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At least 19 records

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 2: Accident Model Document (AMD)

The Accident Model Document is one of three documents of the Preliminary Safety Analysis Report (PSAR) - Reactor System as applied to a Space Base Program. Potential terrestrial nuclear hazards involving the zirconium hydride reactor-Brayton power module are identified for all phases of the Space Base program. The accidents/events that give rise to the hazards are defined and abort sequence trees are developed to determine the sequence of events leading to the hazard and the associated probabilities of occurence. Source terms are calculated to determine the magnitude of the hazards. The above data is used in the mission accident analysis to determine the most probable and significant accidents/events in each mission phase. The only significant hazards during the prelaunch and launch ascent phases of the mission are those which arise form criticality accidents. Fission product inventories during this time period were found to be very low due to very limited low power acceptance testing.

Source record↗

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 2A: Accident model document, appendix

The detailed abort sequence trees for the reference zirconium hydride (ZrH) reactor power module that have been generated for each phase of the reference Space Base program mission are presented. The trees are graphical representations of causal sequences. Each tree begins with the phase identification and the dichotomy between success and failure. The success branch shows the mission phase objective as being achieved. The failure branch is subdivided, as conditions require, into various primary initiating abort conditions.

Source record↗

The Role of Alerting System Failures in Loss of Control Accidents CAST SE-210 Output 2

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane's energy state or attitude and enters an upset condition. In a report by the Commercial Aviation Safety Team, an analysis of accidents and incidents related to loss of airplane state awareness determined that hazard alerting was not effective in producing the appropriate pilot response to a hazard (CAST, 2014). In the current report, we take a detailed look at 28 airplane state awareness accidents and incidents to determine how well the hazard alerting worked. We describe a five-step integrated alerting-to-recovery sequence that prescribes how hazard alerting should lead to effective flight crew actions for managing the hazard. Then, for each hazard in each of the 28 events, we determine if that sequence failed and, if so, how it failed. The results show that there was an alerting failure in every one of the 28 safety events, and that the most frequent failure (20/28) was tied to the flight crew not orienting to (not being aware of) the hazard. The discussion section summarizes findings and identifies alerting issues that are being addressed and issues that are not currently being addressed. We identify a few recent upgrades that have addressed certain alerting failures. Two of these upgrades address alerting design, but one response to the safety events is to upgrade training for approach to stall and stall recovery. We also describe issues that are not being addressed adequately: better alert integration for flight path management types of hazards, airplanes in the fleet that do not meet the current alerting regulations, a lack of innovation for addressing cases of channelized attention, and existing vulnerabilities in managing data validity.

aviation safety↗

NASA: Model development for human factors interfacing

The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.

Smith, L. L.↗

Modeling of the Mode S tracking system in support of aircraft safety research

This report collects, documents, and models data relating the expected accuracies of tracking variables to be obtained from the FAA's Mode S Secondary Surveillance Radar system. The data include measured range and azimuth to the tracked aircraft plus the encoded altitude transmitted via the Mode S data link. A brief summary is made of the Mode S system status and its potential applications for aircraft safety improvement including accident analysis. FAA flight test results are presented demonstrating Mode S range and azimuth accuracy and error characteristics and comparing Mode S to the current ATCRBS radar tracking system. Data are also presented that describe the expected accuracy and error characteristics of encoded altitude. These data are used to formulate mathematical error models of the Mode S variables and encoded altitude. A brief analytical assessment is made of the real-time tracking accuracy available from using Mode S and how it could be improved with down-linked velocity.

Sorensen, J. A.↗

A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety

Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence, and are influenced by, how decision makers characterize problems and identify solutions. In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on safety-producing behaviors, safety management and system design decisions are based on a small sample of non-representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to aviation safety represents a significant and largely unrecognized risk when making policy decisions about safety management and system design. Opportunities exist to leverage the vast amount of data that have already been collected, or could be easily obtained, to increase our understanding of human contributions to safety in commercial aviation. This presentation will focus on those opportunities as well as the challenges associated with collecting and analyzing data on operators’ safety-producing behaviors.

