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All sourcesNASA NTRSDOE OSTI
NASA NTRS1996

Human Factors in Cabin Accident Investigations

Human factors has become an integral part of the accident investigation protocol. However, much of the investigative process remains focussed on the flight deck, airframe, and power plant systems. As a consequence, little data has been collected regarding the human factors issues within and involving the cabin during an accident. Therefore, the possibility exists that contributing factors that lie within that domain may be overlooked. The FAA Office of Accident Investigation is sponsoring a two-day workshop on cabin safety accident investigation. This course, within the workshop, will be of two hours duration and will explore relevant areas of human factors research. Specifically, the three areas of discussion are: Information transfer and resource management, fatigue and other physical stressors, and the human/machine interface. Integration of these areas will be accomplished by providing a suggested checklist of specific cabin-related human factors questions for investigators to probe following an accident.

Chute, Rebecca D.↗
NASA NTRS2003

Applying STAMP in Accident Analysis

Accident models play a critical role in accident investigation and analysis. Most traditional models are based on an underlying chain of events. These models, however, have serious limitations when used for complex, socio-technical systems. Previously, Leveson proposed a new accident model (STAMP) based on system theory. In STAMP, the basic concept is not an event but a constraint. This paper shows how STAMP can be applied to accident analysis using three different views or models of the accident process and proposes a notation for describing this process.

Leveson, Nancy↗
NASA NTRS2011

NASA Medical Response to Human Spacecraft Accidents

This slide presentation reviews NASA's role in the response to spacecraft accidents that involve human fatalities or injuries. Particular attention is given to the work of the Mishap Investigation Team (MIT), the first response to the accidents and the interface to the accident investigation board. The MIT does not investigate the accident, but the objective of the MIT is to gather, guard, preserve and document the evidence. The primary medical objectives of the MIT is to receive, analyze, identify, and transport human remains, provide assistance in the recovery effort, and to provide family Casualty Coordinators with latest recovery information. The MIT while it does not determine the cause of the accident, it acts as the fact gathering arm of the Mishap Investigation Board (MIB), which when it is activated may chose to continue to use the MIT as its field investigation resource. The MIT membership and the specific responsibilities and tasks of the flight surgeon is reviewed. The current law establishing the process is also reviewed.

Patlach, Robert↗
NASA NTRS2012

Simulation Modeling Requirements for Loss-of-Control Accident Prevention of Turboprop Transport Aircraft

In-flight loss of control remains the leading contributor to aviation accident fatalities, with stall upsets being the leading causal factor. The February 12, 2009. Colgan Air, Inc., Continental Express flight 3407 accident outside Buffalo, New York, brought this issue to the forefront of public consciousness and resulted in recommendations from the National Transportation Safety Board to conduct training that incorporates stalls that are fully developed and develop simulator standards to support such training. In 2010, Congress responded to this accident with Public Law 11-216 (Section 208), which mandates full stall training for Part 121 flight operations. Efforts are currently in progress to develop recommendations on implementation of stall training for airline pilots. The International Committee on Aviation Training in Extended Envelopes (ICATEE) is currently defining simulator fidelity standards that will be necessary for effective stall training. These recommendations will apply to all civil transport aircraft including straight-wing turboprop aircraft. Government-funded research over the previous decade provides a strong foundation for stall/post-stall simulation for swept-wing, conventional tail jets to respond to this mandate, but turboprops present additional and unique modeling challenges. First among these challenges is the effect of power, which can provide enhanced flow attachment behind the propellers. Furthermore, turboprops tend to operate for longer periods in an environment more susceptible to ice. As a result, there have been a significant number of turboprop accidents as a result of the early (lower angle of attack) stalls in icing. The vulnerability of turboprop configurations to icing has led to studies on ice accumulation and the resulting effects on flight behavior. Piloted simulations of these effects have highlighted the important training needs for recognition and mitigation of icing effects, including the reduction of stall margins. This paper addresses simulation modeling requirements that are unique to turboprop transport aircraft and highlights the growing need for aerodynamic models suitable for stall training for these configurations. A review of prominent accidents that involved aerodynamic stall is used to illustrate various modeling features unique to turboprop configurations and the impact of stall behavior on susceptibility to loss of control that has led to new training requirements. This is followed by an overview of stability and control behavior of straight-wing turboprops, the related aerodynamic characteristics, and a summary of recent experimental studies on icing effects. In addition, differences in flight dynamics behavior between swept-wing jets and straight-wing turboprop configurations are discussed to compare and contrast modeling requirements. Specific recommendations for aerodynamic models along with further research needs and data measurements are also provided. 1

Crider, Dennis↗
NASA NTRS2012

The Analysis of the Contribution of Human Factors to the In-Flight Loss of Control Accidents

In-flight loss of control (LOC) is currently the leading cause of fatal accidents based on various commercial aircraft accident statistics. As the Next Generation Air Transportation System (NextGen) emerges, new contributing factors leading to LOC are anticipated. The NASA Aviation Safety Program (AvSP), along with other aviation agencies and communities are actively developing safety products to mitigate the LOC risk. This paper discusses the approach used to construct a generic integrated LOC accident framework (LOCAF) model based on a detailed review of LOC accidents over the past two decades. The LOCAF model is comprised of causal factors from the domain of human factors, aircraft system component failures, and atmospheric environment. The multiple interdependent causal factors are expressed in an Object-Oriented Bayesian belief network. In addition to predicting the likelihood of LOC accident occurrence, the system-level integrated LOCAF model is able to evaluate the impact of new safety technology products developed in AvSP. This provides valuable information to decision makers in strategizing NASA's aviation safety technology portfolio. The focus of this paper is on the analysis of human causal factors in the model, including the contributions from flight crew and maintenance workers. The Human Factors Analysis and Classification System (HFACS) taxonomy was used to develop human related causal factors. The preliminary results from the baseline LOCAF model are also presented.

