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NASA NTRS2016

Investigation of Asymmetric Thrust Detection with Demonstration in a Real-Time Simulation Testbed

The purpose of this effort is to develop, demonstrate, and evaluate three asymmetric thrust detection approaches to aid in the reduction of asymmetric thrust-induced aviation accidents. This paper presents the results from that effort and their evaluation in simulation studies, including those from a real-time flight simulation testbed. Asymmetric thrust is recognized as a contributing factor in several Propulsion System Malfunction plus Inappropriate Crew Response (PSM+ICR) aviation accidents. As an improvement over the state-of-the-art, providing annunciation of asymmetric thrust to alert the crew may hold safety benefits. For this, the reliable detection and confirmation of asymmetric thrust conditions is required. For this work, three asymmetric thrust detection methods are presented along with their results obtained through simulation studies. Representative asymmetric thrust conditions are modeled in simulation based on failure scenarios similar to those reported in aviation incident and accident descriptions. These simulated asymmetric thrust scenarios, combined with actual aircraft operational flight data, are then used to conduct a sensitivity study regarding the detection capabilities of the three methods. Additional evaluation results are presented based on pilot-in-the-loop simulation studies conducted in the NASA Glenn Research Center (GRC) flight simulation testbed. Data obtained from this flight simulation facility are used to further evaluate the effectiveness and accuracy of the asymmetric thrust detection approaches. Generally, the asymmetric thrust conditions are correctly detected and confirmed.

propulsion system performance↗
NASA NTRS2004

Lessons Learned Study Final Report for the Exploration Systems Mission Directorate

This report is the final product of a 90-day study performed for the Exploration Systems Mission Directorate. The study was to assemble lessons NASA has learned from previous programs that could help the Exploration Systems Mission Directorate pursue the Exploration vision. It focuses on those lessons that should have the greatest significance to the Directorate during the formulation of program and mission plans. The study team reviewed a large number of lessons learned reports and data bases, including the Columbia Accident Investigation Board and Rogers Commission reports on the Shuttle accidents, accident reports from robotic space flight systems, and a number of management reviews by the Defense Sciences Board, Government Accountability Office, and others. The consistency of the lessons, findings, and recommendations validate the adequacy of the data set. In addition to reviewing existing databases, a series of workshops was held at each of the NASA centers and headquarters that included senior managers from the current workforce as well as retirees. The full text of the workshop reports is included in Appendix A. A lessons learned website was opened up to permit current and retired NASA personnel and on-site contractors to input additional lessons as they arise. These new lessons, when of appropriate quality and relevance, will be brought to the attention of managers. The report consists of four parts: Part 1 provides a small set of lessons, called the Executive Lessons Learned, that represent critical lessons that the Exploration Systems Mission Directorate should act on immediately. This set of Executive Lessons and their supporting rationale have been reviewed at length and fully endorsed by a team of distinguished NASA alumni; Part 2 contains a larger set of lessons, called the Selected Lessons Learned, which have been chosen from the lessons database and center workshop reports on the basis of their specific significance and relevance to the near-term work of the Exploration Directorate. These lessons frequently support the Executive lessons but are more general in nature; Part 3 consists of the reports of the center workshops that were conducted as part of this activity. These reports are included in their entirety (approximately 200 pages) in Appendix G and have significance for specific managers; Part 4 consists of the remainder of the lessons that have been selected by this effort and assembled into a database for the use of the Explorations Directorate. The database is archived and hosted in the Lessons Learned Knowledge Network, which provides a flexible search capability using a wide variety of search terms. Finally, a spreadsheet lists databases searched and a bibliography identifies reports that have been reviewed as sources of lessons for this task. NASA has been presented with many learning opportunities. We have conducted numerous programs, some extremely successful and others total failures. Most have been documented with a formal lessons learned activity, but we have not always incorporated these learning opportunities into our normal modes of business. For example, the Robbins Report of 2001 clearly indicates that many project failures of the past two decades were the result of violating well documented best practices, often in direct violation of management instructions and directives. An overarching lesson emerges: that disciplined execution in accordance with proven best practices is the greatest single contributor to a successful program. The Lessons Learned task team offers a sincere hope that the lessons presented herein will be helpful to the Exploration Systems Directorate in charting and executing their course. The success of the Directorate and of NASA in general depends on our collective ability to move forward without having to relearn the lessons of those who have gone before.

