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This report is a revision of NACA-TR-357. It was prepared by the Committee on Aircraft Accidents. The purpose of this report is to provide a basis for the classification and comparison of aircraft accidents, both civil and military.
This video follows the pre-launch and launch of the Space Shuttle Challenger preceding the accident. It then details the accident investigation report.
An extensive review of the literature and studies relating to performance, medical, operational, and legal data regarding pilot aging issues was performed in order to determine what evidence there is, if any, to support mandatory pilot retirement. Popular misconceptions about aging, including the failure to distinguish between the normal aging process and disease processes that occur more frequently in older individuals, continue to contribute to much of the misunderstanding and controversy that surround this issue. Results: Review of medical data related to the pilot aging issue indicate that recent improvement in medical diagnostics and treatment technology have made it possible to identify to a high degree individuals who are at risk for developing sudden incapacitating illness and for treating those with disqualifying medical conditions. Performance studies revealed that after controlling for the presence of disease states, older pilots are able to perform as well as younger pilots on many performance tasks. Review of accident data showed that older, healthy pilots do not have higher accident rates than younger pilots, and indeeed, evidence suggests that older pilots have an advantage in the cockpit due to higher experience levels. The Man-Machine-Mission-Environment interface of factors can be managed through structured, supervised, and enhanced operations, maintenance, flight reviews, and safety procedures in order to ensure safe and productive operations by reducing the margin of error and by increasing the margin of safety. Conclusions: There is no evidence indicating any specific age as an arbitrary cut-off point for pilots to perform their fight duties. A combination of regular medical screening, performance evaluation, enhanced operational maintenance, and safety procedures can most effectively ensure a safe pilot population than can a mandatory retirement policy based on arbitrary age restrictions.
This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes.
Advances in technology have greatly impacted the appearance of the modern aircraft cockpit. Where once one would see rows upon rows. The introduction of automation has greatly altered the demands on the pilots and the dynamics of aircrew task performance. While engineers and designers continue to implement the latest technological innovations in the cockpit - claiming higher reliability and decreased workload - a large percentage of aircraft accidents are still attributed to human error. Rather than being the main instigators of accidents, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. This paper looks at some of the variables that need to be considered if we are to eliminate at least one of these inheritances - poor design. Specifically, this paper describes the first part of a comprehensive study aimed at identifying the effects of automation on crew coordination.
The EMS flight environment is unique in today's aviation. The pilots must respond quickly to emergency events and often fly to landing zones where they have never been before . The time from initially receiving a call to being airborne can be as little as two to three minutes. Often the EMS pilot is the only aviation professional on site, they have no operations people or other pilots to aid them in making decisons. Further, since they are often flying to accident scenes, not airports, there is often complete weather and condition information. Therefore, the initial decision that the pilot must make, accepting or declining a flight, can become very difficult. The accident rate of EMS helicopters has been relatively high over the past years. NASA-Ames research center has taken several steps in an attempt to aid EMS pilots in their decision making and situational awareness. A preflight risk assessment system (SAFE) was developed to aid pilots in their decision making, and was tested at an EMS service. The resutls of the study were promising and a second version incorporating the lessons learned is under development. A second line of research was the development of a low cost electronic chart display (ECD). This is a digital map display to help pilots maintain geographical orientation. Another thrust was undertaken in conjunction with the Aviation Safety Reporting System (ASRS). This involved publicizing the ASRS to EMS pilots and personnel, and calling each of the reporters back to gather additional information. This paper will discuss these efforts and how they may positively impact the safety of EMS operations.
Approximately 75% of all aviation accidents and incidents are attributable to human failures in monitoring, managing, and operating system. Tactical decision errors were found to be a factor in 25 of 37 major US air transport accidents between 1978 and 1990. These two facts demonstrate the inability of some pilots to maintain situation awareness. Situation awareness (SA) is defined as 'the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future". Thus, when a pilot loses SA, he or she is unable to ether perceive, comprehend, or project the status of the aircraft. In pilots terms, he or she has 'fallen behind the airplane'. Our study this summer involved an analysis of 190 NASA Aviation Safety Reporting System (ASRS) reports.
Partial failures of aircraft primary flight control systems and structural damages to aircraft during flight have led to catastrophic accidents with subsequent loss of lives (e.g. DC-10, B-747, C-5, B-52, and others). Following the DC-10 accident at Sioux City, Iowa in 1989, the National Transportation Safety Board recommended 'Encourage research and development of backup flight control systems for newly certified wide-body airplanes that utilize an alternate source of motive power separate from that source used for the conventional control system.' This report describes the concept of a propulsion controlled aircraft (PCA), discusses pilot controls, displays, and procedures; and presents the results of a PCA piloted simulation test and evaluation of the B747-400 airplane conducted at NASA Ames Research Center in December, 1996. The purpose of the test was to develop and evaluate propulsion control throughout the full flight envelope of the B747-400 including worst case scenarios of engine failures and out of trim moments. Pilot ratings of PCA performance ranged from adequate to satisfactory. PCA performed well in unusual attitude recoveries at 35,000 ft altitude, performed well in fully coupled ILS approaches, performed well in single engine failures, and performed well at aft cg. PCA performance was primarily limited by out-of-trim moments.
