Results for “Accident” — Page 47

NASA NTRS2008

Influence Map Methodology for Evaluating Systemic Safety Issues

"Raising the bar" in safety performance is a critical challenge for many organizations, including Kennedy Space Center. Contributing-factor taxonomies organize information about the reasons accidents occur and therefore are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This project successfully addressed the following two problems: (1) methods and metrics to support the design of effective taxonomies are limited and (2) influence relationships among contributing factors are not explicitly modeled within a taxonomy.

Source record↗

NASA NTRS2010

Experimental Space Shuttle Orbiter Studies to Acquire Data for Code and Flight Heating Model Validation

In an experimental study to obtain detailed heating data over the Space Shuttle Orbiter, CUBRC has completed an extensive matrix of experiments using three distinct models and two unique hypervelocity wind tunnel facilities. This detailed data will be employed to assess heating augmentation due to boundary layer transition on the Orbiter wing leading edge and wind side acreage with comparisons to computational methods and flight data obtained during the Orbiter Entry Boundary Layer Flight Experiment and HYTHIRM during STS-119 reentry. These comparisons will facilitate critical updates to be made to the engineering tools employed to make assessments about natural and tripped boundary layer transition during Orbiter reentry. To achieve the goals of this study data was obtained over a range of Mach numbers from 10 to 18, with flight scaled Reynolds numbers and model attitudes representing key points on the Orbiter reentry trajectory. The first of these studies were performed as an integral part of Return to Flight activities following the accident that occurred during the reentry of the Space Shuttle Columbia (STS-107) in February of 2003. This accident was caused by debris, which originated from the foam covering the external tank bipod fitting ramps, striking and damaging critical wing leading edge heating tiles that reside in the Orbiter bow shock/wing interaction region. During investigation of the accident aeroheating team members discovered that only a limited amount of experimental wing leading edge data existed in this critical peak heating area and a need arose to acquire a detailed dataset of heating in this region. This new dataset was acquired in three phases consisting of a risk mitigation phase employing a 1.8% scale Orbiter model with special temperature sensitive paint covering the wing leading edge, a 0.9% scale Orbiter model with high resolution thin-film instrumentation in the span direction, and the primary 1.8% scale Orbiter model with detailed thin-film resolution in both the span and chord direction in the area of peak heating. Additional objectives of this first study included: obtaining natural or tripped turbulent wing leading edge heating levels, assessing the effectiveness of protuberances and cavities placed at specified locations on the orbiter over a range of Mach numbers and Reynolds numbers to evaluate and compare to existing engineering and computational tools, obtaining cavity floor heating to aid in the verification of cavity heating correlations, acquiring control surface deflection heating data on both the main body flap and elevons, and obtain high speed schlieren videos of the interaction of the orbiter nose bow shock with the wing leading edge. To support these objectives, the stainless steel 1.8% scale orbiter model in addition to the sensors on the wing leading edge was instrumented down the windward centerline, over the wing acreage on the port side, and painted with temperature sensitive paint on the starboard side wing acreage. In all, the stainless steel 1.8% scale Orbiter model was instrumented with over three-hundred highly sensitive thin-film heating sensors, two-hundred of which were located in the wing leading edge shock interaction region. Further experimental studies will also be performed following the successful acquisition of flight data during the Orbiter Entry Boundary Layer Flight Experiment and HYTHIRM on STS-119 at specific data points simulating flight conditions and geometries. Additional instrumentation and a protuberance matching the layout present during the STS-119 boundary layer transition flight experiment were added with testing performed at Mach number and Reynolds number conditions simulating conditions experienced in flight. In addition to the experimental studies, CUBRC also performed a large amount of CFD analysis to confirm and validate not only the tunnel freestream conditions, but also 3D flows over the orbiter acreage, wing leading edge, and controlurfaces to assess data quality, shock interaction locations, and control surface separation regions. This analysis is a standard part of any experimental program at CUBRC, and this information was of key importance for post-test data quality analysis and understanding particular phenomena seen in the data. All work during this effort was sponsored and paid for by the NASA Space Shuttle Program Office at the Johnson Space Center in Houston, Texas.

