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NASA NTRS2014

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↗

NASA NTRS1996

Comprehensive Analysis of Two Downburst-Related Aircraft Accidents

Although downbursts have been identified as the major cause of a number of aircraft takeoff and landing accidents, only the 1985 Dallas/Fort Worth (DFW) and the more recent (July 1994) Charlotte, North Carolina, landing accidents provided sufficient onboard recorded data to perform a comprehensive analysis of the downburst phenomenon. The first step in the present analysis was the determination of the downburst wind components. Once the wind components and their gradients were determined, the degrading effect of the wind environment on the airplane's performance was calculated. This wind-shear-induced aircraft performance degradation, sometimes called the F-factor, was broken down into two components F(sub 1) and F(sub 2), representing the effect of the horizontal wind gradient and the vertical wind velocity, respectively. In both the DFW and Charlotte cases, F(sub 1) was found to be the dominant causal factor of the accident. Next, the aircraft in the two cases were mathematically modeled using the longitudinal equations of motion and the appropriate aerodynamic parameters. Based on the aircraft model and the determined winds, the aircraft response to the recorded pilot inputs showed good agreement with the onboard recordings. Finally, various landing abort strategies were studied. It was concluded that the most acceptable landing abort strategy from both an analytical and pilot's standpoint was to hold constant nose-up pitch attitude while operating at maximum engine thrust.

Shen, J.↗

DOE OSTI2024

Benchmarking MELCOR's NAC Package to ABCOVE Tests AB5 and AB6

This report presents analyses of the AB5 and AB6 ABCOVE sodium spray fire experiments with the MELCOR code. This code simulates the progression of accident events for analysis and auditing purposes of nuclear facilities during accident conditions. Historically, the ABCOVE experiments have contributed to the validation of aerosol physics and related phenomena. Given advancements in sodium-cooled reactor designs, characterization of the sodium spray combustion may further the review and validation of newly incorporated sodium properties and physics packages, namely, the sodium equations of state (EOS) and the sodium combustion (NAC) package within MELCOR. By analyzing the AB5 and AB6 experiments with and without the NAC package, sodium specificity for spray combustion and aerosol formation as well as speciation of the combustion products are reviewed with the new packages. This effort provides code users with a demonstration of the current code capabilities. This report provides the current best practices for the NAC package as well as a discussion of any issues observed while performing the presented analyses.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2025

Benchmarking MELCOR's NAC Package to ABCOVE Test AB7

This report presents analyses of the AB7 ABCOVE sodium spray fire experiment with the MELCOR code. This code simulates the progression of accident events for analysis and auditing purposes of nuclear facilities during accident conditions. Historically, the ABCOVE experiments have contributed to the validation of aerosol physics and related phenomena. Given advancements in sodium-cooled reactor designs, characterization of the sodium spray combustion may further the review and validation of newly incorporated sodium properties and physics packages, namely, the sodium equations of state (EOS) and the sodium combustion (NAC) package within MELCOR. Previously, the AB5 and AB6 experiments were analyzed with and without the NAC package. This work builds on the previous analyses with a demonstration of the current code capabilities of MELCOR with a more mild Na spray and pool fire scenario.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2020

Economic Model for Estimation of GDP Losses in the MACCS Offsite Consequence Analysis Code

