Search NASA⌕ Search

SEARCH · Search NASA

Results for “ACCIDENT CAUSES”

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 163 records · Page 9

Terminal weather information management

Since the mid-1960's, microburst/windshear events have caused at least 30 aircraft accidents and incidents and have killed more than 600 people in the United States alone. This study evaluated alternative means of alerting an airline crew to the presence of microburst/windshear events in the terminal area. Of particular interest was the relative effectiveness of conventional and data link ground-to-air transmissions of ground-based radar and low-level windshear sensing information on microburst/windshear avoidance. The Advanced Concepts Flight Simulator located at Ames Research Center was employed in a line oriented simulation of a scheduled round-trip airline flight from Salt Lake City to Denver Stapleton Airport. Actual weather en route and in the terminal area was simulated using recorded data. The microburst/windshear incident of July 11, 1988 was re-created for the Denver area operations. Six experienced airline crews currently flying scheduled routes were employed as test subjects for each of three groups: (1) A baseline group which received alerts via conventional air traffic control (ATC) tower transmissions; (2) An experimental group which received alerts/events displayed visually and aurally in the cockpit six miles (approx. 2 min.) from the microburst event; and (3) An additional experimental group received displayed alerts/events 23 linear miles (approx. 7 min.) from the microburst event. Analyses of crew communications and decision times showed a marked improvement in both situation awareness and decision-making with visually displayed ground-based radar information. Substantial reductions in the variability of decision times among crews in the visual display groups were also found. These findings suggest that crew performance will be enhanced and individual differences among crews due to differences in training and prior experience are significantly reduced by providing real-time, graphic display of terminal weather hazards.

Lee, Alfred T.↗

Philosophy, policies, and procedures - The three P's of flight-deck operations

Standard operating procedures are drafted and provided to flightcrews to dictate the manner in which tasks are carried out. Failure to conform to Standard Operating Procedures (SOP) is frequently listed as the cause of violations, incidents, and accidents. However, procedures are often designed piecemeal, rather than being based on a sound philosophy of operations and policies that follow from such a philosophy. A framework of philosophy, policies, and procedures is proposed.

Degani, Asaf↗

An Experimental and Numerical Study of Icing Effects on the Performance and Controllability of a Twin Engine Aircraft

In September 1997 the National Transportation Safety Board (NTSB) requested assistance from the NASA Lewis Research Center (LeRC) Icing Branch in the investigation of an aircraft accident that was suspected of being caused by ice contamination. In response to the request NASA agreed to perform an experimental and computational study. The main activities that NASA performed were LERC Icing Research Tunnel (IRT) testing to define ice shapes and 2-D Navier-Stokes analysis to determine the performance degradation that those ice shapes would have caused. An IRT test was conducted in January 1998. Most conditions for the test were based upon raw and derived data from the Flight Data Recorder (FDR) recovered from the accident and upon the current understanding of the Meteorological conditions near the accident. Using a two-dimensional Navier-Stokes code, the flow field and resultant lift and drag were calculated for the wing section with various ice shapes accreted in the IRT test. Before the final calculations could be performed extensive examinations of geometry smoothing and turbulence were conducted. The most significant finding of this effort is that several of the five-minute ice accretions generated in the IRT were found by the Navier-Stokes analysis to produce severe lift and drag degradation. The information generated by this study suggests a possible scenario for the kind of control upset recorded in the accident. Secondary findings were that the ice shapes accreted in the IRT were mostly limited to the protected pneumatic boot region of the wing and that during testing, activation of the pneumatic boots cleared most of the ice.

Reehorst, A.↗

Context-Aware Intelligent Assistant Approach to Improving Pilot's Situational Awareness

Faulty decision making due to inaccurate or incomplete awareness of the situation tends to be the prevailing cause of fatal general aviation accidents. Of these accidents, loss of weather situational awareness accounts for the largest number of fatalities. We describe a method for improving weather situational awareness through the support of a contextaware,domain and task knowledgeable, personalized and adaptive assistant. The assistant automatically monitors weather reports for the pilot's route of flight and warns her of detected anomalies. When and how warnings are issued is determined by phase of flight, the pilot s definition of acceptable weather conditions, and the pilot's preferences for automatic notification. In addition to automatic warnings, the pilot is able to verbally query for weather and airport information. By noting the requests she makes during the approach phase of flight, our system learns to provide the information without explicit requests on subsequent flights with similar conditions. We show that our weather assistant decreases the effort required to maintain situational awareness by more than 5.5 times when compared to the conventional method of in-flight weather briefings.

