Search NASA⌕ Search

SEARCH · Search NASA

Results for “ACCIDENT INVESTIGATION”

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 91 records · Page 5
All sourcesNASA NTRSDOE OSTI
NASA NTRS2016

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilot's taking direct control of the reaction control system. The analysis described here suggests that, rather than events following the pilot's switch to direct control, it was the events preceding the switch that led to the accident. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

X-15↗
NASA NTRS2006

Investigations of Shuttle Main Landing Gear Door Environmental Seals

The Columbia Accident investigation Board (CAIB) requested an investigation into the MLG door seals. Initially, the MLG door seals were thought to have been a potential contributor to the loss of Columbia. These suspicions were later found to be untrue, but the seals remained as a cause for concern in future flights. MLG door seals comprised of thermal barrier and environmental seal. This study focuses on the environmental seal for the MLG door.

Finkbeiner, Joshua↗
NASA NTRS2004

Lessons Learned Study Final Report for the Exploration Systems Mission Directorate

This report is the final product of a 90-day study performed for the Exploration Systems Mission Directorate. The study was to assemble lessons NASA has learned from previous programs that could help the Exploration Systems Mission Directorate pursue the Exploration vision. It focuses on those lessons that should have the greatest significance to the Directorate during the formulation of program and mission plans. The study team reviewed a large number of lessons learned reports and data bases, including the Columbia Accident Investigation Board and Rogers Commission reports on the Shuttle accidents, accident reports from robotic space flight systems, and a number of management reviews by the Defense Sciences Board, Government Accountability Office, and others. The consistency of the lessons, findings, and recommendations validate the adequacy of the data set. In addition to reviewing existing databases, a series of workshops was held at each of the NASA centers and headquarters that included senior managers from the current workforce as well as retirees. The full text of the workshop reports is included in Appendix A. A lessons learned website was opened up to permit current and retired NASA personnel and on-site contractors to input additional lessons as they arise. These new lessons, when of appropriate quality and relevance, will be brought to the attention of managers. The report consists of four parts: Part 1 provides a small set of lessons, called the Executive Lessons Learned, that represent critical lessons that the Exploration Systems Mission Directorate should act on immediately. This set of Executive Lessons and their supporting rationale have been reviewed at length and fully endorsed by a team of distinguished NASA alumni; Part 2 contains a larger set of lessons, called the Selected Lessons Learned, which have been chosen from the lessons database and center workshop reports on the basis of their specific significance and relevance to the near-term work of the Exploration Directorate. These lessons frequently support the Executive lessons but are more general in nature; Part 3 consists of the reports of the center workshops that were conducted as part of this activity. These reports are included in their entirety (approximately 200 pages) in Appendix G and have significance for specific managers; Part 4 consists of the remainder of the lessons that have been selected by this effort and assembled into a database for the use of the Explorations Directorate. The database is archived and hosted in the Lessons Learned Knowledge Network, which provides a flexible search capability using a wide variety of search terms. Finally, a spreadsheet lists databases searched and a bibliography identifies reports that have been reviewed as sources of lessons for this task. NASA has been presented with many learning opportunities. We have conducted numerous programs, some extremely successful and others total failures. Most have been documented with a formal lessons learned activity, but we have not always incorporated these learning opportunities into our normal modes of business. For example, the Robbins Report of 2001 clearly indicates that many project failures of the past two decades were the result of violating well documented best practices, often in direct violation of management instructions and directives. An overarching lesson emerges: that disciplined execution in accordance with proven best practices is the greatest single contributor to a successful program. The Lessons Learned task team offers a sincere hope that the lessons presented herein will be helpful to the Exploration Systems Directorate in charting and executing their course. The success of the Directorate and of NASA in general depends on our collective ability to move forward without having to relearn the lessons of those who have gone before.

Van Laak, Jim↗
NASA NTRS1982

The engineering investigation of aircraft accidents

The organization and plan for an investigation, procedures used at the scene of the accident, engineering aspects covered in the main investigation, use of special analytical techniques and simulation tools, and use of flight recorder data are discussed. Examples of investigations are used to illustrate the processes used.

