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All sourcesNASA NTRSDOE OSTI
NASA NTRS2010

Aircraft Loss of Control Causal Factors and Mitigation Challenges

Loss of control is the leading cause of jet fatalities worldwide. Aside from their frequency of occurrence, accidents resulting from loss of aircraft control seize the public s attention by yielding a large number of fatalities in a single event. In response to the rising threat to aviation safety, the NASA Aviation Safety Program has conducted a study of the loss of control problem. This study gathered four types of information pertaining to loss of control accidents: (1) statistical data; (2) individual accident reports that cite loss of control as a contributing factor; (3) previous meta-analyses of loss of control accidents; and (4) inputs solicited from aircraft manufacturers, air carriers, researchers, and other industry stakeholders. Using these information resources, the study team identified the causal factors that were cited in the greatest number of loss of control accidents, and which were emphasized most by industry stakeholders. This report describes the study approach, the key causal factors for aircraft loss of control, and recommended mitigation strategies to make near-term impacts, mid-term impacts, and Next Generation Air Transportation System impacts on the loss of control accident statistics

Jacobson, Steven R.↗
NASA NTRS2018

Stabilized Approach Criteria: Bridging the Gap Between Theory and Practice

Approach and landing is the most common phase of flight for aviation accidents, accounting annually for approximately 65 percent of all accidents. A Flight Safety Foundation study of 16 years of runway excursions determined that 83 percent could have been avoided with a decision to go around. In other words, 54 percent of all accidents could potentially be prevented by going around. A critical industry policy designed to help prevent such accidents is the go-around policy. However, the collective industry performance of complying with go-around policies is extremely poor and only about three percent of unstable approaches result in a go-around. Improving the go-around compliance rate holds tremendous potential in reducing approach and landing accidents. There are many reasons for flight crews ignoring go-around policies related to pilot judgement and company policies. Examples are the collective industry norm to accept the noncompliance of go-around policies, management being disengaged from go-around noncompliance, and pilot fatigue and lack of situational awareness. One of the biggest factors is that pilots see current stabilized-approach criteria as too complex and restrictive for the operational environment. Following the American Airlines 1420 accident (Little Rock, 1999), where the aircraft overran the runway upon landing and crashed, the National Transportation Safety Board (NTSB) recommended that the Federal Aviation Administration (FAA) define detailed parameters for a stabilized approach, and develop detailed criteria indicating when a go-around should be performed. The experiment discussed in this presentation is the first step towards developing these go-around criteria for commercial transport aircraft.

pilot performance↗
NASA NTRSDate not supplied

An Approach for Defining IASMS Services, Functions, and Capabilities

Assuring safety in the NAS with the inclusion of new entrants, such as Advanced Air Mobility (AAM), will require overcoming unique safety challenges that result from combining innovative technologies with novel airspace concepts for moving people and cargo using autonomous vehicles. The focus of the In-time Aviation Safety Management System (IASMS) is to overcome AAM’s safety assurance challenges. The IASMS Concept of Operations (ConOps) describes an interconnected set of services, functions, and capabilities (SFCs) designed to manage operational risks, identify unknown risks, and inform system designs. This paper describes an approach for defining SFCs based on technology trends in research, assessment of known and unknown risks in voluntary safety reports, and causal and contributing factors in aviation accidents and incidents. This approach would identify potential SFCs that further expand the Monitor, Assess, and Mitigate (M-A-M) functionality that represents the enabling framework of the IASMS. Safety implications that will result from integration of AAM in the transformation of the National Airspace System (NAS) were addressed in National Academies committees reports on AAM and IASMS. Development of a ConOps for IASMS was a top recommendation and can be represented as a reframing of safety assurance that builds on real-time alerting such as the Traffic Alert and Collision Avoidance System, and adds the more encompassing in-time temporal parameter in recognition of the different timelines for collecting and assessing safety data for risk mitigations. For example, mining for safety trends from data sources such as the Aviation Safety Information Analysis and Sharing system occurs over a longer time period. Research on AAM operations poses that SFCs can be designed to monitor the safety margin appropriate for AAM including with regards to the distance between current flight parameters and nominal ideal conditions. These in-time comparisons will become more complex as the density of operations increases at least in certain areas and can include planned and actual 4D trajectory, and in-time comparisons having implications on conflict modeling and prediction including expected and actual departure time, fix/waypoint crossing times, and arrival time. These comparisons would be integrated as part of SFCs that redefine and inform new safety margin. An increased safety margin improves management of operational risks while reducing the potential for anomalies. An increased safety margin also has implications for operator confidence in the certainty of its operations and trust in automation. Technology trends in research could be used to refine existing SFCs and define needs for additional SFCs that provide safety improvements to the design and operation of vehicles, airspace design, and operator performance requirements. NASA is developing innovative approaches to safeguard against major accidents and incidents that have occurred in the NAS and those anticipated with the inclusion of envisioned AAM operations. The innovations use operational performance data to monitor, detect, and predict flight variations exceeding safe nominal patterns, such as would be caused by navigational error, severe weather complications, or hijacking of UAS controls. These innovative approaches have high potential to prevent accidents and incidents in the new AAM era. It is anticipated that elements of the innovations will evolve into SFCs for the IASMS. Voluntary safety reports can be monitored to identify anomalies related to design or operational performance risks. Reports could be periodically monitored and assessed for specific topics. Reports might serve as weak signals or precursors indicative of emergent risk such as when combined with other safety information. The architecture could include SFCs that are based on voluntary safety reports recognizing the periodic temporal nature of data analysis. As previously mentioned, aviation accidents with their causal and contributing precursors can inform the need for SFCs in the IASMS. Accidents and incidents at San Francisco International Airport such as Asiana 214 and Air Canada 759 illustrate how combinations of different factors lead to increased risk. These types of precursors and different factors have implications on the types of SFCs that could be needed to monitor and manage different sources and types of design and operational risk. Continuing to assure the safety of AAM as designs and operations gain in complexity can be accompanied by defining SFCs that also increase in complexity. These SFCs can leverage information from findings and recommendations synthesized across on-going research, voluntary safety reports, and accident and incident reports. These SFCs can serve to refine accuracy of algorithms and resolve limitations with current practices. The IASMS architecture represents the framework for the SFCs and their critical role in safety assurance.

