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At least 91 records · Page 5
All sourcesNASA NTRSDOE OSTI
NASA NTRS1998

Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation

Advances in technology and new levels of automation on commercial jet transports has had many effects. There have been positive effects from both an economic and a safety point of view. The technology changes on the flight deck also have had reverberating effects on many other aspects of the aviation system and different aspects of human performance. Operational experience, research investigations, incidents, and occasionally accidents have shown that new and sometimes surprising problems have arisen as well. What are these problems with cockpit automation, and what should we learn from them? Do they represent over-automation or human error? Or instead perhaps there is a third possibility - they represent coordination breakdowns between operators and the automation? Are the problems just a series of small independent glitches revealed by specific accidents or near misses? Do these glitches represent a few small areas where there are cracks to be patched in what is otherwise a record of outstanding designs and systems? Or do these problems provide us with evidence about deeper factors that we need to address if we are to maintain and improve aviation safety in a changing world? How do the reverberations of technology change on the flight deck provide insight into generic issues about developing human-centered technologies and systems (Winograd and Woods, 1997)? Based on a series of investigations of pilot interaction with cockpit automation (Sarter and Woods, 1992; 1994; 1995; 1997a, 1997 b), supplemented by surveys, operational experience and incident data from other studies (e.g., Degani et al., 1995; Eldredge et al., 1991; Tenney et al., 1995; Wiener, 1989), we too have found that the problems that surround crew interaction with automation are more than a series of individual glitches. These difficulties are symptoms that indicate deeper patterns and phenomena concerning human-machine cooperation and paths towards disaster. In addition, we find the same kinds of patterns behind results from studies of physician interaction with computer-based systems in critical care medicine (e.g., Moll van Charante et al., 1993; Obradovich and Woods, 1996; Cook and Woods, 1996). Many of the results and implications of this kind of research are synthesized and discussed in two comprehensive volumes, Billings (1996) and Woods et al. (1994). This paper summarizes the pattern that has emerged from our research, related research, incident reports, and accident investigations. It uses this new understanding of why problems arise to point to new investment strategies that can help us deal with the perceived "human error" problem, make automation more of a team player, and maintain and improve safety.

Woods, David D.↗
NASA NTRS2000

The ''Rock'': The Role of the Press in Bringing about Change in Aircraft Accident Policy

From 1926 to 1938, the Aeronautics Branch, forerunner of the Federal Aviation Administration (FAA), had been charged with aircraft accident investigation. While the Branch had been investigating accidents since its inception, it had, early in its tenure, put into place a policy making its findings secret. Media and political pressure began to mount in late 1928 over its policy of nondisclosure and the debate brought pressure to bear on the young Aeronautics Branch to reverse its policy and make its findings public. The focusing event for the Branch's policy reversal was the death of Knute Rockne, the famous Notre Dame football coach, in a Transcontinental and Western Airways (TWA) airliner on March 31, 193 1. This paper will examine the role of print media in bringing about a significant, and lasting, change in aircraft accident public-disclosure policy.

Johnson, Randy↗
NASA NTRS2003

Concept of Operations for the NASA Weather Accident Prevention (WxAP) Project

The Weather Accident Prevention Concept of Operations (CONOPS) serves as a decision-making framework for research and technology development planning. It is intended for use by the WxAP members and other related programs in NASA and the FAA that support aircraft accident reduction initiatives. The concept outlines the project overview for program level 3 elements-such as AWIN, WINCOMM, and TPAWS (Turbulence)-that develop the technologies and operating capabilities to form the building blocks for WxAP. Those building blocks include both retrofit of equipment and systems and development of new aircraft, training technologies, and operating infrastructure systems and capabilities. This Concept of operations document provides the basis for the WxAP project to develop requirements based on the operational needs ofthe system users. It provides the scenarios that the flight crews, airline operations centers (AOCs), air traffic control (ATC), and flight service stations (FSS) utilize to reduce weather related accidents. The provision to the flight crew of timely weather information provides awareness of weather situations that allows replanning to avoid weather hazards. The ability of the flight crew to locate and avoid weather hazards, such as turbulence and hail, contributes to safer flight practices.

