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At least 253 records · Page 14
All sourcesNASA NTRSDOE OSTI
NASA NTRS2006

Space Shuttle Columbia Post-Accident Analysis and Investigation

Although the loss of the Space Shuttle Columbia and its crew was tragic, the circumstances offered a unique opportunity to examine a multitude of components which had experienced one of the harshest environments ever encountered by engineered materials: a break up at a velocity in excess of Mach 18 and an altitude exceeding 200,000 feet (63 KM), resulting in a debris field 645 miles/l,038 KM long and 10 miles/16 KM wide. Various analytical tools were employed to ascertain the sequence of events leading to the disintegration of the Orbiter and to characterize the features of the debris. The testing and analyses all indicated that a breach in a left wing reinforced carbon/carbon composite leading edge panel was the access point for hot gasses generated during re-entry to penetrate the structure of the vehicle and compromise the integrity of the materials and components in that area of the Shuttle. The analytical and elemental testing utilized such techniques as X-Ray Diffraction (XRD), Energy Dispersive X-Ray (EDX) dot mapping, Electron Micro Probe Analysis (EMPA), and X-Ray Photoelectron Spectroscopy (XPS) to characterize the deposition of intermetallics adjacent to the suspected location of the plasma breach in the leading edge of the left wing, Fig. 1.

McDanels, Steven J.↗
NASA NTRS2008

Nondestructive Testing As a Tool in the Space Shuttle Columbia Accident Investigation

Nondestructive testing (NDT) played a crucial role in determining the Columbia tragedy's cause. Over 84,000 pieces of debris were recovered; hundreds were subsequently subjected to NDT and materials analysis. Visual NDT of the debris revealed localized areas of damage such as erosion, excessive heating, knife edging and mechanical damage. Three-dimensional reconstructions were made of the left wing leading edge, utilizing a tripod-mounted laser scanning head and focused laser beam, and an advanced topometric optical scanner (ATOS) with digital white light to scan complex-shaped debris, producing monochrome 3-D models. Texture mapping provided a means to capture true colors of the debris and superimpose them on the scanned images. Uniform deposits were found over large portions of debris, obscuring underlying materials. To determine what was beneath, inverse radiography was enlisted. The radiographs guided investigators to where samples should be taken. To ascertain compositions, these samples were subjected to analytical testing, including energy dispersive X-ray spectroscopy and electron microprobe analysis. This combination of visual evidence, radiography, virtual reconstruction, and materials analysis allowed the forensic scientists to verify that a breach occurred in the leading edge of the left wing, the path the plasma followed, and the sequence of events that led to the loss.

McDanels, Steve↗
NASA NTRS2017

Exploring the Evolutionary Accident Hypothesis: Are Extant Protein Folds the Fittest or the Luckiest?

Considering the range of functions proteins perform, it is surprising they fold into a relatively small set of structures or "folds" that facilitate such function. One explanation is that only a minority were fit enough to emerge from Darwinian selection during the early evolution of life. Alternatively, perhaps only a fraction of all possible folds were trialed. Understanding proto-catalyst selection will aid understanding of the origins and early evolution of life. To investigate which explanation is correct, we study a protein evolved in vitro to bind ATP by Jack Szostak (Fig. 1). This protein adopts a fold which is absent from nature. We are testing whether this fold would have possessed the capability to evolve that would have been essential to survive natural selection on early Earth. Folds that couldn't improve their fitness and evolve to perform new functions would have been replaced by rivals that could. To determine whether the fold is evolvable, we are attempting to change the function of the protein by rationally redesigning to bind GTP. Two design strategies in the region of the nucleobase have been implemented to provide hydrogen bonding partners for the ligand i) an insertion ii) a MET to ASN mutation. Redesigns are being studied computationally at Ames Research Center including free energy of binding calculations. Binding affinities of promising redesigns are to be validated by experimental collaborators at ForteBio using Super Streptavidin Biosensors. If the fold is found to be non-evolvable, this may suggest that many structures were trialed, but the majority were pruned on the basis of their evolvability. Alternatively, if the fold is demonstrated to be evolvable, it would be difficult to explain its absence from nature without considering the possibility that the fold simply wasn't sampled on early Earth. This would not only further our understanding of the origins of life on Earth but also suggest a common phe-nomenon of proto-catalyst evolution.