Anderson, S. B.↗
NASA NTRS2004

Test and Analysis Correlation of Form Impact onto Space Shuttle Wing Leading Edge RCC Panel 8

Soon after the Columbia Accident Investigation Board (CAIB) began their study of the space shuttle Columbia accident, "physics-based" analyses using LS-DYNA were applied to characterize the expected damage to the Reinforced Carbon-Carbon (RCC) leading edge from high-speed foam impacts. Forensic evidence quickly led CAIB investigators to concentrate on the left wing leading edge RCC panels. This paper will concentrate on the test of the left-wing RCC panel 8 conducted at Southwest Research Institute (SwRI) and the correlation with an LS-DYNA analysis. The successful correlation of the LS-DYNA model has resulted in the use of LS-DYNA as a predictive tool for characterizing the threshold of damage for impacts of various debris such as foam, ice, and ablators onto the RCC leading edge for shuttle return-to-flight.

Fasanella, Edwin L.↗
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 NTRS2005

Investigations of Shuttle Main Landing Gear Door Environmental Seals

The environmental seals for the main landing gear doors of the Shuttle Orbiters were raised by the Columbia Accident Investigation Board as a potential safety concern. Inspections of seals installed on the Shuttle Discovery revealed that they were permanently deformed and no longer met certified seal compression requirements. Replacement of the seals led to the inability to fully close the main landing gear doors. Johnson Space Center requested that Glenn Research Center conduct tests on the main landing gear door environmental seals to assist in installing the seals in a manner to allow the main landing gear doors to fully close. Further testing was conducted to fill out the seal performance database. Results from the testing indicated that the method of bonding the seals was important in reducing seal loads on the main landing gear doors. Also, the replacement seals installed in Shuttle Discovery were found to have leakage performance sufficient to meet the certification requirements.

Finkbeiner, Joshua↗
NASA NTRSDate not supplied

Horizontally Integrated Informatics to Support Science Operations in Human Spaceflight

Many systems will be designed and developed for the Artemis program. A subset of these systems will be relevant to scientific activities conducted during the program, but it is important to consider that these scientific activities will be conducted within the context of the larger program. Thinking about the program data holistically, and deliberately structuring its data products in a way that preserves the data’s mission context will enable new opportunities for real-time science support, and long-term analysis of the mission and its data for generations to come (see [1] for an example). Here, we show that horizontally integrated mission data products are valuable by describing the SSERVI RISE2 field program. Temporally contextualized data introduces relationships that do not need to be predefined. One field that greatly benefits from freeform relationship building between disparate datasets is anomaly investigation, where investigators need to follow lines of evidence that may not be a priori apparent. Building relationships between data enables accident investigators to react faster to time-sensitive incidents during EVA operation and other critical human spaceflight activities. Another advantage is the long-term data preservation that enables unplanned or yet-to-be conceived applications or study of this data many years in the future. As Artemis activities become more defined, having a horizontally integrated data management plan will be paramount to ensuring successful mission context is captured for generations to come.

B F Feist↗
NASA NTRS2017

Verification Testing: Meet User Needs Figure of Merit

Verification is the process through which Modeling and Simulation(M&S) software goes to ensure that it has been rigorously tested and debugged for its intended use. Validation confirms that said software accurately models and represents the real world system. Credibility gives an assessment of the development and testing effort that the software has gone through as well as how accurate and reliable test results are. Together, these three components form Verification, Validation, and Credibility(VV&C), the process by which all NASA modeling software is to be tested to ensure that it is ready for implementation. NASA created this process following the CAIB (Columbia Accident Investigation Board) report seeking to understand the reasons the Columbia space shuttle failed during reentry. The reports conclusion was that the accident was fully avoidable, however, among other issues, the necessary data to make an informed decision was not there and the result was complete loss of the shuttle and crew. In an effort to mitigate this problem, NASA put out their Standard for Models and Simulations, currently in version NASA-STD-7009A, in which they detailed their recommendations, requirements and rationale for the different components of VV&C. They did this with the intention that it would allow for people receiving MS software to clearly understand and have data from the past development effort. This in turn would allow the people who had not worked with the MS software before to move forward with greater confidence and efficiency in their work. This particular project looks to perform Verification on several MATLAB (Registered Trademark)(The MathWorks, Inc.) scripts that will be later implemented in a website interface. It seeks to take note and define the limits of operation, the units and significance, and the expected datatype and format of the inputs and outputs of each of the scripts. This is intended to prevent the code from attempting to make incorrect or impossible calculations. Additionally, this project will look at the coding generally and note inconsistencies, redundancies, and other aspects that may become problematic or slow down the codes run time. Certain scripts lacking in documentation also will be commented and cataloged.