In-Time Aviation Safety Management System↗
NASA NTRS1980

Decision-problem state analysis methodology

A methodology for analyzing a decision-problem state is presented. The methodology is based on the analysis of an incident in terms of the set of decision-problem conditions encountered. By decomposing the events that preceded an unwanted outcome, such as an accident, into the set of decision-problem conditions that were resolved, a more comprehensive understanding is possible. All human-error accidents are not caused by faulty decision-problem resolutions, but it appears to be one of the major areas of accidents cited in the literature. A three-phase methodology is presented which accommodates a wide spectrum of events. It allows for a systems content analysis of the available data to establish: (1) the resolutions made, (2) alternatives not considered, (3) resolutions missed, and (4) possible conditions not considered. The product is a map of the decision-problem conditions that were encountered as well as a projected, assumed set of conditions that should have been considered. The application of this methodology introduces a systematic approach to decomposing the events that transpired prior to the accident. The initial emphasis is on decision and problem resolution. The technique allows for a standardized method of accident into a scenario which may used for review or the development of a training simulation.

Dieterly, D. L.↗
NASA NTRS1983

Structural response of transport airplanes in crash situations

This report highlights the results of contractural studies of transport accident data undertaken in a joint research program sponsored by the FAA and NASA. From these accident data studies it was concluded that the greatest potential for improved transport crashworthiness is in the reduction of fire related fatalities. Accident data pertaining to fuselage integrity, main landing gear collapse, fuel tank rupture, wing breaks, tearing of tank lower surfaces, and engine pod scrubbing are discussed. In those accidents where the energy absorbing protective capability of the fuselage structure is expended and the airplane experiences major structural damage, trauma caused fatalities are also discussed. The dynamic performance of current seat/restraint systems are examined but it is concluded that the accident data does not adequately define the relationship between occupant response and the dynamic interaction with the seat, floor and fuselage structure.

Thomson, R. G.↗
NASA NTRS1991

Emergency egress requirements for Space Station Freedom

An objective was to determine if the pressurized elements and hatchways of the Space Station Freedom support the emergency egress of crewmembers during operation of the station at the stage of Permanently Manned Capacity. Emergency egress was defined as the exit from a pressurized element when an event occurs which makes that element uninhabitable. The possible egress paths for four emergency scenarios considered were: (1) accident occurs in a module and crewmembers translate to the attached node; (2) accident occurs at a node and crewmembers translate through it to the safe node; (3) accident occurs at a module close to a node and crewmembers are not able to translate through the affected area; and (4) accident occurs at a node and crewmembers cannot translate through it. The structural design of the pressurized elements and the hatches studied is adequate for the emergence egress translation requirement. The current location of a few racks may cause some obstruction for egress to the orbiter. The egress time required in the worst situation is estimated to be about 3 mins. There is a chance of getting crewmembers trapped in a module in case of a severe accident. Aids are needed for emergency egress translation.