This document discusses the development and evaluation of an airborne collision alerting logic for aircraft on closely-spaced approaches to parallel runways. A novel methodology is used when links alerts to collision probabilities: alerting thresholds are set such that when the probability of a collision exceeds an acceptable hazard level an alert is issued. The logic was designed to limit the hazard level to that estimated for the Precision Runway Monitoring system: one accident in every one thousand blunders which trigger alerts. When the aircraft were constrained to be coaltitude, evaluations of a two-dimensional version of the alerting logic show that the achieved hazard level is approximately one accident in every 250 blunders. Problematic scenarios have been identified and corrections to the logic can be made. The evaluations also show that over eighty percent of all unnecessary alerts were issued during scenarios in which the miss distance would have been less than 1000 ft, indicating that the alerts may have been justified. Also, no unnecessary alerts were generated during normal approaches.
This paper is about the National Aeronautics and Space Administration(NASA) and the practice of professional ethics. It has been eleven years(Jan. 28, 1986) since the Challenger accident and the past decade has been a time of investigation, assessment, and finger-pointing, as well as a time for introspection and internal reform. While there has been a lot of rhetoric about ethical commitments at NASA, there has also been a dearth of empirically-based knowledge about what NASA and its various contractors are doing about professional ethics and what decisionmaking criteria are being used. It has been a decade of cost-cutting and personnel cut-backs. One has to wonder what, in all this time, NASA has done to create an ethical climate in which events like the Challenger accident are less likely to happen. In the fall of 1995, as part of competition for a mini-grant from NASA, a request for funding to complete an ethical profile of the agency was submitted. This papeR contributes to knowledge about NASA and ethics by reporting on the results of the first year of research which was spent in doing a comprehensive literature and web-site review along with phone interviews and e-mail correspondence with NASA ethics officers. The goal of this first year was to see what ethics activity has been documented and to ascertain what work is being done to raise the ethical question with NASA. Questions for which answers were sought include: (1) What is NASA now doing regarding ethics?; (2) What training is being provided? By whom? For whom?; (3) Are the answers to these questions different at different NASA installations?
The problems associated with fatigue were brought into the forefront of research by the explosive decompression and structural failure of the Aloha Airlines Flight 243 in 1988. The structural failure of this airplane has been attributed to debonding and multiple cracking along the longitudinal lap splice riveted joint in the fuselage. This crash created what may be termed as a minor "Structural Integrity Revolution" in the commercial transport industry. Major steps have been taken by the manufacturers, operators and authorities to improve the structural airworthiness of the aging fleet of airplanes. Notwithstanding, this considerable effort there are still outstanding issues and concerns related to the formulation of Widespread Fatigue Damage which is believed to have been a contributing factor in the probable cause of the Aloha accident. The lesson from this accident was that Multiple-Site Damage (MSD) in "aging" aircraft can lead to extensive aircraft damage. A strong candidate in which MSD is highly probable to occur is the riveted lap joint.
Although the operation of vehicles like airplanes, cars, and bicycles involves a complex array of perceptual, decision and control activities, most accident statistics clearly show that intoxicated operators are a dominant cause of accidents, and not the difficulty of the task itself. This paper summarizes some recent research on the nature of the impairment of operator control under blood alcohol concentrations (BAC) up to above 0.16 percent. Alcohol toxicity is shown to be quite specific with respect to visual-motor functions involved in control of a vehicle, and experiments with a generalized workload task and special driving simulator show how these are reflected in terms of changes in operator control parameters such as response latency, gains, stability margins, and coherency.
One of the problems facing the aircraft community is landing gear dynamics, especially shimmy and brake-induced vibration. Although neither shimmy nor brake-induced vibrations are usually catastrophic, they can lead to accidents due to excessive wear and shortened life of gear parts and contribute to pilot and passenger discomfort. Recently, NASA has initiated an effort to increase the safety of air travel by reducing the number of accidents by a factor of five in ten years. This safety initiative has spurred an increased interest in improving landing gear design to minimize shimmy and brake-induced vibration that are still largely misunderstood phenomena. In order to increase the understanding of these problems, a literature survey was performed. The major focus of the paper is to summarize work documented from the last ten years to highlight the latest efforts in solving these vibration problems. Older publications are included to understand the longevity of the problem and the findings from earlier researchers. The literature survey revealed a variety of analyses, testing, modeling, and simulation of aircraft landing gear. Experimental validation and characterization of shimmy and brake-induced vibration of aircraft landing gear are also reported. This paper presents an overview of the problem documented in the references together with a history of landing gear dynamic problems and solutions. Based on the assessment of this survey, recommendations of the most critically needed enhancements to the state of the art are given.
