parts One and Two begin with histories, after which the accident is described and then analyzed, leading to findings and recommendations. Part Three contains the Board's views on what is needed to improve the safety of our voyage into space. Part Four is reference material. In addition to this first volume, there will be subsequent volumes that contain technical reports generated by the Columbia Accident Investigation Board and NASA, as well as volumes containing reference documentation and other related material.
Gehman, Harold W., Jr.↗
Investigation of technology needs for avoiding helicopter pilot error related accidents
Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.
Chais, R. I.↗
National Transportation Safety Board Aircraft Accident Investigation Supported
The main purpose of this investigation was for NASA to help the National Transportation Safety Board (NTSB) gain better understanding of the events that led to the loss of Comair Flight 3272 over Monroe, Michigan, on January 9, 1997. In-flight icing was suspected as being the primary cause of this accident. Of particular interest to the Safety Board was what NASA could learn about the potential performance degradation of the wing of the Embraer EMB-120 twin-turboprop commuter aircraft with various levels of ice contamination. NASA agreed to undertake (1) ice-accretion prediction computations with NASA s LEWICE program to bound the kind of contaminations that the vehicle may have developed, (2) testing in the NASA Lewis Research Center's Icing Research Tunnel to verify and refine the ice shapes developed by LEWICE, (3) a two-dimensional Navier- Stokes analysis to determine the performance degradation that those ice shapes could have caused, and (4) an examination using three-dimensional Navier-Stokes codes to study the three-dimensional effects of ice contamination.
Reehorst, Andrew L.↗
Loss of Signal, Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle Mishap
Loss of Signal, a NASA publication to be available in May 2014 presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goal of this book is to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews. This poster presents an outline of Loss of Signal contents and highlights from each of five sections - the mission and mishap, the response, the investigation, the analysis and the future.
Stepaniak, Phillip C.↗