Engineering Papers⌕ Search

SEARCH · Engineering Papers

Results for “Accident Analysis”

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.

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

At least 73 records · Page 4
All sourcesNASA NTRSDOE OSTI
NASA NTRS1984

NASA: Model development for human factors interfacing

The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.

Smith, L. L.↗
NASA NTRS2007

Lessons Learned from Seven Space Shuttle Missions

Much can be learned from well-written descriptions of the technical and organizational factors that lead to an accident. Subsequent analysis by third parties of investigation reports and associated evidence collected during the investigations can lead to additional insight. Much can also be learned from documented close calls that do not result in loss of life or a spacecraft, such as the Mars Exploration Rover Spirit software anomaly, the SOHO mission interruption, and the NEAR burn anomaly. Seven space shuttle incidents fall into the latter category: Rendezvous Target Failure On STS-41B; Rendezvous Radar Anomaly and Trajectory Dispersion-STS-32 ;Rendezvous Lambert Targeting Anomaly-STS-49; Rendezvous Lambert Targeting Anomaly-STS-51; Zero Doppler Steering Maneuver Anomaly-STS-59; Excessive Propellant Consumption During Rendezvous-STS-69; Global Positioning System Receiver and Associated Shuttle Flight Software Anomalies-STS-91 Procedural work-arounds or software changes prevented them from threatening mission success. Extensive investigations, which included the independent recreation of the anomalies by multiple Shuttle Program organizations, were the key to determining the cause, accurately assessing risk, and identifying software and software process improvements. Lessons learned from these incidents not only validated long-standing operational best practices, but serve to promote discussion and mentoring among Program personnel and are applicable to future space flight programs.

Goodman, John↗
NASA NTRS2010

Failure Analysis at the Kennedy Space Center

History has shown that failures occur in every engineering endeavor, and what we learn from those failures contributes to the knowledge base to safely complete future missions. The necessity of failure analysis is at its apex at the end of one aged program (i.e. Shuttle) and at the beginning of a new and untested program (i.e. Constellation). The information that we gain through failure analysis corrects the deficiencies in the current vehicle to make the next generation of vehicles more efficient and safe. The Failure Analysis and Materials Evaluation section in the Materials Science Division at the Kennedy Space Center performs metallurgical, mechanical, electrical, and non-metallic failure analysis and accident investigations on both flight hardware and ground support equipment (GSE) for the Shuttle, International Space Station, Constellation, and Launch Services Programs. This presentation will explore a variety of failure case studies at KSC and the lessons learned that can be applied in future programs.

Salazar, Victoria L.↗
NASA NTRS1972

Analysis of loss-of-coolant accident for a fast-spectrum lithium-cooled nuclear reactor for space-power applications

A two-dimensional, transient, heat-transfer analysis was made to determine the temperature response in the core of a conceptual space-power nuclear reactor following a total loss of reactor coolant. With loss of coolant from the reactor, the controlling mode of heat transfer is thermal radiation. In one of the schemes considered for removing decay heat from the core, it was assumed that the 4 pi shield which surrounds the core acts as a constant-temperature sink (temperature, 700 K) for absorption of thermal radiation from the core. Results based on this scheme of heat removal show that melting of fuel in the core is possible only when the emissivity of the heat-radiating surfaces in the core is less than about 0.40. In another scheme for removing the afterheat, the core centerline fuel pin was replaced by a redundant, constant temperature, coolant channel. Based on an emissivity of 0.20 for all material surfaces in the core, the calculated maximum fuel temperature for this scheme of heat removal was 2840 K, or about 90 K less than the melting temperature of the UN fuel.