Ray, Paul S.↗
NASA NTRS1993

Longitudinal study of astronaut health: Mortality in the years 1959-1991

We conducted a historical cohort study of mortality among 195 astronauts who were exposed to space and medical sources of radiation between 1959 and 1991. Cumulative occupational and medical radiation exposures were obtained from the astronaut radiation exposure history data base. Causes of death were obtained from obligatory death certificates and autopsy reports that were on file in the medical records. A total of 18 deaths occurred during the 32-year follow-up period for which the all-cause standardized mortality ratio (SMR) was 142 (95 percent confidence interval 84 225). There was one cancer death in the buccal cavity and pharynegeal ICD-9 rubric whose occurrence was significantly beyond expectation. Mortality for coronary disease was 59 percent lower than expected (2 deaths; SMR = 41; 95 percent confidence limit 5 147). The crude death rate for 10 occupationally related accidents was 400 deaths per 100,000 person-years, which is an order of magnitude greater than accidental death rates in mining industries. The SMR of 1027 for fatal accidents was significantly beyond expectation (14 deaths; 95 percent confidence limit 561 1723) and was similar to SMRs for accidents among aerial pesticide applications. The 10-year cumulative risk of occupational fatalities based on the exponential, Weibull, Gompertz, and linear-exponential distributions was 10 percent. Mortality from motor vehicle accidents was slightly higher than expected but was not significant (1 death; SMR = 145; 95 percent confidence limit 2 808). Radiation exposures from medical procedures accounted for a majority of cumulative dose when compared with space radiation exposures. The results of the study do not confirm the impression that astronauts are at increased risk of cancer, but this does not obviate the need for further study. Overall, it was found that astronauts are at a health disadvantage as a result of catastrophic accidents.

Peterson, Leif E.↗
NASA NTRS2000

The NASA Aviation Safety Program: Overview

In 1997, the United States set a national goal to reduce the fatal accident rate for aviation by 80% within ten years based on the recommendations by the Presidential Commission on Aviation Safety and Security. Achieving this goal will require the combined efforts of government, industry, and academia in the areas of technology research and development, implementation, and operations. To respond to the national goal, the National Aeronautics and Space Administration (NASA) has developed a program that will focus resources over a five year period on performing research and developing technologies that will enable improvements in many areas of aviation safety. The NASA Aviation Safety Program (AvSP) is organized into six research areas: Aviation System Modeling and Monitoring, System Wide Accident Prevention, Single Aircraft Accident Prevention, Weather Accident Prevention, Accident Mitigation, and Synthetic Vision. Specific project areas include Turbulence Detection and Mitigation, Aviation Weather Information, Weather Information Communications, Propulsion Systems Health Management, Control Upset Management, Human Error Modeling, Maintenance Human Factors, Fire Prevention, and Synthetic Vision Systems for Commercial, Business, and General Aviation aircraft. Research will be performed at all four NASA aeronautics centers and will be closely coordinated with Federal Aviation Administration (FAA) and other government agencies, industry, academia, as well as the aviation user community. This paper provides an overview of the NASA Aviation Safety Program goals, structure, and integration with the rest of the aviation community.

Shin, Jaiwon↗
NASA NTRS2002

Overview of the NASA Systems Approach to Crashworthiness Program

The NASA Aviation Safety Program was developed in response to the federal government's goal to reduce the fatal accident rate for aviation by 80% within 10 years. Accident Mitigation is a primary element of the Aviation Safety Program. The overall Accident Mitigation goal is to provide technology to the air transport industry to enable a decrease in the rate of fatalities and injury from crash loads and from in-flight and post-crash explosion and/or fire. Accident Mitigation is divided into two main elements - Fire Prevention and Systems Approach to Crashworthiness. The Systems Approach to Crashworthiness goal is to develop and promote technology that will increase the human survival rate or reduce the fatality rate in survivable accidents. The technical background and planning, selected technical activities, and summary of future efforts will be presented in this paper.

