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At least 109 records · Page 6

An analysis of pilot error-related aircraft accidents

A multidisciplinary team approach to pilot error-related U.S. air carrier jet aircraft accident investigation records successfully reclaimed hidden human error information not shown in statistical studies. New analytic techniques were developed and applied to the data to discover and identify multiple elements of commonality and shared characteristics within this group of accidents. Three techniques of analysis were used: Critical element analysis, which demonstrated the importance of a subjective qualitative approach to raw accident data and surfaced information heretofore unavailable. Cluster analysis, which was an exploratory research tool that will lead to increased understanding and improved organization of facts, the discovery of new meaning in large data sets, and the generation of explanatory hypotheses. Pattern recognition, by which accidents can be categorized by pattern conformity after critical element identification by cluster analysis.

Kowalsky, N. B.↗

Questioning the Role of Requirements Engineering in the Causes of Safety-Critical Software Failures

Many software failures stem from inadequate requirements engineering. This view has been supported both by detailed accident investigations and by a number of empirical studies; however, such investigations can be misleading. It is often difficult to distinguish between failures in requirements engineering and problems elsewhere in the software development lifecycle. Further pitfalls arise from the assumption that inadequate requirements engineering is a cause of all software related accidents for which the system fails to meet its requirements. This paper identifies some of the problems that have arisen from an undue focus on the role of requirements engineering in the causes of major accidents. The intention is to provoke further debate within the emerging field of forensic software engineering.

Johnson, C. W.↗

Genesis Failure Investigation Report

The-Genesis mission to collect solar-wind samples and return them to Earth for detailed analysis proceeded successfully for 3.5 years. During reentry on September 8, 2004, a failure in the entry, descent and landing sequence resulted in a crash landing of the Genesis sample return capsule. This document describes the findings of the avionics sub-team that supported the accident investigation of the JPL Failure Review Board.

Klein, John↗

Return to Flight Task Group

It has been 29 months since Columbia was lost over East Texas in February 2003. Seven months after the accident, the Columbia Accident Investigation Board (CAIB) released the first volume of its final report, citing a variety of technical, managerial, and cultural issues within NASA and the Space Shuttle Program. To their credit, NASA offered few excuses, embraced the report, and set about correcting the deficiencies noted by the accident board. Of the 29 recommendations issued by the CAIB, 15 were deemed critical enough that the accident board believed they should be implemented prior to returning the Space Shuttle to flight. Some of these recommendations were relatively easy, most were straightforward, a few bordered on the impossible, and others were largely overcome by events, particularly the decision by the President to retire the Space Shuttle by 2010. The Return to Flight Task Group (RTF TG, or simply, the Task Group) was chartered by the NASA Administrator in July 2003 to provide an independent assessment of the implementation of the 15 CAIB return-to-flight recommendations. An important observation must be stated up-front: neither the CAIB nor the RTF TG believes that all risk can be eliminated from Space Shuttle operations; nor do we believe that the Space Shuttle is inherently unsafe. What the CAIB and RTF TG do believe, however, is that NASA and the American public need to understand the risks associated with space travel, and that NASA must make every reasonable effort to minimize such risk. Since the release of the CAIB report, NASA and the Space Shuttle Program expended enormous effort and resources toward correcting the causes of the accident and preparing to fly again. Relative to the 15 specific recommendations that the CAIB indicated should be implemented prior to returning to flight, NASA has met or exceeded most of them the Task Group believes that NASA met the intent of the CAIB for 12 of these recommendations. The remaining three recommendations were so challenging that NASA could not comply completely with the intent of the CAIB.

Source record↗

The Columbia Debris Loan Program; Examples of Microscopic Analysis

Following the tragic loss of the Space Shuttle Columbia NASA formed The Columbia Recovery Office (CRO). The CRO was initially formed at the Johnson Space Center after the conclusion of recovery operations on May 1,2003 and then transferred .to the Kennedy Space Center on October 6,2003 and renamed The Columbia Recovery Office and Preservation. An integral part of the preservation project was the development of a process to loan Columbia debris to qualified researchers and technical educators. The purposes of this program include aiding in the advancement of advanced spacecraft design and flight safety development, the advancement of the study of hypersonic re-entry to enhance ground safety, to train and instruct accident investigators and to establish an enduring legacy for Space Shuttle Columbia and her crew. Along with a summary of the debris loan process examples of microscopic analysis of Columbia debris items will be presented. The first example will be from the reconstruction following the STS- 107 accident and how the Materials and Pro~es~steesa m used microscopic analysis to confirm the accident scenario. Additionally, three examples of microstructural results from the debris loan process from NASA internal, academia and private industry will be presented.