Van Laak, Jim↗
NASA NTRS2016

Pilot Critical Incident Reports as a Means to Identify Human Factors of Remotely Piloted Aircraft

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies. Pilots participated willingly and enthusiastically in the study, and generally had little difficulty recalling critical incidents. The results suggest that pilot interviews can be a productive method of gathering information on incidents that might not otherwise be reported. Some of the issues described in the reports have received significant attention in the literature, or are analogous to human factors of manned aircraft. In other cases, incident reports involved human factors that are poorly understood, and have not yet been the subject of extensive study. Although many of the reported incidents were related to pilot error, the participants also provided examples of the positive contribution that humans make to the operation of highly-automated systems.

unmanned aircraft systems↗
NASA NTRS2016

C2-Related Incidents Reported by UAS Pilots

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. This presentation focuses on incidents that involved the management of the command and control (C2) link. The identified issues include loss of link, interference from undesired transmissions, voice latency, accidental control transfer, and the use of the lost link timer, or lost link OK features.

unmanned aircraft systems↗
NASA NTRS2017

Design Considerations for Attitude State Awareness and Prevention of Entry into Unusual Attitudes

Loss of control - inflight (LOC-I) has historically represented the largest category of commercial aviation fatal accidents. A review of the worldwide transport airplane accidents (2001-2010) evinced that loss of attitude or energy state awareness was responsible for a large majority of the LOC-I events. A Commercial Aviation Safety Team (CAST) study of 18 worldwide loss-of-control accidents and incidents determined that flight crew loss of attitude awareness or energy state awareness due to lack of external visual reference cues was a significant causal factor in 17 of the 18 reviewed flights. CAST recommended that "Virtual Day-Visual Meteorological Condition" (Virtual Day-VMC) displays be developed to provide the visual cues necessary to prevent loss-of-control resulting from flight crew spatial disorientation and loss of energy state awareness. Synthetic vision or equivalent systems (SVS) were identified for a design "safety enhancement" (SE-200). Part of this SE involves the conduct of research for developing minimum aviation system performance standards (MASPS) for these flight deck display technologies to aid flight crew attitude and energy state awareness similar to that of a virtual day-VMC-like environment. This paper will describe a novel experimental approach to evaluating a flight crew's ability to maintain attitude awareness and to prevent entry into unusual attitudes across several SVS optical flow design considerations. Flight crews were subjected to compound-event scenarios designed to elicit channelized attention and startle/surprise within the crew. These high-fidelity scenarios, designed from real-world events, enable evaluation of the efficacy of SVS at improving flight crew attitude awareness to reduce the occurrence of LOC-I incidents in commercial flight operations.

Ellis, Kyle K. E.↗
NASA NTRS2018

Piloted Simulator Evaluation Results of Flight Physics Based Stall Recovery Guidance

In recent studies, it has been observed that loss of control in flight is the most frequent primary cause of accidents. A significant share of accidents in this category can be remedied by upset prevention if possible, and by upset recovery if necessary, in this order of priorities. One of the most important upsets to be recovered from is stall. Recent accidents have shown that a correct stall recovery maneuver remains a big challenge in civil aviation, partly due to a lack of pilot training. A possible strategy to support the flight crew in this demanding context is calculating a recovery guidance signal, and showing this signal in an intuitive way on one of the cockpit displays, for example by means of the flight director. Different methods for calculating the recovery signal, one based on fast model predictive control and another using an energy based approach, have been evaluated in four relevant operational scenarios by experienced commercial as well as test pilots in the Vertical Motion Simulator at NASA Ames Research Center. Evaluation results show that this approach could be able to assist the pilots in executing a correct stall recovery maneuver.

