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At least 271 records · Page 15
All sourcesNASA NTRSDOE OSTI
NASA NTRS2004

GRC Payload Hazard Assessment: Supporting the STS-107 Accident Investigation

A hazard assessment was conducted on the GRC managed payloads in support of a NASA Headquarters Code Q request to examine STS-107 payloads and determine if they were credible contributors to the Columbia accident. This assessment utilized each payload's Final Flight Safety Data Package for hazard identification. An applicability assessment was performed and most of the hazards were eliminated because they dealt with payload operations or crew interactions. A Fault Tree was developed for all the hazards deemed applicable and the safety verification documentation was reviewed for these applicable hazards. At the completion of this hazard assessment, it was concluded that none of the GRC managed payloads were credible contributors to the Columbia accident.

Schoren, William R.↗
NASA NTRS2001

Recommendations for Injury Prevention in Transport Aviation Accidents

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

Grierson, Anita E.↗
NASA NTRS2004

Characterization of Space Shuttle External Tank Thermal Protection System (TPS) Materials in Support of the Columbia Accident Investigation

NASA suffered the loss of the seven-member crew of the Space Shuttle Columbia on February 1, 2003 when the vehicle broke apart upon re-entry to the Earth's atmosphere. The final report of the Columbia Accident Investigation Board (CAIB) determined that the accident was caused by a launch ascent incident-a suitcase-sized chunk of insulating foam on the Shuttle's External Tank (ET) broke off, and moving at almost 500 mph, struck an area of the leading edge of the Shuttle s left wing. As a result, one or more of the protective Reinforced Carbon-Carbon (RCC) panels on the wing leading edge were damaged. Upon re-entry, superheated air approaching 3,000 F breached the wing damage and caused the vehicle breakup and loss of crew. The large chunk of insulating foam that broke off during the Columbia launch was determined to come from the so-called bipod ramp area where the Shuttle s orbiter (containing crew) is attached to the ET. Underneath the foam in the bipod ramp area is a layer of TPS that is a cork-filled silicone rubber composite. In March 2003, the NASA Marshall Space Flight Center (MSFC) in Huntsville, Alabama received cured samples of the foam and composite for testing from the Michoud Assembly Facility (MAF) in New Orleans, Louisiana. The MAF is where the Shuttle's ET is manufactured. The foam and composite TPS materials for the ET have been well characterized for mechanical property data at the super-cold temperatures of the liquid oxygen and hydrogen fuels used in the ET. However, modulus data on these materials is not as well characterized. The TA Instruments 2980 Dynamic Mechanical Analyzer (DMA) was used to determine the modulus of the two TPS materials over a range of -145 to 95 C in the dual cantilever bending mode. Multi-strain, fixed frequency DMA tests were followed by multi-frequency, fixed strain tests to determine the approximate bounds of linear viscoelastic behavior for the two materials. Additional information is included in the original extended abstract.

Wingard, Charles D.↗
NASA NTRS2005

A Technique for Showing Causal Arguments in Accident Reports

In the prototypical accident report, specific findings, particularly those related to causes and contributing factors, are usually written out explicitly and clearly. Also, the evidence upon which these findings are based is typically explained in detail. Often lacking, however, is any explicit discussion, description, or depiction of the arguments that connect the findings and the evidence. That is, the reports do not make clear why the investigators believe that the specific evidence they found necessarily leads to the particular findings they enumerated. This paper shows how graphical techniques can be used to depict relevant arguments supporting alternate positions on the causes of a complex road-traffic accident.

Holloway, C. M.↗
NASA NTRS2005

New Technologies for Weather Accident Prevention

Weather is a causal factor in thirty percent of all aviation accidents. Many of these accidents are due to a lack of weather situation awareness by pilots in flight. Improving the strategic and tactical weather information available and its presentation to pilots in flight can enhance weather situation awareness and enable avoidance of adverse conditions. This paper presents technologies for airborne detection, dissemination and display of weather information developed by the National Aeronautics and Space Administration (NASA) in partnership with the Federal Aviation Administration (FAA), National Oceanic and Atmospheric Administration (NOAA), industry and the research community. These technologies, currently in the initial stages of implementation by industry, will provide more precise and timely knowledge of the weather and enable pilots in flight to make decisions that result in safer and more efficient operations.

