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At least 19 records
All sourcesNASA NTRSDOE OSTI
NASA NTRS2003

A Survey of Logic Formalisms to Support Mishap Analysis

Mishap investigations provide important information about adverse events and near miss incidents. They are intended to help avoid any recurrence of previous failures. Over time, they can also yield statistical information about incident frequencies that helps to detect patterns of failure and can validate risk assessments. However, the increasing complexity of many safety critical systems is posing new challenges for mishap analysis. Similarly, the recognition that many failures have complex, systemic causes has helped to widen the scope of many mishap investigations. These two factors have combined to pose new challenges for the analysis of adverse events. A new generation of formal and semi-formal techniques have been proposed to help investigators address these problems. We introduce the term mishap logics to collectively describe these notations that might be applied to support the analysis of mishaps. The proponents of these notations have argued that they can be used to formally prove that certain events created the necessary and sufficient causes for a mishap to occur. These proofs can be used to reduce the bias that is often perceived to effect the interpretation of adverse events. Others have argued that one cannot use logic formalisms to prove causes in the same way that one might prove propositions or theorems. Such mechanisms cannot accurately capture the wealth of inductive, deductive and statistical forms of inference that investigators must use in their analysis of adverse events. This paper provides an overview of these mishap logics. It also identifies several additional classes of logic that might also be used to support mishap analysis.

Johnson, Chris↗
NASA NTRS2005

Vehicle Assembly Building Fire Mishap Investigation Report. Volume I of V

On January 13, 2005, at approximately 1355, smoke was noticed on the 4th floor of D Tower in the Vehicle Assembly Building (VAB). Subsequently, a 911 call was made, a fire alarm pull station was activated, and the VAB was evacuated. The source of the smoke was determined to be a fire on the Low Bay M/N section roof near the Launch Control Center (LCC) Crossover. Due to the high visibility of the mishap, the KSC Center Director appointed a Mishap Investigation Board. Damage to government property was limited to the roof and a small number of ceiling tiles that were damaged by the fire fighters during the response. At the time of the mishap, there were hazardous commodities in the VAB including Solid Rocket Motors (SRMs) with open grain due to Solid Rocket Booster (SRB) igniter inspections. The Board agrees with the SGS Fire Services' theory that large amounts of smoke concentrated in the VAB D Tower and moved downward into the cable tunnel. The Board determined the proximate cause of this incident to be torching. HRI was installing a torch applied roof membrane which resulted in the ignition of combustible materials under the membrane near a wooden roof expansion joint. The torch applied roofing method is a universally accepted safe industry practice when applied to non-combustible surfaces. The combination of an open flame torch and combustible materiaLs presents an increased level of risk even with skilled applicators. The addition of high winds to this combination results in a risk the Board thinks can not be adequately mitigated. An appropriate risk assessment and analysis must be performed on the proposed roofing method to be used on high visibility facilities which represent unique national assets even when using common industry practices for repair and modification. The Board identified three root causes which contributed to or created the proximate cause and, if eliminated or modified, would have prevented the mishap: 1. Combustible materials in existing roof system 2. Wind speed and direction 3. Inadequate fire watch technique. Two contributing factors were identified which may have contributed to the occurrence but, if eliminated or modified, would not have prevented the occurrence: 1. HRI rushed to dry in and seal the roof on January 13 because heavy rain was predicted for the next day 2. No guidance on torching in windy conditions A total of 17 significant observations were noted during this investigation, which could lead to another mishap, or increase the severity of a mishap, but were not contributing factors in this mishap.

Kight, Ira↗
NASA NTRS2004

InvestigationOrganizer: The Development and Testing of a Web-based Tool to Support Mishap Investigations

InvestigationOrganizer (IO) is a collaborative web-based system designed to support the conduct of mishap investigations. IO provides a common repository for a wide range of mishap related information, and allows investigators to make explicit, shared, and meaningful links between evidence, causal models, findings and recommendations. It integrates the functionality of a database, a common document repository, a semantic knowledge network, a rule-based inference engine, and causal modeling and visualization. Thus far, IO has been used to support four mishap investigations within NASA, ranging from a small property damage case to the loss of the Space Shuttle Columbia. This paper describes how the functionality of IO supports mishap investigations and the lessons learned from the experience of supporting two of the NASA mishap investigations: the Columbia Accident Investigation and the CONTOUR Loss Investigation.