validation↗
NASA NTRSDate not supplied

Nasa Pilot Fatigue Research: Past, Present & Future

Pilot fatigue research at NASA Ames has a long history, initiated by a Congressional request to investigate the magnitude of fatigue, sleep loss and circadian disruption in flight operations, and how these factors impact crew performance. Research has been conducted in a broad range of aviation operations, including short-haul, long-haul, rotorcraft, overnight cargo, corporate/business, and regional airlines. Studies have been conducted in the field during actual flight operations, in simulated settings, focus group meetings, and with surveys. Other investigations have examined mitigation strategies including in-flight rest periods and lighting applications. Other activities have included education and training, publications, accident investigation support and the development of research methods and tools. Future research may include further lighting interventions, controlled rest strategies, use of automation, the effectiveness of modeling tools, and implementation of organizational fatigue management programs.

aviation↗
NASA NTRS1972

Processes of technology assessment: The National Transportation Safety Board

The functions and operations of the Safety Board as related to technology assessment are described, and a brief history of the Safety Board is given. Recommendations made for safety in all areas of transportation and the actions taken are listed. Although accident investigation is an important aspect of NTSB's activity, it is felt that the greatest contribution is in pressing for development of better accident prevention programs. Efforts of the Safety Board in changing transportation technology to improve safety and prevent accidents are illustrated.

Weiss, E.↗
NASA NTRS1987

A/C 67 Investigation Board Final Report

On March 26, 1987, after the launch of an Atlas/Centaur rocket with a payload of a Navy Communications Satellite, a problem developed and the rocket was lost. John Busse chaired the Accident Investigation Board that was convened to investigate the incident. This videotape is a press conference with Mr Busse, who reviews the findings of the investigation concerning the loss of the Atlas/Centaur-67 launch vehicle. The loss is primarily attributed to a hardover engine yaw command that was caused by an erroneous signal from the digital computer unit. The generation of the erroneous signal is blamed on unfavorable weather conditions which created a lightning hazard. Mr. Busse, also, reviews the investigation's recommendations for avoiding similar occurrences. The press then asks questions about the findings and recommendations.

Source record↗
NASA NTRS1997

Wings: A New Paradigm in Human-Centered Design

Many aircraft accidents/incidents investigations cite crew error as a causal factor (Boeing Commercial Airplane Group 1996). Human factors experts suggest that crew error has many underlying causes and should be the start of an accident investigation and not the end. One of those causes, the flight deck design, is correctable. If a flight deck design does not accommodate the human's unique abilities and deficits, crew error may simply be the manifestation of this mismatch. Pilots repeatedly report that they are "behind the aircraft" , i.e., they do not know what the automated aircraft is doing or how the aircraft is doing it until after the fact. Billings (1991) promotes the concept of "human-centered automation"; calling on designers to allocate appropriate control and information to the human. However, there is much ambiguity regarding what it mean's to be human-centered. What often are labeled as "human-centered designs" are actually designs where a human factors expert has been involved in the design process or designs where tests have shown that humans can operate them. While such designs may be excellent, they do not represent designs that are systematically produced according to some set of prescribed methods and procedures. This paper describes a design concept, called Wings, that offers a clearer definition for human-centered design. This new design concept is radically different from current design processes in that the design begins with the human and uses the human body as a metaphor for designing the aircraft. This is not because the human is the most important part of the aircraft (certainly the aircraft would be useless without lift and thrust), but because he is the least understood, the least programmable, and one of the more critical elements. The Wings design concept has three properties: a reversal in the design process, from aerodynamics-, structures-, and propulsion-centered to truly human-centered; a design metaphor that guides function allocation and control and display design; and a deliberate distinction between two fundamental functions of design, to complement and to interpret human performance. The complementary function extends the human's capabilities beyond his or her current limitations - this includes sensing, computation, memory, physical force, and human decision making styles and skills. The interpretive (or hermeneutic, Hollnagel 1991) function translates information, functionality, and commands between the human and the aircraft. The Wings design concept allows the human to remain aware of the aircraft through natural interpretation. It also affords great improvements in system performance by maximizing the human's natural abilities and complementing the human's skills in a natural way. This paper will discuss the Wings design concept by describing the reversal in the traditional design process, the function allocation strategy of Wings, and the functions of complementing and interpreting the human.

