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All sourcesNASA NTRSDOE OSTI
NASA NTRS1995

Decision Making in the Airplane

The Importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful In improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that all crew members have essential information, but it also regulates and coordinates crew actions and is the medium of collective thinking In response to a problem, This presentation will examine the relations between leadership, communication, decision making and overall crew performance. Implications of these findings for training will be discussed.

Orasanu, Judith↗
NASA NTRS1996

Early Warning: Development of Confidential Incident Reporting Systems

Accidents hardly ever happen without warning. The combination, or sequence, of failures and mistakes that cause an accident may indeed be unique but the individual failures and mistakes rarely are. In the USA in 1974 the crews on two different aircraft misunderstood the same aeronautical chart and descended towards their destination dangerously early towards a mountain. The first crew were in good weather conditions and could see the mountain and resolved their misinterpretation of the chart. The second crew six weeks later were not so lucky. In cloud they had no clues to point out their mistake nor the presence of the mountain. The resulting crash and the ensuing inquiry, which brought to light the previous incident, shocked the country but gave it the impetus to instigate a safety reporting system. This system eventually became the NASA's Aviation Safety Reporting System (ASRS). The programme collects incident reports from pilots, controllers, mechanics, cabin attendants and many others involved in aviation operations. By disseminating this safety information the ASRS has helped enormously to give US airlines and airspace the highest safety standards. Accident prevention is a goal sought by everyone in the aviation industry and establishing effective incident reporting programmes can go a long way toward achieving that goal. This article will describe the steps and issues required to establish an incident reporting system. The authors summarize the lessons learned from the ASRS, now in its twentieth year of operation and from the Confidential Human Factors Reporting (HER) Programme run by British Airways, an airline that is a recognized world leader in safety reporting and analysis. The differences between government and airline operation of confidential safety reporting systems will be addressed.

OLeary, Mike J.↗
NASA NTRS2002

General Aviation Pilots' Perceived Usage and Valuation of Aviation Weather Information Sources

Aviation suffers many accidents due to the lack of good weather information in flight. Existing aviation weather information is difficult to obtain when it is most needed and is not well formatted for in-flight use. Because it is generally presented aurally, aviation weather information is difficult to integrate with spatial flight information and retain for reference. Efforts, by NASA's Aviation Weather Information (AWIN) team and others, to improve weather information accessibility, usability and decision aiding will enhance General Aviation (GA) pilots' weather situation awareness and decision-making and therefore should improve the safety of GA flight. Consideration of pilots' economic concerns will ensure that in-flight weather information systems are financially accessible to GA pilots as well. The purpose of this survey was to describe how aviation operator communities gather and use weather information as well as how weather related decisions are made between flight crews and supporting personnel. Pilots of small GA aircraft experience the most weather-related accidents as well as the most fatal weather related accident. For this reason, the survey design and advertisement focused on encouraging participation from GA pilots. Perhaps as a result of this emphasis, most responses, 97 responses or 85% of the entire response set, were from GA pilots, This paper presents only analysis of these GA pilots' responses. The insights provided by this survey regarding GA pilots' perceived value and usage of current aviation weather information. services, and products provide a basis for technological approaches to improve GA safety. Results of this survey are discussed in the context of survey limitations and prior work, and serve as the foundation for a model of weather information value, guidance for the design of in-flight weather information systems, and definition of further research toward their development.

Latorella, Kara↗
NASA NTRS1996

A Risk Assessment Model for Reduced Aircraft Separation: A Quantitative Method to Evaluate the Safety of Free Flight