Carvalho, Robert F.↗
NASA NTRS2014

Loss of Signal: Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle Mishap

The editors of Loss of Signal wanted to document the aeromedical lessons learned from the Space Shuttle Columbia mishap. The book is intended to be an accurate and easily understood account of the entire process of recovering and analyzing the human remains, investigating and analyzing what happened to the crew, and using the resulting information to recommend ways to prevent mishaps and provide better protection to crewmembers. Our goal is to capture the passions of those who devoted their energies in responding to the Columbia mishap. We have reunited authors who were directly involved in each of these aspects. These authors tell the story of their efforts related to the Columbia mishap from their point of view. They give the reader an honest description of their responsibilities and share their challenges, their experiences, and their lessons learned on how to enhance crew safety and survival, and how to be prepared to support space mishap investigations. As a result of this approach, a few of the chapters have some redundancy of information and authors' opinions may differ. In no way did we or they intend to assign blame or criticize anyone's professional efforts. All those involved did their best to obtain the truth in the situations to which they were assigned.

Stepaniak, Philip C.↗
NASA NTRS1971

Mishaps with Oxygen in NASA Operations

Data from a substantial number of oxygen mishaps obtained from NASA and contractor records are presented. Information from several Air Force records, concerning oxygen accidents involving aircraft operations, are also included. Descriptions of the mishaps and their causes, for both liquid and gaseous oxygen in ground test facilities and space vehicle systems, are given. A number of safety regulations aimed at reducing the accident probability is discussed. The problems related to material compatibility and materials testing are considered, and the limited information on factors affecting the ignition of materials in oxygen is presented. In addition, details are given of several of the accident/incidents listed in order to define the combination of conditions causing the mishap. In addition to propellant system mishaps, accident/incidents which occurred in space and ground system structures were included, as well as those in electrical systems, ground support facilities, ordnance, and related operations.

Ordin, Paul M.↗
NASA NTRS2007

X-31 Mishap: Lessons Learned

The experimental X-31 High Angle of Attack Research Aircraft crashed during a 1995 test mission flight conducted by NASA at Edwards Air Force Base, California. The pilot lost control of the airplane and was forced to eject, sustaining a permanent back injury that ended his flying career. Prior to this incident the airplane had a perfect record of several hundred non-eventful flights supported by an experienced team. During the subsequent investigation by a mishap committee it was discovered that a series of cascading events contributed to this accident. Some of the identified contributing factors that resulted in this mishap are common to aircraft design and to flight-test in general. The mistakes and the solutions are presented here so that the flight-test community may consider and learn from them. The primary cause of the crash was icing and, ultimately, a complete blockage of the pitot-static nose probe. The icing was caused by a freak weather phenomenon that was neither expected nor known to exist on the day of the mishap. The normal probe had been replaced with a special Kiel probe to allow total pressure measurements of up to 70 degrees angle of attack for flight-test purposes. The Kiel probe did not include a heater, because it was assumed that the airplane would not be flown in the clouds or in conditions conducive to icing. This assumption was later proven to be incorrect. The iced Kiel probe caused incorrect gain scheduling in the flight control system, resulting in an unstable aircraft. This failure was essentially undetected because of a faulty design in the flight control system architecture. There were, however, also a number of other issues that lead up to this situation that never should have happened. This presentation discusses what the issues were that contributed to the incident. After the incident was investigated, some of these issues were addressed and some changes were made. The second X-31 aircraft flew the remainder of the flight tests, and the program was successfully completed without incident. This presentation also shows a video of the mishap including lessons learned, and the changes that were made to resume the flight-test program are presented.

Larson, Richard R.↗
NASA NTRS2007

Investigation of the NOAA N' S Search and Rescue Antenna Inadvertent Deployment: Type C Mishap

The NOAA N' Search and Rescue Antenna (SRA) inadvertently deployed during a spacecraft rotation on April 14,2007. This rotation was part of a normal operation to configure the spacecraft for additional antenna and the solar array boom deployments. This procedure (red flag written) had been modified to look for a lost metal washer and a thermal blanket button. The modification to the procedure was reviewed and approved by the Lockheed Martin Missiles and Space (LMMS) Material Review Board (MRB) per standard procedures. The flag to the procedure introduced a counter clockwise rotation before the normal clockwise rotation. The antenna was temporally stowed and held in place via lacing cord. The lacing cord broke and allowed the SRA to inadvertently deploy during the clockwise rotation. The SRA broke through a hard stop bracket and damaged an instrument optical sensor radiator panel. The satellite damage appears to be minimal and there were no injuries to personnel. The damage to the Advanced Microwave Sounding Unit (AMSU)-A1 instrument has not been fully assessed. Based on mishap site visits, interviews and data analysis, the Mishap Investigation Team (MIT) identified the underlying causes of the mishap. Event and causal factor tree diagrams were developed, resulting in the identification of the proximate (or direct) cause and root causes of the mishap.