Lombaerts, Thomas↗
NASA NTRS2016

Human Factors of Remotely Piloted Aircraft Systems: Lessons from Incident Reports

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. A total of 90 incidents were reported. This presentation begins with an overview of RPAS human factors and then considers the emerging issues identified by pilot reports.

incidents↗
NASA NTRS2019

Human Performance Contributions to Safety in Commercial Aviation

Every day in aviation, pilots, air traffic controllers, and other front-line personnel perform countless correct judgments and actions in a variety of operational environments. These judgments and actions are often the difference between an accident and a non-event. Ironically, data on these behaviors are rarely collected or analyzed. Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence how decision makers characterize problems and identify solutions. Large volumes of data are collected on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that result in routine successful outcomes, safety management and system design decisions are based on a small sample of nonrepresentative safety data. This assessment aimed to find and document “safety successes” made possible by human operators. With many Aeronautics Research Mission Directorate (ARMD) Programs and Projects focusing on increased automation and autonomy and decreased human involvement, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant risk — a risk that has not been recognized to date. Without understanding how humans contribute to safety, any estimate of predicted safety of autonomous capabilities is incomplete and inherently suspect. Furthermore, understanding the ways in which humans contribute to safety can promote strategic interactions among safety technologies, functions, procedures and the people using them. Without this understanding, the full benefits of an integrated, optimized human/technology or autonomous system will not be realized. Historically, safety has been consistently defined in terms of the occurrence of accidents or recognized risks (i.e., in terms of things that go wrong). These adverse outcomes are explained by identifying their causes, and safety is restored by eliminating or mitigating these causes. An alternative to this approach is to focus on what goes right and identify how to replicate that process. Focusing on the rare cases of failures attributed to “human error” provides little information about why human performance routinely prevents adverse events. Hollnagel has proposed that things go right because people continuously adjust their work to match their operating conditions. These adjustments become increasingly important as systems continue to grow in complexity. Thus, the definition of safety should reflect not only “avoiding things that go wrong” but “ensuring that things go right.” The basis for safety management requires developing an understanding of everyday activities. However, few mechanisms to monitor everyday work exist in the aviation domain, which limits opportunities to learn how designs function in reality. This concept of safety thinking and safety management is reflected in the emerging field of resilience engineering. According to Hollnagel, a system is resilient if it can sustain required operations under expected and unexpected conditions by adjusting its functioning prior to, during, or following changes, disturbances, and opportunities. To explore “positive” behaviors that contribute to resilient performance in commercial aviation, the assessment team examined a range of existing sources of data about pilot and air traffic control (ATC) tower controller performance, including subjective interviews with domain experts and objective aircraft flight data records. These data were used to identify strategies that support resilient performance, methods for exploring and refining those strategies in existing data, and proposed methods for capturing and analyzing new data.

Null, Cynthia H.↗
NASA NTRS2019

Human Performance Contributions to Safety in Commercial Aviation

In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that contribute to routine successful outcomes, safety management and system design decisions are based on a small sample of non- representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant and largely unrecognized risk when making policy decisions about human roles and responsibilities. Opportunities exist to leverage the vast amount of data that has already been collected, or could be easily obtained, to increase our understanding of human contributions to “things going right” in commercial aviation. The principal focus of this assessment was to identify current gaps and explore methods for identifying human “success” data generated by the aviation system, from personnel and within the supporting infrastructure.

Holbrook, Jon B.↗
NASA NTRS2020

Monitoring for Flight Path Management: Inputs to Pilot Monitoring Training

The commercial aviation industry world-wide has identified a need for improved pilot monitoring (e.g., ICAO, 2016). More specifically, aviation safety data indicate that failures in pilots' monitoring for flight path management (FPM) have contributed to a range of undesired outcomes: accidents, major upsets, and non-compliance with ATC guidance. The 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). An important element of this additional complexity will be the introduction of new automation or artificial intelligence that is intended to work with the flight crew but can add additional 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 guidance for FAA training and standards organizations—such as the Air Carrier Training Aviation Rulemaking Committee (ACT ARC)—to aid in reducing the risk of incidents and accidents due to inadequate pilot monitoring/awareness.