Spirkovska, Lilly↗

Aircraft Ice Accretion Due to Large-Droplet Icing Clouds

Studies of aircraft icing due to clouds consisting of individual droplets 10 times larger than those normally found in icing conditions are being carried out by members of the NASA Lewis Research Center's Icing Technology Branch. When encountered by an aircraft in freezing conditions, clouds consisting of large water droplets have a significantly different effect than those with normal droplets. A large-water-droplet cloud has been suggested as the cause of a commuter airplane accident in the late fall of 1994. As a result, studies of what happens to aircraft flying in these rare, but potentially very hazardous, conditions have been reemphasized.

Source record↗

Single pilot IFR operating problems determined from accidental data analysis

The accident reports examined were restricted to instrument rated pilots flying in IFR weather. A brief examination was made of accidents which occurred during all phases of flight and which were due to all causes. A detailed examination was made of those accidents which involved a single pilot which occurred during the landing phases of flight, and were due to pilot error. Problem areas found include: (1) landing phase operations especially final approach, (2) pilot weather briefings, (3) night approaches in low IFR weather, (4) below minimum approaches, (5) aircraft icing, (6) imprecise navigation, (7) descending below minimum IFR altitudes, (8) fuel mismanagement, (9) pilot overconfidence, and (10) high pilot workload especially in twins. Some suggested areas of research included: (1) low cost deicing systems, (2) standardized navigation displays, (3) low cost low-altitude warning systems, (4) improved fuel management systems, (5) improved ATC communications, (6) more effective pilot training and experience acquisition methods, and (7) better weather data dissemination techniques.

Forsyth, D. L.↗

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Johnson, C. W.↗

Structural analysis of a bolted joint concept for the space shuttle's solid rocket motor casing

The Space Shuttle Challenger accident is thought to have been caused by the failure of one of the tang-clevis joints joining together the casing segments of the Solid Rocket Motors (SRM). Excessive displacement between the tang and clevis, possibly unseating the O-ring seals, may have initiated the resulting accident. An effort was made at NASA Langley Research Center to design an alternative concept for mating the casing segments. A bolted flange joint concept was designed and analyzed to determine if the concept would effectively maintain a seal while minimizing joint weight and controlling stress levels. It is shown that under the loading conditions analyzed the seal area of the joint remains seated. The only potential stress problem is a stress concentration in the flange at the edge of the bolt hole, which is highly localized. While heavier than the existing joint, this concept does have some advantages making the bolted joint an attractive alternative.

Lindell, Michael C.↗

Structural analysis of a bolted joint concept for the Space Shuttle's solid rocket motor casing

The Space Shuttle Challenger accident is thought to have been caused by the failure of one of the tang-clevis joints which join together the casing segments of the Solid Rocket Motors (SRM). Excessive displacement between the tang and clevis, possibly unseating the O-ring seals, may have initiated the resulting accident. An effort was undertaken at NASA's Langley Research Center to design an alternative concept for mating the casing segments. A bolted flanged joint concept was designed and analyzed to determine if the concept would effectively maintain a seal while minimizing joint weight and controlling stress levels. It is shown that under the loading condition analyzed the seal area of the joint remains seated. The only potential stress problem is a stress concentration in the flange at the edge of the bolt hole, which is highly localized. While heavier than the existing joint, this concept does have some advantages which make the bolted joint an attractive alternative.

Lindell, Michael C.↗

NASA Weather Support 2017

In the mid to late 1980's, as NASA was studying ways to improve weather forecasting capabilities to reduce excessive weather launch delays and to reduce excessive weather Launch Commit Criteria (LCC) waivers, the Challenger Accident occurred and the AC-67 Mishap occurred.[1] NASA and USAF weather personnel had advance knowledge of extremely high levels of weather hazards that ultimately caused or contributed to both of these accidents. In both cases, key knowledge of the risks posed by violations of weather LCC was not in the possession of final decision makers on the launch teams. In addition to convening the mishap boards for these two lost missions, NASA convened expert meteorological boards focusing on weather support. These meteorological boards recommended the development of a dedicated organization with the highest levels of weather expertise and influence to support all of American spaceflight. NASA immediately established the Weather Support Office (WSO) in the Office of Space Flight (OSF), and in coordination with the United Stated Air Force (USAF), initiated an overhaul of the organization and an improvement in technology used for weather support as recommended. Soon after, the USAF established a senior civilian Launch Weather Officer (LWO) position to provide meteorological support and continuity of weather expertise and knowledge over time. The Applied Meteorology Unit (AMU) was established by NASA, USAF, and the National Weather Service to support initiatives to place new tools and methods into an operational status. At the end of the Shuttle Program, after several weather office reorganizations, the WSO function had been assigned to a weather branch at Kennedy Space Center (KSC). This branch was dismantled in steps due to further reorganization, loss of key personnel, and loss of budget line authority. NASA is facing the loss of sufficient expertise and leadership required to provide current levels of weather support. The recommendation proposed herein is to re-establish the WSO under a high level office, with funding set at about the same levels as today, with a revitalized charter and focus to allow for the WSO to operate as originally intended.