As new technologies and procedures are introduced into the National Airspace System, whether they are intended to improve efficiency, capacity, or safety level, the quantification of potential changes in safety levels is of vital concern. Applications of technology can improve safety levels and allow the reduction of separation standards. An excellent example is the Precision Runway Monitor (PRM). By taking advantage of the surveillance and display advances of PRM, airports can run instrument parallel approaches to runways separated by 3400 feet with the same level of safety as parallel approaches to runways separated by 4300 feet using the standard technology. Despite a wealth of information from flight operations and testing programs, there is no readily quantifiable relationship between numerical safety levels and the separation standards that apply to aircraft on final approach. This paper presents a modeling approach to quantify the risk associated with reducing separation on final approach. Reducing aircraft separation, both laterally and longitudinally, has been the goal of several aviation R&D programs over the past several years. Many of these programs have focused on technological solutions to improve navigation accuracy, surveillance accuracy, aircraft situational awareness, controller situational awareness, and other technical and operational factors that are vital to maintaining flight safety. The risk assessment model relates different types of potential aircraft accidents and incidents and their contribution to overall accident risk. The framework links accident risks to a hierarchy of failsafe mechanisms characterized by procedures and interventions. The model will be used to assess the overall level of safety associated with reducing separation standards and the introduction of new technology and procedures, as envisaged under the Free Flight concept. The model framework can be applied to various aircraft scenarios, including parallel and in-trail approaches. This research was performed under contract to NASA and in cooperation with the FAA's Safety Division (ASY).

Cassell, Rick↗
NASA NTRS1996

Cross-Cultural Barriers to Effective Communication in Aviation

Communication is essential to safe flight, as evidenced by several accidents in which crew communicates was found to have contributed to the accidents. This chapter documents the essential role of explicit efficient communication to flight safety with a global context. It addresses communication between flight crews and air traffic controllers in regions a the world where pilots and controllers speak different native languages, as well as cases in which crew members within the flight deck represent different native languages and cultures. It also addresses problems associated with "exporting" crew resource management training programs to parts of the world which values and norms differ from those of the United States, where these programs were initially developed. This chapter is organized around several central questions: (1) What are various kinds of communication failures and what are their consequences; (2) What are the causes of communication failure; (3) What are features of effective crew communication; (4) What can be done to enhance communication success? To explore a wider range of communication failures than available from accident reports, we examined a set of incident reports from the Aviation Safety Reporting System. These could be classified into three major categories: those in which language actually interfered with transmission of a message; those in which transmission was adequate but the context was not expressed unambiguously and thus the message received was not the same as the message intended; and those in which the message was received as intended, but was not adequately understood or acted upon, mainly because of cultural factors. The consequences of failed communication can be flight errors (such as when a clearance is not received correctly), loss of situation awareness, or failure of crew members (or ATC and pilots) to build a shared understanding of a situation. Causes of misunderstanding can be traced to a number of sources, often grounded in faulty assumptions held by one or both parties to a conversation. Speakers and listeners often experience "illusionary understanding" in which they think they understand each other, but in fact do not. While this problem can exist within a single culture, it is much more serious across cultures. Training in effective explicit communication is a component of Crew Resource Management training programs developed in the U.S. These programs are being adopted by airlines around the world, with varying degrees of success. The level of success in part depends on how similar the conversational and social styles of those cultures are to those of the U.S. A factor that influences conversational style is a culture's relative positioned on two major dimensions that distinguish national cultural groups: individualism vs. collectivism and degree of power distance. The chapter concludes with a discussion of techniques for overcoming the various classes of communication failures and for effectively adapting training programs to fit the values and norms of cultures around the globe.

Fischer, U.↗
NASA NTRS1997

Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

Increasing numbers of aircraft are operating on the surface of airports throughout the world. Airport operations are forecast to grow by more that 50%, by the year 2005. Airport surface movement traffic would therefore be expected to become increasingly congested. Safety of these surface operations will become a focus as airport capacity planning efforts proceed toward the future. Several past events highlight the prevailing risks experienced while moving aircraft during ground operations on runways, taxiways, and other areas at terminal, gates, and ramps. The 1994 St. Louis accident between a taxiing Cessna crossing an active runway and colliding with a landing MD-80 emphasizes the importance of a fail-safe system for airport operations. The following study explores reports of incidents occurring on an airport surface that did not escalate to an accident event. The Aviation Safety Reporting System has collected data on surface movement incidents since 1976. This study sampled the reporting data from June, 1993 through June, 1994. The coding of the data was accomplished in several categories. The categories include location of airport, phase of ground operation, weather /lighting conditions, ground conflicts, flight crew characteristics, human factor considerations, and airport environment. These comparisons and distributions of variables contributing to surface movement incidents can be invaluable to future airport planning, accident prevention efforts, and system-wide improvements.

