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NASA NTRS2007

An Application of CICCT Accident Categories to Aviation Accidents in 1988-2004

Interventions or technologies developed to improve aviation safety often focus on specific causes or accident categories. Evaluation of the potential effectiveness of those interventions is dependent upon mapping the historical aviation accidents into those same accident categories. To that end, the United States civil aviation accidents occurring between 1988 and 2004 (n=26,117) were assigned accident categories based upon the taxonomy developed by the CAST/ICAO Common Taxonomy Team (CICTT). Results are presented separately for four main categories of flight rules: Part 121 (large commercial air carriers), Scheduled Part 135 (commuter airlines), Non-Scheduled Part 135 (on-demand air taxi) and Part 91 (general aviation). Injuries and aircraft damage are summarized by year and by accident category.

Evans, Joni K.↗
NASA NTRS2001

Recommendations for Injury Prevention in Transport Aviation Accidents

In 1996, a national objective was established to reduce the rate of fatal accidents in aviation. To assist in determining the best methods for improving aircraft crash survivability, a combined approach was used involving database research and the examination of case studies of transport aviation accidents. The results of the study include recommendations for maintaining occupiable space, enhancing occupant restraint, managing energy transferred to the occupant, improving egress, and increasing post-crash survival.

Grierson, Anita E.↗
NASA NTRS2016

Differences in Characteristics of Aviation Accidents during 1993-2012 Based on Flight Purpose

Usually aviation accidents are categorized and analyzed within flight conduct rules (Part 121, Part 135, Part 91) because differences in accident rates within flight rules have been demonstrated. Even within a particular flight rule the flights have different purposes. For many, Part 121 flights are synonymous with scheduled passenger transport, and indeed this is the largest group of Part 121 accidents. But there are also non-scheduled (charter) passenger transport and cargo flights. The primary purpose of the analysis reported here is to examine the differences in aviation accidents based on the purpose of the flight. Some of the factors examined are the accident severity, aircraft characteristics and accident occurrence categories. Twenty consecutive years of data were available and utilized to complete this analysis.

Evans, Joni K.↗
NASA NTRS2005

The Role of Spatial Disorientation in Fatal General Aviation Accidents

In-flight Spatial Disorientation (SD) in pilots is a serious threat to aviation safety. Indeed, SD may play a much larger role in aviation accidents than the approximate 6-8% reported by the National Transportation Safety Board (NTSB) each year, because some accidents coded by the NTSB as aircraft control-not maintained (ACNM) may actually result from SD. The purpose of this study is to determine whether SD is underestimated as a cause of fatal general aviation (GA) accidents in the NTSB database. Fatal GA airplane accidents occurring between January 1995 and December 1999 were reviewed from the NTSB aviation accident database. Cases coded as ACNM or SD as the probable cause were selected for review by a panel of aerospace medicine specialists. Using a rating scale, each rater was instructed to determine if SD was the probable cause of the accident. Agreement between the raters and agreement between the raters and the NTSB were evaluated by Kappa statistics. The raters agreed that 11 out of 20 (55%) accidents coded by the NTSB as ACNM were probably caused by SD (p less than 0.05). Agreement between the raters and the NTSB did not reach significance (p greater than 0.05). The 95% C.I. for the sampling population estimated that between 33-77% of cases that the NTSB identified as ACNM could be identified by aerospace medicine experts as SD. Aerospace medicine specialists agreed that some cases coded by the NTSB as ACNM were probably caused by SD. Consequently, a larger number of accidents may be caused by the pilot succumbing to SD than indicated in the NTSB database. This new information should encourage regulating agencies to insure that pilots receive SD recognition training, enabling them to take appropriate corrective actions during flight. This could lead to new training standards, ultimately saving lives among GA airplane pilots.

