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NASA NTRS2018

Part 121 Taxi/Parked Ground Conflict Related Incidents

This presentation reviews voluntary safety reports received by NASA's Aviation Safety Reporting System pertaining to Part 121 Taxi/Parked Ground Conflicts. Ground Conflict, Critical • Two or more aircraft (one may be airborne) in conflict, or an aircraft in conflict with a vehicle/person/object in which the reporter or other involved party took evasive action to avoid a collision, or a collision that almost occurred in cases where evasive action was not taken or possible. The evasive action can include an emergency go-around, veering on a taxiway/runway, rejected takeoff/abort, emergency braking, or an aircraft overflying another aircraft 50 feet or less.  Ground Conflict, Less Severe • Two or more aircraft (one may be airborne) in conflict, or an aircraft in conflict with a vehicle/person/object in which the reporter or other involved party may, or may not have taken precautionary avoidance action, and in which a collision hazard was not imminent.  Ground Event / Encounter – Aircraft • Actual physical contact with another aircraft when aircraft is on the ground. All Aircraft Involved in Incidents Conflicting Aircraft by Weight Classification Flight Conditions and Time (Quarter of Day) Contributing Factors and Human Factors (Event)

taxi↗
NASA NTRS1996

Early Warning: Development of Confidential Incident Reporting Systems

Accidents hardly ever happen without warning. The combination, or sequence, of failures and mistakes that cause an accident may indeed be unique but the individual failures and mistakes rarely are. In the USA in 1974 the crews on two different aircraft misunderstood the same aeronautical chart and descended towards their destination dangerously early towards a mountain. The first crew were in good weather conditions and could see the mountain and resolved their misinterpretation of the chart. The second crew six weeks later were not so lucky. In cloud they had no clues to point out their mistake nor the presence of the mountain. The resulting crash and the ensuing inquiry, which brought to light the previous incident, shocked the country but gave it the impetus to instigate a safety reporting system. This system eventually became the NASA's Aviation Safety Reporting System (ASRS). The programme collects incident reports from pilots, controllers, mechanics, cabin attendants and many others involved in aviation operations. By disseminating this safety information the ASRS has helped enormously to give US airlines and airspace the highest safety standards. Accident prevention is a goal sought by everyone in the aviation industry and establishing effective incident reporting programmes can go a long way toward achieving that goal. This article will describe the steps and issues required to establish an incident reporting system. The authors summarize the lessons learned from the ASRS, now in its twentieth year of operation and from the Confidential Human Factors Reporting (HER) Programme run by British Airways, an airline that is a recognized world leader in safety reporting and analysis. The differences between government and airline operation of confidential safety reporting systems will be addressed.

OLeary, Mike J.↗
NASA NTRS1990

Mission safety evaluation report for STS-33: Postflight edition

Space Transportation System 33 (STS-33) safety risk factors that represent a change from previous flights, factors from previous flights that have an impact on this flight, and the factors that are not unique to this flight are discussed. While some changes to the safety risk baseline are included to highlight their significance in risk level change, the primary purpose is to insure that changes which were too late to include in formal changes through the Failure Modes and Effects Analysis/Critical Items List and Hazard Analysis process are documented along with the safety position, which includes the acceptance rationale.

Hill, William C.↗
NASA NTRS1991

Mission safety evaluation report for STS-35: Postflight edition

Space Transportation System 35 (STS-35) safety risk factors that represent a change from previous flights that had an impact on this flight, and factors that were unique to this flight are discussed. While some changes to the safety risk baseline since the previous flight are included to highlight their significance in risk level change, the primary purpose is to insure that changes which were too late too include in formal changes through the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) and Hazard Analysis process are documented along with the safety position, which includes the acceptance rationale.

