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At least 307 records · Page 17
All sourcesNASA NTRSDOE OSTI
NASA NTRS2015

Reliability and Probabilistic Risk Assessment - How They Play Together

Since the Space Shuttle Challenger accident in 1986, NASA has extensively used probabilistic analysis methods to assess, understand, and communicate the risk of space launch vehicles. Probabilistic Risk Assessment (PRA), used in the nuclear industry, is one of the probabilistic analysis methods NASA utilizes to assess Loss of Mission (LOM) and Loss of Crew (LOC) risk for launch vehicles. PRA is a system scenario based risk assessment that uses a combination of fault trees, event trees, event sequence diagrams, and probability distributions to analyze the risk of a system, a process, or an activity. It is a process designed to answer three basic questions: 1) what can go wrong that would lead to loss or degraded performance (i.e., scenarios involving undesired consequences of interest), 2) how likely is it (probabilities), and 3) what is the severity of the degradation (consequences). Since the Challenger accident, PRA has been used in supporting decisions regarding safety upgrades for launch vehicles. Another area that was given a lot of emphasis at NASA after the Challenger accident is reliability engineering. Reliability engineering has been a critical design function at NASA since the early Apollo days. However, after the Challenger accident, quantitative reliability analysis and reliability predictions were given more scrutiny because of their importance in understanding failure mechanism and quantifying the probability of failure, which are key elements in resolving technical issues, performing design trades, and implementing design improvements. Although PRA and reliability are both probabilistic in nature and, in some cases, use the same tools, they are two different activities. Specifically, reliability engineering is a broad design discipline that deals with loss of function and helps understand failure mechanism and improve component and system design. PRA is a system scenario based risk assessment process intended to assess the risk scenarios that could lead to a major/top undesirable system event, and to identify those scenarios that are high-risk drivers. PRA output is critical to support risk informed decisions concerning system design. This paper describes the PRA process and the reliability engineering discipline in detail. It discusses their differences and similarities and how they work together as complementary analyses to support the design and risk assessment processes. Lessons learned, applications, and case studies in both areas are also discussed in the paper to demonstrate and explain these differences and similarities.

Safie, Fayssal↗
NASA NTRS2017

Getting to the Heart of Cardiovascular Risk Assessment in Astronauts for Exploration Class Missions

Since the beginning of manned spaceflight, NASA has recognized the potential risk of cardiovascular decrements due to stressors in the space environment. Of particular concern is the effect of space radiation on cardiovascular disease since astronauts will be exposed to higher levels of galactic cosmic rays outside the Earth's protective magnetosphere. To date, only a few studies have examined the effects of heavy ion radiation on cardiovascular disease, and at lower, space-relevant doses, the association between radiation exposure and cardiovascular pathology is more varied and unclear. Furthermore, other spaceflight conditions such as microgravity, circadian shifts, and confinement stress pose unique challenges in estimating the health risks that can be attributed to exposure to ionizing radiations. In this work, we review age, cause of mortality, and radiation exposure amongst early NASA astronauts in selection groups and discuss the limitations of assessing such a cohort when attempting to characterize the risk of space flight, including stressors such as space radiation and microgravity exposure, on cardiovascular health. METHODS: NASA astronauts in selection groups 1-7 were chosen and the comparison population was white men of the same birth cohort as drawn from data from the CDC Wonder Database and CDC National Center for Health Statistics Life Tables. Cause of death information was obtained from the Lifetime Surveillance of Astronaut Health program and deceased astronauts were classified based on ICD-10 codes: ischemic heart disease (IHD), stroke, cancer, acute occupational events, non-NASA accidents, and other/unknown. Expected years of life left and expected age at death were calculated for the cohort. RESULTS AND CONCLUSIONS: There were 32 deaths in this early astronaut population, 12 of which were due to accidents or acute occupational events that impacted lifespan considerably. The average age at death from these causes is 30 years lower than the average expected ~70 years of age in the general population. Remarkably, all 41 living early astronauts outlived our calculated expected age at death for members of their birth cohort; furthermore, 13 of the 20 deceased astronauts who did not die in NASA/non-NASA accidents exceeded this age. There was no difference in IHD between the astronaut cohort and the comparison population; therefore, it is not possible to associate IHD mortality with radiation in that astronaut cohort. As NASA looks toward future exploration-class missions, early astronaut cohorts provide a convenient option for assessing these risks and for developing mitigation strategies. However, many challenges still exist when assessing such limited evidence, including small cohort size, health and lifestyle confounders (such as smoking and drinking), the high accident mortality rate, and the fact that many of these astronauts are still alive, outliving many of their birth-cohort peers. Future analysis should include a longitudinal study, monitoring cases as they occur in the cohort. As this cohort is currently followed-up over time, and as more IHD cases are anticipated in a population of this age, this type of study is not as resource-intensive as would normally be the case.