Sabelhaus, Phil↗
NASA NTRS2011

The Use of Crow-AMSAA Plots to Assess Mishap Trends

Crow-AMSAA (CA) plots are used to model reliability growth. Use of CA plots has expanded into other areas, such as tracking events of interest to management, maintenance problems, and safety mishaps. Safety mishaps can often be successfully modeled using a Poisson probability distribution. CA plots show a Poisson process in log-log space. If the safety mishaps are a stable homogenous Poisson process, a linear fit to the points in a CA plot will have a slope of one. Slopes of greater than one indicate a nonhomogenous Poisson process, with increasing occurrence. Slopes of less than one indicate a nonhomogenous Poisson process, with decreasing occurrence. Changes in slope, known as "cusps," indicate a change in process, which could be an improvement or a degradation. After presenting the CA conceptual framework, examples are given of trending slips, trips and falls, and ergonomic incidents at NASA (from Agency-level data). Crow-AMSAA plotting is a robust tool for trending safety mishaps that can provide insight into safety performance over time.

Dawson, Jeffrey W.↗
NASA NTRS2006

Investigation of the Building M6-794 Roofing Fatality, Type A Mishap

The Building M6-794 Roofing Fatality Mishap Investigation Board (Board) was commissioned to gather information; analyze the facts; identify the proximate causes, root causes, and contributing factors relating to the mishap; and recommend appropriate actions to prevent a similar mishap from occurring in the future. During the investigation of this mishap, the Board also examined the fall protection policies of other NASA Centers and operating locations to gain an understanding of how those entities conduct fall protection, as well as the degree to which fall protection is standardized across the Agency.

Casper, John H.↗
NASA NTRSDate not supplied

What Went Wrong: A Survey of Wildfire UAS Mishaps through Named Entity Recognition

Increasingly, unmanned aircraft systems (UAS) are being applied to wildfire incidents for tasks such as mapping, aerial ignition, and delivery. As a result, incident reporting systems for wildfires are beginning to accumulate data related to UAS mishaps in wildfire response. In this research, we apply state-of-the-art natural language processing (NLP) techniques to develop a custom Named Entity Recognition (NER) model which extracts a Failure Modes and Effects Analysis (FMEA)-style survey of wildfire UAS mishaps reported in SAFECOM. The custom NER model is built by fine-tuning an existing (BERT) model, resulting in a generalizable NER model that can extract engineering relevant entities including failure modes, causes, effects, control processes, and recommendations from any failure-relevant text. Similar mishaps are clustered and reported as single rows within the FMEA. For each cluster, frequency, severity, and overall risk are computed. The methodology can be applied as part of a broader safety management system to track trends in mishaps and discover knowledge that can be utilized to improve safety outcomes and system performance.

Machine Learning↗
NASA NTRSDate not supplied

What Went Wrong: A Survey of Wildfire UAS Mishaps through Named Entity Recognition

Increasingly, unmanned aircraft systems (UAS) are being applied to wildfire incidents for tasks such as mapping, aerial ignition, and delivery. As a result, aviation incident reporting systems for wildfires are beginning to accumulate data related to UAS mishaps in wildfire response. In this research, we apply state-of-the-art natural language processing (NLP) techniques to develop a custom Named Entity Recognition (NER) model which extracts entities relevant to safety analysts. The custom NER model is built by fine-tuning an existing Bidirectional Encoder Representations from Transformers (BERT) model, resulting in a generalizable NER model that can extract engineering relevant entities including failure modes, causes, effects, control processes, and recommendations from failure-relevant text. This model performs passably, with a weighted average f1 score of 0.33 across entity types, indicating more labeled training data is needed. Extracted entities are used to form a Failure Modes and Effects Analysis (FMEA)-style survey of wildfire UAS mishaps reported using the SAFECOM system. Similar mishaps are manually clustered and reported as single rows within an FMEA. Foreach cluster, we compute frequency, severity, and overall riskin accordance with FAA standards. This methodology can beapplied as part of a broader safety management system totrack trends in mishaps (e.g., likelihood, severity) and discoverknowledge (e.g., causes, effects) that can be utilized to improvesafety outcomes and system performance.

Machine Learning↗
NASA NTRSDate not supplied

What Went Wrong: A Survey of Wildfire UAS Mishaps through Named Entity Recognition

Increasingly, unmanned aircraft systems (UAS) are being applied to wildfire incidents for tasks such as mapping, aerial ignition, and delivery. As a result, incident reporting systems for wildfires are beginning to accumulate data related to UAS mishaps in wildfire response. In this research, we apply state-of-the-art natural language processing (NLP) techniques to develop a custom Named Entity Recognition (NER) model which extracts a Failure Modes and Effects Analysis (FMEA)-style survey of wildfire UAS mishaps reported in SAFECOM. The custom NER model is built by fine-tuning an existing (BERT) model, resulting in a generalizable NER model that can extract engineering relevant entities including failure modes, causes, effects, control processes, and recommendations from any failure-relevant text. Similar mishaps are clustered and reported as single rows within the FMEA. For each cluster, frequency, severity, and overall risk are computed. The methodology can be applied as part of a broader safety management system to track trends in mishaps and discover knowledge that can be utilized to improve safety outcomes and system performance.