Hill, William C.↗
NASA NTRS1989

Mission safety evaluation report for STS-29, postflight edition

The topics covered include: (1) an STS-29 mission summary; (2) safety risk factors/issues; (3) resolved STS-29 safety risk factors; (4) STS-27 flight anomalies; (5) STS-26 flight anomalies; and (6) the STS-29 official inflight anomaly report. Background information and a list of acronyms are also presented.

Source record↗
NASA NTRS1989

Mission safety evaluation report for STS-30, postflight edition

The topics covered include: (1) an STS-30 mission summary; (2) safety risk factors/issues; (3) resolved STS-30 safety risk factors; (4) STS-29 inflight anomalies; (5) STS-27 inflight anomalies; and (6) the STS-30 official inflight anomaly report. Background information and a list of acronyms are also presented.

Finkel, Seymour I.↗
NASA NTRS1990

Mission Safety Evaluation Report for STS-32, Postflight Edition

The topics covered include: (1) an STS-32 mission summary; (2) safety risk factors/issues; (3) resolved STS-32 safety risk factors; (4) STS-32 inflight anomalies; (5) STS-28 inflight anomalies; and (6) STS-32 inflight anomalies. Background information and a list of acronyms are also presented.

Hill, William C.↗
NASA NTRS1990

Mission Safety Evaluation Report for STS-36, Postflight Edition

The topics covered include: (1) an STS-36 mission summary; (2) safety risk factors/issues; (3) resolved STS-36 safety risk factors; (4) STS-32 inflight anomalies; (5) STS-34 inflight anomalies; and (6) STS-36 inflight anomalies. Background information and a list of acronyms are also presented.

Hill, William C.↗
NASA NTRS1991

Mission Safety Evaluation Report for STS-43, Postflight Edition

Some of the topics covered include: (1) an STS-43 mission summary; (2) safety risks factors/issues; (3) resolved STS-43 safety risk factors; (4) STS-40 inflight anomalies; (5) STS-37 inflight anomalies; and (6) STS-43 inflight anomalies. Background information and a list of acronyms are also presented.

Hill, William C.↗
NASA NTRS1991

Mission safety evaluation report for STS-37, postflight edition

STS-37/Atlantis was launched on April 5, 1991 from Kennedy Space Center launch complex 39B at 9:23 a.m. Eastern Standard Time (EST). Launch was delayed 4 minutes 45 seconds because of safety concerns about the low cloud ceiling and the wind direction in the potential blast area. Based on the limited number and type of inflight anomalies encountered, the Space Shuttle operated satisfactorily throughout the STS-37 mission. A contingency EVA was performed by the crew on Flight Day (FD) 3 to free a sticky Gamma Ray Observatory (GRO) high gain antenna, after which the GRO primary payload was successfully deployed by the Orbiter's Remote Manipulator System. The GRO, which weighed just over 35,000 lbs, was the heaviest NASA science satellite ever deployed by the Space Shuttle into low Earth orbit. The scheduled entry/landing on FD 6 was waved off for one day due to high wind conditions at Edwards Air Force Base. Atlantis landed on FD 7, 11 April 1991 on Edwards AFB lakebed runway 33 at 9:55 a.m. Eastern Daylight Time.

Hill, William C.↗
NASA NTRS2002

Crew Factors in Flight Operations XIV: Alertness Management in Regional Flight Operations Education Module

Regional operations encompass a broad range of pilots and equipment. This module is intended to help all those involved in regional aviation, including pilots, schedulers, dispatchers, maintenance technicians, policy makers, and others, to understand the physiological factors underlying fatigue, how flight operations affect fatigue, and what can be done to counteract fatigue and maximize alertness and performance in their operations. The overall purpose of this module is to promote aviation safety, performance, and productivity. It is intended to meet three specific objectives: (1) to explain the current state of knowledge about the physiological mechanisms underlying fatigue; (2) to demonstrate how this knowledge can be applied to improving flight crew sleep, performance, and alertness; and (3) to offer strategies for alertness management. Aviation Safety Reporting System (ASRS) and National Transportation Safety Board (NISH) reports are used throughout this module to demonstrate that fatigue is a safety issue in the regional operations community. The appendices at the end of this module include the ASRS reports used for the examples contained in this publication, brief introductions to sleep disorders and relaxation techniques, summaries of relevant NASA publications, and a list of general readings on sleep, sleep disorders, and circadian rhythms.