Green, Walter S.↗
NASA NTRS2004

Distribution of Causes in Selected US Aviation Accident Reports Between 1996 and 2003

This paper describes the results of an independent analysis of the probable and contributory causes of selected aviation accidents in the United States between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a variety of causal factors in the reporting of these adverse events. Although our results show that more of these high consequence accidents were attributed to human error than to any other single factor, a large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These wider issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Holloway, C. M.↗
NASA NTRS2005

Structural Analysis for the American Airlines Flight 587 Accident Investigation: Global Analysis

NASA Langley Research Center (LaRC) supported the National Transportation Safety Board (NTSB) in the American Airlines Flight 587 accident investigation due to LaRC's expertise in high-fidelity structural analysis and testing of composite structures and materials. A Global Analysis Team from LaRC reviewed the manufacturer s design and certification procedures, developed finite element models and conducted structural analyses, and participated jointly with the NTSB and Airbus in subcomponent tests conducted at Airbus in Hamburg, Germany. The Global Analysis Team identified no significant or obvious deficiencies in the Airbus certification and design methods. Analysis results from the LaRC team indicated that the most-likely failure scenario was failure initiation at the right rear main attachment fitting (lug), followed by an unstable progression of failure of all fin-to-fuselage attachments and separation of the VTP from the aircraft. Additionally, analysis results indicated that failure initiates at the final observed maximum fin loading condition in the accident, when the VTP was subjected to loads that were at minimum 1.92 times the design limit load condition for certification. For certification, the VTP is only required to support loads of 1.5 times design limit load without catastrophic failure. The maximum loading during the accident was shown to significantly exceed the certification requirement. Thus, the structure appeared to perform in a manner consistent with its design and certification, and failure is attributed to VTP loads greater than expected.

Young, Richard D.↗
NASA NTRS2006

Why System Safety Professionals Should Read Accident Reports

System safety professionals, both researchers and practitioners, who regularly read accident reports reap important benefits. These benefits include an improved ability to separate myths from reality, including both myths about specific accidents and ones concerning accidents in general; an increased understanding of the consequences of unlikely events, which can help inform future designs; a greater recognition of the limits of mathematical models; and guidance on potentially relevant research directions that may contribute to safety improvements in future systems.

Holloway, C. M.↗
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 NTRS2010

Causal Factors and Adverse Conditions of Aviation Accidents and Incidents Related to Integrated Resilient Aircraft Control

The causal factors of accidents from the National Transportation Safety Board (NTSB) database and incidents from the Federal Aviation Administration (FAA) database associated with loss of control (LOC) were examined for four types of operations (i.e., Federal Aviation Regulation Part 121, Part 135 Scheduled, Part 135 Nonscheduled, and Part 91) for the years 1988 to 2004. In-flight LOC is a serious aviation problem. Well over half of the LOC accidents included at least one fatality (80 percent in Part 121), and roughly half of all aviation fatalities in the studied time period occurred in conjunction with LOC. An adverse events table was updated to provide focus to the technology validation strategy of the Integrated Resilient Aircraft Control (IRAC) Project. The table contains three types of adverse conditions: failure, damage, and upset. Thirteen different adverse condition subtypes were gleaned from the Aviation Safety Reporting System (ASRS), the FAA Accident and Incident database, and the NTSB database. The severity and frequency of the damage conditions, initial test conditions, and milestones references are also provided.

Reveley, Mary S.↗
NASA NTRS2011

Aeromedical Lessons Learned from the Space Shuttle Columbia Accident Investigation

This slide presentation provides an update on the Columbia accident response presented in 2005 with additional information that was not available at that time. It will provide information on the following topics: (1) medical response and Search and Rescue, (2) medico-legal issues associated with the accident, (3) the Spacecraft Crew Survival Integrated Investigation Team Report published in 2008, and (4) future NASA flight surgeon spacecraft accident response training.