Jones, Lisa E.↗
NASA NTRS2005

Return to Flight Task Group

It has been 29 months since Columbia was lost over East Texas in February 2003. Seven months after the accident, the Columbia Accident Investigation Board (CAIB) released the first volume of its final report, citing a variety of technical, managerial, and cultural issues within NASA and the Space Shuttle Program. To their credit, NASA offered few excuses, embraced the report, and set about correcting the deficiencies noted by the accident board. Of the 29 recommendations issued by the CAIB, 15 were deemed critical enough that the accident board believed they should be implemented prior to returning the Space Shuttle to flight. Some of these recommendations were relatively easy, most were straightforward, a few bordered on the impossible, and others were largely overcome by events, particularly the decision by the President to retire the Space Shuttle by 2010. The Return to Flight Task Group (RTF TG, or simply, the Task Group) was chartered by the NASA Administrator in July 2003 to provide an independent assessment of the implementation of the 15 CAIB return-to-flight recommendations. An important observation must be stated up-front: neither the CAIB nor the RTF TG believes that all risk can be eliminated from Space Shuttle operations; nor do we believe that the Space Shuttle is inherently unsafe. What the CAIB and RTF TG do believe, however, is that NASA and the American public need to understand the risks associated with space travel, and that NASA must make every reasonable effort to minimize such risk. Since the release of the CAIB report, NASA and the Space Shuttle Program expended enormous effort and resources toward correcting the causes of the accident and preparing to fly again. Relative to the 15 specific recommendations that the CAIB indicated should be implemented prior to returning to flight, NASA has met or exceeded most of them the Task Group believes that NASA met the intent of the CAIB for 12 of these recommendations. The remaining three recommendations were so challenging that NASA could not comply completely with the intent of the CAIB.

Source record↗
NASA NTRS2005

Introduction and Mission Response Team (MRT)

On February 1, 2003 the Space Shuttle Columbia, returning to Earth with a crew of seven astronauts, disintegrated along a track extending from California to Louisiana. Observers on the ground filmed breakup of the spacecraft. Debris fell along a 567 statute mile track from Littlefield, Texas to Fort Polk, Louisiana; the largest ever recorded debris field. At the time of the accident the National Aeronautics and Space Administration (NASA) flight surgeon on-duty at the Mission Control Center (MCC) in Houston, Texas initiated the medical contingency response. The DOD surgeon at Patrick Air Force Base was notified, NASA medical personnel were recalled and the services of Armed Forces Institute of Pathology (AFIP) were requested. Subsequent to the accident the NASA flight surgeons that had supported the crew on orbit now provided medical support to the crewmember s families. Federal Emergency Management Agency (FEMA), the National Transportation Safety Board (NTSB), the Federal Bureau of Investigation (FBI) and numerous other federal, state and local agencies along with the citizens of Texas and Louisiana responded to the disaster. Search and recovery was managed from a Disaster Field Office (DFO) established in Lufkin, Texas. Mishap Investigation Team (MIT) medical operations were managed from Barksdale Air Force Base, Louisiana. Accident investigation teams (Columbia Accident Investigation Task Force (CAITF) and Columbia Accident Investigation Board (CAIB)) appointed immediately after the disaster included current and former authorities in space medicine. In August 2003, the CAIB concluded its investigation and released its findings in a report published in February 2004.

Pool, Sam↗
NASA NTRS2010

Validation and Verification of Future Integrated Safety-Critical Systems Operating under Off-Nominal Conditions

Loss of control remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft loss-of-control accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents and reducing them will require a holistic integrated intervention capability. Future onboard integrated system technologies developed for preventing loss of vehicle control accidents must be able to assure safe operation under the associated off-nominal conditions. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V and V) and ultimate certification. The V and V of complex integrated systems poses major nontrivial technical challenges particularly for safety-critical operation under highly off-nominal conditions associated with aircraft loss-of-control events. This paper summarizes the V and V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft loss-of-control accidents. A summary of recent research accomplishments in this effort is also provided.

Belcastro, Christine M.↗
NASA NTRS2010

Aircraft Loss of Control Study

Loss of control has become the leading cause of jet fatalities worldwide. Aside from their frequency of occurrence, accidents resulting from loss of aircraft control seize the public s attention by yielding large numbers of fatalities in a single event. In response to the rising threat to aviation safety, NASA's Aviation Safety Program has conducted a study of the loss of control problem. This study gathered four types of information pertaining to loss of control accidents: (1) statistical data; (2) individual accident reports that cite loss of control as a contributing factor; (3) previous meta-analyses of loss of control accidents; and (4) inputs solicited from aircraft manufacturers, air carriers, researchers, and other industry stakeholders. Using these information resources, the study team identified causal factors that were cited in the greatest number of loss of control accidents, and which were emphasized most by industry stakeholders. For each causal factor that was linked to loss of control, the team solicited ideas about what solutions are required and future research efforts that could potentially help avoid their occurrence or mitigate their consequences when they occurred in flight.

