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At least 37 records · Page 2

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NASA NTRS1994

Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation Accident

Flight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.

Rosekind, Mark R.↗

NASA NTRS2004

Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence

Almost every year there is at least one technological disaster that highlights the challenge of managing technological risk. On February 1, 2003, the space shuttle Columbia and her crew were lost during reentry into the atmosphere. In the summer of 2003, there was a blackout that left millions of people in the northeast United States without electricity. Forensic analyses, congressional hearings, investigations by scientific boards and panels, and journalistic and academic research have yielded a wealth of information about the events that led up to each disaster, and questions have arisen. Why were the events that led to the accident not recognized as harbingers? Why were risk-reducing steps not taken? This line of questioning is based on the assumption that signals before an accident can and should be recognized. To examine the validity of this assumption, the National Academy of Engineering (NAE) undertook the Accident Precursors Project in February 2003. The project was overseen by a committee of experts from the safety and risk-sciences communities. Rather than examining a single accident or incident, the committee decided to investigate how different organizations anticipate and assess the likelihood of accidents from accident precursors. The project culminated in a workshop held in Washington, D.C., in July 2003. This report includes the papers presented at the workshop, as well as findings and recommendations based on the workshop results and committee discussions. The papers describe precursor strategies in aviation, the chemical industry, health care, nuclear power and security operations. In addition to current practices, they also address some areas for future research.

Phimister, James R.↗

NASA NTRS2005

NASA Structural Analysis Report on the American Airlines Flight 587 Accident - Local Analysis of the Right Rear Lug

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

Raju, Ivatury S↗

NASA NTRS2011

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

Reveley, Mary S.↗

NASA NTRS2011

NASA Accident Precursor Analysis Handbook, Version 1.0

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.

Groen, Frank↗

NASA NTRS2014

Preliminary Analysis of Aircraft Loss of Control Accidents: Worst Case Precursor Combinations and Temporal Sequencing

Aircraft loss of control (LOC) is a leading cause of fatal accidents across all transport airplane and operational classes, and can result from a wide spectrum of hazards, often occurring in combination. Technologies developed for LOC prevention and recovery must therefore be effective under a wide variety of conditions and uncertainties, including multiple hazards, and their validation must provide a means of assessing system effectiveness and coverage of these hazards. This requires the definition of a comprehensive set of LOC test scenarios based on accident and incident data as well as future risks. This paper defines a comprehensive set of accidents and incidents over a recent 15 year period, and presents preliminary analysis results to identify worst-case combinations of causal and contributing factors (i.e., accident precursors) and how they sequence in time. Such analyses can provide insight in developing effective solutions for LOC, and form the basis for developing test scenarios that can be used in evaluating them. Preliminary findings based on the results of this paper indicate that system failures or malfunctions, crew actions or inactions, vehicle impairment conditions, and vehicle upsets contributed the most to accidents and fatalities, followed by inclement weather or atmospheric disturbances and poor visibility. Follow-on research will include finalizing the analysis through a team consensus process, defining future risks, and developing a comprehensive set of test scenarios with correlation to the accidents, incidents, and future risks. Since enhanced engineering simulations are required for batch and piloted evaluations under realistic LOC precursor conditions, these test scenarios can also serve as a high-level requirement for defining the engineering simulation enhancements needed for generating them.

Belcastro, Christine M.↗

NASA NTRS2016

Differences in Characteristics of Aviation Accidents during 1993-2012 Based on Flight Purpose

Usually aviation accidents are categorized and analyzed within flight conduct rules (Part 121, Part 135, Part 91) because differences in accident rates within flight rules have been demonstrated. Even within a particular flight rule the flights have different purposes. For many, Part 121 flights are synonymous with scheduled passenger transport, and indeed this is the largest group of Part 121 accidents. But there are also non-scheduled (charter) passenger transport and cargo flights. The primary purpose of the analysis reported here is to examine the differences in aviation accidents based on the purpose of the flight. Some of the factors examined are the accident severity, aircraft characteristics and accident occurrence categories. Twenty consecutive years of data were available and utilized to complete this analysis.

Evans, Joni K.↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Context: The manufacture and operation of sUAS are not as regulated as today’s commercial operation, and their widespread use introduces new risks and hazards to the general public. Aim: Our intent is to understand the various processes that prevent or portend sUAS incidents or accidents and the influence that pilots’ expectations and training have on these processes. Method: We use classic grounded theory on sUAS reported accidents (and incidents). Results: We identified three categories, Control Interference, Reviewing and Reporting, which describe various processes surrounding UAS accidents based on the dataset analyzed. Conclusion: The use of grounded theory can offer a different perspective in the analysis of UAS accidents. In addition, the traceability between data sources and the method results facilitate result validation, and navigation. While the results are preliminary, the concepts can be expanded through the use of other accident datasets or used as basis for UAS accident surveys.