lessons learned↗

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.↗

Helicopter Safety Research

In response to the President's challenge to reduce civil aviation accidents by a factor of 10 by the year 2022, NASA has embarked on an ambitious safety program in partnership with other government agencies and industry. The helicopter element of the NASA initiative has been guided by a series of accident analyses aimed at identifying the most frequent causes and consequences and initiating research to prevent or mitigate these factors. This talk will summarize the key findings of three of the accident analyses, the major elements of the safety program, and how helicopter safety research relates to the safety program.

Hart, Sandra G.↗

Incorporation of wind shear terms into the governing equations of aircraft motion

Conventional analyses of aircraft motion in the atmosphere have neglected wind speed variability on the scales associated with many atmospheric phenomena such as thunderstorms, low-level jets, etc. These phemonena produce wind shears that have been determined as the probable cause in many recent commercial airline accidents. This paper derives the six degrees equations of motion or an aircraft incorporating the variable wind terms. The equations are presented in several coordinate systems (i.e., body coordinates, inertial coordinates, etc.). The wind shear terms, including the temporal and spatial gradients of the wind, appear differently in the various coordinate system. These terms are discussed. Also, the influence of wind shear on inputs to computing the aerodynamic coefficients such as the effects of wind velocity vector rotation on relative angular rates of rotation and on the time rate of change of angles of attack and side slip are addressed.

Frost, W.↗

Bayesian Safety Risk Modeling of Human-Flightdeck Automation Interaction

Usage of automatic systems in airliners has increased fuel efficiency, added extra capabilities, enhanced safety and reliability, as well as provide improved passenger comfort since its introduction in the late 80's. However, original automation benefits, including reduced flight crew workload, human errors or training requirements, were not achieved as originally expected. Instead, automation introduced new failure modes, redistributed, and sometimes increased workload, brought in new cognitive and attention demands, and increased training requirements. Modern airliners have numerous flight modes, providing more flexibility (and inherently more complexity) to the flight crew. However, the price to pay for the increased flexibility is the need for increased mode awareness, as well as the need to supervise, understand, and predict automated system behavior. Also, over-reliance on automation is linked to manual flight skill degradation and complacency in commercial pilots. As a result, recent accidents involving human errors are often caused by the interactions between humans and the automated systems (e.g., the breakdown in man-machine coordination), deteriorated manual flying skills, and/or loss of situational awareness due to heavy dependence on automated systems. This paper describes the development of the increased complexity and reliance on automation baseline model, named FLAP for FLightdeck Automation Problems. The model development process starts with a comprehensive literature review followed by the construction of a framework comprised of high-level causal factors leading to an automation-related flight anomaly. The framework was then converted into a Bayesian Belief Network (BBN) using the Hugin Software v7.8. The effects of automation on flight crew are incorporated into the model, including flight skill degradation, increased cognitive demand and training requirements along with their interactions. Besides flight crew deficiencies, automation system failures and anomalies of avionic systems are also incorporated. The resultant model helps simulate the emergence of automation-related issues in today's modern airliners from a top-down, generalized approach, which serves as a platform to evaluate NASA developed technologies

Ancel, Ersin↗

Evaluation of Synthetic Vision Display Concepts for Improved Awareness in Unusual Attitude Recovery Scenarios

A recent study conducted by the Commercial Aviation Safety Team (CAST) determined 40 percent of all fixed-wing fatal accidents, between 2001 and 2011, were caused by Loss-of-Control (LOC) in flight (National Transportation Safety Board, 2015). Based on their findings, CAST recommended manufacturers develop and implement virtual day-visual meteorological conditions (VMC) display systems, such as synthetic vision or equivalent systems (CAST, 2016). In a 2015 simulation study conducted at NASA Langley Research Center (LaRC), researchers gathered to test and evaluate virtual day-VMC displays under realistic flight operation scenarios capable of inducing reduced attention states in pilots. Each display concept was evaluated to determine its efficacy to improve attitude awareness. During the experiment, Evaluation Pilots (EPs) were shown the following three display concepts on the Primary Flight Display (PFD): Baseline, Synthetic Vision (SV) with color gradient, and SV with texture. The baseline configuration was a standard, conventional 'blue over brown' display. Experiment scenarios were simulated over water to evaluate Unusual Attitude (UA) recovery over 'featureless terrain' environments. Thus, the SV with color gradient configuration presented a 'blue over blue' display with a linear blue color progression, to differentiate attitude changes between sky and ocean. The SV with texture configuration presented a 'blue over blue' display with a black checkerboard texture atop a synthetic ocean. These displays were paired with a Background Attitude Indicator (BAI) concept. The BAI was presented across all four Head-Down Displays (HDDs), displaying a wide field-of-view blue-over-blue attitude indicator. The BAI aligned with the PFD and showed through the background of the navigation displays with opaque transparency. Each EP participated in a two-part experiment series with a total seventy-five trial runs: Part I included a set of twenty-five Unusual Attitude Recovery (UAR) scenarios; Part II included a set of fifty Attitude Memory Recall Tasks (AMRT). At the conclusion of each trial, EPs were asked to complete a set post-run questionnaires. Quantitative results showed that there were no significant statistical effects on UA recovery times when utilizing SV with or without the presence of a BAI. Qualitative results show the SV displays (color, texture) with BAI On are most preferred for both UA recognition and recovery when compared with the baseline display. When only comparing SV display concepts, EPs performed better when using the SV with texture, BAI On, than any other display configuration. This is an interesting find considering most EPs noted their preference towards the SV with color gradient when the BAI was on.