Connell, Linda J.↗
NASA NTRS1998

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Orasanu, Judith↗
NASA NTRS1999

Helicopter Safety Research

In response to the President's challenge to reduce civil aviation accidents by a factor of 10 by the year 2022, NASA has embarked on an ambitious safety program in partnership with other government agencies and industry. The helicopter element of the NASA initiative has been guided by a series of accident analyses aimed at identifying the most frequent causes and consequences and initiating research to prevent or mitigate these factors. This talk will summarize the key findings of three of the accident analyses, the major elements of the safety program, and how helicopter safety research relates to the safety program.

Hart, Sandra G.↗
NASA NTRS2003

Risk-based Classification of Incidents

As the penetration of software into safety-critical systems progresses, accidents and incidents involving software will inevitably become more frequent. Identifying lessons from these occurrences and applying them to existing and future systems is essential if recurrences are to be prevented. Unfortunately, investigative agencies do not have the resources to fully investigate every incident under their jurisdictions and domains of expertise and thus must prioritize certain occurrences when allocating investigative resources. In the aviation community, most investigative agencies prioritize occurrences based on the severity of their associated losses, allocating more resources to accidents resulting in injury to passengers or extensive aircraft damage. We argue that this scheme is inappropriate because it undervalues incidents whose recurrence could have a high potential for loss while overvaluing fairly straightforward accidents involving accepted risks. We then suggest a new strategy for prioritizing occurrences based on the risk arising from incident recurrence.

Greenwell, William S.↗
NASA NTRS2003

Synthetic Vision CFIT Experiments for GA and Commercial Aircraft: "A Picture Is Worth A Thousand Lives"

Because restricted visibility has been implicated in the majority of commercial and general aviation accidents, solutions will need to focus on how to enhance safety during instrument meteorological conditions (IMC). The NASA Synthetic Vision Systems (SVS) project is developing technologies to help achieve these goals through the synthetic presentation of how the outside world would look to the pilot if vision were not reduced. The potential safety outcome would be a significant reduction in several accident categories, such as controlled-flight-into-terrain (CFIT), that have restricted visibility as a causal factor. The paper describes two experiments that demonstrated the efficacy of synthetic vision technology to prevent CFIT accidents for both general aviation and commercial aircraft.

Prinzel, Lawrence J., III↗
NASA NTRS2004

'Systemic Failures' and 'Human Error' in Canadian TSB Aviation Reports Between 1996 and 2002

This paper describes the results of an independent analysis of the primary and contributory causes of aviation accidents in Canada between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of these adverse events. Our results suggest that the majority of these high consequence accidents were attributed to human error. A large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗
NASA NTRS2004

Improving Performance of the System Safety Function at Marshall Space Flight Center

The Columbia Accident Investigation Board (CAIB) determined that organizational and management issues were significant contributors to the loss of Space Shuttle Columbia. In addition, the CAIB observed similarities between the organizational and management climate that preceded the Challenger accident and the climate that preceded the Columbia accident. To prevent recurrence of adverse organizational and management climates, effective implementation of the system safety function is suggested. Attributes of an effective system safety program are presented. The Marshall Space Flight Center (MSFC) system safety program is analyzed using the attributes. Conclusions and recommendations for improving the MSFC system safety program are offered in this case study.

Kiessling, Ed↗
NASA NTRS2003

Methods Developed by the Tools for Engine Diagnostics Task to Monitor and Predict Rotor Damage in Real Time