Elgart, S. R.↗
NASA NTRS2017

Quantifying Pilot Contribution to Flight Safety During an In-Flight Airspeed Failure

Accident statistics cite the flight crew as a causal factor in over 60% of large transport fatal accidents. Yet a well-trained and well-qualified crew is acknowledged as the critical center point of aircraft systems safety and an integral component of the entire commercial aviation system. A human-in-the-loop test was conducted using a Level D certified Boeing 737-800 simulator to evaluate the pilot's contribution to safety-of-flight during routine air carrier flight operations and in response to system failures. To quantify the human's contribution, crew complement was used as an independent variable in a between-subjects design. This paper details the crew's actions and responses while dealing with an in-flight airspeed failure. Accident statistics often cite flight crew error (Baker, 2001) as the primary contributor in accidents and incidents in transport category aircraft. However, the Air Line Pilots Association (2011) suggests "a well-trained and well-qualified pilot is acknowledged as the critical center point of the aircraft systems safety and an integral safety component of the entire commercial aviation system." This is generally acknowledged but cannot be verified because little or no quantitative data exists on how or how many accidents/incidents are averted by crew actions. Anecdotal evidence suggest crews handle failures on a daily basis and Aviation Safety Action Program data generally supports this assertion, even if the data is not released to the public. However without hard evidence, the contribution and means by which pilots achieve safety of flight is difficult to define. Thus, ways to improve the human ability to contribute or overcome deficiencies are ill-defined.

Etherington, Timothy J.↗
NASA NTRS2018

Day of Remembrance

Every year in late January, NASA holds a Day of Remembrance, honoring the astronauts lost in three major space flight accidents: Apollo 1, Challenger and Columbia. In an odd tragic coincidence, all three of the accidents happened in late January or early February, although many years apart: Apollo 1 on January 27, 1967; Challenger on January 28, 1986; and Columbia on February 1, 2003. While the day is a solemn one to commemorate the astronauts who lost their lives, it is also a day to reflect on the errors that led to the accidents and to remind all NASA workers and managers to be ever vigilant so that preventable accidents don't happen again.

Day of Remembranc↗
NASA NTRS2003

Associations between errors and contributing factors in aircraft maintenance

In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.

Professional Competence↗
NASA NTRS2002

Unsafe acts and unsafe outcomes in aircraft maintenance

Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.

Maintenance/manpower/methods↗
NASA NTRS2020

Analysis of Pilot Monitoring Skills and a Review of Training Effectiveness

The commercial aviation industry world-wide has identified a need for improved pilot monitoring and awareness (e.g., FAA, 2013, ICAO, 2016). More specifically, aviation safety data indicate that failures in pilots’ flight path management (FPM) monitoring and awareness have contributed to a range of undesired outcomes: accidents, major upsets, and non-compliance with air traffic control (ATC) guidance. The Federal Aviation Administration (FAA) has further stated that these types of FPM failures are likely to worsen with the increasingly complex air traffic control systems and FPM concepts proposed for NextGen (https://www.faa. gov/nextgen/what_is_nextgen/) operations (e.g., see Hah et al., 2017). Adding to this complexity is the introduction of increasingly automated aircraft systems that can increase monitoring burdens. One potential mitigation for this situation is to enhance pilot training for effective monitoring. NASA Ames Research Center was asked to identify and evaluate training approaches that have the potential to enhance pilots’ ability to effectively monitor for FPM (with the result of improved awareness). The focus of this work is to identify, develop or validate training guidance to improve pilot monitoring/awareness regarding FPM and mitigate the recent trend of accidents and incidents, especially loss of control (LOC) events. The result of this work should be input for improved industry standards and FAA guidance to reduce the risk of incidents and accidents due to inadequate pilot monitoring/awareness. This is the first of three reports that were developed for this project.