Russell, Rick↗

Orbiter Return-To-Flight Entry Aeroheating

The Columbia accident on February 1, 2003 began an unprecedented level of effort within the hypersonic aerothermodynamic community to support the Space Shuttle Program. During the approximately six month time frame of the primary Columbia Accident Investigation Board activity, many technical disciplines were involved in a concerted effort to reconstruct the last moments of the Columbia and her crew, and understand the critical events that led to that loss. Significant contributions to the CAIB activity were made by the hypersonic aerothermodynamic community(REF CAIB) in understanding the re-entry environments that led to the propagation of an ascent foam induced wing leading edge damage to a subsequent breech of the wing spar of Columbia, and the subsequent breakup of the vehicle. A core of the NASA hypersonic aerothermodynamics team that was involved in the CAIB investigation has been combined with the United Space Alliance and Boeing Orbiter engineering team in order to position the Space Shuttle Program with a process to perform in-flight Thermal Protection System damage assessments. This damage assessment process is now part of the baselined plan for Shuttle support, and is a direct out-growth of the Columbia accident and NASAs response. Multiple re-entry aeroheating tools are involved in this damage assessment process, many of which have been developed during the Return To Flight activity. In addition, because these aeroheating tools are part of an overall damage assessment process that also involves the thermal and stress analyses community, in addition to a much broader mission support team, an integrated process for performing the damage assessment activities has been developed by the Space Shuttle Program and the Orbiter engineering community. Several subsets of activity in the Orbiter aeroheating communities support to the Return To Flight effort have been described in previous publications (CFD?, Cavity Heating? Any BLT? Grid Generation?). This work will provide a description of the integrated process utilized to perform Orbiter tile damage assessment, and in particular will seek to provide a description of the integrated aeroheating tools utilized to perform these assessments. Individual aeroheating tools will be described which provide the nominal re-entry heating environment characterization for the Orbiter, the heating environments for tile damage, heating effects due to exposed Thermal Protection System substrates, the application of Computational Fluid Dynamics for the description of tile cavity heating, and boundary layer transition prediction. This paper is meant to provide an overall view of the integrated aeroheating assessment process for tile damage assessment as one of a sequence of papers on the development of the boundary layer transition prediction capability in support of Space Shuttle Return To Flight efforts.

Campbell, Charles H.↗

Test-Analysis Correlation for Space Shuttle External Tank Foam Impacting RCC Wing Leading Edge Component Panels

The Space Shuttle Columbia Accident Investigation Board recommended that NASA develop, validate, and maintain a modeling tool capable of predicting the damage threshold for debris impacts on the Space Shuttle Reinforced Carbon-Carbon (RCC) wing leading edge and nosecap assembly. The results presented in this paper are one part of a multi-level approach that supported the development of the predictive tool used to recertify the shuttle for flight following the Columbia Accident. The assessment of predictive capability was largely based on test analysis comparisons for simpler component structures. This paper provides comparisons of finite element simulations with test data for external tank foam debris impacts onto 6-in. square RCC flat panels. Both quantitative displacement and qualitative damage assessment correlations are provided. The comparisons show good agreement and provided the Space Shuttle Program with confidence in the predictive tool.

Lyle, Karen H.↗

Flame Retardant Fibers for Human Space Exploration - Past, Present, and Future

The National Aeronautics and Space Administration (NASA) has led in the development of unique flame retardant fibers for human spaceflight since the beginning of the Apollo program. After the Apollo 1 fire which killed Command Pilot Virgil I 'Gus' Grissom, Senior Pilot Edward H. White II, and Pilot Roger B. Chaffee from cardiac arrest on January 27, 1967, the accident investigators found severe third degree burns and melted spacesuits on the astronauts bodies. NASA immediately initiated an extensive research program aimed at developing flame retardant and flame resistant fibers for the enriched oxygen atmosphere of the Apollo crew cabin. Fibers are flame retardant when they have been modified by chemical and thermal treatments. Fibers are flame resistant when they are made of inherently flame resistant materials (i.e. glass, ceramic, highly aromatic polymers). Immediately after this tragic accident, NASA funded extensive research in specifically developing flame retardant fibers and fabrics. The early developmental efforts for human spaceflight were for the outer layer of the Apollo spacesuit. It was imperative that non-flammable fabrics be used in a 100% oxygen environment. Owens-Corning thus developed the Beta fiber that was immediately used in the Apollo program and later in the Space Shuttle program. Aside from the urgent need for protective fabrics for the spacesuit, NASA also needed flame retardant fabrics for both clothing and equipment inside the spacecraft. From the mid-1960s to the early 1980's, NASA contracted with many companies to develop inherently flame retardant fibers and flame retardant finishes for existing fibers. Fluorocarbons and aromatic polyamides were the polymers of great interest for the development of new inherently flame retardant fibers for enriched oxygen environments. These enriched environments varied for different space programs. For example, the Apollo program requirements were for materials that would not support combustion in a 70%/30% oxygen/nitrogen environment at 6.3 pounds per square inch (psi). The Skylab program flammability requirements were set at 80%/20% oxygen/nitrogen ratios at 5 psi. While many fibers produced under several NASA contracts were never used, a few have become commercial products. The intent of this paper is to present the developmental history of some of these new or modified textile fibers. These developmental efforts are presented at various levels of details depending on the source of the historical records.

