SEARCH · Engineering Papers

Results for “Accident”

Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

SourceResearch connectionFrom yearThrough year

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 73 records · Page 4

All sources NASA NTRS DOE OSTI

NASA NTRS2004

A Summary of the Space Shuttle Columbia Tragedy and the Use of LS Dyna in the Accident Investigation and Return to Flight Efforts

On February 1, 2003, the Space Shuttle Columbia broke apart during reentry resulting in loss of 7 crewmembers and craft. For the next several months an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA concluded in August, 2003 that the cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the missions launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing which ultimately led to the breakup of the orbiter. In order to gain a better understanding the foam impact on the orbiters RCC wing leading edge, a multi-center team of NASA and Boeing impact experts was formed to characterize the foam and RCC materials for impact analysis using LS Dyna. Dyna predictions were validated with sub-component and full scale tests. LS Dyna proved to be a valuable asset in supporting both the Columbia Accident Investigation and NASA s return to flight efforts. This paper summarizes Columbia Accident and the nearly seven month long investigation that followed. The use of LS-DYNA in this effort is highlighted. Contributions to the investigation and return to flight efforts of the multicenter team consisting of members from NASA Glenn, NASA Langley, and Boeing Philadelphia are introduced and covered in detail in papers to follow in these proceedings.

Melis, Matthew↗

NASA NTRS2005

The Implications of Handling Qualities in Civil Helicopter Accidents Involving Hover and Low Speed Flight

Because of increasing accident rates in Army helicopters in hover and low speed flight, a study was made in 1999 of accidents which could be attributed to inadequate stability augmentation. A study of civil helicopter accidents from 1993-2004 was then undertaken to pursue the issue of poor handling qualities in helicopters which, in almost all cases, had no stability augmentation. The vast majority of the mishaps studied occurred during daylight in visual meteorological condition, reducing the impact of degraded visual environments (DVE) on the results. Based on the Cooper-Harper Rating Scale, the handling qualities of many of the helicopters studied could be described as having from "very objectionable" to "major" deficiencies. These costly deficiencies have resulted in unnecessary loss of life, injury, and high dollar damage. Low cost and lightweight augmentation systems for helicopters have been developed in the past and are still being investigated. They offer the potential for significant reductions in the accident rate.

Dugan, Daniel C.↗

NASA NTRS2007

The Columbia Accident Investigation and The NASA Glenn Ballistic Impact Laboratory Contributions Supporting NASA's Return to Flight

On February 1, 2003, the Space Shuttle Columbia broke apart during reentry, resulting in loss of the vehicle and its seven crewmembers. For the next several months, an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA, concluded in August, 2003 that the most likely cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the mission's launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing, which ultimately led to the breakup of the orbiter. The findings of the CAIB were supported by ballistic impact tests, which simulated the physics of External Tank Foam impact on the RCC wing leading edge material. These tests ranged from fundamental material characterization tests to full-scale Orbiter Wing Leading Edge tests. Following the accident investigation, NASA spent the next 18 months focused on returning the shuttle safely to flight. In order to fully evaluate all potential impact threats from the many debris sources on the Space Shuttle during ascent, NASA instituted a significant impact testing program. The results from these tests led to the validation of high-fidelity computer models, capable of predicting actual or potential Shuttle impact events, were used in the certification of STS-114, NASA s Return to Flight Mission, as safe to fly. This presentation will provide a look into the inner workings of the Space Shuttle and a behind the scenes perspective on the impact analysis and testing done for the Columbia Accident Investigation and NASA's Return to Flight programs. In addition, highlights from recent Shuttle missions are presented.

Melis, Matthew E.↗

NASA NTRS2007

Pressing the Approach: A NASA Study of 19 Recent Accidents Yields a New Perspective on Pilot Error

This article begins with a review of two sample airplane accidents that were caused by pilot error. The analysis of these and 17 other accidents suggested that almost all experienced pilot operating in the same environment in which the accident crews were operating and knowing only what the accident crews knew at each moment of the flight, would be vulnerable to making a similar decision and similar errors. Whether a particular crew in a given situation makes errors depends on somewhat random interaction of factors. Two themes that seem to be prevalent in these cases are: Plan Continuation Bias, and Snowballing Workload.

Berman, Benjamin A.↗

NASA NTRS2010

Aircraft Loss-of-Control Accident Analysis

Loss of control remains one of the largest contributors to fatal aircraft accidents worldwide. Aircraft loss-of-control accidents are complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents. To gain a better understanding into aircraft loss-of-control events and possible intervention strategies, this paper presents a detailed analysis of loss-of-control accident data (predominantly from Part 121), including worst case combinations of causal and contributing factors and their sequencing. Future potential risks are also considered.

