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Aircraft accident investigations are discussed with emphasis on those accidents that involved weather as a contributing factor. The organization of the accident investigation board for air carrier accidents is described along with the hearings, and formal report preparation. Statistical summaries of the investigations of general aviation accidents are provided.
The aircraft accident data recorded and maintained by the National Transportation Safety Board for 1964 to 1979 were analyzed to determine what problems exist in the general aviation single pilot instrument flight rules environment. A previous study conducted in 1978 for the years 1964 to 1975 provided a basis for comparison. The purpose was to determine what changes, if any, have occurred in trends and cause-effect relationships reported in the earlier study. The increasing numbers have been tied to measures of activity to produce accident rates which in turn were analyzed in terms of change. Where anomalies or unusually high accident rates were encountered, further analysis was conducted to isolate pertinent patterns of cause factors and/or experience levels of involved pilots. The bulk of the effort addresses accidents in the landing phase of operations. A detailed analysis was performed on controlled/uncontrolled collisions and their unique attributes delineated. Estimates of day vs. night general aviation activity and accident rates were obtained.
The aircraft accident data recorded by the National Transportation and Safety Board (NTSR) for 1964-1979 were analyzed to determine what problems exist in the general aviation (GA) single pilot instrument flight rule (SPIFR) environment. A previous study conducted in 1978 for the years 1964-1975 provided a basis for comparison. This effort was generally limited to SPIFR pilot error landing phase accidents but includes some SPIFR takeoff and enroute accident analysis as well as some dual pilot IFR accident analysis for comparison. Analysis was performed for 554 accidents of which 39% (216) occurred during the years 1976-1979.
The National Transportation Safety Board (NTSB) has attributed wind shear as a cause or contributing factor in 15 accidents involving transport-categroy airplanes since 1970. Nine of these were nonfatal; but the other six accounted for 440 lives. Five of the fatal accidents and seven of the nonfatal accidents involved encounters with convective downbursts or microbursts. Of other accidents, two which were nonfatal were encounters with a frontal system shear, and one which was fatal was the result of a terrain induced wind shear. These accidents are discussed with reference to helping the aircraft to avoid the wind shear or if impossible to help the pilot to get through the wind shear.
Potential radiation impacts from launch of the Ulysses solar exploration experiment were evaluated using eight postulated accident scenarios. Lifetime individual dose estimates rarely exceeded 1 mrem. Most of the potential health effects would come from inhalation exposures immediately after an accident, rather than from ingestion of contaminated food or water, or from inhalation of resuspended plutonium from contaminated ground. For local Florida accidents (that is, during the first minute after launch), an average source term accident was estimated to cause a total added cancer risk of up to 0.2 deaths. For accidents at later time after launch, a worldwide cancer risk of up to three cases was calculated (with a four in a million probability). Upper bound estimates were calculated to be about 10 times higher.
The revised report includes the chart for the analysis of aircraft accidents, combining consideration of the immediate causes, underlying causes, and results of accidents, as prepared by the special committee, with a number of the definitions clarified. A brief statement of the organization and work of the special committee and of the Committee on Aircraft Accidents; and statistical tables giving a comparison of the types of accidents and causes of accidents in the military services on the one hand and in civil aviation on the other, together with explanations of some of the important differences noted in these tables.
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.
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.
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.
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
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.
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.
Y-12 has installed one CAAS system under the ANS 8.3 framework as a safety significant system, and is in the process of designing, installing, and qualifying another. As a safety significant system, the Y-12 CAAS is required to demonstrate that it is able to perform its function and actuate an alarm when exposed to the radiation from both a Minimum Accident of Concern and a maximum intensity accident. The ANS 8-series standards do not present a maximum accident to be considered, nor do they specify dose rate tolerance requirements, leading CAAS vendors to potentially use other standards that provide inadequate criteria. A maximum intensity accident is proposed, and the effects of this accident on CAAS analysis and the vendor’s equipment qualification are discussed
The use of accident tolerant fuel (ATF) cladding can increase coping times during and beyond design basis accidents. While such gains may be incremental, they provide a margin that can potentially be recovered to enable high-burnup (HBU) operation. Realizing such a margin requires demonstrating that the combination of HBU and ATF has not led to an overall increase in source term. This study investigates the influence of cladding technology (Zr-based, Cr-coated Zr, and FeCrAl) and fuel cycle length (18 and 24 months) on radiological dose at the boundary of the exclusion zone for a four-loop pressurized water reactor to investigate whether ATF claddings can provide such benefits. We analyze a recovered large break loss-of-coolant accident scenario to investigate the impact of transient timescale on the benefits of such coping time increases. The simulations have been performed using the MELCOR and MELCOR Accident Consequence Code System codes. For the cases analyzed, increased fuel cycle length did not necessarily increase radionuclide release and hydrogen generation, as these were found to be sensitive to the core power distribution. Similarly, off-site dose consequence is dominated by short-lived radionuclides that tend to saturate earlier in the burnup, so higher burnup operation did not necessarily increase the source term for the phenomena and transients analyzed here. Delays in recovery of the lowpressure safety injection system increase hydrogen production and radionuclide release, especially between 780 s and 1620 s, due to the nonlinear oxidation and core degradation behavior. Results show that Cr-coated Zr enhances safety by delaying heatup and gap release. Here, when uncertainty propagation on oxidation properties is considered, FeCrAl exhibits the lowest overall radionuclide release and off-site dose throughout the spectrum. However, while the considered “base model” performance is superior under delayed injection scenarios, upper-bound cases display hydrogen generation risk comparable to the Zr-based cladding.
During a severe accident in a nuclear reactor, there are a number of phenomenological events which can present a challenge to containment integrity. These include the generation and combustion of hydrogen, energetic fuel-coolant interactions, thermal attack of fission product barriers, core-concrete interactions, direct containment heating, and gradual overpressurization. The advanced design of the NuScale small modular reactor has resulted in the reduced likelihood and severity of severe accident challenges to containment. This paper discusses the features of the NuScale design that reduce the likelihood of occurrence of these severe accident phenomena, and discusses the ability of containment to survive in the unlikely event that they do occur. Here, the impact of severe accident phenomena for the NuScale design is compared and contrasted against other advanced light water reactors, such as AP1000 and ESBWR, as well as the existing fleet, using information from publicly available documents.
Studies indicate that early identification of persons involved in and receiving high doses of radiation in accidents is key to providing life-saving medical treatment. Although the risk of criticality accidents is low the potential impact to workers is significant. For facilities that employ large numbers of workers a key element in the response to a radiological emergency is identifying personnel that received significant, and potentially harmful, doses. Also important is having the ability to screen large numbers of workers to identify persons that did not receive significant exposure so as to reduce the impact on emergency response efforts. At the Y-12 National Security Complex the focus on criticality accident response is the rapid triage of personnel in order to identify persons exposed to large radiation doses and to prioritize those persons receiving the highest exposures. Once identified personnel are transported to local medical facilities including the Radiation Emergency Assistance Center/Training Site (REAC/TS) for medical evaluation and treatment. The Y-12 external dosimetry program utilizes a number of techniques to identify and prioritize workers and these methods were evaluated at a criticality dosimetry intercomparison exercise. Finally, the methods used were shown to perform as intended and other sites may consider incorporating these methods into their accident dosimetry response procedures.
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.
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.