Turney, G. E.↗
NASA NTRS2014

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗
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.↗
NASA NTRS1975

A study of carburetor/induction system icing in general aviation accidents

An assessment of the frequency and severity of carburetor/induction icing in general-aviation accidents was performed. The available literature and accident data from the National Transportation Safety Board were collected. A computer analysis of the accident data was performed. Between 65 and 90 accidents each year involve carburetor/induction system icing as a probable cause/factor. Under conditions conducive to carburetor/induction icing, between 50 and 70 percent of engine malfunction/failure accidents (exclusive of those due to fuel exhaustion) are due to carburetor/induction system icing. Since the evidence of such icing may not remain long after an accident, it is probable that the frequency of occurrence of such accidents is underestimated; therefore, some extrapolation of the data was conducted. The problem of carburetor/induction system icing is particularly acute for pilots with less than 1000 hours of total flying time. The severity of such accidents is about the same as any accident resulting from a forced landing or precautionary landing. About 144 persons, on the average, are exposed to death and injury each year in accidents involving carburetor/induction icing as a probable cause/factor.

Obermayer, R. W.↗
NASA NTRS1986

Teacher in Space Program - The challenge to education in the space age

An account is given of the significant events which occurred in the Teacher in Space Program following the Challenger Space Shuttle accident on January 28, 1986. The analysis indicates that the accident has not prevented the continuing effective implementation of the three educational goals of the Teacher in Space Program which are to: (1) raise the prestige of the teaching profession, (2) increase the awareness in the education community of the impact of technology and science on this country's future in preparing students for the future, and (3) use aeronautics and space as a catalyst to enhance all subject areas and grade levels of U.S. education systems.

Brown, R. W.↗
NASA NTRS2010

Examination of Icing Induced Loss of Control and Its Mitigations

Factors external to the aircraft are often a significant causal factor in loss of control (LOC) accidents. In today s aviation world, very few accidents stem from a single cause and typically have a number of causal factors that culminate in a LOC accident. Very often the "trigger" that initiates an accident sequence is an external environment factor. In a recent NASA statistical analysis of LOC accidents, aircraft icing was shown to be the most common external environmental LOC causal factor for scheduled operations. When investigating LOC accident or incidents aircraft icing causal factors can be categorized into groups of 1) in-flight encounter with super-cooled liquid water clouds, 2) take-off with ice contamination, or 3) in-flight encounter with high concentrations of ice crystals. As with other flight hazards, icing induced LOC accidents can be prevented through avoidance, detection, and recovery mitigations. For icing hazards, avoidance can take the form of avoiding flight into icing conditions or avoiding the hazard of icing by making the aircraft tolerant to icing conditions. Icing detection mitigations can take the form of detecting icing conditions or detecting early performance degradation caused by icing. Recovery from icing induced LOC requires flight crew or automated systems capable of accounting for reduced aircraft performance and degraded control authority during the recovery maneuvers. In this report we review the icing induced LOC accident mitigations defined in a recent LOC study and for each mitigation describe a research topic required to enable or strengthen the mitigation. Many of these research topics are already included in ongoing or planned NASA icing research activities or are being addressed by members of the icing research community. These research activities are described and the status of the ongoing or planned research to address the technology needs is discussed

Reehorst, Andrew L.↗
NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

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

Carlos Paradis↗
NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

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

Carlos Paradis↗
NASA NTRS2007

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Johnson, C. W.↗
NASA NTRS1980

Civil helicopter wire strike assessment study. Volume 1: Findings and recommendations

Approximately 208 civil helicopter wire strike accidents for a ten year period 1970 to 1979 are analyzed. It is found that 83% of the wire strikes occurred during bright clear weather. Analysis of the accidents is organized under pilot, environment, and machine factors. Methods to reduce the wire strike accident rate are discussed, including detection/warning devices, identification of wire locations prior to flight, wire cutting devices, and implementation of training programs. The benefits to be gained by implementing accident avoidance methods are estimated to be fully justified by reduction in injury and death and reduction of aircraft damage and loss.

Tuomela, C. H.↗
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 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 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 NTRS1977

An analysis of three weather-related aircraft accidents

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

Fujita, T. T.↗