Safety↗

Prospective Safety Analysis and the Complex Aviation System

Fatal accident rates in commercial passenger aviation are at historic lows yet have plateaued and are not showing evidence of further safety advances. Modern aircraft accidents reflect both historic causal factors and new unexpected "Black Swan" events. The ever-increasing complexity of the aviation system, along with its associated technology and organizational relationships, provides fertile ground for fresh problems. It is important to take a proactive approach to aviation safety by working to identify novel causation mechanisms for future aviation accidents before they happen. Progress has been made in using of historic data to identify the telltale signals preceding aviation accidents and incidents, using the large repositories of discrete and continuous data on aircraft and air traffic control performance and information reported by front-line personnel. Nevertheless, the aviation community is increasingly embracing predictive approaches to aviation safety. The "prospective workshop" early assessment tool described in this paper represents an approach toward this prospective mindset-one that attempts to identify the future vectors of aviation and asks the question: "What haven't we considered in our current safety assessments?" New causation mechanisms threatening aviation safety will arise in the future because new (or revised) systems and procedures will have to be used under future contextual conditions that have not been properly anticipated. Many simulation models exist for demonstrating the safety cases of new operational concepts and technologies. However the results from such models can only be as valid as the accuracy and completeness of assumptions made about the future context in which the new operational concepts and/or technologies will be immersed. Of course that future has not happened yet. What is needed is a reasonably high-confidence description of the future operational context, capturing critical contextual characteristics that modulate both the likelihood of occurrence of hazards, and the likelihood that those hazards will lead to negative safety events. Heuristics extracted from scenarios, questionnaires, and observed trends from scanning the aviation horizon may be helpful in capturing those future changes in a way conducive to safety assessment. What is also needed is a checklist of potential sources of emerging risk that arise from organizational features that are frequently overlooked. The ultimate goal is to develop a pragmatic, workable method for using descriptions of the future aviation context, to generate valid predictions of safety risks.

prospection↗

Human Performance Contributions to Safety in Commercial Aviation

In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that contribute to routine successful outcomes, safety management and system design decisions are based on a small sample of non- representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant and largely unrecognized risk when making policy decisions about human roles and responsibilities. Opportunities exist to leverage the vast amount of data that has already been collected, or could be easily obtained, to increase our understanding of human contributions to “things going right” in commercial aviation. The principal focus of this assessment was to identify current gaps and explore methods for identifying human “success” data generated by the aviation system, from personnel and within the supporting infrastructure.

Holbrook, Jon B.↗

Structural Analysis for the American Airlines Flight 587 Accident Investigation: Global Analysis

NASA Langley Research Center (LaRC) supported the National Transportation Safety Board (NTSB) in the American Airlines Flight 587 accident investigation due to LaRC's expertise in high-fidelity structural analysis and testing of composite structures and materials. A Global Analysis Team from LaRC reviewed the manufacturer s design and certification procedures, developed finite element models and conducted structural analyses, and participated jointly with the NTSB and Airbus in subcomponent tests conducted at Airbus in Hamburg, Germany. The Global Analysis Team identified no significant or obvious deficiencies in the Airbus certification and design methods. Analysis results from the LaRC team indicated that the most-likely failure scenario was failure initiation at the right rear main attachment fitting (lug), followed by an unstable progression of failure of all fin-to-fuselage attachments and separation of the VTP from the aircraft. Additionally, analysis results indicated that failure initiates at the final observed maximum fin loading condition in the accident, when the VTP was subjected to loads that were at minimum 1.92 times the design limit load condition for certification. For certification, the VTP is only required to support loads of 1.5 times design limit load without catastrophic failure. The maximum loading during the accident was shown to significantly exceed the certification requirement. Thus, the structure appeared to perform in a manner consistent with its design and certification, and failure is attributed to VTP loads greater than expected.

Young, Richard D.↗

Archetypes for Organisational Safety

We propose a framework using system dynamics to model the dynamic behavior of organizations in accident analysis. Most current accident analysis techniques are event-based and do not adequately capture the dynamic complexity and non-linear interactions that characterize accidents in complex systems. In this paper we propose a set of system safety archetypes that model common safety culture flaws in organizations, i.e., the dynamic behaviour of organizations that often leads to accidents. As accident analysis and investigation tools, the archetypes can be used to develop dynamic models that describe the systemic and organizational factors contributing to the accident. The archetypes help clarify why safety-related decisions do not always result in the desired behavior, and how independent decisions in different parts of the organization can combine to impact safety.