Feary, Mike↗
NASA NTRSDate not supplied

Biocybernetic Closed-Loop System for Mitigating Hazardous States of Awareness

The past century of passenger flight has seen continuous improvement in aviation safety by the aerospace industry. However, while commercial aviation accident rates have continued to decline, human error-related incident and accident rates remain remarkably constant across all types of aviation (Shappell, et al., 2007). Unfortunately, this level of human error is unacceptable when considering projections for increased traffic volume (FAA, 2009), and is likely to yield more incidents and accidents unless a more complete understanding of operator error is achieved and remediations are implemented. One area of interest highlighted by researchers is Hazardous States of Awareness (HSAs) that can result from deficiencies in the design and inappropriate use of human-machine interfaces. Identifying and mitigating HSAs is critical for reducing operator errors. One promising approach uses psychophysiological measures which enable automated systems to adapt to the operator?s state and modify modes of operation to support optimal human performance (Scerbo, 2007). This paper will survey previous research and describe future directions for the application of psychophysiological measures of operators derived from cortical and autonomic assessment to perform real-time adaptive modulation of human-automation task mode mixes. The authors will present a summary of previous work done at NASA LaRC and Old Dominion University using a Psychophysiologically Adaptive System (PAS) in which the level of automation of the NASA Multi-Attribute Task Battery was modulated based on Engagement Indices derived from the users? electroencephalogram (Pope, Bogart, & Bartolome, 1995; for review see, Scerbo, Freeman, & Mikulka, 2003). Future theoretical and methodological directions for this type of closed-loop research will be discussed. Specifically, the capacity for this type of PAS to maintain effective operator state and to enable validation of candidate physiological indices will be described. Consideration will also be given to critical system characteristics (e.g., engagement indices, methods for invoking changes among system states, individual differences among users, etc.) that have been or still need to be studied. The potential of the PAS approach for interactive system design and prototyping will also be described. Examples of adaptive automation flight deck concepts in recent experiments will be highlighted and discussed.

Chad L Stephens↗
NASA NTRSDate not supplied

A Data-Driven Approach to Recognizing and Understanding Human Contributions to Aviation Safety

Data-driven decisions about safety management and design of safety-critical systems are limited by the available data, which influence, and are influenced by, how decision makers characterize problems and identify solutions. In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on safety-producing behaviors, safety management and system design decisions are based on a small sample of non-representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to aviation safety represents a significant and largely unrecognized risk when making policy decisions about safety management and system design. Opportunities exist to leverage the vast amount of data that have already been collected, or could be easily obtained, to increase our understanding of human contributions to safety in commercial aviation. This presentation will focus on those opportunities as well as the challenges associated with collecting and analyzing data on operators’ safety-producing behaviors.

Safety↗
NASA NTRSDate not supplied

Going beyond reliability to robustness and resilience in space systems

The words reliability, robustness, and resilience, are often used interchangeably to describe tough and dependable systems but the distinctions between them suggest how to design more serviceable space systems. Reliability is simply the quality of consistently performing well. A system that dependably meets its design requirements in the specified environments is reliable. The designers may not consider themselves responsible for failures under unanticipated conditions. Robustness is the capability of performing without failure under a wide range of conditions, which can go beyond the expected range to include possible off-nominal conditions. Resilience is the ability to recover from or adapt to damaging events, such as failures, accidents, external disruptions, and repurposing. Such changes are usually unanticipated. They often invalidate the usual operating assumptions and cause system failure. Reliability, robustness, and resilience describe dependable performance under increasingly difficult conditions, first the specified environment, then a wider possible environment, and finally unanticipated damaging events. These three are increasingly desirable and increasingly difficult to achieve. Engineering for resilience would design systems that can ignore or repair failures, survive accidents, and recover from disruptions. Increasing the resilience of space systems, the ability to perform after unanticipated events, would greatly increase space crew safety. Improving reliability and robustness can be done by dealing with known sources of problems, but improving resilience requires implementing a general approach to reducing the impact of unknown future events. Two contrasting approaches are reducing system complexity and adding supervisory control. The need for resilience has been claimed for decades but little has been accomplished. Systems designers assume that they understand requirements, technologies, designs, architectures, integration, testing, operations, and environments. The potential problems of changes, failures, accidents, unknown environments, and unknown unknowns are ignored. Systems designers are typically overconfident and ignore the need for robustness and resilience.