Machine Learning↗
NASA NTRSDate not supplied

Recurring Causes of Human Spaceflight Mishaps During Flight Tests and Early Operations

An analysis of recurring causes underlying human spaceflight mishaps that occurred during flight tests and early operations was performed. Eight mishaps from the Apollo, Soyuz, Skylab, Space Shuttle, and Constellation Programs (i.e., the Ares-1X test flight) and early commercial suborbital operations were included in the study. Detailed event analyses were performed for the historical mishaps and aggregate data analyses conducted to identify recurring issues. The nine most frequent issues were inadequate technical controls or risk management practices, incomplete procedures, system design and development issues, inadequate inspection or secondary verification requirements, failures of organizations to learn from previous incidents, inadequate schedule controls, inadequate task analyses or design processes, flaws in the design of organizations, and issues with organizational safety cultures.

Human Spaceflight↗
NASA NTRS1971

Mishaps with oxygen in NASA operations.

Oxygen safety programs were conducted, taking into consideration a review of the hazards, the available data concerning the failure of components and systems, and the oxygen handling procedures followed by NASA and its contractors. Information is presented regarding a substantial number of oxygen mishaps together with safety regulations aimed at reducing the accident probability. The information was used to establish categories of events causing the mishap. These categories include materials incompatibility deficiency, materials failure, design deficiency, cleaning deficiency, and procedural deficiencies. Mishaps are generally caused by a number of interacting factors.

Ordin, P. M.↗
NASA NTRS1994

Mishap risk control for advanced aerospace/composite materials

Although advanced aerospace materials and advanced composites provide outstanding performance, they also present several unique post-mishap environmental, safety, and health concerns. The purpose of this paper is to provide information on some of the unique hazards and concerns associated with these materials when damaged by fire, explosion, or high-energy impact. Additionally, recommended procedures and precautions are addressed as they pertain to all phases of a composite aircraft mishap response, including fire-fighting, investigation, recovery, clean-up, and guidelines are general in nature and not application-specific. The goal of this project is to provide factual and realistic information which can be used to develop consistent and effective procedures and policies to minimize the potential environmental, safety, and health impacts of a composite aircraft mishap response effort.

Olson, John M.↗
NASA NTRS2002

The Strengths and Weaknesses of Logic Formalisms to Support Mishap Analysis

The increasing complexity of many safety critical systems poses new problems for mishap analysis. Techniques developed in the sixties and seventies cannot easily scale-up to analyze incidents involving tightly integrated software and hardware components. Similarly, the realization that many failures have systemic causes has widened the scope of many mishap investigations. Organizations, including NASA and the NTSB, have responded by starting research and training initiatives to ensure that their personnel are well equipped to meet these challenges. One strand of research has identified a range of mathematically based techniques that can be used to reason about the causes of complex, adverse events. The proponents of these techniques have argued that they can be used to formally prove that certain events created the necessary and sufficient causes for a mishap to occur. Mathematical proofs can reduce the bias that is often perceived to effect the interpretation of adverse events. Others have opposed the introduction of these techniques by identifying social and political aspects to incident investigation that cannot easily be reconciled with a logic-based approach. Traditional theorem proving mechanisms cannot accurately capture the wealth of inductive, deductive and statistical forms of inference that investigators routinely use in their analysis of adverse events. This paper summarizes some of the benefits that logics provide, describes their weaknesses, and proposes a number of directions for future research.

Johnson, C. W.↗
NASA NTRS2010

Digital Reconstruction Supporting Investigation of Mishaps

In support of investigations of mishaps like the crash of the space shuttle Columbia, a process based on digital reconstruction from recovered components has been developed. The process is expected to reduce the need for physical reconstruction from recovered parts, reduce the time and cost of determining the cause of a mishap, and provide information useful in redesigning to prevent future mishaps. The process involves utilization of pre-existing techniques, hardware, and software to capture sizes and shapes of recovered parts in sets of digital data. The data are manipulated to enable rendering of captured geometric information by use of computer-aided design (CAD) and viewing software. The digitization of a part and study of its spatial relationship with other parts is taken to one of three levels of successively greater detail, depending on its importance to the investigation. The process includes a trajectory-analysis subprocess in which information from the digital reconstruction is combined with locations of recovered parts to reduce the area that must be searched to find other specified parts that have not yet been recovered. The digital product of the process is compatible with preexisting CAD and solid-model-rendering software.

Macy, William D.↗