Chandler, Mike↗
NASA NTRS2005

Techniques and Tools of NASA's Space Shuttle Columbia Accident Investigation

The Space Shuttle Columbia accident investigation was a fusion of many disciplines into a single effort. From the recovery and reconstruction of the debris, Figure 1, to the analysis, both destructive and nondestructive, of chemical and metallurgical samples, Figure 2, a multitude of analytical techniques and tools were employed. Destructive and non-destructive testing were utilized in tandem to determine if a breach in the left wing of the Orbiter had occurred, and if so, the path of the resultant high temperature plasma flow. Nondestructive analysis included topometric scanning, laser mapping, and real-time radiography. These techniques were useful in constructing a three dimensional virtual representation of the reconstruction project, specifically the left wing leading edge reinforced carbon/carbon heat protectant panels. Similarly, they were beneficial in determining where sampling should be performed on the debris. Analytic testing included such techniques as Energy Dispersive Electron Microprobe Analysis (EMPA), Electron Spectroscopy Chemical Analysis (ESCA), and X-Ray dot mapping; these techniques related the characteristics of intermetallics deposited on the leading edge of the left wing adjacent to the location of a suspected plasma breach during reentry. The methods and results of the various analyses, along with their implications into the accident, are discussed, along with the findings and recommendations of the Columbia Accident Investigation Board. Likewise, NASA's Return To Flight efforts are highlighted.

McDanels, Steve J.↗
NASA NTRS2012

Object-Oriented Bayesian Networks (OOBN) for Aviation Accident Modeling and Technology Portfolio Impact Assessment

The concern for reducing aviation safety risk is rising as the National Airspace System in the United States transforms to the Next Generation Air Transportation System (NextGen). The NASA Aviation Safety Program is committed to developing an effective aviation safety technology portfolio to meet the challenges of this transformation and to mitigate relevant safety risks. The paper focuses on the reasoning of selecting Object-Oriented Bayesian Networks (OOBN) as the technique and commercial software for the accident modeling and portfolio assessment. To illustrate the benefits of OOBN in a large and complex aviation accident model, the in-flight Loss-of-Control Accident Framework (LOCAF) constructed as an influence diagram is presented. An OOBN approach not only simplifies construction and maintenance of complex causal networks for the modelers, but also offers a well-organized hierarchical network that is easier for decision makers to exploit the model examining the effectiveness of risk mitigation strategies through technology insertions.

Shih, Ann T.↗
NASA NTRS2014

A Comprehensive Analysis of the X-15 Flight 3-65 Accident

The November 15, 1967, loss of X-15 Flight 3-65-97 (hereafter referred to as Flight 3-65) was a unique incident in that it was the first and only aerospace flight accident involving loss of crew on a vehicle with an adaptive flight control system (AFCS). In addition, Flight 3-65 remains the only incidence of a single-pilot departure from controlled flight of a manned entry vehicle in a hypersonic flight regime. To mitigate risk to emerging aerospace systems, the NASA Engineering and Safety Center (NESC) proposed a comprehensive review of this accident. The goal of the assessment was to resolve lingering questions regarding the failure modes of the aircraft systems (including the AFCS) and thoroughly analyze the interactions among the human agents and autonomous systems that contributed to the loss of the pilot and aircraft. This document contains the outcome of the accident review.

Dennehy, Cornelius J.↗
NASA NTRS1992

Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses

A hospital-based survey on shift work, sleep, and accidents was carried out among 635 Massachusetts nurses. In comparison to nurses who worked only day/evening shifts, rotators had more sleep/wake cycle disruption and nodded off more at work. Rotators had twice the odds of nodding off while driving to or from work and twice the odds of a reported accident or error related to sleepiness. Application of circadian principles to the design of hospital work schedules may result in improved health and safety for nurses and patients.

Non-NASA Center↗
NASA NTRS2015

Reliability and Failure in NASA Missions: Blunders, Normal Accidents, High Reliability, Bad Luck

NASA emphasizes crew safety and system reliability but several unfortunate failures have occurred. The Apollo 1 fire was mistakenly unanticipated. After that tragedy, the Apollo program gave much more attention to safety. The Challenger accident revealed that NASA had neglected safety and that management underestimated the high risk of shuttle. Probabilistic Risk Assessment was adopted to provide more accurate failure probabilities for shuttle and other missions. NASA's "faster, better, cheaper" initiative and government procurement reform led to deliberately dismantling traditional reliability engineering. The Columbia tragedy and Mars mission failures followed. Failures can be attributed to blunders, normal accidents, or bad luck. Achieving high reliability is difficult but possible.