Wadhams, T. P.↗

NASA NTRS2010

A Biomathematical Model of Lymphopoiesis and Its Application to Acute and Chronic Irradiation Assessment

After the events of September 11, 2001, there is an increasing concern of the occurrence of radiological terrorism that may result in significant casualties in densely populated areas. Much effort has been made to establish various biomarkers to rapidly assess radiation dose in mass-casualty and population-monitoring scenarios, which are demanded for effective medical management and treatment of the exposed victims. Among these the count of lymphocytes in peripheral blood and their depletion kinetics are the most important early indicators of the severity of the radiation injury. In this study, we examine a biomathematical model of lymphopoiesis which has been successfully utilized to simulate and interpret experimental data of acute and chronic irradiations on rodents [1]. With revised parameters for humans, we find this model can reproduce several sets of clinical lymphocyte data of accident victims over a wide range of absorbed doses. In addition, the absolute lymphocyte counts and the depletion rate constants calculated by this model also show good correlation with the Guskova formula and the Goans model, the two empirical tools which have been widely recognized for early estimation of the exposed dose after radiation accidents [2]. We also use the model to analyze the hematological data of the Techa River residents which were exposed to chronic low-dose irradiation during 1950-1956 [3]. This model can serve as a computational tool in radiation accident management, military operations involving nuclear warfare, radiation therapy, and space radiation risk assessment.

Hu, Shaowen↗

NASA NTRS2004

Challenger and Columbia Lessons Learned

The Space Shuttle Challenger and Columbia accidents resulted in tragic loss of life and national assets, and investigations into both accidents produced important lessons to prevent future accidents

Hoffman, William C., III↗

NASA NTRS2012

Photogrammetry Tool for Forensic Analysis

A system allows crime scene and accident scene investigators the ability to acquire visual scene data using cameras for processing at a later time. This system uses a COTS digital camera, a photogrammetry calibration cube, and 3D photogrammetry processing software. In a previous instrument developed by NASA, the laser scaling device made use of parallel laser beams to provide a photogrammetry solution in 2D. This device and associated software work well under certain conditions. In order to make use of a full 3D photogrammetry system, a different approach was needed. When using multiple cubes, whose locations relative to each other are unknown, a procedure that would merge the data from each cube would be as follows: 1. One marks a reference point on cube 1, then marks points on cube 2 as unknowns. This locates cube 2 in cube 1 s coordinate system. 2. One marks reference points on cube 2, then marks points on cube 1 as unknowns. This locates cube 1 in cube 2 s coordinate system. 3. This procedure is continued for all combinations of cubes. 4. The coordinate of all of the found coordinate systems is then merged into a single global coordinate system. In order to achieve maximum accuracy, measurements are done in one of two ways, depending on scale: when measuring the size of objects, the coordinate system corresponding to the nearest cube is used, or when measuring the location of objects relative to a global coordinate system, a merged coordinate system is used. Presently, traffic accident analysis is time-consuming and not very accurate. Using cubes with differential GPS would give absolute positions of cubes in the accident area, so that individual cubes would provide local photogrammetry calibration to objects near a cube.