Tools for Engine Diagnostics is a major task in the Propulsion System Health Management area of the Single Aircraft Accident Prevention project under NASA s Aviation Safety Program. The major goal of the Aviation Safety Program is to reduce fatal aircraft accidents by 80 percent within 10 years and by 90 percent within 25 years. The goal of the Propulsion System Health Management area is to eliminate propulsion system malfunctions as a primary or contributing factor to the cause of aircraft accidents. The purpose of Tools for Engine Diagnostics, a 2-yr-old task, is to establish and improve tools for engine diagnostics and prognostics that measure the deformation and damage of rotating engine components at the ground level and that perform intermittent or continuous monitoring on the engine wing. In this work, nondestructive-evaluation- (NDE-) based technology is combined with model-dependent disk spin experimental simulation systems, like finite element modeling (FEM) and modal norms, to monitor and predict rotor damage in real time. Fracture mechanics time-dependent fatigue crack growth and damage-mechanics-based life estimation are being developed, and their potential use investigated. In addition, wireless eddy current and advanced acoustics are being developed for on-wing and just-in-time NDE engine inspection to provide deeper access and higher sensitivity to extend on-wing capabilities and improve inspection readiness. In the long run, these methods could establish a base for prognostic sensing while an engine is running, without any overt actions, like inspections. This damage-detection strategy includes experimentally acquired vibration-, eddy-current- and capacitance-based displacement measurements and analytically computed FEM-, modal norms-, and conventional rotordynamics-based models of well-defined damages and critical mass imbalances in rotating disks and rotors.

Baaklini, George Y.↗
NASA NTRS2004

Understanding Columbia's Reentry Problems

Soon after the Space Shuttle Columbia accident occurred last year, a group of CFD analysts from NASA centers and private industry was organized to help determine the cause of the accident. This group was under the direction of the Applied Aeroscience and CFD Branch of the Aeroscience and Flight Mechanics Division at the Johnson Space Center. For external flow simulations, noncommercial CFD codes that specialize in hypersonic or high Mach number flows were used. These tools were used to determine heating rates, pressures, and temperatures for a large number of vehicle damage scenarios. Lockheed Martin Space Operations was called upon to provide CFD support in the area of internal flows within the shuttle wing cavity, and or these simulations, FLUENT 6.1 was chosen. Two large-scale, simplified models were run to understand the flow patterns once a breach of the internal wing cavity was initiated. The results were primarily used to visualize flow patterns within the wing cavity. The first CFD model included the entire left wing without the wheel. well cavity. The purpose of the first model, which did not include the reinforced carbon-carbon (RCC) cavity along the wing leading edge, was to visualize the flow field within the wing cavity immediately after the leading edge spar breach, This model assumed that the flow coming into the wing cavity was nom1 to the spar. It included all o f the primary vents that allow for flow between the main cavities of the wing. A six-inch diameter hole was modeled in the spar at the approximate location where the spar breach was judged to have occurred, which was between RCC panels 8 and 9. The results of the modeling showed that at this location, the high temperature, high velocity gas stream entering the wing cavity impinged on the outboard wheel well cavity. Instrumentation in the Shuttle wheel well cavity registered abnormal temperatures during reentry, so the FLUENT results helped support the conclusion of the accident investigation team that the spar breach was in the RCC panel 8-9 area, and that the initial spar breach was likely entering the wing cavity normal to the spar. This model also showed that the flow entering the wing cavity tended to swirl within the cavity just outboard of the wheel well, and did not initially penetrate further into the rear cavities of the wing. The second CFD model was a 2-D simulation of the left wing cavity and the RCC cavity. It was used to visualize the flow through the RCC breach, through the wing spar breach, and into the wing cavity directly outboard of the wheel well. The purpose of this model was to verify whether or not it was possible for the flow to come into the wing cavity normal to the leading edge spar. The results from this 2-D model showed that the internal structure behind the RCC panels probably deflected the flow entering the RCC cavity so that it impinged normal to the spar. As in the 3-D model, this deflected flow stream was found to impinge on the wheel well outer wall. This model again supported the conclusions regarding the location of the spar breach and how the flow behaved inside the wing cavity.