Harry W Jones↗
NASA NTRSDate not supplied

Going Beyond Reliability to Robustness and Resilience in Space Life Support Systems

The words reliability, robustness, and resilience are often used interchangeably to describe tough and dependable systems but the distinctions between them suggest how to design more serviceable space systems. Reliability is simply the quality of consistently performing well. A system that dependably meets its design requirements in the specified environment is reliable. The designers may not consider themselves responsible for failures under unanticipated conditions. Robustness is the capability of performing without failure under a wide range of conditions, which can go beyond the expected range to include possible off-nominal conditions. Resilience is the ability to recover from or adapt to unanticipated damaging events, such as failures, accidents, external disruptions, and repurposing. Such changes can invalidate the usual operating assumptions and cause system failure. Reliability, robustness, and resilience describe dependable performance under increasingly difficult conditions, first the specified environment, then a wider possible environment, and finally unanticipated damaging conditions. These three qualities are increasingly desirable and increasingly difficult to achieve. Engineering for resilience would design systems that can ignore or repair failures, survive accidents, and recover from unanticipated disruptions. Increasing the resilience of space systems would greatly increase space crew safety. Improving reliability and robustness requires dealing with known problems, but improving resilience requires implementing a general approach to reducing the impact of unknown future events. The need for robustness and resilience has been stated for decades but little has been done. Systems designers often assume that they understand everything they need to know. The potential failures caused by changes, failures, accidents, unknown environments, and unknown unknowns can be ignored. Such overconfidence can lead to neglect of reliability, robustness, and resilience.

Harry W. Jones↗
NASA NTRSDate not supplied

Going Beyond Reliability to Robustness and Resilience in Space Life Support Systems

The words reliability, robustness, and resilience are often used interchangeably to describe tough and dependable systems but the distinctions between them suggest how to design more serviceable space systems. Reliability is simply the quality of consistently performing well. A system that dependably meets its design requirements in the specified environment is reliable. The designers may not consider themselves responsible for failures under unanticipated conditions. Robustness is the capability of performing without failure under a wide range of conditions, which can go beyond the expected range to include possible off-nominal conditions. Resilience is the ability to recover from or adapt to unanticipated damaging events, such as failures, accidents, external disruptions, and repurposing. Such changes can invalidate the usual operating assumptions and cause system failure. Reliability, robustness, and resilience describe dependable performance under increasingly difficult conditions, first the specified environment, then a wider possible environment, and finally unanticipated damaging conditions. These three qualities are increasingly desirable and increasingly difficult to achieve. Engineering for resilience would design systems that can ignore or repair failures, survive accidents, and recover from unanticipated disruptions. Increasing the resilience of space systems would greatly increase space crew safety. Improving reliability and robustness requires dealing with known problems, but improving resilience requires implementing a general approach to reducing the impact of unknown future events. The need for robustness and resilience has been stated for decades but little has been done. Systems designers often assume that they understand everything they need to know. The potential failures caused by changes, failures, accidents, unknown environments, and unknown unknowns can be ignored. Such overconfidence can lead to neglect of reliability, robustness, and resilience.

