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Validation and Verification (V&V) of Safety-Critical Systems Operating Under Off-Nominal Conditions

Loss of control (LOC) remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft LOC accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. Research is underway at the National Aeronautics and Space Administration (NASA) in the development of advanced onboard system technologies for preventing or recovering from loss of vehicle control and for assuring safe operation under off-nominal conditions associated with aircraft LOC accidents. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V&V) and ultimate certification. The V&V of complex integrated systems poses highly significant technical challenges and is the subject of a parallel research effort at NASA. This chapter summarizes the V&V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft LOC accidents. A summary of recent research accomplishments in this effort is referenced.

Belcastro, Christine M.↗

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗

TA-18-1 Slotin Building Restoration – Summary of Work to be Performed

The National Historic Preservation Act (NHPA) requires LANL to identify, evaluate, record, and protect eligible historic properties like TA-18-1 Slotin Building. The Environmental Protection and Compliance-Environmental Stewardship (EPC-ES) Cultural Resources program consults with the New Mexico State Historic Preservation Office (SHPO) on undertakings that may affect these properties. TA-18-1 Slotin Building is an exceptionally significant Manhattan Project Property that has been determined eligible for the National Register of Historic Places and is included within the boundary of the Manhattan Project National Historical Park. The building was constructed in 1946 and served as laboratory space for criticality testing. It is the location of the May 1946 criticality accident that resulted in the death of Louis Slotin. As a result of the accident, new procedures and designs for criticality experiments were implemented to prevent further accidents.

96 KNOWLEDGE MANAGEMENT AND PRESERVATION↗

Renewed Commitment to Excellence: An Assessment of the NASA Agency-Wide Applicability of the Columbia Accident Investigation Board Report

The Space Shuttle fleet has been grounded since the Columbia accident. As a result, 'Return to Flight' has become not just a phrase but a program and the global of virtually everyone associated with NASA. Even those who are not affiliated with the Shuttle Program are looking forward to the safe and successful completion of the next Shuttle mission. In this recovery process, NASA will be guided by the Report of the Columbia Accident Investigation Board (CAIB). The CAIB was an investigating body, convened by NASA Administrator O'Keefe the day of the Columbia accident, according to procedures established after the loss of Space Challenger.

SPACE SHUTTLE COLUMBIA↗

TPSAS-NF1676L-18905-DND

Aircraft loss of control is a leading cause of fatal accidents across all transport airplane and operational classes. Aircraft loss-of-control (LOC) accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents. This presentation will define LOC as a dynamics and control problem, summarize LOC accident analysis results, and discuss current NASA research that supports a holistic approach for significantly reducing aircraft LOC accidents for current and future aircraft. The approach includes onboard systems technologies for LOC prevention and recovery, as well as a parallel effort for their validation. The onboard systems technologies provide improved situational awareness, guidance, and control under realistic LOC hazards, and include: hazards effects detection and mitigation; upset detection, prevention and recovery; and multiple hazards mitigation. Validation technologies include analytical, simulation, and experimental methods, tools and testbeds as well as the development of a comprehensive set of realistic LOC test scenarios. Future research directions will also be discussed.

Christine Belcastro↗

Aircraft Loss-of-Control Accident Analysis

Loss of control remains one of the largest contributors to fatal aircraft accidents worldwide. Aircraft loss-of-control accidents are complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents. To gain a better understanding into aircraft loss-of-control events and possible intervention strategies, this paper presents a detailed analysis of loss-of-control accident data (predominantly from Part 121), including worst case combinations of causal and contributing factors and their sequencing. Future potential risks are also considered.

Belcastro, Christine M.↗

Fire prevention on airplanes. Part II

This part of the report presents a detailed examination of spark prevention, fire extinguishers, and fuel tank location and design. A continued program of investigations and research is also proposed.

FIRE PREVENTION↗

Synthetic Vision CFIT Experiments for GA and Commercial Aircraft: "A Picture Is Worth A Thousand Lives"

Because restricted visibility has been implicated in the majority of commercial and general aviation accidents, solutions will need to focus on how to enhance safety during instrument meteorological conditions (IMC). The NASA Synthetic Vision Systems (SVS) project is developing technologies to help achieve these goals through the synthetic presentation of how the outside world would look to the pilot if vision were not reduced. The potential safety outcome would be a significant reduction in several accident categories, such as controlled-flight-into-terrain (CFIT), that have restricted visibility as a causal factor. The paper describes two experiments that demonstrated the efficacy of synthetic vision technology to prevent CFIT accidents for both general aviation and commercial aircraft.