Shannon, G.↗
NASA NTRS2021

The Enigmatic Brown Dwarf WISEA J153429.75-104303.3 (a.k.a. "The Accident")

Continued follow-up of WISEA J153429.75−104303.3, announced in Meisner et al., has proven it to have an unusual set of properties. New imaging data from Keck/MOSFIRE and HST/WFC3 shows that this object is one of the few faint proper motion sources known withJ−ch2>8 mag, indicating a very cold temperature consistent with the latest known Y dwarfs. Despite this, it has W1−W2 and ch1−ch2 colors∼1.6 mag bluer than a typical Y dwarf. A new trigonometric parallax measurement from a combination of WISE, Spitzer, and HST astrometry confirms a nearby distance of-+16.31.21.4pc and a large transverse velocity of 207.4±15.9 km s−1. The absoluteJ,W2, and ch2 magnitudes are in line with the coldest known Y dwarfs, despite the highly discrepant W1−W2 andch1−ch2 colors. We explore possible reasons for the unique traits of this object and conclude that it is most likely an old, metal-poor brown dwarf and possibly the first Y subdwarf. Given that the object has an HST F110Wmagnitude of 24.7 mag, broadband spectroscopy and photometry from JWST are the best options for testing this hypothesis

J Davy Kirkpatrick↗
NASA NTRSDate not supplied

Changing the Narrative About the Human Role in Accidents

It is often said that to err is human. It's true that failures can be traced to human limitation, but what's more important is that all successes, all safe operations are the result of human capabilities. This talk highlights the resilience people bring to aviation operations and discusses ways to change the common narrative that people are the creators of safety rather than only the source of error and failure.

operations↗
NASA NTRSDate not supplied

Identifying Human Errors and Error Mechanisms From Accident Reports Using Large Language Models

Emerging operational concepts for aviation hinge on novel paradigms for human machine interaction. Critical to their safe operation is early consideration of human error into the design process. Existing methods for consideration of human error require significant expert input, which is challenging both in early design and in novel systems for which there is little existing safety expertise. In this research, we propose a methodology for identifying human error, error producing factors, and mechanisms in early design from historical incident reports. Additionally, we hypothesize that cross-domain sharing of lessons learned can aid with early design human considerations in circumstances where data is not relevant or incomplete. This is addressed by identifying causes of human error in aviation and railway domains through applying state-of-the art natural language processing techniques to historical incident reports. Using this method, it is possible to extract extensive reports on human error from past incidents. Using the proposed approach, we identify nine human errors from railway reports and fourteen from aviation reports, with three errors common to both domains. There is at least one error producing conditions for each human error while a majority of the errors have more than one error mechanism. We also found that a majority of the human errors, error producing factors, and error mechanisms (even if they are not common between the domains) can be used to inform safe operations across domains as long as the errors are not domain specific and are interpreted and contextualized using engineering judgement.

Human Errors↗
NASA NTRS1932

Statistics of the Bureau Veritas

Statistics are indispensable factors for the amelioration of safety. Through the reconciliation of accidents which may appear isolated to interested parties, they permit tracking of typical causes of accidents; conversely, they can prevent, after a serious accident due to some fortuitous cause, the taking of incautious measures under the pressure of public opinion, which always inclines to gauge the gravity of the causes by that of the results. Lastly, they permit appraisal of the efficacy of rules in force. We should add that statistics provide an agency of prevention for future accidents. A careful inspection of all signs of malfunction of material quite often prevents the occurrence of an accident. In this respect, many pilot's report, perfectly normal in every way as far as operation is concerned, can reveal much more interesting technical data than an accident, although it does not diminish the importance of statistics. Therefore, from the inception of its aeronautical service, at the end of 1922, the Bureau Veritas has kept annual statistics of all accidents which occurred in French civil aviation. In order to correctly perform their proper function, the statistics must be exact and sufficiently explicit and complete. To be exact, they must bear on all pertinent events, and on these alone. It is a matter then, first of all, defining the accident in such a way that no sinister detail bearing on the definition may escape control. The consideration of accidents to personnel only has appeared too limited. One of the essential qualities of statistics is to permit the taking of averages and in consequence to apply them ot a sufficiently large number; such is happily not the case in accidents to personnel.