Schutte, Paul C.↗
NASA NTRS2007

Shuttle Entry Imaging Using Infrared Thermography

During the Columbia Accident Investigation, imaging teams supporting debris shedding analysis were hampered by poor entry image quality and the general lack of information on optical signatures associated with a nominal Shuttle entry. After the accident, recommendations were made to NASA management to develop and maintain a state-of-the-art imagery database for Shuttle engineering performance assessments and to improve entry imaging capability to support anomaly and contingency analysis during a mission. As a result, the Space Shuttle Program sponsored an observation campaign to qualitatively characterize a nominal Shuttle entry over the widest possible Mach number range. The initial objectives focused on an assessment of capability to identify/resolve debris liberated from the Shuttle during entry, characterization of potential anomalous events associated with RCS jet firings and unusual phenomenon associated with the plasma trail. The aeroheating technical community viewed the Space Shuttle Program sponsored activity as an opportunity to influence the observation objectives and incrementally demonstrate key elements of a quantitative spatially resolved temperature measurement capability over a series of flights. One long-term desire of the Shuttle engineering community is to calibrate boundary layer transition prediction methodologies that are presently part of the Shuttle damage assessment process using flight data provided by a controlled Shuttle flight experiment. Quantitative global imaging may offer a complementary method of data collection to more traditional methods such as surface thermocouples. This paper reviews the process used by the engineering community to influence data collection methods and analysis of global infrared images of the Shuttle obtained during hypersonic entry. Emphasis is placed upon airborne imaging assets sponsored by the Shuttle program during Return to Flight. Visual and IR entry imagery were obtained with available airborne imaging platforms used within DoD along with agency assets developed and optimized for use during Shuttle ascent to demonstrate capability (i.e., tracking, acquisition of multispectral data, spatial resolution) and identify system limitations (i.e., radiance modeling, saturation) using state-of-the-art imaging instrumentation and communication systems. Global infrared intensity data have been transformed to temperature by comparison to Shuttle flight thermocouple data. Reasonable agreement is found between the flight thermography images and numerical prediction. A discussion of lessons learned and potential application to a potential Shuttle boundary layer transition flight test is presented.

Horvath, Thomas↗
NASA NTRS2003

Applying STAMP in Accident Analysis

Accident models play a critical role in accident investigation and analysis. Most traditional models are based on an underlying chain of events. These models, however, have serious limitations when used for complex, socio-technical systems. Previously, Leveson proposed a new accident model (STAMP) based on system theory. In STAMP, the basic concept is not an event but a constraint. This paper shows how STAMP can be applied to accident analysis using three different views or models of the accident process and proposes a notation for describing this process.

Leveson, Nancy↗
NASA NTRS1987

Analysis of Convair 990 rejected-takeoff accident with emphasis on decision making, training and procedures

This paper analyzes a NASA Convair 990 (CV-990) accident with emphasis on rejected-takeoff (RTO) decision making, training, procedures, and accident statistics. The NASA Aircraft Accident Investigation Board was somewhat perplexed that an aircraft could be destroyed as a result of blown tires during the takeoff roll. To provide a better understanding of tire failure RTO's, The Board obtained accident reports, Federal Aviation Administration (FAA) studies, and other pertinent information related to the elements of this accident. This material enhanced the analysis process and convinced the Accident Board that high-speed RTO's in transport aircraft should be given more emphasis during pilot training. Pilots should be made aware of various RTO situations and statistics with emphasis on failed-tire RTO's. This background information could enhance the split-second decision-making process that is required prior to initiating an RTO.

Batthauer, Byron E.↗
NASA NTRS2004

Improving Performance of the System Safety Function at Marshall Space Flight Center

The Columbia Accident Investigation Board (CAIB) determined that organizational and management issues were significant contributors to the loss of Space Shuttle Columbia. In addition, the CAIB observed similarities between the organizational and management climate that preceded the Challenger accident and the climate that preceded the Columbia accident. To prevent recurrence of adverse organizational and management climates, effective implementation of the system safety function is suggested. Attributes of an effective system safety program are presented. The Marshall Space Flight Center (MSFC) system safety program is analyzed using the attributes. Conclusions and recommendations for improving the MSFC system safety program are offered in this case study.

Kiessling, Ed↗