Carlos Paradis↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Carlos Paradis↗

NASA NTRS2015

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilots taking direct control of the reaction control system. The analysis described here suggests that all of the events that caused the accident occurred well before the moment when the pilot switched to direct control. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

accident investigation↗

NASA NTRS2016

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilot's taking direct control of the reaction control system. The analysis described here suggests that, rather than events following the pilot's switch to direct control, it was the events preceding the switch that led to the accident. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

X-15↗

NASA NTRS1977

An analysis of three weather-related aircraft accidents

Two aircraft accidents in 1975, one at John F. Kennedy International Airport in New York City on 24 June and the other at Stapleton International Airport in Denver on 7 August, were examined in detail. A third accident on 23 June 1976 at Philadelphia International Airport is being investigated. Amazingly, there was a spearhead echo just to the north of each accident site. The echoes formed from 5 to 50 min in advance of the accident and moved faster than other echoes in the vicinity. These echoes were photographed by National Weather Service radars, 130-205 km away. At closer ranges, however, one or more circular echoes were depicted by airborne and ground radars. These cells were only 3-5 km in diameter, but they were accompanied by downdrafts of extreme intensity, called downbursts. All accidents occurred as aircraft, either descending or climbing, lost altitude while experiencing strong wind shear inside downburst cells.

Fujita, T. T.↗

NASA NTRS1979

Accident investigation

Aircraft accident investigations are discussed with emphasis on those accidents that involved weather as a contributing factor. The organization of the accident investigation board for air carrier accidents is described along with the hearings, and formal report preparation. Statistical summaries of the investigations of general aviation accidents are provided.

Brunstein, A. I.↗

NASA NTRS1982

Single pilot IFR accident data analysis

The aircraft accident data recorded and maintained by the National Transportation Safety Board for 1964 to 1979 were analyzed to determine what problems exist in the general aviation single pilot instrument flight rules environment. A previous study conducted in 1978 for the years 1964 to 1975 provided a basis for comparison. The purpose was to determine what changes, if any, have occurred in trends and cause-effect relationships reported in the earlier study. The increasing numbers have been tied to measures of activity to produce accident rates which in turn were analyzed in terms of change. Where anomalies or unusually high accident rates were encountered, further analysis was conducted to isolate pertinent patterns of cause factors and/or experience levels of involved pilots. The bulk of the effort addresses accidents in the landing phase of operations. A detailed analysis was performed on controlled/uncontrolled collisions and their unique attributes delineated. Estimates of day vs. night general aviation activity and accident rates were obtained.

Harris, D. F.↗

NASA NTRS1983

Single pilot IFR accident data analysis

The aircraft accident data recorded by the National Transportation and Safety Board (NTSR) for 1964-1979 were analyzed to determine what problems exist in the general aviation (GA) single pilot instrument flight rule (SPIFR) environment. A previous study conducted in 1978 for the years 1964-1975 provided a basis for comparison. This effort was generally limited to SPIFR pilot error landing phase accidents but includes some SPIFR takeoff and enroute accident analysis as well as some dual pilot IFR accident analysis for comparison. Analysis was performed for 554 accidents of which 39% (216) occurred during the years 1976-1979.

Harris, D. F.↗

NASA NTRS1987

Accident investigation

The National Transportation Safety Board (NTSB) has attributed wind shear as a cause or contributing factor in 15 accidents involving transport-categroy airplanes since 1970. Nine of these were nonfatal; but the other six accounted for 440 lives. Five of the fatal accidents and seven of the nonfatal accidents involved encounters with convective downbursts or microbursts. Of other accidents, two which were nonfatal were encounters with a frontal system shear, and one which was fatal was the result of a terrain induced wind shear. These accidents are discussed with reference to helping the aircraft to avoid the wind shear or if impossible to help the pilot to get through the wind shear.

Laynor, William G. Bud↗

NASA NTRS1991

Potential health risks from postulated accidents involving the Pu-238 RTG on the Ulysses solar exploration mission

Potential radiation impacts from launch of the Ulysses solar exploration experiment were evaluated using eight postulated accident scenarios. Lifetime individual dose estimates rarely exceeded 1 mrem. Most of the potential health effects would come from inhalation exposures immediately after an accident, rather than from ingestion of contaminated food or water, or from inhalation of resuspended plutonium from contaminated ground. For local Florida accidents (that is, during the first minute after launch), an average source term accident was estimated to cause a total added cancer risk of up to 0.2 deaths. For accidents at later time after launch, a worldwide cancer risk of up to three cases was calculated (with a four in a million probability). Upper bound estimates were calculated to be about 10 times higher.

Goldman, Marvin↗

NASA NTRS1931

Aircraft accidents : method of analysis

The revised report includes the chart for the analysis of aircraft accidents, combining consideration of the immediate causes, underlying causes, and results of accidents, as prepared by the special committee, with a number of the definitions clarified. A brief statement of the organization and work of the special committee and of the Committee on Aircraft Accidents; and statistical tables giving a comparison of the types of accidents and causes of accidents in the military services on the one hand and in civil aviation on the other, together with explanations of some of the important differences noted in these tables.

Source record↗