Hydrogen safety Progress report no. 7 1 Jul. - 30 Sep. 1965
Performance characteristics of two console-type hydrogen gas detectors sampling by diffusion and convection
DIFFUSION↗
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Hydrogen safety annual report, 1 jan. - 31 dec. 1965
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Grumer, J.↗
A review of in-flight emergencies in the ASRS data base
A series of 154 in-flight emergencies as reported to the Aviation Safety Reporting System are described. The various types of emergencies are examined and an attempt is made to determine the human errors and other factors associated with each incident, as well as the measures taken to resolve the emergency. It is concluded that nearly one half of those emergencies reported were related to failure or malfunction of aircraft subsystems. Of all the emergencies, nearly one quarter were associated with power plant failure. Other frequently encountered emergency types are associated with operation in instrument meteorological conditions without appropriate clearance or qualification, and with low fuel state situations. Human error is prominently featured in many of the incidents, appearing in the actions of pilots and air traffic controllers.
Porter, R. F.↗
Operational problems experienced by single pilots in instrument meteorological conditions
The development and implementation of a search strategy to extract pertinent reports from the Aviation Safety Reporting System-2 (ASRS-2) database are described. For any particular occurence to be pertinent to the study, it must have satisfied the following conditions: the aircraft must be of the type usually flown by a single pilot; operation on an IFR flight plan in instrument meteorological conditions; pilot experienced an operational problem. The occurances consist of reports by the pilot about his own performance, by the pilot about the system performance, or by an air traffic controller about a pilot's performance.
Weislogel, S.↗
Mission safety evaluation report for STS-39, postflight edition
After a delay of approximately 2 months due to a rollback from the pad to replace the External Tank door lug housing, Space Shuttle Discovery was launched from NASA-Kennedy at 7:33 a.m. Eastern Daylight Time on 28 April 1991. STS-39 was the first unclassified DoD Shuttle mission. On 28 April, countdown proceeded normally through the T-20 minute hold. No significant problems were encountered except for the Operations Sequence-2 recorder starting unexpectedly; it was stopped by an uplink command. Discovery landed on KSC runway 15 at 2:55 p.m. EDT on 6 May 1991. This was the second time in 6 months that the Space Shuttle was diverted to KSC for landing because of high winds at Edwards AFB, Calif. This was also the 7th of 40 Shuttle missions to land at KSC in the history of the Space Shuttle Program. The Main Landing Gear outer right tire shredded 3 of the 16 cords due to either an uneven landing or a maximum force breaking test during rollout. Contributing factors to the tire cord shredding were the development of last minute crosswinds and reluctance of the ground controllers to distract the Shuttle pilots with warnings of the low flight path. As a corrective action, communication procedures will be modified for future flights.
Hardie, Kenneth O.↗
Mission safety evaluation report for STS-38, postflight edition
After several months delay due to Liquid Hydrogen (LH2) leaks in the External Tank (ET) 17 in LH2 umbilical disconnect, Atlantis was launched at 6:48 p.m. Eastern Standard Time on 15 Nov. 1990. Atlantis was cleared for launch after the replacement of the ET 17 in umbilical disconnect and a successful tanking test on 24 Oct. 1990. No technical concerns were encountered during the countdown. The end of the STS-38 mission was extended by one day because of high crosswinds at the primary landing site, Edwards Air Force Base (EAFB), Calif. On the next day, 20 Nov. 1990, the winds were too high for a safe landing at EAFB, and a decision was made to select the Shuttle Landing Facility (SLF) at the Kennedy Space Center (KSC) at the primary landing site. The deorbit burn was performed on orbit 79 of the STS-38 mission. Reentry and descent were effected with no problems. Postlanding inspection of Atlantis' exterior found little evidence of damage. There has been a concern about returning an Orbiter to KSC, because the last mission to do so experienced tire failure. Atlantis' tires and brakes were in excellent condition with no indication of excessive wear.