Prinzel, Lawrence J., III↗

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↗

Lessons Learned—Fluoride Exposure and Response

Laboratory research can expose workers to a wide variety of chemical hazards. Researchers must not only take personal responsibility for their safety but also inevitably rely on coworkers to also work safely. The foundations for protocols, requirements, and behaviors come from our history and lessons learned from others. For that reason, here, a recent incident is examined in which a researcher suffered hydrofluoric acid (HF) burns while working with an inorganic digestion mixture of aqueous HF (8%) and nitric acid (HNO 3 , 58%). HF education is critical for workers because delays in treatment, improper treatment, and delay of symptoms are all factors in unfavorable outcomes in case reports. Furthermore, while the potential severity of the incident was elevated due to bypassed engineered controls and lack of proper personal protective equipment, only minor injuries were sustained. We discuss the results of a causal analysis of the incident that revealed areas of improvement in protocols, personal protective equipment, and emergency response that could help prevent similar accidents from occurring. We also present simple improvements that anyone can implement to reduce the potential consequences of an accident, based upon our lessons learned.

37 INORGANIC, ORGANIC, PHYSICAL, AND ANALYTICAL CH↗

Nuclear Criticality Safety Fundamentals [Slides]

Objectives of this presentation are: 1. Explain the difference between radiation safety vs. criticality safety, 2. Define criticality, 3. Explain the three types of chain reactions, 4. Define two terms scientists use to characterize criticality, 5. Explain what occurs during a criticality accident, 6. Identify prevention measures for avoiding a criticality accident, and 7. Identify the parameters that effect criticality of a system.

61 RADIATION PROTECTION AND DOSIMETRY↗

Space-Spurred Metallized Materials

Among a score of applications for a space spinoff reflective material called TXG is the emergency blanket manufactured by Metallized Products, Inc. Used by ski patrol to protect a skier shaken by a fall, the blanket retains up to 80% of user's body heat preventing post accident shock or chills. Carried by many types of emergency teams, blanket is large when unfolded, but folds into a package no larger than a deck of cards. Many other uses include, emergency blankets, all weather blanket, tanning blanket, window shields, radar reflector life raft canopies, etc.

Source record↗

Metallized Products

Since the early 1960's, virtually all NASA spacecraft have used metallized films for a variety of purposes, principally thermal radiation insulation. King Seeley manufactures a broad line of industrial and consumer oriented metallized film, fabric, paper and foam in single layer sheets and multi-layer laminates. A few examples, commercialized by MPI Outdoor Safety Products, are the three ounce Thermos Emergency Blanket which reflects and retains up to 80 percent of the user's body heat helping prevent post accident shock or keeping a person warm for hours under emergency cold weather conditions.

Source record↗

Columbia Accident Investigation Board Report. Volume Two

Volume II of the Report contains appendices that were cited in Volume I. The Columbia Accident Investigation Board produced many of these appendices as working papers during the investigation into the February 1, 2003 destruction of the Space Shuttle Columbia. Other appendices were produced by other organizations (mainly NASA) in support of the Board investigation. In the case of documents that have been published by others, they are included here in the interest of establishing a complete record, but often at less than full page size. Contents include: CAIB Technical Documents Cited in the Report: Reader's Guide to Volume II; Appendix D. a Supplement to the Report; Appendix D.b Corrections to Volume I of the Report; Appendix D.1 STS-107 Training Investigation; Appendix D.2 Payload Operations Checklist 3; Appendix D.3 Fault Tree Closure Summary; Appendix D.4 Fault Tree Elements - Not Closed; Appendix D.5 Space Weather Conditions; Appendix D.6 Payload and Payload Integration; Appendix D.7 Working Scenario; Appendix D.8 Debris Transport Analysis; Appendix D.9 Data Review and Timeline Reconstruction Report; Appendix D.10 Debris Recovery; Appendix D.11 STS-107 Columbia Reconstruction Report; Appendix D.12 Impact Modeling; Appendix D.13 STS-107 In-Flight Options Assessment; Appendix D.14 Orbiter Major Modification (OMM) Review; Appendix D.15 Maintenance, Material, and Management Inputs; Appendix D.16 Public Safety Analysis; Appendix D.17 MER Manager's Tiger Team Checklist; Appendix D.18 Past Reports Review; Appendix D.19 Qualification and Interpretation of Sensor Data from STS-107; Appendix D.20 Bolt Catcher Debris Analysis.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