Rosekind, Mark R.↗
NASA NTRS2002

Crew Factors in Flight Operations XV: Alertness Management in General Aviation Education Module

Regional operations encompass a broad range of pilots and equipment. This module is intended to help all those involved in regional aviation, including pilots, schedulers, dispatchers, maintenance technicians, policy makers, and others, to understand the physiological factors underlying fatigue, how flight operations affect fatigue, and what can be done to counteract fatigue and maximize alertness and performance in their operations. The overall purpose of this module is to promote aviation safety, performance, and productivity. It is intended to meet three specific objectives: (1) to explain the current state of knowledge about the physiological mechanisms underlying fatigue; (2) to demonstrate how this knowledge can be applied to improving flight crew sleep, performance, and alertness; and (3) to offer strategies for alertness management. Aviation Safety Reporting System (ASRS) and National Transportation Safety Board (NISH) reports are used throughout this module to demonstrate that fatigue is a safety issue in the regional operations community. The appendices at the end of this module include the ASRS reports used for the examples contained in this publication, brief introductions to sleep disorders and relaxation techniques, summaries of relevant NASA publications, and a list of general readings on sleep, sleep disorders, and circadian rhythms.

Rosekind, Mark R.↗
NASA NTRSDate not supplied

An Approach for Defining IASMS Services, Functions, and Capabilities

Assuring safety in the NAS with the inclusion of new entrants, such as Advanced Air Mobility (AAM), will require overcoming unique safety challenges that result from combining innovative technologies with novel airspace concepts for moving people and cargo using autonomous vehicles. The focus of the In-time Aviation Safety Management System (IASMS) is to overcome AAM’s safety assurance challenges. The IASMS Concept of Operations (ConOps) describes an interconnected set of services, functions, and capabilities (SFCs) designed to manage operational risks, identify unknown risks, and inform system designs. This paper describes an approach for defining SFCs based on technology trends in research, assessment of known and unknown risks in voluntary safety reports, and causal and contributing factors in aviation accidents and incidents. This approach would identify potential SFCs that further expand the Monitor, Assess, and Mitigate (M-A-M) functionality that represents the enabling framework of the IASMS. Safety implications that will result from integration of AAM in the transformation of the National Airspace System (NAS) were addressed in National Academies committees reports on AAM and IASMS. Development of a ConOps for IASMS was a top recommendation and can be represented as a reframing of safety assurance that builds on real-time alerting such as the Traffic Alert and Collision Avoidance System, and adds the more encompassing in-time temporal parameter in recognition of the different timelines for collecting and assessing safety data for risk mitigations. For example, mining for safety trends from data sources such as the Aviation Safety Information Analysis and Sharing system occurs over a longer time period. Research on AAM operations poses that SFCs can be designed to monitor the safety margin appropriate for AAM including with regards to the distance between current flight parameters and nominal ideal conditions. These in-time comparisons will become more complex as the density of operations increases at least in certain areas and can include planned and actual 4D trajectory, and in-time comparisons having implications on conflict modeling and prediction including expected and actual departure time, fix/waypoint crossing times, and arrival time. These comparisons would be integrated as part of SFCs that redefine and inform new safety margin. An increased safety margin improves management of operational risks while reducing the potential for anomalies. An increased safety margin also has implications for operator confidence in the certainty of its operations and trust in automation. Technology trends in research could be used to refine existing SFCs and define needs for additional SFCs that provide safety improvements to the design and operation of vehicles, airspace design, and operator performance requirements. NASA is developing innovative approaches to safeguard against major accidents and incidents that have occurred in the NAS and those anticipated with the inclusion of envisioned AAM operations. The innovations use operational performance data to monitor, detect, and predict flight variations exceeding safe nominal patterns, such as would be caused by navigational error, severe weather complications, or hijacking of UAS controls. These innovative approaches have high potential to prevent accidents and incidents in the new AAM era. It is anticipated that elements of the innovations will evolve into SFCs for the IASMS. Voluntary safety reports can be monitored to identify anomalies related to design or operational performance risks. Reports could be periodically monitored and assessed for specific topics. Reports might serve as weak signals or precursors indicative of emergent risk such as when combined with other safety information. The architecture could include SFCs that are based on voluntary safety reports recognizing the periodic temporal nature of data analysis. As previously mentioned, aviation accidents with their causal and contributing precursors can inform the need for SFCs in the IASMS. Accidents and incidents at San Francisco International Airport such as Asiana 214 and Air Canada 759 illustrate how combinations of different factors lead to increased risk. These types of precursors and different factors have implications on the types of SFCs that could be needed to monitor and manage different sources and types of design and operational risk. Continuing to assure the safety of AAM as designs and operations gain in complexity can be accompanied by defining SFCs that also increase in complexity. These SFCs can leverage information from findings and recommendations synthesized across on-going research, voluntary safety reports, and accident and incident reports. These SFCs can serve to refine accuracy of algorithms and resolve limitations with current practices. The IASMS architecture represents the framework for the SFCs and their critical role in safety assurance.