Belcastro, Christine M.↗

NASA NTRS2010

Future Integrated Systems Concept for Preventing Aircraft Loss-of-Control Accidents

Loss of control remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft loss-of-control accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents. This paper presents future system concepts and research directions for preventing aircraft loss-of-control accidents.

Belcastro, Christine M.↗

NASA NTRS2009

Orbiter Payload Bay Bucket Hoist Mishap...An Accident We Should Never Forget

This slide presentation reviews the accident that occurred in 1985 when a bay bucket hoist fell from its stowed position. This accident damaged the orbiter, injured a technician, and delayed the launch. The accident was investigated, and the cause of the accident was determined to be the practice of two-blocking. Two-blocking is the result of hoisting beyond the intended safe upper limit of hook travel to the point of solid contact between the load block and the upper block or hoist/trolley structure. The usual result is immediate failure of the wire rope, due to the ropes being cut by the grooves of the drum or sheaves. The design of the hoist, the inspection, and the operator training were all in part responsible for this failure.

Lytle, Bradford P.↗

NASA NTRS2012

Comparing the Identification of Recommendations by Different Accident Investigators Using a Common Methodology

Accident reports play a key role in the safety of complex systems. These reports present the recommendations that are intended to help avoid any recurrence of past failures. However, the value of these findings depends upon the causal analysis that helps to identify the reasons why an accident occurred. Various techniques have been developed to help investigators distinguish root causes from contributory factors and contextual information. This paper presents the results from a study into the individual differences that can arise when a group of investigators independently apply the same technique to identify the causes of an accident. This work is important if we are to increase the consistency and coherence of investigations following major accidents.

Johnson, Chris W.↗

NASA NTRS2014

The X-15 3-65 Accident: An Aircraft Systems and Flight Control Perspective

Despite the NASA X-15 program's outstanding success in developing and operating the first manned hypersonic research platform, the program suffered a fatal accident on November 15, 1967, when X-15-3, the only aircraft outfitted with advanced pilot displays and an adaptive flight control system, was lost after entering uncontrolled flight at an altitude of 230,000 feet and a velocity near Mach 5. The pilot, Major Michael J. Adams, was incapacitated by the aircraft accelerations and was killed either during the ensuing breakup or upon ground impact. In light of mitigating risk to current and emerging manned aerospace vehicles, a comprehensive systems level analysis of the accident is presented with a focus on the electrical power, flight control, and instrumentation failures that affected not only the vehicle dynamics but substantially impacted the pilot decisions that led to an inevitable loss of control. Insights based on reconstructed flight data as well as analysis and simulation of the X-15's unique adaptive control system, yield new conclusions about the reasons for the control systems anomalous behavior and the system-level interactions and human-machine interface design oversights that led to the accident.

Accident Investigation↗

NASA NTRS2019

The Role of Alerting System Failures in Loss of Control Accidents CAST SE-210 Output 2

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane's energy state or attitude and enters an upset condition. In a report by the Commercial Aviation Safety Team, an analysis of accidents and incidents related to loss of airplane state awareness determined that hazard alerting was not effective in producing the appropriate pilot response to a hazard (CAST, 2014). In the current report, we take a detailed look at 28 airplane state awareness accidents and incidents to determine how well the hazard alerting worked. We describe a five-step integrated alerting-to-recovery sequence that prescribes how hazard alerting should lead to effective flight crew actions for managing the hazard. Then, for each hazard in each of the 28 events, we determine if that sequence failed and, if so, how it failed. The results show that there was an alerting failure in every one of the 28 safety events, and that the most frequent failure (20/28) was tied to the flight crew not orienting to (not being aware of) the hazard. The discussion section summarizes findings and identifies alerting issues that are being addressed and issues that are not currently being addressed. We identify a few recent upgrades that have addressed certain alerting failures. Two of these upgrades address alerting design, but one response to the safety events is to upgrade training for approach to stall and stall recovery. We also describe issues that are not being addressed adequately: better alert integration for flight path management types of hazards, airplanes in the fleet that do not meet the current alerting regulations, a lack of innovation for addressing cases of channelized attention, and existing vulnerabilities in managing data validity.

aviation safety↗

NASA NTRS2019

Factors that Influenced Airplane State Awareness Accidents and Incidents: CAST SE-210 Output 2: Report 2 of 6

commercial aviation↗

NASA NTRS1924

Investigations of aviation accidents and lessons to be drawn from them

Similarities in the study of aviation accidents in different countries are made as well as statistics on the causes of those accidents.

STATISTICS - ACCIDENTS (FR )↗

NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Four

This is Volume Four of a set of six reports produced by NASA and other organizations which were provided to the Columbia Accident Investigation Board (CAIB) in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia. The Technical Documents included in this volume are: Appendix F.1 Water Absorption by Foam; Appendix F.2 Follow the TPS; Appendix F.3 MADS Sensor Data; Appendix F.4 ET Cryoinsulation; Appendix F.5 Space Shuttle STS-107 Columbia Accident Investigation, and External Tank Working Group Final Report - Volume 1.