Lane, John↗

NASA NTRS2013

High Speed Mobility Through On-Demand Aviation

Game changing advances come about by the introduction of new technologies at a time when societal needs create the opportunity for new market solutions. A unique opportunity exists for NASA to bring about such a mobility revolution in General Aviation, extendable to other aviation markets, to maintain leadership in aviation by the United States. This report outlines the research carried out so far under NASA's leadership towards developing a new mobility choice, called Zip Aviation1,2,3. The feasibility, technology and system gaps that need to be addressed, and pathways for successful implementation have been investigated to guide future investment. The past decade indicates exciting trends in transportation technologies, which are quickly evolving. Automobiles are embracing automation to ease driver tasks as well as to completely control the vehicle with added safety (Figure 1). Electric propulsion is providing zero tail-pipe emission vehicles with dramatically lower energy and maintenance costs. These technologies have not yet been applied to aviation, yet offer compelling potential benefits across all aviation markets, and in particular to General Aviation (GA) as an early adopter market. The benefits of such an adoption are applicable in the following areas: 􀁸 Safety: The GA market experiences accident rates that are substantially higher than automobiles or commercial airlines, with 7.5 fatal accidents per 100 million vehicle miles compared to 1.3 for automobiles and.068 for airlines. Approximately 80% of these accidents are caused by some form of pilot error, with another 13% caused by single point propulsion system failure. 􀁸 Emissions: Environmental constraints are pushing for the elimination of 100Low Lead (LL) fuel used in most GA aircraft, with aviation fuel the #1 source of lead emissions into the environment. Aircraft also have no emission control systems (i.e. no catalytic converters etc.), so they are gross hydrocarbon polluters compared to automobiles. 􀁸 Community Noise: Hub and smaller GA airports are facing increasing noise restrictions, and while commercial airliners have dramatically decreased their community noise footprint over the past 30 years, GA aircraft noise has essentially remained same, and moreover, is located in closer proximity to neighborhoods and businesses. 􀁸 Operating Costs: GA operating costs have risen dramatically due to average fuel costs of over $6 per gallon, which has constrained the market over the past decade and resulted in more than 50% lower sales and 35% less yearly operations. Infusion of autonomy and electric propulsion technologies can accomplish not only a transformation of the GA market, but also provide a technology enablement bridge for both larger aircraft and the emerging civil Unmanned Aerial Systems (UAS) markets. The NASA Advanced General Aviation Transport Experiments (AGATE) project successfully used a similar approach to enable the introduction of primary composite structures and flat panel displays in the 1990s, establishing both the technology and certification standardization to permit quick adoption through partnerships with industry, academia, and the Federal Aviation Administration (FAA). Regional and airliner markets are experiencing constant pressure to achieve decreasing levels of community emissions and noise, while lowering operating costs and improving safety. But to what degree can these new technology frontiers impact aircraft safety, the environment, operations, cost, and performance? Are the benefits transformational enough to fundamentally alter aircraft competiveness and productivity to permit much greater aviation use for high speed and On-Demand Mobility (ODM)? These questions were asked in a Zip aviation system study named after the Zip Car, an emerging car-sharing business model. Zip Aviation investigates the potential to enable new emergent markets for aviation that offer "more flexibility than the existing transportation solutions." These studies indicate that autonomy and electric propulsion technology infusions offer a unique opportunity to provide breakthrough capabilities for new high speed, on-demand travel alternatives that can leapfrog the need for future expensive ground-based infrastructure investment. At the same time, such investments offer a method of laying the foundation for these technologies to be incubated for commercial aviation at lower cost, and with lower initial certification thresholds due to the relatively poor capabilities of GA aircraft to permit early adoption and private market capitalization by rapid technology accelerations, as depicted in Figure 2.

Moore, Mark D.↗

NASA NTRS2014

Loss of Signal, Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle Mishap

Loss of Signal, a NASA publication to be available in May 2014 presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goal of this book is to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews. This poster presents an outline of Loss of Signal contents and highlights from each of five sections - the mission and mishap, the response, the investigation, the analysis and the future.

Stepaniak, Phillip C.↗

NASA NTRS2014

Loss of Signal, Aeromedical Lessons Learned for the STS-I07 Columbia Space Shuttle Mishap

Loss of Signal, a NASA publication to be available in May 2014, presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goals of this book are to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews.

