CAUSES OF IMPACT INJURY IN AUTOMOBILE ACCIDENTS
Causes of impact injury in automobile accidents
AUTOMOBILE ACCIDENT↗
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Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents. CRM/HF Conference, Held in Denver, Colorado on April 16-17, 2006
Reviewed NTSB reports of the 19 U.S. airline accidents between 1991-2000 attributed primarily to crew error. Asked: Why might any airline crew in situation of accident crew--knowing only what they knew--be vulnerable. Can never know with certainty why accident crew made specific errors but can determine why the population of pilots is vulnerable. Considers variability of expert performance as function of interplay of multiple factors.
Aviation accidents↗
Performance Data Errors in Air Carrier Operations: Causes and Countermeasures
Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.
countermeasures↗
The Columbia Accident: Synopsis of CAIB Report Regarding the Physical Cause of the Accident and and Personal Thoughts
This seminar describes the process of determining the physical cause of The Shuttle Columbia Accident. The presentation is based on the published CIAB Report, and is based mainly on Appendix F2, Vol IV of the CIAB report by J. O. Arnold, H. E. Goldstein and D. J. Rigalli. As a part of the seminar, I would also indicate how my education in Engineering Physics at the University of Kansas helped prepare me to accept the assignment to serve as an investigator for the CAIB. A similar presentation was given at Purdue in 2005. Presentation charts are attached.
Arnold, James O.↗
Another Approach to Enhance Airline Safety: Using Management Safety Tools
The ultimate goal of conducting an accident investigation is to prevent similar accidents from happening again and to make operations safer system-wide. Based on the findings extracted from the investigation, the "lesson learned" becomes a genuine part of the safety database making risk management available to safety analysts. The airline industry is no exception. In the US, the FAA has advocated the usage of the System Safety concept in enhancing safety since 2000. Yet, in today s usage of System Safety, the airline industry mainly focuses on risk management, which is a reactive process of the System Safety discipline. In order to extend the merit of System Safety and to prevent accidents beforehand, a specific System Safety tool needs to be applied; so a model of hazard prediction can be formed. To do so, the authors initiated this study by reviewing 189 final accident reports from the National Transportation Safety Board (NTSB) covering FAR Part 121 scheduled operations. The discovered accident causes (direct hazards) were categorized into 10 groups Flight Operations, Ground Crew, Turbulence, Maintenance, Foreign Object Damage (FOD), Flight Attendant, Air Traffic Control, Manufacturer, Passenger, and Federal Aviation Administration. These direct hazards were associated with 36 root factors prepared for an error-elimination model using Fault Tree Analysis (FTA), a leading tool for System Safety experts. An FTA block-diagram model was created, followed by a probability simulation of accidents. Five case studies and reports were provided in order to fully demonstrate the usefulness of System Safety tools in promoting airline safety.
Lu, Chien-tsug↗
Common denominator of three weather-related aircraft accidents
Three aircraft accidents are analyzed to gain an understanding of thunderstorm-related downbursts, or extremely rapid downdrafts, which interfered with takeoff or landing maneuvers in each of the three cases. For the purposes of this study, downbursts are defined as having downward speeds greater than 3.6 m/sec at 91 m altitude, and diameters of 800 m or greater. Few of the strongest downdrafts investigated reach the intensity of a downburst. The downburst cells mature about 5-10 minutes after formation, and are generally no more than 3-4 miles in diameter at maturity. A spearhead echo is found to be associated with each of the downburst-caused accidents.
Fujita, T. T.↗
Fault tree applications within the safety program of Idaho Nuclear Corporation
Computerized fault tree analyses are used to obtain both qualitative and quantitative information about the safety and reliability of an electrical control system that shuts the reactor down when certain safety criteria are exceeded, in the design of a nuclear plant protection system, and in an investigation of a backup emergency system for reactor shutdown. The fault tree yields the modes by which the system failure or accident will occur, the most critical failure or accident causing areas, detailed failure probabilities, and the response of safety or reliability to design modifications and maintenance schemes.
W. E. Vesely↗
Crew Communication as a Factor in Aviation Accidents
The incidence of air transport accidents caused by problems in crew communication and coordination was investigated. Communication patterns which are most effective in specific situations were determined. Methods to assess the effectiveness of crew communication patterns were developed. The results lead to the development of new methods training crews in effective communication and provide guidelines for the design of aviation procedures and equipment.
Goguen, J. A.↗
Acute stress
A number of case stories of aircraft accidents caused by pilot stress are related.
Bateman, Robert P.↗
NASA/FAA Tailplane Icing Program Overview
The effects of tailplane icing were investigated in a four-year NASA/FAA Tailplane Icing, Program (TIP). This research program was developed to improve the understanding, of iced tailplane aeroperformance and aircraft aerodynamics, and to develop design and training aides to help reduce the number of incidents and accidents caused by tailplane icing. To do this, the TIP was constructed with elements that included icing, wind tunnel testing, dry-air aerodynamic wind tunnel testing, flight tests, and analytical code development. This paper provides an overview of the entire program demonstrating the interconnectivity of the program elements and reports on current accomplishments.