Jacobson, Steven R.↗
NASA NTRS2011

Aircraft Loss-of-Control: Analysis and Requirements for Future Safety-Critical Systems and Their Validation

Loss of control remains one of the largest contributors to fatal aircraft accidents worldwide. Aircraft loss-of-control accidents are complex, resulting from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. This paper summarizes recent analysis results in identifying worst-case combinations of loss-of-control accident precursors and their time sequences, a holistic approach to preventing loss-of-control accidents in the future, and key requirements for validating the associated technologies.

Belcastro, Christine M.↗
NASA NTRS2012

Analyzing a Mid-Air Collision Over the Hudson River

On August 8, 2009, a private airplane collided with a sightseeing helicopter over the Hudson River near Hoboken, New Jersey. All three people aboard the airplane, the pilot and two passengers, and all six people aboard the helicopter, the pilot and five passengers, were killed. The National Transportation Safety Board report on the accident identified inherent limitations of the see-and-avoid concept, inadequate regulations, and errors by the pilots and an air traffic controller as causing or contributing to the accident. This paper presents the results of analyzing the accident using the Systems-Theoretic Accident Model and Processes (STAMP) approach to determining accident causation.

Brown, Sean↗
NASA NTRS2012

Validation and Verification (V&V) of Safety-Critical Systems Operating Under Off-Nominal Conditions

Loss of control (LOC) remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft LOC accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. Research is underway at the National Aeronautics and Space Administration (NASA) in the development of advanced onboard system technologies for preventing or recovering from loss of vehicle control and for assuring safe operation under off-nominal conditions associated with aircraft LOC accidents. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V&V) and ultimate certification. The V&V of complex integrated systems poses highly significant technical challenges and is the subject of a parallel research effort at NASA. This chapter summarizes the V&V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft LOC accidents. A summary of recent research accomplishments in this effort is referenced.

Belcastro, Christine M.↗
NASA NTRS2014

Solid Rocket Launch Vehicle Explosion Environments

Empirical explosion data from full scale solid rocket launch vehicle accidents and tests were collected from all available literature from the 1950s to the present. In general data included peak blast overpressure, blast impulse, fragment size, fragment speed, and fragment dispersion. Most propellants were 1.1 explosives but a few were 1.3. Oftentimes the data from a single accident was disjointed and/or missing key aspects. Despite this fact, once the data as a whole was digitized, categorized, and plotted clear trends appeared. Particular emphasis was placed on tests or accidents that would be applicable to scenarios from which a crew might need to escape. Therefore, such tests where a large quantity of high explosive was used to initiate the solid rocket explosion were differentiated. Also, high speed ground impacts or tests used to simulate such were also culled. It was found that the explosions from all accidents and applicable tests could be described using only the pressurized gas energy stored in the chamber at the time of failure. Additionally, fragmentation trends were produced. Only one accident mentioned the elusive "small" propellant fragments, but upon further analysis it was found that these were most likely produced as secondary fragments when larger primary fragments impacted the ground. Finally, a brief discussion of how this data is used in a new launch vehicle explosion model for improving crew/payload survival is presented.

Richardson, E. H.↗
NASA NTRS2017

Crew State Monitoring and Line-Oriented Flight Training for Attention Management

Loss of control - inflight (LOC-I) has historically represented the largest category of commercial aviation fatal accidents. A review of worldwide transport airplane accidents (2001-2010) indicated that loss of airplane state awareness (ASA) was responsible for the majority of the LOC-I fatality rate. The Commercial Aviation Safety Team (CAST) ASA study identified 12 major themes that were indicated across the ASA accident and incident events. One of the themes was crew distraction or ineffective attention management, which was found to be involved in all 18 events including flight crew channelized attention, startle/surprise, diverted attention, and/or confirmation bias. Safety Enhancement (SE)-211, "Training for Attention Management" was formed to conduct research to develop and assess commercial airline training methods and realistic scenarios that can address these attention-related human performance limitations. This paper describes NASA SE-211 research for new design approaches and validation of line-oriented flight training (LOFT). Recent accident and incident data suggests that Spatial Disorientation (SD) and Loss-of-Energy State Awareness (LESA) for transport category aircraft are becoming an increasingly prevalent safety concern in all domestic and international operations (Commercial Aviation Safety Team, 2014a). SD is defined as an erroneous perception of aircraft attitude that can lead directly to a Loss-of-Control Inflight (LOC-I) event and result in an accident or incident. LESA is typically characterized by a failure to monitor or understand energy state indications (e.g., airspeed, altitude, vertical speed, commanded thrust) and a resultant failure to maintain safe flight.

Stephens, Chad↗