Orndoff, Evelyne↗

Rapid Structured Volume Grid Smoothing and Adaption Technique

A rapid, structured volume grid smoothing and adaption technique, based on signal processing methods, was developed and applied to the Shuttle Orbiter at hypervelocity flight conditions in support of the Columbia Accident Investigation. Because of the fast pace of the investigation, computational aerothermodynamicists, applying hypersonic viscous flow solving computational fluid dynamic (CFD) codes, refined and enhanced a grid for an undamaged baseline vehicle to assess a variety of damage scenarios. Of the many methods available to modify a structured grid, most are time-consuming and require significant user interaction. By casting the grid data into different coordinate systems, specifically two computational coordinates with arclength as the third coordinate, signal processing methods are used for filtering the data [Taubin, CG v/29 1995]. Using a reverse transformation, the processed data are used to smooth the Cartesian coordinates of the structured grids. By coupling the signal processing method with existing grid operations within the Volume Grid Manipulator tool, problems related to grid smoothing are solved efficiently and with minimal user interaction. Examples of these smoothing operations are illustrated for reduction in grid stretching and volume grid adaptation. In each of these examples, other techniques existed at the time of the Columbia accident, but the incorporation of signal processing techniques reduced the time to perform the corrections by nearly 60%. This reduction in time to perform the corrections therefore enabled the assessment of approximately twice the number of damage scenarios than previously possible during the allocated investigation time.

Alter, Stephen J.↗

Rapid Structured Volume Grid Smoothing and Adaption Technique

A rapid, structured volume grid smoothing and adaption technique, based on signal processing methods, was developed and applied to the Shuttle Orbiter at hypervelocity flight conditions in support of the Columbia Accident Investigation. Because of the fast pace of the investigation, computational aerothermodynamicists, applying hypersonic viscous flow solving computational fluid dynamic (CFD) codes, refined and enhanced a grid for an undamaged baseline vehicle to assess a variety of damage scenarios. Of the many methods available to modify a structured grid, most are time-consuming and require significant user interaction. By casting the grid data into different coordinate systems, specifically two computational coordinates with arclength as the third coordinate, signal processing methods are used for filtering the data [Taubin, CG v/29 1995]. Using a reverse transformation, the processed data are used to smooth the Cartesian coordinates of the structured grids. By coupling the signal processing method with existing grid operations within the Volume Grid Manipulator tool, problems related to grid smoothing are solved efficiently and with minimal user interaction. Examples of these smoothing operations are illustrated for reductions in grid stretching and volume grid adaptation. In each of these examples, other techniques existed at the time of the Columbia accident, but the incorporation of signal processing techniques reduced the time to perform the corrections by nearly 60%. This reduction in time to perform the corrections therefore enabled the assessment of approximately twice the number of damage scenarios than previously possible during the allocated investigation time.

Alter, Stephen J.↗

Analysis of general-aviation accidents using ATC radar records

It is pointed out that general aviation aircraft usually do not carry flight recorders, and in accident investigations the only available data may come from the Air Traffic Control (ATC) records. A description is presented of a technique for deriving time-histories of aircraft motions from ATC radar records. The employed procedure involves a smoothing of the raw radar data. The smoothed results, in combination with other available information (meteorological data and aircraft aerodynamic data) are used to derive the expanded set of motion time-histories. Applications of the considered analytical methods are related to different types of aircraft, such as light piston-props, executive jets, and commuter turboprops, as well as different accident situations, such as takeoff, climb-out, icing, and deep stall.

Wingrove, R. C.↗

NASA Accident Precursor Analysis Handbook, Version 1.0

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.