Harry W. Jones↗
NASA NTRSDate not supplied

Revisiting the Soyuz-1 Parachute Failure in the Context of Safety in the Modern Era

The Soyuz‑1 accident remains one of the most consequential parachute related failures in human spaceflight history and provides enduring lessons for modern Entry, Descent, and Landing (EDL) system design. Occurring during the height of the Cold War and the Space Race, the mission unfolded under extraordinary political and schedule pressure as the Soviet Union sought to maintain its early leadership in space achievements following the death of chief designer Sergei Korolev. Despite unresolved propulsion, electrical, and parachute system deficiencies, Soyuz‑1 proceeded to launch and immediately encountered critical inflight anomalies, including a failed solar panel deployment, attitude control issues, and communication dropouts. Upon reentry, a malfunction in the parachute system, driven by a primary main canopy that failed to deploy, and subsequent entanglement of the reserve main canopy with the primary drogue parachute, resulted in insufficient deceleration and the fatal crash of cosmonaut Vladimir Komarov. Subsequent investigations revealed deep rooted cultural and organizational issues within the Soviet space program, including inadequate testing, suppression of dissent, undocumented last minute design changes, and the absence of integrated parachute system verification. More than 200 design flaws were identified after the accident, and firsthand accounts, including those from Yuri Gagarin, highlighted widespread concern prior to launch. Over time, the Soviet program implemented substantial reforms: systematic design corrections, rigorous process documentation, and an extensive series of drop tests that ultimately transformed the Soyuz system into one of the world’s most reliable human-rated return vehicles. This paper examines the technical architecture of the Soyuz‑1 parachute system, reconstructs the likely deployment sequence and failure mechanism, and analyzes the cultural contributors that shaped the accident. The study draws parallels to modern spacecraft parachute development, emphasizing the critical importance of integrated system testing, transparent engineering culture, and continuous hardware surveillance. These lessons remain directly relevant to today’s NASA and Commercial Crew Programs (CCP), where the Government continues to refine its understanding of aggregate risk and strengthen overall astronaut safety in the face of increasingly complex parachute systems.

Aaron L Morris↗
NASA NTRS1921

Airplane crashes: engine troubles : a possible explanation

The aim was to bring attention to what might be the cause of some aircraft accidents for which there was no satisfactory explanation. The author notes that in testing aircraft accidents at the Bureau of Standards, it happened frequently that the engine performance became erratic when the temperature of the air entering the carburetor was between 0 C and 20 C. Investigation revealed the trouble to have been caused by the formation and collection of snow somewhere between the entrance to the carburetor and the manifold, probably at the throttle. Proof scarcely less convincing was obtained during engine tests. The results of such engine tests are described. Granting that the loss of power and the sudden increases in power were caused by the condensation of moisture from the air and the subsequent formation of snow, two solutions proved effective. The removal of the moisture or an increase in temperature cured the problem.

ENGINE TROUBLE↗
NASA NTRS1989

Impaired driving performance in shiftworkers: the role of the circadian system in a multifactorial model

A substantial and growing percentage of the U.S. work force now works on a rotating shift schedule. The repeated changes in sleep-wake, meal and work times inherent in such schedules conflict with the dictates of the internal biological clock and have adverse consequences for the health of the shiftworker population. An important consequence of this conflict is impaired performance, both on and off the job, as indexed by the increased incidence of motor vehicle accidents in shift workers. In this paper we report the results of a survey administered to rotating shift and straight day workers at a manufacturing plant in the eastern U.S. This survey documents an increased incidence of motor vehicle accidents or "near misses" in which sleepiness was implicated as a cause by the respondent. Complaints of poor sleep and increased sleepiness were also significantly more common in shiftworkers than day workers. Last, shiftworkers reported higher caffeine and alcohol consumption, and were more likely to use alcohol as a sleep aid. Although causal links cannot be established using these associative observations alone, previously reported experience with alteration of shift schedules, improvement of levels of alertness, and reduction in adverse performance outcomes corroborate the possibility of a causal link and suggest potential interventions.

NASA Discipline Regulatory Physiology↗