aviation human factors↗
NASA NTRS1972

Processes of technology assessment: The National Transportation Safety Board

The functions and operations of the Safety Board as related to technology assessment are described, and a brief history of the Safety Board is given. Recommendations made for safety in all areas of transportation and the actions taken are listed. Although accident investigation is an important aspect of NTSB's activity, it is felt that the greatest contribution is in pressing for development of better accident prevention programs. Efforts of the Safety Board in changing transportation technology to improve safety and prevent accidents are illustrated.

Weiss, E.↗
NASA NTRS1974

Assembly and analysis of fragmentation data for liquid propellant vessels

Fragmentation data was assembled and analyzed for exploding liquid propellant vessels. These data were to be retrieved from reports of tests and accidents, including measurements or estimates of blast yield, etc. A significant amount of data was retrieved from a series of tests conducted for measurement of blast and fireball effects of liquid propellant explosions (Project PYRO), a few well-documented accident reports, and a series of tests to determine auto-ignition properties of mixing liquid propellants. The data were reduced and fitted to various statistical functions. Comparisons were made with methods of prediction for blast yield, initial fragment velocities, and fragment range. Reasonably good correlation was achieved. Methods presented in the report allow prediction of fragment patterns, given type and quantity of propellant, type of accident, and time of propellant mixing.

Baker, W. E.↗
NASA NTRS1978

A historical overview of stall/spin characteristics of general aviation aircraft

Even today, stall/spin accidents involving general aviation aircraft account for more fatal and serious injuries than any other kind of accident. The classic stall/spin accident is one in which the pilot stalls the aircraft at too low an altitude to affect recovery. The primary attention in the investigation is given to aerodynamic considerations, although it is recognized that human factors and pilot training are also very important aspects of the total problem. A review of some 70 years of flight indicates that incorporation of the proper combination of aerodynamic parameters to provide good stall/spin avoidance has persistently remained an elusive goal for designers of general aviation aircraft.

Anderson, S. B.↗
NASA NTRS1978

Single pilot IFR operating problems determined from accidental data analysis

The accident reports examined were restricted to instrument rated pilots flying in IFR weather. A brief examination was made of accidents which occurred during all phases of flight and which were due to all causes. A detailed examination was made of those accidents which involved a single pilot which occurred during the landing phases of flight, and were due to pilot error. Problem areas found include: (1) landing phase operations especially final approach, (2) pilot weather briefings, (3) night approaches in low IFR weather, (4) below minimum approaches, (5) aircraft icing, (6) imprecise navigation, (7) descending below minimum IFR altitudes, (8) fuel mismanagement, (9) pilot overconfidence, and (10) high pilot workload especially in twins. Some suggested areas of research included: (1) low cost deicing systems, (2) standardized navigation displays, (3) low cost low-altitude warning systems, (4) improved fuel management systems, (5) improved ATC communications, (6) more effective pilot training and experience acquisition methods, and (7) better weather data dissemination techniques.

Forsyth, D. L.↗
NASA NTRS1979

Carbon fiber dispersion models used for risk analysis calculations

For evaluating the downwind, ground level exposure contours from carbon fiber dispersion, two fiber release scenarios were chosen. The first is the fire and explosion release in which all of the fibers are released instantaneously. This model applies to accident scenarios where an explosion follows a short-duration fire in the aftermath of the accident. The second is the plume release scenario in which the total mass of fibers is released into the fire plume. This model applies to aircraft accidents where only a fire results. These models are described in detail.