Ancel, Ersin↗
NASA NTRS2014

Frequency of Specific Categories of Aviation Accidents and Incidents During 2001-2010

The purpose of this study was to determine the types of accidents or incidents that are most important to the aviation safety risk. All accidents and incidents from 2001-2010 were assigned occurrence categories based on the taxonomy developed by the Commercial Aviation Safety Team/International Civil Aviation Organization (CAST/ICAO) Common Taxonomy Team (CICTT). The most frequently recorded categories were selected within each of five metrics: total accidents, fatal accidents, total injuries, fatal injuries and total incidents. This analysis was done separately for events within Part 121, Scheduled Part 135, Non-Scheduled Part 135 and Part 91. Combining those five sets of categories resulted in groups of between seven and eleven occurrence categories, depending on the flight operation. These groups represent 65-85% of all accidents and 68-81% of incidents.

Evans, Joni K.↗
NASA NTRS2003

Columbia Accident Investigation Board. Volume One

The Columbia Accident Investigation Board's independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Board's 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecraft's debris. In the process, Columbia's tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident. This report concludes with recommendations, some of which are specifically identified and prefaced as 'before return to flight.' These recommendations are largely related to the physical cause of the accident, and include preventing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protection System. The remaining recommendations, for the most part, stem from the Board's findings on organizational cause factors. While they are not 'before return to flight' recommendations, they can be viewed as 'continuing to fly' recommendations, as they capture the Board's thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term. These recommendations reflect both the Board's strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board's conviction that operation of the Space Shuttle, and all human space-flight, is a developmental activity with high inherent risks.

SPACE SHUTTLE COLUMBIA↗
NASA NTRS2004

Renewed Commitment to Excellence: An Assessment of the NASA Agency-Wide Applicability of the Columbia Accident Investigation Board Report

The Space Shuttle fleet has been grounded since the Columbia accident. As a result, 'Return to Flight' has become not just a phrase but a program and the global of virtually everyone associated with NASA. Even those who are not affiliated with the Shuttle Program are looking forward to the safe and successful completion of the next Shuttle mission. In this recovery process, NASA will be guided by the Report of the Columbia Accident Investigation Board (CAIB). The CAIB was an investigating body, convened by NASA Administrator O'Keefe the day of the Columbia accident, according to procedures established after the loss of Space Challenger.

SPACE SHUTTLE COLUMBIA↗
NASA NTRS2007

Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents. CRM/HF Conference, Held in Denver, Colorado on April 16-17, 2006

Reviewed NTSB reports of the 19 U.S. airline accidents between 1991-2000 attributed primarily to crew error. Asked: Why might any airline crew in situation of accident crew--knowing only what they knew--be vulnerable. Can never know with certainty why accident crew made specific errors but can determine why the population of pilots is vulnerable. Considers variability of expert performance as function of interplay of multiple factors.

Aviation accidents↗
NASA NTRS1974

An analysis of pilot error-related aircraft accidents

A multidisciplinary team approach to pilot error-related U.S. air carrier jet aircraft accident investigation records successfully reclaimed hidden human error information not shown in statistical studies. New analytic techniques were developed and applied to the data to discover and identify multiple elements of commonality and shared characteristics within this group of accidents. Three techniques of analysis were used: Critical element analysis, which demonstrated the importance of a subjective qualitative approach to raw accident data and surfaced information heretofore unavailable. Cluster analysis, which was an exploratory research tool that will lead to increased understanding and improved organization of facts, the discovery of new meaning in large data sets, and the generation of explanatory hypotheses. Pattern recognition, by which accidents can be categorized by pattern conformity after critical element identification by cluster analysis.

Kowalsky, N. B.↗
NASA NTRS1979

Probabilistic analysis of air carrier accidents

In order to estimate the potential risks due to carbon fibers (CF) released from aircraft accidents, it was necessary to quantify the probability of an accident or incident at a major hub airport. This probability was contingent upon various conditions surrounding the incident including the phase of operation, aircraft type, and the weather conditions. The type of accident predicted was categorized according to its location relative to the runway and the severity of damage sustained. The methodology utilized to estimate the probability of a specific type of accident is outlined and the various models that were developed in the course of this work are described.