In-Time Aviation Safety Management System↗
NASA NTRS1991

Who or what saved the day? A comparison of traditional and glass cockpits

This study examined incidents reported to NASAs Aviation Safety Reporting System from a different perspective: rather than focusing on the factors contributing to or causing incidents, this study concentrated on who and what (subsystems and information) enabled the recovery from an anomaly. Incident reports describing altitude deviations were classified as to cockpit type (glass or traditional), flight phase, agent restoring safety, and cockpit subsystems providing specific information that helped restore safety. The data revealed and quantified the agents, information, and factors that 'saved the day'. The flight crews used many sources of information to detect the altitude deviations: altimeter, outside scene, altitude alert, kinesthesia, attitude and communications monitoring. In the glass cockpits the crews also used the map display and autothrottles to detect deviations from assigned altitudes. There was an interaction between the person detecting the anomaly (controller/flight crew) and the type of cockpit. Glass cockpit flight crews detect proportionally more deviations than their counterparts in traditional cockpits, while controllers tend to detect more deviations involving traditional cockpits. There was no effect of cockpit position (captain/first officer). A model that details the flow of altitude information between air traffic control, flight crews, and cockpit subsystems, was developed and validated. This model identifies strengths and weaknesses in the flow of altitude information within the current ground/air system.

Degani, Asaf↗
NASA NTRS1991

Mission safety evaluation report for STS-48, postflight edition

Space Shuttle Discovery was launched into a 57 deg inclination orbit from the Kennedy Space Center (KSC) Launch Complex 39A at 7:11 p.m. EDT on 12 Sep. 1991. STS-48 was the second mission since return-to-flight to have KSC as the planned end-of-mission landing site, and the first mission to have a planned night landing at KSC. However, due to weather conditions at KSC, Discovery flew one extra orbit and landed at Edwards AFB, Calif. at 3:38 a.m. EDT on 18 Sep. 1991. Operation of all systems was generally satisfactory during the 5 day mission. On flight day 3, the Upper Atmospheric Research Satellite (UARS) was deployed from Discovery's payload bay 350 statute miles above Earth. This orbiting observatory will study mankind's effects on the planet's atmosphere and its shielding ozone layer. STS-48 safety risk factors are addressed that represent a change from previous flights, factors from previous flights that had an impact on this flight, and factors that are unique to this flight.

Clatterbuck, Guy E.↗