This Final Supplemental Environmental Impact Statement (FSEIS) to the 1995 Cassini mission Environmental Impact Statement (EIS) focuses on information recently made available from updated mission safety analyses. This information is pertinent to the consequence and risk analyses of potential accidents during the launch and cruise phases of the mission that were addressed in the EIS. The type of accidents evaluated are those which could potentially result in a release of plutonium dioxide from the three Radioisotope Thermoelectric Generators (RTGS) and the up to 129 Radioisotope Heater Units (RHUS) onboard the Cassini spacecraft. The RTGs use the heat of decay of plutonium dioxide to generate electric power for the spacecraft and instruments. The RHUs, each of which contains a small amount of plutonium dioxide, provide heat for controlling the thermal environment of the spacecraft and several of its instruments. The planned Cassini mission is an international cooperative effort of the National Aeronautics and Space Administration (NASA), the European Space Agency (ESA), and the Italian Space Agency (ASI) to conduct a 4-year scientific exploration of the planet Saturn, its atmosphere, moons, rings, and magnetosphere.
One of the problems facing the aircraft community is landing gear dynamics, especially shimmy and brake-induced vibration. Although neither shimmy nor brake-induced vibrations are usually catastrophic, they can lead to accidents due to excessive wear and shortened life of gear parts and contribute to pilot and passenger discomfort. Recently, NASA has initiated an effort to increase the safety of air travel by reducing the number of accidents by a factor of five in ten years. This safety initiative has spurred an increased interest in improving landing gear design to minimize shimmy and brake-induced vibration that are still largely misunderstood phenomena. In order to increase the understanding of these problems, a literature survey was performed. The major focus of the paper is to summarize work documented from the last ten years to highlight the latest efforts in solving these vibration problems. Older publications are included to understand the longevity of the problem and the findings from earlier researchers. The literature survey revealed a variety of analyses, testing, modeling, and simulation of aircraft landing gear. Experimental validation and characterization of shimmy and brake-induced vibration of aircraft landing gear are also reported. This paper presents an overview of the problem documented in the references together with a history of landing gear dynamic problems and solutions. Based on the assessment of this survey, recommendations of the most critically needed enhancements to the state of the art are given.
This NASA KSC video release presents part of a press conference held prior to Discovery flight STS-26, the first shuttle mission flown following the 51-L Challenger accident. The first portion of the video presents the 5 member flight crew, (Frederick H. Hauck, Commander, Richard O. Covey, Pilot, John M. Lounge, Mission Specialist, George D. Nelson, Mission Specialist, and David C. Hilmers, Mission Specialist) answering questions posed by scientific journalists. Inquiries are made regarding the approximately 250 changes implemented on the orbiter and boosters, failures that occurred during 51-L, astronaut attitudes about flying the first mission since the Challenger accident, and the issue of range safety. The second part of the video includes viewgraph presentations given by Dr. Dale W. Harris (TDRS Project Manager, Goddard Space Flight Center(GSFC)) and Gary A. Morse (Network Director, GSFC) that discuss the primary payload, the NASA Tracking and Data Relay Satellite-3 (TDRS-3) that is attached to an Inertial Upper Stage (IUS), and is the second TDRS deployed.
This NASA KSC video release presents part of a press conference held prior to Discovery flight STS-26, the first shuttle mission flown following the 51-L Challenger accident. The video opens with a statement from Commander Frederick H. Hauck, and the introductions of crew members, Richard O. Covey, Pilot, and mission specialists, John M. Lounge, George D. Nelson, and David C. Hilmers. Some of the questions posed by scientific journalists addressed the following subjects: launch preparation in the month prior to flight, astronaut family anxieties in light of the Challenger accident, extent of safety measures made prior to flight, flight readiness firing, the crew escape system, civilians in space, conservative mission design, astronaut selection, mission turnaround and launch rate, and the ability to maintain a high level of scrutiny regarding safety on future missions.
The Aviation Safety Program (AvSP) has as its goal an improvement in aviation safety by a factor of 5 over the next 10 years and a factor of 10 over the next 20 years. Since weather has a big impact on aviation safety and is associated with 30% of all aviation accidents, Weather Accident Prevention (WxAP) is a major element under this program. The Aviation Weather Information (AWIN) Distribution and Presentation project is one of three projects under this element. This report contains the findings of a study conducted by the Georgia Tech Research Institute (GTRI) under the Enhanced Weather Products effort, which is a task under AWIN. The study examines current aviation weather products and there application. The study goes on to identify deficiencies in the current system and to define requirements for aviation weather products that would lead to an increase in safety. The study also provides an overview the current set of sensors applied to the collection of aviation weather information. New, modified, or fused sensor systems are identified which could be applied in improving the current set of weather products and in addressing the deficiencies defined in the report. In addition, the study addresses and recommends possible sensors for inclusion in an electronic pilot reporting (EPIREP) system.