Ratvasky, Thomas P.↗
Enhancing the Flight Safety Culture Through Training
In the 1970's, flight safety professionals became profoundly concerned about the prevalence of crew-caused accidents and incidents, and the role of human error in flight operations. As result, they initiated a change in the flight safety culture which has grown to significant proportions today. At the heart of the evolution were crew concepts such as flightdeck management, crew coordination, and cockpit resource management, concepts which seemed to target critical deficiencies. In themselves, the concepts were not new but their incorporation into training as a direct means of changing the flight safety culture was an untried, almost 'grassroots' approach. The targeted crew concepts and skills were not an integral part of the typical training program; the methods, curriculum, media, and even course content itself, would have to be developed and implemented from the bottom up. A familiar truism in the pilot culture is that you should 'Train the way you fly; Fly the way you train'. In short, training was expected to provide the pilot with practical operational skills that were consistent with the performance standards they were required to maintain and the operational demands they met on a daily basis. In short, one could not simply command crews to use good CRM; one would have to research and define these skills operationally as well as develop and implement a consistent and effective training program. Furthermore, one would need active support and collaboration among the research, industry and government communities in order to ensure acceptance and continued commitment. Additional information is contained in the original extended abstract.
Kanki, Barbara G.↗
Organizational Culture and Safety
'..only a fool perseveres in error.' Cicero. Humans will break the most advanced technological devices and override safety and security systems if they are given the latitude. Within the workplace, the operator may be just one of several factors in causing accidents or making risky decisions. Other variables considered for their involvement in the negative and often catastrophic outcomes include the organizational context and culture. Many organizations have constructed and implemented safety programs to be assimilated into their culture to assure employee commitment and understanding of the importance of everyday safety. The purpose of this paper is to examine literature on organizational safety cultures and programs that attempt to combat vulnerability, risk taking behavior and decisions and identify the role of training in attempting to mitigate unsafe acts.
Adams, Catherine A.↗
Tailoring a Human Reliability Analysis to Your Industry Needs
Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.
DeMott, D. L.↗
Identification of Scenarios for System Interface Design Evaluation: CAST SE-210 Output 2 Report 5 of 6
This report is one in a series of reports describing research to develop enhanced approaches to design and evaluation of flight deck interaction. The research was conducted to support the Commercial Aviation Safety Team (CAST) response to incidents and accidents caused by failure of the flight crew to maintain aircraft attitude or energy state awareness. This report partially responds to Safety Enhancement (SE) 210.2 (CAST, 2014) by describing development of operational scenarios for evaluation of flight crew interaction. Evaluations of human performance with an interface rely on asking humans to perform operational tasks in an appropriate operational context. The report includes the major sources of material for developing operational scenarios—which include system state, operational tasks, operational context, and safety events—and a method for developing an appropriate set of operational scenarios for interface evaluation.
commercial aviation↗
Columbia Accident Investigation Board Report. Volume Five
Volume V of the Report contains appendices that were not cited in VolumeI. These consist of documents produced by NASA and other organizations, which were provided to the Columbia Accident Investigation Board in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia The contents include:. Appendix G.1 Requirements and Procedures for Certification of Flight Readiness; Appendix G.2 Appendix R, Space Shuttle Program Contingency Action Plan; Appendix G.3 CAIB Charter, with Revisions; Appendix G.4 Group 1 Matrix Brief on Maintenance, Material, and Management; Appendix G.5 Vehicle Data Mapping(VDM) Team Final Report, Jun 13, 2003; Appendix G.6 SRB Working Group Presentation to CAIB; Appendix G. 7 Starfire Team Final Report, Jun 3, 2003; Appendix G.8 Using the Data and Observations from Flight STS-107, Executive Summary; Appendix G.9 Contracts, Incentives, and Safety/Technical Excellence; Appendix G.10 Detailed Summaries: Rogers Commission Report, ASAP Report, SIAT Report; Appendix G.11 Foam Application and Production Chart; Appendix G.12 Crew Survivability Report; and Appendix G.12 Aero/Aerothermal/ Thermal/Structures Team FinalReport, August 6, 2003.
CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
Investigations of aviation accidents and lessons to be drawn from them
Similarities in the study of aviation accidents in different countries are made as well as statistics on the causes of those accidents.
STATISTICS - ACCIDENTS (FR )↗
Aircraft accidents : method of analysis
The revised report includes the chart for the analysis of aircraft accidents, combining consideration of the immediate causes, underlying causes, and results of accidents, as prepared by the special committee, with a number of the definitions clarified. A brief statement of the organization and work of the special committee and of the Committee on Aircraft Accidents; and statistical tables giving a comparison of the types of accidents and causes of accidents in the military services on the one hand and in civil aviation on the other, together with explanations of some of the important differences noted in these tables.
Source record↗
Distribution of Causes in Selected US Aviation Accident Reports Between 1996 and 2003
This paper describes the results of an independent analysis of the probable and contributory causes of selected aviation accidents in the United States between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a variety of causal factors in the reporting of these adverse events. Although our results show that more of these high consequence accidents were attributed to human error than to any other single factor, a large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These wider issues are more likely to appear as contributory rather than primary causes in this set of accident reports.
Holloway, C. M.↗