Scheuring, RIchard↗
NASA NTRS2011

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

Reveley, Mary S.↗
NASA NTRS1975

A study of carburetor/induction system icing in general aviation accidents

An assessment of the frequency and severity of carburetor/induction icing in general-aviation accidents was performed. The available literature and accident data from the National Transportation Safety Board were collected. A computer analysis of the accident data was performed. Between 65 and 90 accidents each year involve carburetor/induction system icing as a probable cause/factor. Under conditions conducive to carburetor/induction icing, between 50 and 70 percent of engine malfunction/failure accidents (exclusive of those due to fuel exhaustion) are due to carburetor/induction system icing. Since the evidence of such icing may not remain long after an accident, it is probable that the frequency of occurrence of such accidents is underestimated; therefore, some extrapolation of the data was conducted. The problem of carburetor/induction system icing is particularly acute for pilots with less than 1000 hours of total flying time. The severity of such accidents is about the same as any accident resulting from a forced landing or precautionary landing. About 144 persons, on the average, are exposed to death and injury each year in accidents involving carburetor/induction icing as a probable cause/factor.

Obermayer, R. W.↗
NASA NTRS2017

Analysis of Alerting System Failures in Commercial Aviation Accidents

The role of an alerting system is to make the system operator (e.g., pilot) aware of an impending hazard or unsafe state so the hazard can be avoided or managed successfully. A review of 46 commercial aviation accidents (between 1998 and 2014) revealed that, in the vast majority of events, either the hazard was not alerted or relevant hazard alerting occurred but failed to aid the flight crew sufficiently. For this set of events, alerting system failures were placed in one of five phases: Detection, Understanding, Action Selection, Prioritization, and Execution. This study also reviewed the evolution of alerting system schemes in commercial aviation, which revealed naive assumptions about pilot reliability in monitoring flight path parameters; specifically, pilot monitoring was assumed to be more effective than it actually is. Examples are provided of the types of alerting system failures that have occurred, and recommendations are provided for alerting system improvements.

aviation accidents↗
NASA NTRS2004

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.↗
NASA NTRS1980

As assessment of power system vulnerability to release of carbon fibers during commercial aviation accidents

The vulnerability of a power distribution system in Bedford and Lexington, Massachusetts to power outages as a result of exposure to carbon fibers released in a commercial aviation accident in 1993 was examined. Possible crash scenarios at Logan Airport based on current operational data and estimated carbon fiber usage levels were used to predict exposure levels and occurrence probabilities. The analysis predicts a mean time between carbon fiber induced power outages of 2300 years with an expected annual consequence of 0.7 persons losing power. In comparison to historical outage data for the system, this represents a 0.007% increase in outage rate and 0.07% increase in consequence.

Larocque, G. R.↗
NASA NTRS2013

An Examination of Aviation Accidents Associated with Turbulence, Wind Shear and Thunderstorm

The focal point of the study reported here was the definition and examination of turbulence, wind shear and thunderstorm in relation to aviation accidents. NASA project management desired this information regarding distinct subgroups of atmospheric hazards, in order to better focus their research portfolio. A seven category expansion of Kaplan's turbulence categories was developed, which included wake turbulence, mountain wave turbulence, clear air turbulence, cloud turbulence, convective turbulence, thunderstorm without mention of turbulence, and low altitude wind shear, microburst or turbulence (with no mention of thunderstorms).More than 800 accidents from flights based in the United States during 1987-2008 were selected from a National Transportation Safety Board (NTSB) database. Accidents were selected for inclusion in this study if turbulence, thunderstorm, wind shear or microburst was considered either a cause or a factor in the accident report, and each accident was assigned to only one hazard category. This report summarizes the differences between the categories in terms of factors such as flight operations category, aircraft engine type, the accident's geographic location and time of year, degree of injury to aircraft occupants, aircraft damage, age and certification of the pilot and the phase of flight at the time of the accident.