Volmerange, Andre↗
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.↗
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 NTRS2017

Current Safety Nets Within the U.S. National Airspace System

There are over 70,000 flights managed per day in the National Airspace System, with approximately 7,000 aircraft in the air over the United States at any given time. Operators of each of these flights would prefer to fly a user-defined “4D” trajectory (4DT), which includes arrival and departure times; preferred gates and runways at the airport; efficient, wind-optimal routes for departure, cruise and arrival phase of flight; and fuel efficient altitude profiles. To demonstrate the magnitude of this achievement a single flight from Los Angeles to Baltimore, accesses over 35 shared or “constrained” resources that are managed by roughly 30 air traffic controllers (at towers, approach control and en route sectors); along with traffic managers at 12 facilities, using over 22 different, independent automation system (including TBFM, ERAM, STARS, ASDE-X, FSM, TSD, GPWS, TCAS, etc.). In addition, dispatchers, ramp controllers and others utilize even more systems to manage each flight’s access to operator-managed resources. Flying an ideal 4DT requires successful coordination of all flight constraints among all flights, facilities, operators, pilots and controllers. Additionally, when conditions in the NAS change, the trajectories of one or more aircraft may need to be revised to avoid loss of flight efficiency, predictability, separation or system throughput. The Aviation Safety Network has released the 2016 airliner accident statistics showing a very low total of 19 fatal airliner accidents, resulting in 325 fatalities1. Despite several high profile accidents, the year 2016 turned out to be a very safe year for commercial aviation, Aviation Safety Network data show. Over the year 2016 the Aviation Safety Network recorded a total of 19 fatal airliner accidents [1], resulting in 325 fatalities. This makes 2016 the second safest year ever, both by number of fatal accidents as well as in terms of fatalities. In 2015 ASN recorded 16 accidents while in 2013 a total of 265 lives were lost. How can we keep it that way and not upset the apple cart by premature insertion of innovative technologies, functions, and procedures? In aviation, safety nets function as the last system defense against incidents and accidents. Current ground-based and airborne safety nets are well established and development to make them more efficient and reliable continues. Additionally, future air traffic control safety nets may emerge from new operational concepts.

Smith, Brian E.↗
NASA NTRS1971

The practical application of mishap data in Army aircraft system safety programs

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

James T. Darrah, Jr↗
NASA NTRS2003

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↗
NASA NTRS2004

A Formal Methods Approach to the Analysis of Mode Confusion

The goal of the new NASA Aviation Safety Program (AvSP) is to reduce the civil aviation fatal accident rate by 80% in ten years and 90% in twenty years. This program is being driven by the accident data with a focus on the most recent history. Pilot error is the most commonly cited cause for fatal accidents (up to 70%) and obviously must be given major consideration in this program. While the greatest source of pilot error is the loss of situation awareness , mode confusion is increasingly becoming a major contributor as well. The January 30, 1995 issue of Aviation Week lists 184 incidents and accidents involving mode awareness including the Bangalore A320 crash 2/14/90, the Strasbourg A320 crash 1/20/92, the Mulhouse-Habsheim A320 crash 6/26/88, and the Toulouse A330 crash 6/30/94. These incidents and accidents reveal that pilots sometimes become confused about what the cockpit automation is doing. Consequently, human factors research is an obvious investment area. However, even a cursory look at the accident data reveals that the mode confusion problem is much deeper than just training deficiencies and a lack of human-oriented design. This is readily acknowledged by human factors experts. It seems that further progress in human factors must come through a deeper scrutiny of the internals of the automation. It is in this arena that formal methods can contribute. Formal methods refers to the use of techniques from logic and discrete mathematics in the specification, design, and verification of computer systems, both hardware and software. The fundamental goal of formal methods is to capture requirements, designs and implementations in a mathematically based model that can be analyzed in a rigorous manner. Research in formal methods is aimed at automating this analysis as much as possible. By capturing the internal behavior of a flight deck in a rigorous and detailed formal model, the dark corners of a design can be analyzed. This paper will explore how formal models and analyses can be used to help eliminate mode confusion from flight deck designs and at the same time increase our confidence in the safety of the implementation. The paper is based upon interim results from a new project involving NASA Langley and Rockwell Collins in applying formal methods to a realistic business jet Flight Guidance System (FGS).

Butler, Ricky W.↗
NASA NTRS2006

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↗
NASA NTRS2006

Structural Analysis of the Right Rear Lug of American Airlines Flight 587

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985- certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003-subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs.

Raju, Ivatury S.↗