Hill, William C.↗
"Oops, It didn't arm." - A Case Study of Two Automation Assisted Altitude Deviations
Altitude deviations are the most common pilot error reported to the Aviation Safety Reporting System. Last year, altitude deviations were reported to the ASRS at the rate of about one per hour. The reporting pilot's narrative is usually our only source of information about what happened in these incidents. In a recent line-oriented, simulator study, twenty-two airline crews flew a realistic, two-hour mission in a DC-9 and an MD-88 aircraft. This paper will describe and analyze two of the five altitude deviations that were observed during this study. The paper focuses on the flight crews' use (or misuse) of the autopilot and autothrottle during these incidents.
Plamer, Everett↗
Identification of Error Patterns in Terminal-Area ATC Communications
Advancing air traffic management technologies have enabled a greater number of aircraft to use the same airspace more effectively. As aircraft separations are reduced and final approaches are more finely timed, there is less room for error. The present study examined 122 terminal-area, loss-of-separation and procedure violation incidents reported to the Aviation Safety Reporting System (ASRS) by air traffic controllers. Narrative description codes were used for the incidents for type of violation, contributing factors, recovery strategies, and consequences. Usually multiple errors occurred prior to the violation. Error sequences were analyzed and common patterns of errors were identified. In half of the incidents, errors were noticed in time to correct mistakes. Of these, almost 43% committed additional errors during the recovery attempt. This analysis shows that redundancies in the present air traffic control system may not be sufficient to support large increases in traffic density. Error prevention and design considerations for air traffic management systems are discussed.
Quinn, Cheryl↗
Part 121 Low Altitude Events: An Analysis of ASRS Reports
This presentation provides an aviation SME's human factors analysis of selected Low Altitude and Controlled Flight Towards Terrain (CFTT) events involving Part 121 air carriers as reported to the Aviation Safety Reporting System (ASRS).
low altitude↗
Why System Safety Professionals Should Read Accident Reports
System safety professionals, both researchers and practitioners, who regularly read accident reports reap important benefits. These benefits include an improved ability to separate myths from reality, including both myths about specific accidents and ones concerning accidents in general; an increased understanding of the consequences of unlikely events, which can help inform future designs; a greater recognition of the limits of mathematical models; and guidance on potentially relevant research directions that may contribute to safety improvements in future systems.
Holloway, C. M.↗
Multi-media authoring - Instruction and training of air traffic controllers based on ASRS incident reports
This paper discusses the use of computer-assisted instructions and flight simulations to enhance procedural and perceptual motor task training. Attention is called to the fact that incorporating the accident and incident data contained in reports filed with the Aviation Safety Reporting System (ASRS) would be a valuable training tool which the learner could apply for other situations. The need to segment the events is emphasized; this would make it possible to modify events in order to suit the needs of the training environment. Methods were developed for designing meaningful scenario development on runway incursions on the basis of analysis of ASRS reports. It is noted that, while the development of interactive training tools using the ASRS and other data bases holds much promise, the design and production of interactive video programs and laser disks are very expensive. It is suggested that this problem may be overcome by sharing the costs of production to develop a library of materials available to a broad range of users.
Armstrong, Herbert B.↗
What ASRS incident data tell about flight crew performance during aircraft malfunctions
This research examined 230 reports in NASA's Aviation Safety Reporting System's (ASRS) database to develop a better understanding of factors that can affect flight crew performance when crew are faced with inflight aircraft malfunctions. Each report was placed into one of two categories, based on severity of the malfunction. Report analysis was then conducted to extract information regarding crew procedural issues, crew communications and situational awareness. A comparison of these crew factors across malfunction type was then performed. This comparison revealed a significant difference in ways that crews dealt with serious malfunctions compared to less serious malfunctions. The authors offer recommendations toward improving crew performance when faced with inflight aircraft malfunctions.