The MACCS (MELCOR Accident Consequence Code System) code is the U.S. Nuclear Regulatory Commission (NRC) tool used to perform probabilistic health and economic consequence assessments for atmospheric releases of radionuclides. It is also used by international organizations, both reactor owners and regulators. It is intended and most commonly used for hypothetical accidents that could potentially occur in the future rather than to evaluate past accidents or to provide emergency response during an ongoing accident. It is designed to support probabilistic risk and consequence analyses and is used by the NRC, U.S. nuclear licensees, the Department of Energy, and international vendors, licensees, and regulators. This report describes the modeling framework, implementation, verification, and benchmarking of a GDP-based model for economic losses that has recently been developed as an alternative to the original cost-based economic loss model in MACCS. The GDP-based model has its roots in a code developed by Sandia National Laboratories for the Department of Homeland Security to estimate short-term losses from natural and manmade accidents, called the Regional Economic Accounting analysis tool (REAcct). This model was adapted and modified for MACCS and is now called the Regional Disruption Economic Impact Model (RDEIM). It is based on input-output theory, which is widely used in economic modeling. It accounts for direct losses to a disrupted region affected by an accident, indirect losses to the national economy due to disruption of the supply chain, and induced losses from reduced spending by displaced workers. RDEIM differs from REAcct in its treatment and estimation of indirect loss multipliers, elimination of double counting associated with inter-industry trade in the affected area, and that it is designed to be used to estimate impacts for extended periods that can occur from a major nuclear reactor accident, such as the one that occurred at the Fukushima Daiichi site in Japan. Most input-output models do not account for economic adaptation and recovery, and in this regard RDEIM differs from its parent, REAcct, because it allows for a user-definable national recovery period. Implementation of a recovery period was one of several recommendations made by an independent peer review panel to ensure that RDEIM is state-of-practice. For this and several other reasons, RDEIM differs from REAcct. Both the original and the RDEIM economic loss models account for costs from evacuation and relocation, decontamination, depreciation, and condemnation. Where the original model accounts for an expected rate of return, based on the value of property, that is lost during interdiction, the RDEIM model instead accounts for losses of GDP based on the industrial sectors located within a county. The original model includes costs for disposal of crops and milk that the RDEIM model currently does not, but these costs tend to contribute insignificantly to the overall losses. This document discusses three verification exercises to demonstrate that the RDEIM model is implemented correctly in MACCS. It also describes a benchmark study at five nuclear power plants chosen to represent the spectrum of U.S. commercial sites. The benchmarks provide perspective on the expected differences between the RDEIM and the original cost-based economic loss models. The RDEIM model is shown to consistently predict larger losses than the original model, probably in part because it accounts for national losses by including indirect and induced losses; whereas, the original model only accounts for regional losses. Nonetheless, the RDEIM model predicts losses that are remarkably consistent with the original cost-based model, differing by 16% at most for the five sites combined with three source terms considered in this benchmark.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2020

Safety Risk Reliability Model Library

SR2ML is a software package which contains a set of safety and reliability models designed to be interfaced with the INL developed RAVEN code. These models can be employed to perform both static and dynamic system risk analysis and determine risk importance of specific elements of the considered system. Two classes of reliability models have been developed; the first class includes all classical reliability models (Fault-Trees, Event-Trees, Markov models and Reliability Block Diagrams) which have been extended to deal not only with Boolean logic values but also time dependent values. The second class includes several components aging models. Models of these two classes are designed to be included in a RAVEN ensemble model to perform time dependent system reliability analysis (dynamic analysis). Similarly, these models can be interfaced with system analysis codes to determine failure time of systems and evaluate accident progression (static analysis).

Wang, Congjian↗

DOE OSTI2024

Safety Analysis of Chromium-Coated Accident-Tolerant Fuels with Increased Enrichment and Extended Burnup [Slides]

This report documents research and development conducted in support of deployment of accident-tolerant fuels. Specifically, the performance of chromium coating during a beyond design basis accident was investigated. An 18m reference core was considered, and the performance of cases with and without chromium coating compared. An extended cycle length of 24m was then considered with the chromium coating, to determine if the benefit of using the chromium coating was more or less significant than the increased fission product inventory when considering fission product release. The chromium coating model utilized here is a preliminary implementation and further work is recommended on a more detailed model.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

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 NTRS1986

Teacher in Space Program - The challenge to education in the space age

An account is given of the significant events which occurred in the Teacher in Space Program following the Challenger Space Shuttle accident on January 28, 1986. The analysis indicates that the accident has not prevented the continuing effective implementation of the three educational goals of the Teacher in Space Program which are to: (1) raise the prestige of the teaching profession, (2) increase the awareness in the education community of the impact of technology and science on this country's future in preparing students for the future, and (3) use aeronautics and space as a catalyst to enhance all subject areas and grade levels of U.S. education systems.

Brown, R. W.↗

NASA NTRS2010

Examination of Icing Induced Loss of Control and Its Mitigations

Factors external to the aircraft are often a significant causal factor in loss of control (LOC) accidents. In today s aviation world, very few accidents stem from a single cause and typically have a number of causal factors that culminate in a LOC accident. Very often the "trigger" that initiates an accident sequence is an external environment factor. In a recent NASA statistical analysis of LOC accidents, aircraft icing was shown to be the most common external environmental LOC causal factor for scheduled operations. When investigating LOC accident or incidents aircraft icing causal factors can be categorized into groups of 1) in-flight encounter with super-cooled liquid water clouds, 2) take-off with ice contamination, or 3) in-flight encounter with high concentrations of ice crystals. As with other flight hazards, icing induced LOC accidents can be prevented through avoidance, detection, and recovery mitigations. For icing hazards, avoidance can take the form of avoiding flight into icing conditions or avoiding the hazard of icing by making the aircraft tolerant to icing conditions. Icing detection mitigations can take the form of detecting icing conditions or detecting early performance degradation caused by icing. Recovery from icing induced LOC requires flight crew or automated systems capable of accounting for reduced aircraft performance and degraded control authority during the recovery maneuvers. In this report we review the icing induced LOC accident mitigations defined in a recent LOC study and for each mitigation describe a research topic required to enable or strengthen the mitigation. Many of these research topics are already included in ongoing or planned NASA icing research activities or are being addressed by members of the icing research community. These research activities are described and the status of the ongoing or planned research to address the technology needs is discussed