Stough, H. Paul, III↗
NASA NTRS2006

Characterization of Space Shuttle Thermal Protection System (TPS) Materials for Return-to-Flight following the Shuttle Columbia Accident Investigation

During the Space Shuttle Columbia Accident Investigation, it was determined that a large chunk of polyurethane insulating foam (= 1.67 lbs) on the External Tank (ET) came loose during Columbia's ascent on 2-1-03. The foam piece struck some of the protective Reinforced Carbon-Carbon (RCC) panels on the leading edge of Columbia's left wing in the mid-wing area. This impact damaged Columbia to the extent that upon re-entry to Earth, superheGed air approaching 3,000 F caused the vehicle to break up, killing all seven astronauts on board. A paper after the Columbia Accident Investigation highlighted thermal analysis testing performed on External Tank TPS materials (1). These materials included BX-250 (now BX-265) rigid polyurethane foam and SLA-561 Super Lightweight Ablator (highly-filled silicone rubber). The large chunk of foam from Columbia originated fiom the left bipod ramp of the ET. The foam in this ramp area was hand-sprayed over the SLA material and various fittings, allowed to dry, and manually shaved into a ramp shape. In Return-to-Flight (RTF) efforts following Columbia, the decision was made to remove the foam in the bipod ramp areas. During RTF efforts, further thermal analysis testing was performed on BX-265 foam by DSC and DMA. Flat panels of foam about 2-in. thick were sprayed on ET tank material (aluminum alloys). The DSC testing showed that foam material very close to the metal substrate cured more slowly than bulk foam material. All of the foam used on the ET is considered fully cured about 21 days after it is sprayed. The RTF culminated in the successful launch of Space Shuttle Discovery on 7-26-05. Although the flight was a success, there was another serious incident of foam loss fiom the ET during Shuttle ascent. This time, a rather large chunk of BX-265 foam (= 0.9 lbs) came loose from the liquid hydrogen (LH2) PAL ramp, although the foam did not strike the Shuttle Orbiter containing the crew. DMA testing was performed on foam samples taken fiom a simulated PAL ramp panel. It was found that the smooth rind on the foam facing the cable tray did significantly affect the properties of foam at the PAL ramp surface. The smooth rind increased the storage modulus E' of the foam as much as 20- 40% over a temperature range of -145 to 95 C. Because of foam loss fiom the PAL ramp, future Shuttle flights were grounded indefinitely to allow further testing to better understand foam properties. The decision was also made to remove foam from the LH2 PAL, ramp. Other RTF efforts prior to the launch of Discovery included

Wingard, Doug↗
NASA NTRS2008

The Role of Trust and Interaction in Global Positioning System Related Accidents

The Global Positioning System (GPS) uses a network of satellites to calculate the position of a receiver over time. This technology has revolutionized a wide range of safety-critical industries and leisure applications. These systems provide diverse benefits; supplementing the users existing navigation skills and reducing the uncertainty that often characterizes many route planning tasks. GPS applications can also help to reduce workload by automating tasks that would otherwise require finite cognitive and perceptual resources. However, the operation of these systems has been identified as a contributory factor in a range of recent accidents. Users often come to rely on GPS applications and, therefore, fail to notice when they develop faults or when errors occur in the other systems that use the data from these systems. Further accidents can stem from the over confidence that arises when users assume automated warnings will be issued when they stray from an intended route. Unless greater attention is paid to the role of trust and interaction in GPS applications then there is a danger that we will see an increasing number of these failures as positioning technologies become integral in the functioning of increasing numbers of applications.

Johnson, Chris W.↗
NASA NTRS2008

How Past Loss of Control Accidents May Inform Safety Cases for Advanced Control Systems on Commercial Aircraft

This paper describes five loss of control accidents involving commercial aircraft, and derives from those accidents three principles to consider when developing a potential safety case for an advanced flight control system for commercial aircraft. One, among the foundational evidence needed to support a safety case is the availability to the control system of accurate and timely information about the status and health of relevant systems and components. Two, an essential argument to be sustained in the safety case is that pilots are provided with adequate information about the control system to enable them to understand the capabilities that it provides. Three, another essential argument is that the advanced control system will not perform less safely than a good pilot.

Holloway, C. M.↗
NASA NTRS2010

An Accident Precursor Analysis Process Tailored for NASA Space Systems

Accident Precursor Analysis (APA) serves as the bridge between existing risk modeling activities, which are often based on historical or generic failure statistics, and system anomalies, which provide crucial information about the failure mechanisms that are actually operative in the system and which may differ in frequency or type from those in the various models. These discrepancies between the models (perceived risk) and the system (actual risk) provide the leading indication of an underappreciated risk. This paper presents an APA process developed specifically for NASA Earth-to-Orbit space systems. The purpose of the process is to identify and characterize potential sources of system risk as evidenced by anomalous events which, although not necessarily presenting an immediate safety impact, may indicate that an unknown or insufficiently understood risk-significant condition exists in the system. Such anomalous events are considered accident precursors because they signal the potential for severe consequences that may occur in the future, due to causes that are discernible from their occurrence today. Their early identification allows them to be integrated into the overall system risk model used to intbrm decisions relating to safety.