Evans, Joni K.↗
NASA NTRS2012

NASA-ONERA Collaboration on Human Factors in Aviation Accidents and Incidents

This is the first annual report jointly prepared by NASA and ONERA on the work performed under the agreement to collaborate on a study of the human factors entailed in aviation accidents and incidents, particularly focused on the consequences of decreases in human performance associated with fatigue. The objective of this agreement is to generate reliable, automated procedures that improve understanding of the levels and characteristics of flight-crew fatigue factors whose confluence will likely result in unacceptable crew performance. This study entails the analyses of numerical and textual data collected during operational flights. NASA and ONERA are collaborating on the development and assessment of automated capabilities for extracting operationally significant information from very large, diverse (textual and numerical) databases; much larger than can be handled practically by human experts.

Srivastava, Ashok N.↗
NASA NTRS2012

First Annual Report: NASA-ONERA Collaboration on Human Factors in Aviation Accidents and Incidents

This is the first annual report jointly prepared by NASA and ONERA on the work performed under the agreement to collaborate on a study of the human factors entailed in aviation accidents and incidents particularly focused on consequences of decreases in human performance associated with fatigue. The objective of this Agreement is to generate reliable, automated procedures that improve understanding of the levels and characteristics of flight-crew fatigue factors whose confluence will likely result in unacceptable crew performance. This study entails the analyses of numerical and textual data collected during operational flights. NASA and ONERA are collaborating on the development and assessment of automated capabilities for extracting operationally significant information from very large, diverse (textual and numerical) databases much larger than can be handled practically by human experts. This report presents the approach that is currently expected to be used in processing and analyzing the data for identifying decrements in aircraft performance and examining their relationships to decrements in crewmember performance due to fatigue. The decisions on the approach were based on samples of both the numerical and textual data that will be collected during the four studies planned under the Human Factors Monitoring Program (HFMP). Results of preliminary analyses of these sample data are presented in this report.

Srivastava, Ashok↗
NASA NTRS1994

Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation Accident

Flight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.

Rosekind, Mark R.↗
NASA NTRS2015

Differences in Characteristics of Aviation Accidents During 1993-2012 Based on Aircraft Type

Civilian aircraft are available in a variety of sizes, engine types, construction materials and instrumentation complexity. For the analysis reported here, eleven aircraft categories were developed based mostly on aircraft size and engine type, and these categories were applied to twenty consecutive years of civil aviation accidents. Differences in various factors were examined among these aircraft types, including accident severity, pilot characteristics and accident occurrence categories. In general, regional jets and very light sport aircraft had the lowest rates of adverse outcomes (injuries, fatal accidents, aircraft destruction, major accidents), while aircraft with twin (piston) engines or with a single (piston) engine and retractable landing gear carried the highest incidence of adverse outcomes. The accident categories of abnormal runway contact, runway excursions and non-powerplant system/component failures occur frequently within all but two or three aircraft types. In contrast, ground collisions, loss of control - on ground/water and powerplant system/component failure occur frequently within only one or two aircraft types. Although accidents in larger aircraft tend to have less severe outcomes, adverse outcome rates also differ among accident categories. It may be that the type of accident has as much or more influence on the outcome as the type of aircraft.

Evans, Joni K.↗
NASA NTRS2012

Object-Oriented Bayesian Networks (OOBN) for Aviation Accident Modeling and Technology Portfolio Impact Assessment

The concern for reducing aviation safety risk is rising as the National Airspace System in the United States transforms to the Next Generation Air Transportation System (NextGen). The NASA Aviation Safety Program is committed to developing an effective aviation safety technology portfolio to meet the challenges of this transformation and to mitigate relevant safety risks. The paper focuses on the reasoning of selecting Object-Oriented Bayesian Networks (OOBN) as the technique and commercial software for the accident modeling and portfolio assessment. To illustrate the benefits of OOBN in a large and complex aviation accident model, the in-flight Loss-of-Control Accident Framework (LOCAF) constructed as an influence diagram is presented. An OOBN approach not only simplifies construction and maintenance of complex causal networks for the modelers, but also offers a well-organized hierarchical network that is easier for decision makers to exploit the model examining the effectiveness of risk mitigation strategies through technology insertions.

Shih, Ann T.↗