Paul, Thomas H.↗
NASA NTRS2006

Understanding Columbia's Reentry Problems

Soon after the Space Shuttle Columbia accident occurred last year, a group of CFD analysts from NASA centers and private industry was organized to help determine the cause of the accident. This group was under the direction of the Applied Aeroscience and CFD Branch of the Aeroscience and Flight Mechanics Division at the Johnson Space Center. For external flow simulations, noncommercia2 CFD codes that specialize in hypersonic or high Mach number flows were used. These tools were used to determine heating rates, pressures, and temperatures for a large number of vehicle damage scenarios. Lockheed Martin Space Operations was called upon to provide CFD support in the area of internal flows within the shuttle wing cavity, and for these simulations, FLUENT 6.1 was chosen. Two large-scale, simplified models were m to understand the flow patterns once a breach of the internal wing cavity was initiated. The results were primarily used to visualize flow patterns within the wing cavity. The first CFD model included the entire lee wing without the wheel well cavity. The purpose of the first model, which did not include the reinforced carbon-carbon (RCC) cavity along the wing leading edge, was to visualize the flow field within the wing cavity immediately after the leading edge spar breach, This model assumed that the flow coming into the wing cavity was normal to the spar. It included all of the primary vents that allow for flow between the main cavities of the wing. A six-inch diameter hole was modeled in the spar at the approximate location where the spar breach was judged to have occurred, which was between RCC panels 8 and 9. The results of the modeling showed that at this location, the high temperature, high velocity gas stream entering the wing cavity impinged on the outboard wheel well cavity. Instrumentation in the Shuttle wheel well cavity registered abnormal temperatures during reentry, so the FLUENT results helped support the conclusion of the accident investigation team that the spar breach was in the RCC panel 8-9 area, and that the initial spar breach was likely entering the wing cavity normal to the spar. This model also showed that the flow entering the wing cavity tended to swirl within the cavity just outboard of the wheel well, and did not initially penetrate further into the rear cavities of the wing. The second CFD model was a 2-D simulation of the left wing cavity and the RCC cavity. It was used to visualize the flow through the RCC breach, through the wing spar breach, and into the wing cavity directly outboard of the wheel well. The purpose of this model was to verify whether or not it was possible for the flow to come into the wing cavity normal to the leading edge spar. The results from this 2-D model showed that the internal structure behind the RCC panels probably deflected the flow entering the RCC cavity so that it impinged normal to the spar. As in the 3-D model, this deflected flow stream was Found to impinge on the wheel well outer wall. This model again supported the conclusions regarding the location of the spar breach and how the flow behaved inside the wing cavity.

Paul, Thomas↗
NASA NTRS2006

Questioning the Role of Requirements Engineering in the Causes of Safety-Critical Software Failures

Many software failures stem from inadequate requirements engineering. This view has been supported both by detailed accident investigations and by a number of empirical studies; however, such investigations can be misleading. It is often difficult to distinguish between failures in requirements engineering and problems elsewhere in the software development lifecycle. Further pitfalls arise from the assumption that inadequate requirements engineering is a cause of all software related accidents for which the system fails to meet its requirements. This paper identifies some of the problems that have arisen from an undue focus on the role of requirements engineering in the causes of major accidents. The intention is to provoke further debate within the emerging field of forensic software engineering.