Groen, Frank↗

Measurements of Parachute Dynamics in the World's Largest Wind Tunnel by Stereo Photogrammetry

Between 2012 and 2017, parachutes for four NASA Projects were tested in the 80- by 120-Ft test section of the National Full-Scale Aerodynamic Complex (NFAC) at NASA Ames Research Center. These projects were: (1) Low-Density Supersonic Decelerator (LDSD); (2) Capsule Parachute Assembly System (CPAS, for Orion); (3) Interior Exploration using Seismic Investigations, Geodesy and Heat Transport (InSight, a Mars mission); and (4) Mars 2020. In all tests stereo photogrammetry was used to measure time-dependent positions of features on the canopies. For the LDSD and CPAS tests, where the purpose was to study the trade-off between stability and drag of different parachute designs, the pendulum motion of the canopies about the riser attachment point was measured by calibrated cameras in the diffuser. The CPAS test also included static measurements where the inflated parachutes were pulled to the side by a system of tethers. The Insight tests were structural qualification tests where each canopy was packed in a bag and launched from a mortar. Cameras in the diffuser measured the trajectory of the bag and the stripping of the bag from the canopy. The Mars 2020 test was a workmanship verification test where the canopies were either launched from a mortar or deployed from a sleeve stretched along the tunnel axis. The deployments were recorded from many directions by thirteen high-speed cameras distributed in the diffuser and test section. Photogrammetry was not planned; however, after a tunnel-related accident ended the test prematurely, photogrammetric measurements were bootstrapped from the images to support the accident investigations. This paper describes how the photogrammetry measurements were made in each test and presents typical results.

Schairer, Edward T.↗

Overview of NASA/Marshall Space Flight Center's program on knowledge of atmospheric processes

The Marshall Space Flight Center (MSFC) is charged with the responsibility to enhance aviation safety through improving understanding of various atmospheric phenomena. A brief discussion is presented concerning the tasks and work being accomplished by MSFC. The tasks are defined as follows: (1) to determine and define the turbulence and steady wind environments induced by buildings, towers, hills, trees, etc., (2) to identify, develop, and apply natural environment technology for the reconstruction and/or simulation of the natural environment for aircraft accident investigation and hazard identification, (3) to develop basic information about free atmosphere perturbations, (4) to develop and apply fog modification mathematical models to assess candidate fog modification schemes and to develop appropriate instrumentation to aquire basic data about fog. To accomplish these tasks MSFC has developed a program involving field data acquisition, wind tunnel studies, theoretical studies, data analysis, and flight simulation studies.

Camp, D. W.↗

Proceedings: Fourth Annual Workshop on Meteorological and Environmental Inputs to Aviation Systems

The proceedings of a workshop on meteorological and environmental inputs to aviation systems held at The University of Tennessee Space Institute, Tullahoma, Tennessee, March 25-27, 1980, are reported. The workshop was jointly sponsored by NASA, NOAA, and FAA and brought together many disciplines of the aviation communities in round table discussions. The major objectives of the workshop are to satisfy such needs of the sponsoring agencies as the expansion of our understanding and knowledge of the interaction of the atmosphere with aviation systems, the better definition and implementation of services to operators, and the collection and interpretation of data for establishing operational criteria relating the total meteorological inputs from the atmospheric sciences to the needs of aviation communities. The unique aspects of the workshop were the diversity of the participants and the achievement of communication across the interface of the boundaries between pilots, meteorologists, training personnel, accident investigators, traffic controllers, flight operation personnel from military, civil, general aviation, and commercial interests alike. Representatives were in attendance from government, airlines, private agencies, aircraft manufacturers, Department of Defense, industries, research institutes, and universities. Full-length papers from invited speakers addressed topics on icing, turbulence, wind and wind shear, ceilings and visibility, lightning, and atmospheric electricity. These papers are contained in the proceedings together with the committee chairmen's reports on the results and conclusions of their efforts on similar subjects.

Frost, Walter↗

Conceptual design study for an advanced cab and visual system, volume 2

The performance, design, construction and testing requirements are defined for developing an advanced cab and visual system. The rotorcraft system integration simulator is composed of the advanced cab and visual system and the rotorcraft system motion generator, and is part of an existing simulation facility. User's applications for the simulator include rotorcraft design development, product improvement, threat assessment, and accident investigation.

Rue, R. J.↗

Factors influencing aircraft ground handling performance

Problems associated with aircraft ground handling operations on wet runways are discussed and major factors which influence tire/runway braking and cornering traction capability are identified including runway characteristics, tire hydroplaning, brake system anomalies, and pilot inputs. Research results from tests with instrumented ground vehicles and aircraft, and aircraft wet runway accident investigation are summarized to indicate the effects of different aircraft, tire, and runway parameters. Several promising means are described for improving tire/runway water drainage capability, brake system efficiency, and pilot training to help optimize aircraft traction performance on wet runways.

Yager, T. J.↗