CRYOINSULATION↗

NASA NTRS1972

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 2: Accident Model Document (AMD)

The Accident Model Document is one of three documents of the Preliminary Safety Analysis Report (PSAR) - Reactor System as applied to a Space Base Program. Potential terrestrial nuclear hazards involving the zirconium hydride reactor-Brayton power module are identified for all phases of the Space Base program. The accidents/events that give rise to the hazards are defined and abort sequence trees are developed to determine the sequence of events leading to the hazard and the associated probabilities of occurence. Source terms are calculated to determine the magnitude of the hazards. The above data is used in the mission accident analysis to determine the most probable and significant accidents/events in each mission phase. The only significant hazards during the prelaunch and launch ascent phases of the mission are those which arise form criticality accidents. Fission product inventories during this time period were found to be very low due to very limited low power acceptance testing.

Source record↗

NASA NTRS1981

The effect of heavy rain on windshear attributed accidents

In recent years several commercial aircraft accidents have occurred as an aircraft attempted landing in a thunderstorm cell. The horizontal and vertical windshear associated with the cell have been identified as the factors responsible for the accident. In addition to the wind shear encounter, several of these aircraft simultaneously penetrated a heavy rain cell. Heavy rain affects the aircraft by imparting a momentum penalty, and a drag penalty, due to the rain roughening of the airfoil. These penalties have been evaluated by a computer model that, when incorporated with a landing simulation program, was used to assess the relative influence of heavy rain versus wind shear. Using this model, an assessment was made of the influence of heavy rain on several wind shear attributed accidents.

Luers, J. K.↗

NASA NTRS1983

Heavy rain influence on airplane accidents

The aerodynamic effects of heavy rain on two windshear accidents have been evaluated according to the theoretical results of Haines and Luers (1983). A number of other accidents in which the presence of low-level windshear was a distinct possibility are also discussed. The results indicate that there are two major types of rain-related accidents. In one, the aircraft touches down prior to the runway because increased drag and momentum loss make the aircraft descend below glide slope. In the other, the aircraft loses airspeed while attempting a go-around in the heavy rain environment.

Luers, J.↗

NASA NTRS1986

Report of the Presidential Commission on the Space Shuttle Challenger Accident, Volume 1

The findings of the Commission regarding the circumstances surrounding the Challenger accident are reported and recommendations for corrective action are outlined. All available mission data, subsequent tests, and wreckage analyses were reviewed and specific failure scenarios were developed. The Commission concluded that the cause of the Mission 51-L accident was the failure of the pressure seal in the aft field joint of the right solid rocket motor. The failure was due to a faulty design unacceptably sensitive to a number of factors. These factors were the effects of temperature, physical dimensions, the character of materials, the effects of reuse, processing, and the reaction of the joint to dynamic loading. In addition to analyzing the material causes of the accident, the Commission examined the chain of decisions that culminated in approval of the launch. It concluded that the decision making process was flawed in several ways including (1) failure in communication resulting in a launch decision based on incomplete and misleading information, (2) a conflict between engineering data and management judgements, and (3) a NASA management structure that permitted flight safety problems to bypass key Shuttle managers.

Rogers, W. P.↗

NASA NTRS1996

Comprehensive Analysis of Two Downburst-Related Aircraft Accidents

Although downbursts have been identified as the major cause of a number of aircraft takeoff and landing accidents, only the 1985 Dallas/Fort Worth (DFW) and the more recent (July 1994) Charlotte, North Carolina, landing accidents provided sufficient onboard recorded data to perform a comprehensive analysis of the downburst phenomenon. The first step in the present analysis was the determination of the downburst wind components. Once the wind components and their gradients were determined, the degrading effect of the wind environment on the airplane's performance was calculated. This wind-shear-induced aircraft performance degradation, sometimes called the F-factor, was broken down into two components F(sub 1) and F(sub 2), representing the effect of the horizontal wind gradient and the vertical wind velocity, respectively. In both the DFW and Charlotte cases, F(sub 1) was found to be the dominant causal factor of the accident. Next, the aircraft in the two cases were mathematically modeled using the longitudinal equations of motion and the appropriate aerodynamic parameters. Based on the aircraft model and the determined winds, the aircraft response to the recorded pilot inputs showed good agreement with the onboard recordings. Finally, various landing abort strategies were studied. It was concluded that the most acceptable landing abort strategy from both an analytical and pilot's standpoint was to hold constant nose-up pitch attitude while operating at maximum engine thrust.

Shen, J.↗