Source record↗
NASA NTRS1980

Civil helicopter wire strike assessment study. Volume 2: Accident analysis briefs

A description and analysis of each of the 208 civil helicopter wire strike accidents reported to the National Transportation Safety Board (NTSB) for the ten year period 1970-1979 is given. The accident analysis briefs were based on pilot reports, FAA investigation reports, and such accident photographs as were made available. Briefs were grouped by year and, within year, by NTSB accident report number.

Tuomela, C. H.↗
NASA NTRS1985

Investigation of technology needs for avoiding helicopter pilot error related accidents

Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.

Chais, R. I.↗
NASA NTRS1986

The use of flight test techniques in aircraft accident investigations

Wind shear is a serious safety hazard to commercial aviation. Low level wind shear (downburst) was the cause of the takeoff accident in New Orleans, July 9, 1982, and the landing accident in Dallas, Aug. 2, 1985. Shear layer instability is a common cause of clear air turbulence (CAT) at cruising altitudes. A number of encounters with severe CAT, in which passengers were injured, have recently occurred (Hannibal, MO, April 1981; Morton, WY, July 1982; etc.). Improved accident investigation techniques can lead to a better understanding of the nature of the wind environment associated with downbursts and CAT and to better detection and avoidance procedures. For the past several years, NASA-Ames has worked closely with the National Transportation Safety Board in the investigation of wind related accidents.

Parks, E. K.↗
NASA NTRS1992

Analysis of accidents during instrument approaches

General aviation and air taxi approach phase accidents, which occurred during VFR and IFR, respectively over the last 25 years, were analyzed. The data suggest that there is a 204 percent higher risk during the approach and landing phase of VFR flights, than during similar IFR operations (14.82 vs 7.27 accidents/100,000 approaches). Alarmingly, the night single pilot IFR (SPIFR) accident rate is almost 8 times the rate of day IFR, 35.43 vs 4.47 accidents/100,000 approaches, and two and a half times that of day VFR approaches, 35.43 vs 14.82 accidents/100,000 approaches. Surprisingly, the overall SPIFR accident rates are not much higher than dual-pilot IFR (DPIFR), 7.27 vs 6.48 accidents/100,000 approaches. The generally static ratio of the statistics for SPIFR/DPIFR accident rates may be accounted for by little or no change in general aviation cockpit technology during the last 25 years, and because IFR operational flight task management training has not kept pace.

Bennett, C. T.↗
NASA NTRS1929

Aircraft accidents : method of analysis

This report on a method of analysis of aircraft accidents has been prepared by a special committee on the nomenclature, subdivision, and classification of aircraft accidents organized by the National Advisory Committee for Aeronautics in response to a request dated February 18, 1928, from the Air Coordination Committee consisting of the Assistant Secretaries for Aeronautics in the Departments of War, Navy, and Commerce. The work was undertaken in recognition of the difficulty of drawing correct conclusions from efforts to analyze and compare reports of aircraft accidents prepared by different organizations using different classifications and definitions. The air coordination committee's request was made "in order that practices used may henceforth conform to a standard and be universally comparable." the purpose of the special committee therefore was to prepare a basis for the classification and comparison of aircraft accidents, both civil and military. (author)

Source record↗
NASA NTRS2000

U.S. Civil Rotorcraft Accidents, 1963 Through 1997

Narrative summary data produced by the U.S. National Transportation Safety Board (NTSB) has been obtained and analyzed for all 8,436 U.S. civil registered rotorcraft accidents which occurred from mid-1963 through 1997. This analysis was based on the NTSB's assignment of each mishap into one of 21 "first event" categories. The number of U.S. civil registered rotorcraft as recorded by the Federal Aviation Administration (FAA) for the same period has also been obtained. Taken together, these data indicate the civil rotorcraft accident rate (on a per 1,000 registered rotorcraft basis) has decreased by almost a factor of 10 (i.e., from 130 accidents per 1,000 rotorcraft in 1964 to 13.4 per 1,000 in 1997). Analysis of the mishap data indicates over 70% of the rotorcraft accidents were associated with one of the following four NTSB "first event" categories: 2408 Loss of engine power (28.5%); 1,322 In-flight collisions with objects (15.7%); 1,114 Loss of control (13.2%); 1,083 Airframe/component/system failure or malfunction (12.8%).

Harris, Franklin D.↗
NASA NTRS2002

Characterizing the Severe Turbulence Environments Associated With Commercial Aviation Accidents: 44 Case Study Synoptic Observational Analyses - Part 1

A 44 case study analysis of the large-scale atmospheric structure associated with development of accident-producing aircraft turbulence is described. Categorization is a function of the accident location, altitude, time of year, time of day, and the turbulence category, which classifies disturbances. National Centers for Environmental Prediction Reanalyses data sets and satellite imagery are employed to diagnose synoptic scale predictor fields associated with the large-scale environment preceding severe turbulence. These analyses indicate a predominance of severe accident-producing turbulence within the entrance region of a jet stream at the synoptic scale. Typically, a flow curvature region is just upstream within the jet entrance region, convection is within 100 km of the accident, vertical motion is upward, absolute vorticity is low, vertical wind shear is increasing, and horizontal cold advection is substantial. The most consistent predictor is upstream flow curvature and nearby convection is the second most frequent predictor.

Kaplan, Michael L.↗