Patlach, Robert↗

NASA NTRS2013

Work Practice Simulation of Complex Human-Automation Systems in Safety Critical Situations: The Brahms Generalized berlingen Model

The transition from the current air traffic system to the next generation air traffic system will require the introduction of new automated systems, including transferring some functions from air traffic controllers to on-board automation. This report describes a new design verification and validation (V&V) methodology for assessing aviation safety. The approach involves a detailed computer simulation of work practices that includes people interacting with flight-critical systems. The research is part of an effort to develop new modeling and verification methodologies that can assess the safety of flight-critical systems, system configurations, and operational concepts. The 2002 Ueberlingen mid-air collision was chosen for analysis and modeling because one of the main causes of the accident was one crew's response to a conflict between the instructions of the air traffic controller and the instructions of TCAS, an automated Traffic Alert and Collision Avoidance System on-board warning system. It thus furnishes an example of the problem of authority versus autonomy. It provides a starting point for exploring authority/autonomy conflict in the larger system of organization, tools, and practices in which the participants' moment-by-moment actions take place. We have developed a general air traffic system model (not a specific simulation of Überlingen events), called the Brahms Generalized Ueberlingen Model (Brahms-GUeM). Brahms is a multi-agent simulation system that models people, tools, facilities/vehicles, and geography to simulate the current air transportation system as a collection of distributed, interactive subsystems (e.g., airports, air-traffic control towers and personnel, aircraft, automated flight systems and air-traffic tools, instruments, crew). Brahms-GUeM can be configured in different ways, called scenarios, such that anomalous events that contributed to the Überlingen accident can be modeled as functioning according to requirements or in an anomalous condition, as occurred during the accident. Brahms-GUeM thus implicitly defines a class of scenarios, which include as an instance what occurred at Überlingen. Brahms-GUeM is a modeling framework enabling "what if" analysis of alternative work system configurations and thus facilitating design of alternative operations concepts. It enables subsequent adaption (reusing simulation components) for modeling and simulating NextGen scenarios. This project demonstrates that BRAHMS provides the capacity to model the complexity of air transportation systems, going beyond idealized and simple flights to include for example the interaction of pilots and ATCOs. The research shows clearly that verification and validation must include the entire work system, on the one hand to check that mechanisms exist to handle failures of communication and alerting subsystems and/or failures of people to notice, comprehend, or communicate problematic (unsafe) situations; but also to understand how people must use their own judgment in relating fallible systems like TCAS to other sources of information and thus to evaluate how the unreliability of automation affects system safety. The simulation shows in particular that distributed agents (people and automated systems) acting without knowledge of each others' actions can create a complex, dynamic system whose interactive behavior is unexpected and is changing too quickly to comprehend and control.

complex systems↗

NASA NTRS2014

Aviation Trends Related to Atmospheric Environment Safety Technologies Project Technical Challenges

Current and future aviation safety trends related to the National Aeronautics and Space Administration's Atmospheric Environment Safety Technologies Project's three technical challenges (engine icing characterization and simulation capability; airframe icing simulation and engineering tool capability; and atmospheric hazard sensing and mitigation technology capability) were assessed by examining the National Transportation Safety Board (NTSB) accident database (1989 to 2008), incidents from the Federal Aviation Administration (FAA) accident/incident database (1989 to 2006), and literature from various industry and government sources. The accident and incident data were examined for events involving fixed-wing airplanes operating under Federal Aviation Regulation (FAR) Parts 121, 135, and 91 for atmospheric conditions related to airframe icing, ice-crystal engine icing, turbulence, clear air turbulence, wake vortex, lightning, and low visibility (fog, low ceiling, clouds, precipitation, and low lighting). Five future aviation safety risk areas associated with the three AEST technical challenges were identified after an exhaustive survey of a variety of sources and include: approach and landing accident reduction, icing/ice detection, loss of control in flight, super density operations, and runway safety.

Reveley, Mary S.↗

NASA NTRS2015

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.

aircraft safety↗

NASA NTRS2015

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.

gas turbine engines↗

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↗