Marais, Karen↗

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗

A Method for Evaluating the Safety Impacts of Air Traffic Automation

This report describes a methodology for analyzing the safety and operational impacts of emerging air traffic technologies. The approach integrates traditional reliability models of the system infrastructure with models that analyze the environment within which the system operates, and models of how the system responds to different scenarios. Products of the analysis include safety measures such as predicted incident rates, predicted accident statistics, and false alarm rates; and operational availability data. The report demonstrates the methodology with an analysis of the operation of the Center-TRACON Automation System at Dallas-Fort Worth International Airport.

Kostiuk, Peter↗

Preliminary Results Obtained in Integrated Safety Analysis of NASA Aviation Safety Program Technologies

The goal of the NASA Aviation Safety Program (AvSP) is to develop and demonstrate technologies that contribute to a reduction in the aviation fatal accident rate by a factor of 5 by the year 2007 and by a factor of 10 by the year 2022. Integrated safety analysis of day-to-day operations and risks within those operations will provide an understanding of the Aviation Safety Program portfolio. Safety benefits analyses are currently being conducted. Preliminary results for the Synthetic Vision Systems (SVS) and Weather Accident Prevention (WxAP) projects of the AvSP have been completed by the Logistics Management Institute under a contract with the NASA Glenn Research Center. These analyses include both a reliability analysis and a computer simulation model. The integrated safety analysis method comprises two principal components: a reliability model and a simulation model. In the reliability model, the results indicate how different technologies and systems will perform in normal, degraded, and failed modes of operation. In the simulation, an operational scenario is modeled. The primary purpose of the SVS project is to improve safety by providing visual-flightlike situation awareness during instrument conditions. The current analyses are an estimate of the benefits of SVS in avoiding controlled flight into terrain. The scenario modeled has an aircraft flying directly toward a terrain feature. When the flight crew determines that the aircraft is headed toward an obstruction, the aircraft executes a level turn at speed. The simulation is ended when the aircraft completes the turn.

Reveley, Mary S.↗

Civil helicopter wire strike assessment study. Volume 2: Accident analysis briefs

A description and analysis of each of the 208 civil helicopter wire strike accidents reported to the National Transportation Safety Board (NTSB) for the ten year period 1970-1979 is given. The accident analysis briefs were based on pilot reports, FAA investigation reports, and such accident photographs as were made available. Briefs were grouped by year and, within year, by NTSB accident report number.

Tuomela, C. H.↗

Designing for auto safety

Safety design features in the motor vehicle and highway construction fields result from systems analysis approach to prevent or lessen death, injury, and property damage results. Systems analysis considers the prevention of crashes, increased survivability in crashes, and prompt medical attention to injuries as well as other postcrash salvage measures. The interface of these system elements with the driver, the vehicle, and the environment shows that action on the vehicle system produces the greatest safety payoff through design modifications. New and amended safety standards developed through hazard analysis technique improved accident statistics in the 70'; these regulations include driver qualifications and countermeasures to identify the chronic drunken driver who is involved in more than two-thirds of all auto deaths.

Elwood T. Driver↗

Final (Tier 1) environmental impact statement for the Galileo and Ulysses Missions

Presented here is a Final (Tier 1) Environmental Impact Statement (EIS) addressing the potential environmental consequences associated with continuing the modifications of the Galileo and Ulysses spacecraft for launch using a booster/upper stage combination that is different from the one planned for use prior to the Challenger accident, while conducting the detailed safety and environmental analysis in order to preserve the October 1989 launch opportunity for Galileo and an October 1990 launch opportunity for Ulysses. While detailed safety and environmental analyses associated with the missions are underway, they currently are not complete. Nevertheless, sufficient information is available to enable a choice among the reconfiguration alternatives presented. Relevant assessments of the potential for environmental impacts are presented.

Source record↗

Single pilot IFR accident data analysis

The aircraft accident data recorded by the National Transportation and Safety Board (NTSR) for 1964-1979 were analyzed to determine what problems exist in the general aviation (GA) single pilot instrument flight rule (SPIFR) environment. A previous study conducted in 1978 for the years 1964-1975 provided a basis for comparison. This effort was generally limited to SPIFR pilot error landing phase accidents but includes some SPIFR takeoff and enroute accident analysis as well as some dual pilot IFR accident analysis for comparison. Analysis was performed for 554 accidents of which 39% (216) occurred during the years 1976-1979.

Harris, D. F.↗