Johnson, C. W.↗
NASA NTRS2006

Orbiter Return-To-Flight Entry Aeroheating

The Columbia accident on February 1, 2003 began an unprecedented level of effort within the hypersonic aerothermodynamic community to support the Space Shuttle Program. During the approximately six month time frame of the primary Columbia Accident Investigation Board activity, many technical disciplines were involved in a concerted effort to reconstruct the last moments of the Columbia and her crew, and understand the critical events that led to that loss. Significant contributions to the CAIB activity were made by the hypersonic aerothermodynamic community(REF CAIB) in understanding the re-entry environments that led to the propagation of an ascent foam induced wing leading edge damage to a subsequent breech of the wing spar of Columbia, and the subsequent breakup of the vehicle. A core of the NASA hypersonic aerothermodynamics team that was involved in the CAIB investigation has been combined with the United Space Alliance and Boeing Orbiter engineering team in order to position the Space Shuttle Program with a process to perform in-flight Thermal Protection System damage assessments. This damage assessment process is now part of the baselined plan for Shuttle support, and is a direct out-growth of the Columbia accident and NASAs response. Multiple re-entry aeroheating tools are involved in this damage assessment process, many of which have been developed during the Return To Flight activity. In addition, because these aeroheating tools are part of an overall damage assessment process that also involves the thermal and stress analyses community, in addition to a much broader mission support team, an integrated process for performing the damage assessment activities has been developed by the Space Shuttle Program and the Orbiter engineering community. Several subsets of activity in the Orbiter aeroheating communities support to the Return To Flight effort have been described in previous publications (CFD?, Cavity Heating? Any BLT? Grid Generation?). This work will provide a description of the integrated process utilized to perform Orbiter tile damage assessment, and in particular will seek to provide a description of the integrated aeroheating tools utilized to perform these assessments. Individual aeroheating tools will be described which provide the nominal re-entry heating environment characterization for the Orbiter, the heating environments for tile damage, heating effects due to exposed Thermal Protection System substrates, the application of Computational Fluid Dynamics for the description of tile cavity heating, and boundary layer transition prediction. This paper is meant to provide an overall view of the integrated aeroheating assessment process for tile damage assessment as one of a sequence of papers on the development of the boundary layer transition prediction capability in support of Space Shuttle Return To Flight efforts.

Campbell, Charles H.↗
NASA NTRS2005

NASA's Radio Frequency Bolt Monitor: A Lifetime of Spinoffs

This story begins in the 1970s, when Dr. Joseph Heyman, a young scientist at NASA s Langley Research Center, was asked to support the investigation of a wind tunnel accident at a sister center. Although the work was outside of his physics background, it sparked a research focus that guided his lengthy NASA career and would earn him a slew of accolades, including NASA s highest award medals for Exceptional Leadership, Exceptional Achievement, and Exceptional Service; the coveted Silver Snoopy Astronaut Award for Space Shuttle Return to Flight; and the Arthur Fleming Award for being one of the Top Ten Federal Scientists in Government Service. He won 30 additional NASA awards, including the Agency s Invention of the Year and the Agency s highest award for technology transfer, and was the only person to ever win 4 R&D 100 Awards. Back in 1973, though, Heyman was a young civil servant with a background in physics who was asked to sit on an accident review panel. The panel met at Ames Research Center, in Moffet Field, California, and after considerable investigation, concluded that a high-pressure pebble heater used for heating gas had failed, due to improperly tightened bolts in a 1,000-pound gate valve control section. The accident showered the facility with incendiary ceramic spheres and nearly a ton of metal, but, luckily, caused no injuries. Heyman returned to Langley and began work on a solution. He developed an ultrasonic device that would measure bolt elongation, as opposed to torque, the factor typically measured in testing bolt preload or tension. Torque measurement can lead to load errors, with miscalculations as high as 80 percent that can be passed over during installation. Bolt stretch, however, is nearly always accurate to 1 percent or better. Within 1 month, he had an acoustic resonance solution that accurately determined bolt elongation. He assumed his work on this project had ended, but it was actually the start of nearly 15 years of work perfecting, improving, inventing, and modifying the "bolt monitor", all the while, filing numerous patents, presenting papers, and holding demonstrations as the technology matured. Industry engineers challenged Heyman s inventiveness, and reminded the physicist that most bolts are not perfect resonators, and that early devices required that the bolt have reasonably flat and parallel faces. The U.S. Geological Survey asked NASA for help in determining the load in mine roof bolts, which are 8- to 10-feet-long and rough cut. To solve that problem, Heyman modified the original device to operate at a lower frequency and to generate propagation modes that could be used to "lock" the instrument on a particular mode. Further work in this vein led to the development of the Pulsed Phase Locked Loop (P2L2) that worked on the mine bolts. The next set of problems involved high-strength bolts with head markings. For this solution, Heyman invented a modified P2L2 that tracked a specific phase point in the measurement wave. This class of instrumentation, well suited to measuring small changes in acoustic velocity, won the NASA "Invention of the Year" award in 1982. Other scientists and engineers have continued the evolution of this technology both inside NASA and outside of the Agency. Within NASA, the technology has been improved for medical applications, with a particular focus on intercranial pressure (ICP) monitoring.

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