Groen, Frank↗
NASA NTRS2010

NASA's Accident Precursor Analysis Process and the International Space Station

This viewgraph presentation reviews the implementation of Accident Precursor Analysis (APA), as well as the evaluation of In-Flight Investigations (IFI) and Problem Reporting and Corrective Action (PRACA) data for the identification of unrecognized accident potentials on the International Space Station.

Groen, Frank↗
NASA NTRS2002

Predicting System Accidents with Model Analysis During Hybrid Simulation

Standard discrete event simulation is commonly used to identify system bottlenecks and starving and blocking conditions in resources and services. The CONFIG hybrid discrete/continuous simulation tool can simulate such conditions in combination with inputs external to the simulation. This provides a means for evaluating the vulnerability to system accidents of a system's design, operating procedures, and control software. System accidents are brought about by complex unexpected interactions among multiple system failures , faulty or misleading sensor data, and inappropriate responses of human operators or software. The flows of resource and product materials play a central role in the hazardous situations that may arise in fluid transport and processing systems. We describe the capabilities of CONFIG for simulation-time linear circuit analysis of fluid flows in the context of model-based hazard analysis. We focus on how CONFIG simulates the static stresses in systems of flow. Unlike other flow-related properties, static stresses (or static potentials) cannot be represented by a set of state equations. The distribution of static stresses is dependent on the specific history of operations performed on a system. We discuss the use of this type of information in hazard analysis of system designs.

Malin, Jane T.↗
NASA NTRS2011

An Examination of Commercial Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

The Integrated Vehicle Health Management (IVHM) Project is one of the four projects within the National Aeronautics and Space Administration's (NASA) Aviation Safety Program (AvSafe). The IVHM Project conducts research to develop validated tools and technologies for automated detection, diagnosis, and prognosis that enable mitigation of adverse events during flight. Adverse events include those that arise from system, subsystem, or component failure, faults, and malfunctions due to damage, degradation, or environmental hazards that occur during flight. Determining the causal factors and adverse events related to IVHM technologies will help in the formulation of research requirements and establish a list of example adverse conditions against which IVHM technologies can be evaluated. This paper documents the results of an examination of the most recent statistical/prognostic accident and incident data that is available from the Aviation Safety Information Analysis and Sharing (ASIAS) System to determine the causal factors of system/component failures and/or malfunctions in U.S. commercial aviation accidents and incidents.

Reveley, Mary S.↗
NASA NTRS2020

Information Management to Mitigate Loss of Control Airline Accidents

Loss of control inflight continues to be the leading contributor to airline accidents worldwide and unreliable airspeed has been a contributing factor in many of these accidents. Airlines and the FAA developed training programs for pilot recognition of these airspeed events and many checklists have been designed to help pilots troubleshoot. In addition, new aircraft designs incorporate features to detect and respond in such situations. NASA has been using unreliable airspeed events while conducting research recommended by the Commercial Aviation Safety Team. Even after significant industry focus on unreliable airspeed, research and other evidence shows that highly skilled and trained pilots can still be confused by the condition and there is a lack of understanding of what the associated checklist(s) attempts to uncover. Common mode failures of analog sensors designed for measuring airspeed continue to confound both humans and automation when determining which indicators are correct. This paper describes failures that have occurred in the past and where/how pilots may still struggle in determining reliable airspeed when confronted with conflicting information. Two latest generation aircraft architectures will be discussed and contrasted. This information will be used to describe why more sensors used in classic control theory will not solve the problem. Technology concepts are suggested for utilizing existing synoptic pages and a new synoptic page called System Interactive Synoptic (SIS). SIS details the flow of flight critical data through the avionics system and how it is used by the automation. This new synoptic page as well as existing synoptics can be designed to be used in concert with a simplified electronic checklist (sECL) to significantly reduce the time to configure the flight deck avionics in the event of a system or sensor failure.

Etherington, Timothy J.↗
NASA NTRSDate not supplied

Analyses of the Boeing 737-MAX Accidents: Formal Models and Psychological Perspectives

Two fatal accidents involving the B737MAX resulted from the flight crews’ inability to overcome the effects of the Maneuvering Characteristics Augmentation System (MCAS). MCAS was designed to mimic the control column feel pressure and pitching behavior of the B737NG, which was the certification basis for the B737MAX. We briefly describe the potential role of formally modeling different perspectives during system design, and how such modeling can reveal gaps and conflicts between perspectives. We also discuss some of the relevant human factors issues involved in these accidents and how the aircraft’s behavior may have affected the pilots’ psychological states. Implications for automation design are considered.