Nicholas, Stephanie↗

Going Beyond Reliability to Robustness and Resilience in Space Life Support Systems

The words reliability, robustness, and resilience are often used interchangeably to describe tough and dependable systems but the distinctions between them suggest how to design more serviceable space systems. Reliability is simply the quality of consistently performing well. A system that dependably meets its design requirements in the specified environment is reliable. The designers may not consider themselves responsible for failures under unanticipated conditions. Robustness is the capability of performing without failure under a wide range of conditions, which can go beyond the expected range to include possible off-nominal conditions. Resilience is the ability to recover from or adapt to unanticipated damaging events, such as failures, accidents, external disruptions, and repurposing. Such changes can invalidate the usual operating assumptions and cause system failure. Reliability, robustness, and resilience describe dependable performance under increasingly difficult conditions, first the specified environment, then a wider possible environment, and finally unanticipated damaging conditions. These three qualities are increasingly desirable and increasingly difficult to achieve. Engineering for resilience would design systems that can ignore or repair failures, survive accidents, and recover from unanticipated disruptions. Increasing the resilience of space systems would greatly increase space crew safety. Improving reliability and robustness requires dealing with known problems, but improving resilience requires implementing a general approach to reducing the impact of unknown future events. The need for robustness and resilience has been stated for decades but little has been done. Systems designers often assume that they understand everything they need to know. The potential failures caused by changes, failures, accidents, unknown environments, and unknown unknowns can be ignored. Such overconfidence can lead to neglect of reliability, robustness, and resilience.

Harry W. Jones↗

Going Beyond Reliability to Robustness and Resilience in Space Life Support Systems

The words reliability, robustness, and resilience are often used interchangeably to describe tough and dependable systems but the distinctions between them suggest how to design more serviceable space systems. Reliability is simply the quality of consistently performing well. A system that dependably meets its design requirements in the specified environment is reliable. The designers may not consider themselves responsible for failures under unanticipated conditions. Robustness is the capability of performing without failure under a wide range of conditions, which can go beyond the expected range to include possible off-nominal conditions. Resilience is the ability to recover from or adapt to unanticipated damaging events, such as failures, accidents, external disruptions, and repurposing. Such changes can invalidate the usual operating assumptions and cause system failure. Reliability, robustness, and resilience describe dependable performance under increasingly difficult conditions, first the specified environment, then a wider possible environment, and finally unanticipated damaging conditions. These three qualities are increasingly desirable and increasingly difficult to achieve. Engineering for resilience would design systems that can ignore or repair failures, survive accidents, and recover from unanticipated disruptions. Increasing the resilience of space systems would greatly increase space crew safety. Improving reliability and robustness requires dealing with known problems, but improving resilience requires implementing a general approach to reducing the impact of unknown future events. The need for robustness and resilience has been stated for decades but little has been done. Systems designers often assume that they understand everything they need to know. The potential failures caused by changes, failures, accidents, unknown environments, and unknown unknowns can be ignored. Such overconfidence can lead to neglect of reliability, robustness, and resilience.

Harry W. Jones↗

Economical Video Monitoring of Traffic

Data compression allows video signals to be transmitted economically on telephone circuits. Telephone lines transmit television signals to remote traffic-control center. Lines also carry command signals from center to TV camera and compressor at highway site. Video system with television cameras positioned at critical points on highways allows traffic controllers to determine visually, almost immediately, exact cause of traffic-flow disruption; e.g., accidents, breakdowns, or spills, almost immediately. Controllers can then dispatch appropriate emergency services and alert motorists to minimize traffic backups.

Houser, B. C.↗