Sumwalt, Robert L.↗
MIKA: Manager for Intelligent Knowledge Access Toolkit for Engineering Knowledge Discovery and Information Retrieval
Repositories of safety reports are often underutilized and only analyzed manually by trained experts, despite safety management systems requiring reports. These collections of documents contain a wealth of information from past projects and operations that could improve system safety and design. Advances in natural language processing techniques have improved information extraction and retrieval in consumer technology, biomedicine, and finance, for instance, but have not been applied to engineering documents on the same scale. To this end, the Manager for Intelligent Knowledge Access (MIKA) open-source toolkit has been developed for rapid knowledge discovery and information retrieval in safety engineering applications. The MIKA toolkit uses state-of-the-art natural language processing algorithms and allows a user to apply these methods to their own dataset. This paper describes the MIKA toolkit and its two primary capabilities, knowledge discovery and information retrieval, and demonstrates the toolkit via a case study on National Transportation Safety Board (NTSB) reports.
Machine Learning↗
MIKA: Manager for Intelligent Knowledge Access Toolkit for Engineering Knowledge Discovery and Information Retrieval
Repositories of safety reports are often underutilized and only analyzed manually by trained experts, despite safety management systems requiring reports. These collections of documents contain a wealth of information from past projects and operations that could improve system safety and design. Advances in natural language processing techniques have improved information extraction and retrieval in consumer technology, biomedicine, and finance, for instance, but have not been applied to engineering documents on the same scale. To this end, the Manager for Intelligent Knowledge Access (MIKA) open-source toolkit has been developed for rapid knowledge discovery and information retrieval in safety engineering applications. The MIKA toolkit uses state-of-the-art natural language processing algorithms and allows a user to apply these methods to their own dataset. This paper describes the MIKA toolkit and its two primary capabilities, knowledge discovery and information retrieval, and demonstrates the toolkit via a case study on National Transportation Safety Board (NTSB) reports.
Systems Engineering↗
ASRS for Unmanned Aviation Systems
This presentation provides an overview of NASA's Aviation Safety Reporting System (ASRS) for Unmanned Aviation Systems / drones
Aviation Safety Reporting System↗
Personal Electronic Devices and Their Interference with Aircraft Systems
A compilation of data on personal electronic devices (PEDs) attributed to having created anomalies with aircraft systems. Charts and tables display 14 years of incidents reported by pilots to the Aviation Safety Reporting System (ASRS). Affected systems, incident severity, sources of anomaly detection, and the most frequently identified PEDs are some of the more significant data. Several reports contain incidents of aircraft off course when all systems indicated on course and of critical events that occurred during landings and takeoffs. Additionally, PEDs that should receive priority in testing are identified.
Ross, Elden↗
Resilience, ASRS, and the Narrative about Human Error
We present a study of weather-related incident reports submitted to NASA’s Aviation Safety Reporting System (ASRS) by air carrier pilots in the US. Using specific examples, we examine the relevant aspects of human performance and resilience management exhibited during these incidents. We describe the common narrative about human error and how ASRS data can be used to change it.
resilience↗
A New Cure for Medical Errors
In May 2000, senior officials of the U.S. Department of Veterans Affairs (VA) and NASA signed an agreement that would commit the two agencies to create the Patient Safety Reporting System (PSRS) to report: events or situations that could have resulted in accident, injury, or illness, but did not, either by chance or through timely intervention (close-calls); unexpected serious occurrences that involved a patient or employee's death, physical injury, or psychological injury; lessens learned; and safety ideas. The VA provided NASA with funding for the initial development of the new system, which automatically removes all personal names, facility names and locations, and other potentially identifying information before entering reports into its database. Designed to complement the VA's current internal reporting systems, the PSRS is modeled after NASA's Aviation Safety Reporting System, which was established in 1975 under a Memorandum of Agreement between the Federal Aviation Administration and NASA and began operation in 1976.
Source record↗