5737MAX↗
DOE OSTI2023

Modeling The DLOFC Accident Scenario of HTR-PM Equilibrium Core Using NEAMS Tools

High-Temperature Gas-cooled Reactors (HTGRs) have excellent characteristics in terms of safety and high thermal efficiency, and they are gaining a large interest from the industry as a candidate of Gen-IV reactors for a wide range of applications. The High Temperature gas-cooled Reactor Pebble-bed Module project (HTR-PM) is one of these designs and where helium gas is used to cool the pebble-bed region that consists of spherical fuel elements moderated with graphite. The HTR-PM design is based on the combined experience from the German pebble-bed reactor program from the 1960s through the 1990s and the HTR-10 experience in China during the 2000s. Idaho National Laboratory has a long experience in modeling of HTGRs working in developing neutronics and thermal hydraulics tools for the proper modeling of these reactors. The neutronics code Griffin has the capability to model pebble depletion . While the thermal hydraulics code Pronghorn was developed mainly to model the pebble bed reactors with the porous media assumption. In this work, an equilibrium core Multiphysics model was developed for the HTR-PM reactor to analyze the depressurized loss of forced cooling accident scenario (DLOFC). This paper is organized as follows: First, a brief description of the reactor and model specifications are provided. Then, the developed Multiphysics model is discussed. Finally, verification results of the steady-state equilibrium core and DLOFC accident are presented followed by a summary of the conclusions.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗
DOE OSTI2024

DEVELOPMENT OF TRANSIENT FISSION GAS RELEASE CAPABILITIES TO STUDY HIGH BURNUP COMMERCIAL FUEL PERFORMANCE UNDER LOSS OF COOLANT ACCIDENT CONDITIONS

The contribution of transient fission gas release to the burst behaviour of high burnup fuel during a loss of coolant accident (LOCA) for commercial light water reactors is a complex phenomenon that is not fully understood. During the temperature ramp associated with a LOCA, there is significant, additional transient fission gas release in excess of steady state fission gas release from normal operation. The timing of this release and the various conditions that impact this release warrant further study. To better characterize this phenomenon, a system was developed to capture and characterize fission gas released from irradiated fuel during simulated LOCAs. This system is an upgrade to the existing Oak Ridge National Laboratory Severe Accident Test Station LOCA test apparatus and detects fission gas by gamma counting cryogenically cooled cold traps and by using an online gas mass spectrometer. The examined fuel can be pressurized or open to the furnace atmosphere. The design and operation of this new capability are discussed. Results from the first tests on high burnup fuel are presented. In the initial test, the LOCA relevant transient fission gas release was 5.3% for an unpressurized segment. Post-test microscopy on the tested samples is presented to demonstrate the likely radial source of transient fission gas release.

Harp, Jason↗
DOE OSTI2024

NON-DESTRUCTIVE POST IRRADIATION EXAMINATION OF FIRST CYCLE ACCIDENT TOLERANT AND ADVANCED ZIRCONIUM ALLOY HIGH BURNUP FUEL RODS

Post irradiation examination (PIE) of accident tolerant fuel concepts and high burnup uranium dioxide advanced zirconium alloy clad fuel contribute to near term nuclear industry goals of enhancing light water reactor safety and economics. Westinghouse is developing chromium coated zirconium alloy cladding as an accident tolerant fuel option for current pressurized water reactors. Examination of high burnup fuel further augments the technical foundation for extending the peak rod average burnup limits beyond the current regulatory limit of 62 MWd/kgU. Seven fuel rods were received at the Oak Ridge National Laboratory Irradiated Fuel Examination Facility. This includes three chromium coated zirconium alloy fuel rods and four high burnup advanced zirconium alloy fuel rods. Six of the seven rods were fueled with standard uranium dioxide while one of the chromium coated rods contained Westinghouse’s ADOPT fuel. The overall hot-cell PIE plan and some PIE results have been presented previously. This paper focuses on the additional non-destructive examination and fission gas release. Highlights from visual examination of these rods are presented. The chromium coating showed little to no visual change following irradiation. Observations of the axial burnup trends in the fuel rods are derived from full rod axial gamma-ray scans with additional observations related to local fission product migration. The axial dimensional changes of the seven rods are evaluated. As expected, creep down had not yet occurred in the chromium coated rods, and the maximum diameter strain in the high burnup advanced zirconium alloy cladding was less than 0.5%. Finally, the steady state fission gas release for these rods was measured ranging from 4.1% to 17.6% which matched expectation from literature. These fuel rods now await further destructive examination.

Harp, Jason↗