accidents↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Six

In the course of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia, the Columbia Accident Investigation Board conducted a series of public hearings at Houston, Texas; Cape Canaveral, Florida; and Washington, DC. Testimony from these hearings was recorded and then transcribed. This appendix, Volume VI of the Report, is a compilation of those transcripts. Contents: Transcripts of Board Public Hearings; Appendix H.1 March 6, 2003 Houston, Texas; Appendix H.2 March 17, 2003 Houston, Texas; Appendix H.3 March 18, 2003 Houston, Texas; Appendix H. 4 March 25, 2003 Cape Canaveral, Florida; Appendix H.5 March 26, 2003 Cape Canaveral, Florida; Appendix H.6 April 7, 2003 Houston, Texas; Appendix H.7 April 8, 2003 Houston, Texas; Appendix H.8 April 23, 2003 Houston, Texas; Appendix H.9 May 6, 2003 Houston, Texas; Appendix H.10 June 12, 2003 Washington, DC.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Two

Volume II of the Report contains appendices that were cited in Volume I. The Columbia Accident Investigation Board produced many of these appendices as working papers during the investigation into the February 1, 2003 destruction of the Space Shuttle Columbia. Other appendices were produced by other organizations (mainly NASA) in support of the Board investigation. In the case of documents that have been published by others, they are included here in the interest of establishing a complete record, but often at less than full page size. Contents include: CAIB Technical Documents Cited in the Report: Reader's Guide to Volume II; Appendix D. a Supplement to the Report; Appendix D.b Corrections to Volume I of the Report; Appendix D.1 STS-107 Training Investigation; Appendix D.2 Payload Operations Checklist 3; Appendix D.3 Fault Tree Closure Summary; Appendix D.4 Fault Tree Elements - Not Closed; Appendix D.5 Space Weather Conditions; Appendix D.6 Payload and Payload Integration; Appendix D.7 Working Scenario; Appendix D.8 Debris Transport Analysis; Appendix D.9 Data Review and Timeline Reconstruction Report; Appendix D.10 Debris Recovery; Appendix D.11 STS-107 Columbia Reconstruction Report; Appendix D.12 Impact Modeling; Appendix D.13 STS-107 In-Flight Options Assessment; Appendix D.14 Orbiter Major Modification (OMM) Review; Appendix D.15 Maintenance, Material, and Management Inputs; Appendix D.16 Public Safety Analysis; Appendix D.17 MER Manager's Tiger Team Checklist; Appendix D.18 Past Reports Review; Appendix D.19 Qualification and Interpretation of Sensor Data from STS-107; Appendix D.20 Bolt Catcher Debris Analysis.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Three

The Columbia Accident Investigation Board's (CAIB) independent investigation into the February 1, 2003 destruction of the Space Shuttle Columbia produced a six volume report. This is Volume III of the report. Volume III contains other technical documents produced by NASA and other organizations, which were provided to the CAIB in support of its inquiry into the tragedy. Technical documents included in the report are: Appendix E.1 CoFR Endorsements; Appendix E.2 STS-107 Image Analysis Team Final Report; Appendix E.3 An Assessment of Potential Material Candidates for the 'Flight Day 2', Radar Object Observed during the NASA Mission STS-107; Appendix E.4 Columbia Early Sighting Assessment Team Final Report.

STS-107↗
NASA NTRS2003

Columbia Accident Investigation Board Report. Volume Five

Volume V of the Report contains appendices that were not cited in VolumeI. These consist of documents produced by NASA and other organizations, which were provided to the Columbia Accident Investigation Board in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia The contents include:. Appendix G.1 Requirements and Procedures for Certification of Flight Readiness; Appendix G.2 Appendix R, Space Shuttle Program Contingency Action Plan; Appendix G.3 CAIB Charter, with Revisions; Appendix G.4 Group 1 Matrix Brief on Maintenance, Material, and Management; Appendix G.5 Vehicle Data Mapping(VDM) Team Final Report, Jun 13, 2003; Appendix G.6 SRB Working Group Presentation to CAIB; Appendix G. 7 Starfire Team Final Report, Jun 3, 2003; Appendix G.8 Using the Data and Observations from Flight STS-107, Executive Summary; Appendix G.9 Contracts, Incentives, and Safety/Technical Excellence; Appendix G.10 Detailed Summaries: Rogers Commission Report, ASAP Report, SIAT Report; Appendix G.11 Foam Application and Production Chart; Appendix G.12 Crew Survivability Report; and Appendix G.12 Aero/Aerothermal/ Thermal/Structures Team FinalReport, August 6, 2003.

CAIB (COLUMBIA ACCIDENT INVESTIGATION BOARD)↗