Source record↗
NASA NTRS1980

Advanced risk assessment of the effects of graphite fibers on electronic and electric equipment

An assessment of the risk associated with accidents involving aircraft with carbon fiber composite structural components is examined. The individual fiber segments cause electrical and electronic equipment to fail under certain operating conditions. A Monte Carlo simulation model was used to computer the risk. Aircraft accidents with fire, release of carbon fiber material, entrainment of carbon fibers in a smoke plume transport of fibers downwind, transfer of some fibers/into the the interior of buildings, failures of electrical and electronic equipment, and economic impact of failures are discussed. Risk profiles were prepared for individual airports and the Nation. The vulnerability of electrical transmission equipment to carbon fiber incursion and aircraft accident total costs is investigated.

Pocinki, L.↗
NASA NTRS1984

Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)

It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.

Billings, C. E.↗
NASA NTRS1985

Pilots of the future - Human or computer?

In connection with the occurrence of aircraft accidents and the evolution of the air-travel system, questions arise regarding the computer's potential for making fundamental contributions to improving the safety and reliability of air travel. An important result of an analysis of the causes of aircraft accidents is the conclusion that humans - 'pilots and other personnel' - are implicated in well over half of the accidents which occur. Over 70 percent of the incident reports contain evidence of human error. In addition, almost 75 percent show evidence of an 'information-transfer' problem. Thus, the question arises whether improvements in air safety could be achieved by removing humans from control situations. In an attempt to answer this question, it is important to take into account also certain advantages which humans have in comparison to computers. Attention is given to human error and the effects of technology, the motivation to automate, aircraft automation at the crossroads, the evolution of cockpit automation, and pilot factors.

Chambers, A. B.↗
NASA NTRS1988

Human error in aviation operations

The role of human error in commercial and general aviation accidents and the techniques used to evaluate it are reviewed from a human-factors perspective. Topics addressed include the general decline in accidents per million departures since the 1960s, the increase in the proportion of accidents due to human error, methods for studying error, theoretical error models, and the design of error-resistant systems. Consideration is given to information acquisition and processing errors, visually guided flight, disorientation, instrument-assisted guidance, communication errors, decision errors, debiasing, and action errors.

Nagel, David C.↗
NASA NTRS1989

Risk-Based Fire Safety Experiment Definition for Manned Spacecraft

Risk methodology is used to define experiments to be conducted in space which will help to construct and test the models required for accident sequence identification. The development of accident scenarios is based on the realization that whether damage occurs depends on the time competition of two processes: the ignition and creation of an adverse environment, and the detection and suppression activities. If the fire grows and causes damage faster than it is detected and suppressed, then an accident occurred. The proposed integrated experiments will provide information on individual models that apply to each of the above processes, as well as previously unidentified interactions and processes, if any. Initially, models that are used in terrestrial fire risk assessments are considered. These include heat and smoke release models, detection and suppression models, as well as damage models. In cases where the absence of gravity substantially invalidates a model, alternate models will be developed. Models that depend on buoyancy effects, such as the multizone compartment fire models, are included in these cases. The experiments will be performed in a variety of geometries simulating habitable areas, racks, and other spaces. These simulations will necessitate theoretical studies of scaling effects. Sensitivity studies will also be carried out including the effects of varying oxygen concentrations, pressures, fuel orientation and geometry, and air flow rates. The experimental apparatus described herein includes three major modules: the combustion, the fluids, and the command and power modules.

Apostolakis, G. E.↗
NASA NTRS1990

Safety status of space radioisotope and reactor power sources

The current overall safety criterion for both radioisotope and reactor power sources is containment or immobilization in the case of a reentry accident. In addition, reactors are designed to remain subcritical under conditions of land impact or water immersion. A very extensive safety test and analysis program was completed on the radioisotope thermoelectric generators (RTGs) in use on the Galileo spacecraft and planned for use on the Ulysses spacecraft. The results of this work show that the RTGs will pose little or no risk for any credible accident. The SP-100 space nuclear reactor program has begun addressing its safety criteria, and the design is planned to be such as to ensure meeting the various safety criteria. Preliminary mission risk analyses on SP-100 show the expected value population dose from postulated accidents on the reference mission to be very small. It is concluded that the current US nuclear power sources are the safest flown.

Bennett, Gary L.↗