Reehorst, Andrew L.↗

DOE OSTI2021

Material Interactions in Severe Accidents – Benchmarking the MELCOR V2.2 Eutectics Model for a BWR-3 Mark-I Station Blackout: Part II – Uncertainty Analysis

Single case comparisons between severe accident simulations can provide detailed insights into severe accident model behavior, however, they cannot offer insights into model uncertainty, sensitivity to uncertain parameters, or underlying model biases.Here in this analysis, the single case benchmark comparison of the MELCOR material interaction models for a station blackout (SBO) scenario of a boiling water reactor (BWR) using representative Fukushima Daiichi Unit 1 boundary conditions is expanded to include an uncertainty analysis. As part of this uncertainty analysis, 1200 simulations are performed for each material interaction model (2400 total), with random sampling of 14 uncertain MELCOR input parameters. Input parameters are selected for their impact on models representing core degradation processes. These include candling, fuel rod failure, debris quenching and dryout. The analysis performed here is not a traditional “best-estimate” uncertainty analysis that uses best-estimate parameters or identifies best-estimate figure of merit distributions. Instead, it is an exploratory uncertainty analysis that identifies and interrogates underlying model form biases of the two material interaction models (eutectics and interactive materials models). Uniform distributions are applied to all uncertain parameters to ensure coverage of the model parameter uncertainty space. Key findings from this study include underlying model form biases exhibited by material interaction models, and notable differences in accident progression outcomes between the material interaction models. This uncertainty study extends and confirms the conclusions from the first part of this study, which compared the impact of material interaction modeling on simulation of a short-term station blackout scenario with representative Fukushima Daiichi Unit I boundary conditions. In particular, this study confirms that the eutectics model generally exhibits accelerated degradation and failure of fuel components, the core plate, and the lower head. The eutectics model also has a tendency to exhibit a greater degree of core degradation, greater debris mass formation, and larger debris mass ejection. Finally, the eutectics model exhibits higher maximum temperatures for fuel, cladding, particulate debris, oxidic molten pool, and metallic molten pool components than the interactive materials model; interactive materials model simulations exhibit a soft “limitation” on maximum temperatures that is related to the temperature at which material relocation occurs.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

DOE OSTI2023

Application of the ANSI/ANS-8.3-2022 Minimum Accident to Tube Vault Storage

In support of planned site activities, the existing basis for criticality safety in nuclear facilities is being revisited. One such technical basis is the demonstration of Criticality Accident Alarm System (CAAS) coverage in tube vaults at Y-12 National Security Complex. The configuration of the vaults places significant shielding between the source and the detector stations and is dissimilar to drum storage or other processes. This paper describes tube vault storage at Y-12, describes the basis for the application of the 2022 minimum accident for system design (MASD) to the analysis, and presents how the accident is implemented in the analysis.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Context: The manufacture and operation of sUAS are not as regulated as today’s commercial operation, and their widespread use introduces new risks and hazards to the general public. Aim: Our intent is to understand the various processes that prevent or portend sUAS incidents or accidents and the influence that pilots’ expectations and training have on these processes. Method: We use classic grounded theory on sUAS reported accidents (and incidents). Results: We identified three categories, Control Interference, Reviewing and Reporting, which describe various processes surrounding UAS accidents based on the dataset analyzed. Conclusion: The use of grounded theory can offer a different perspective in the analysis of UAS accidents. In addition, the traceability between data sources and the method results facilitate result validation, and navigation. While the results are preliminary, the concepts can be expanded through the use of other accident datasets or used as basis for UAS accident surveys.

Carlos Paradis↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Carlos Paradis↗

NASA NTRS2007

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.↗

NASA NTRS1980

Civil helicopter wire strike assessment study. Volume 1: Findings and recommendations

Approximately 208 civil helicopter wire strike accidents for a ten year period 1970 to 1979 are analyzed. It is found that 83% of the wire strikes occurred during bright clear weather. Analysis of the accidents is organized under pilot, environment, and machine factors. Methods to reduce the wire strike accident rate are discussed, including detection/warning devices, identification of wire locations prior to flight, wire cutting devices, and implementation of training programs. The benefits to be gained by implementing accident avoidance methods are estimated to be fully justified by reduction in injury and death and reduction of aircraft damage and loss.

Tuomela, C. H.↗

NASA NTRSDate not supplied

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↗

NASA NTRS2019

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.↗