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At least 91 records · Page 5
All sourcesNASA NTRSDOE OSTI
NASA NTRS1979

Comparative analysis of PA-31-350 Chieftain (N44LV) accident and NASA crash test data

A full scale, controlled crash test to simulate the crash of a Piper PA-31-350 Chieftain airplane is described. Comparisons were performed between the simulated crash and the actual crash in order to assess seat and floor behavior, and to estimate the acceleration levels experienced in the craft at the time of impact. Photographs, acceleration histories, and the tested airplane crash data is used to augment the accident information to better define the crash conditions. Measured impact parameters are presented along with flight path velocity and angle in relation to the impact surface.

Hayduk, R. J.↗
NASA NTRS2010

Introduction of the Space Shuttle Columbia Accident, Investigation Details, Findings and Crew Survival Investigation Report

As the Space Shuttle Program comes to an end, it is important that the lessons learned from the Columbia accident be captured and understood by those who will be developing future aerospace programs and supporting current programs. Aeromedical lessons learned from the Accident were presented at AsMA in 2005. This Panel will update that information, closeout the lessons learned, provide additional information on the accident and provide suggestions for the future. To set the stage, an overview of the accident is required. The Space Shuttle Columbia was returning to Earth with a crew of seven astronauts on 1Feb, 2003. It disintegrated along a track extending from California to Louisiana and observers along part of the track filmed the breakup of Columbia. Debris was recovered from Littlefield, Texas to Fort Polk, Louisiana, along a 567 statute mile track; the largest ever recorded debris field. The Columbia Accident Investigation Board (CAIB) concluded its investigation in August 2003, and released their findings in a report published in February 2004. NASA recognized the importance of capturing the lessons learned from the loss of Columbia and her crew and the Space Shuttle Program managers commissioned the Spacecraft Crew Survival Integrated Investigation Team (SCSIIT) to accomplish this. Their task was to perform a comprehensive analysis of the accident, focusing on factors and events affecting crew survival, and to develop recommendations for improving crew survival, including the design features, equipment, training and procedures intended to protect the crew. NASA released the Columbia Crew Survival Investigation Report in December 2008. Key personnel have been assembled to give you an overview of the Space Shuttle Columbia accident, the medical response, the medico-legal issues, the SCSIIT findings and recommendations and future NASA flight surgeon spacecraft accident response training. Educational Objectives: Set the stage for the Panel to address the investigation, medico-legal issues, the Spacecraft Crew Survival Integrated Investigation Team report and training for accident response.

Chandler, Michael↗
NASA NTRS2015

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilots taking direct control of the reaction control system. The analysis described here suggests that all of the events that caused the accident occurred well before the moment when the pilot switched to direct control. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

accident investigation↗
NASA NTRS2009

Columbia Crew Survival Investigation Report

NASA commissioned the Columbia Accident Investigation Board (CAIB) to conduct a thorough review of both the technical and the organizational causes of the loss of the Space Shuttle Columbia and her crew on February 1, 2003. The accident investigation that followed determined that a large piece of insulating foam from Columbia s external tank (ET) had come off during ascent and struck the leading edge of the left wing, causing critical damage. The damage was undetected during the mission. The CAIB's findings and recommendations were published in 2003 and are available on the web at http://caib.nasa.gov/. NASA responded to the CAIB findings and recommendations with the Space Shuttle Return to Flight Implementation Plan. Significant enhancements were made to NASA's organizational structure, technical rigor, and understanding of the flight environment. The ET was redesigned to reduce foam shedding and eliminate critical debris. In 2005, NASA succeeded in returning the space shuttle to flight. In 2010, the space shuttle will complete its mission of assembling the International Space Station and will be retired to make way for the next generation of human space flight vehicles: the Constellation Program. The Space Shuttle Program recognized the importance of capturing the lessons learned from the loss of Columbia and her crew to benefit future human exploration, particularly future vehicle design. The program commissioned the Spacecraft Crew Survival Integrated Investigation Team (SCSIIT). The SCSIIT was asked to perform a comprehensive analysis of the accident, focusing on factors and events affecting crew survival, and to develop recommendations for improving crew survival for all future human space flight vehicles. To do this, the SCSIIT investigated all elements of crew survival, including the design features, equipment, training, and procedures intended to protect the crew. This report documents the SCSIIT findings, conclusions, and recommendations.

Source record↗
NASA NTRS2020

Changes in Frequency of the Severity and Type of Aviation Accidents (1987 to 2016)

This document reports the fourth analysis to identify the types of accidents with the greatest impact on the overall safety risk in U.S. civil aviation. The first three analyses examined accidents in 1997-20061, in 2001-20102 and in 2005-20143. The safety risks herein are defined to include four elements: (1) the number of total accidents; (2) the number of fatal accidents; (3) the number of total injuries; (4) the number of fatal injuries. Two of the previous analyses also included the number of incidents, but incident data since 2007 are difficult to separate by flight operation. Other incident details are no longer recorded as well. Due to these changes, the author’s working copy of the incident data has not been updated since 2011 (for incidents through 2010), and the incident data were not included in this analysis. Powerplant and non-powerplant system component failures were the only categories with a greater contribution to the overall safety risk from incidents than from accidents. Accident types, as well as accident rates, have been shown to vary considerably among different flight operations (e.g., large air carriers versus general aviation). For this reason, all analyses were done separately for four types of flight operations (Part 121, Scheduled Part 135, Non- Scheduled Part 135 and Part 91).

Evans, Joni K.↗
NASA NTRS2016

The Human Factors of an Early Space Accident: Flight 3-65 of the X-15

The X-15 was a critical research vehicle in the early days of space flight. On November 15, 1967, the X-15-3 suffered an in-flight breakup. This 191st flight of the X-15 and the 65th flight of this third configuration was the only fatal accident of the X-15 program. This paper presents an analysis, from a human factors perspective, of the events that led up to the accident. The analysis is based on the information contained in the report of the Air Force-NASA Accident Investigation Board (AIB) dated January, 1968. The AIBs analysis addressed, primarily, the events that occurred subsequent to the pilot's taking direct control of the reaction control system. The analysis described here suggests that, rather than events following the pilot's switch to direct control, it was the events preceding the switch that led to the accident. Consequently, the analyses and conclusions regarding the causal factors of, and the contributing factors to, the loss of Flight 3-65 presented here differ from those of the AIB based on the same evidence. Although the accident occurred in 1967, the results of the presented analysis are still relevant today. We present our analysis and discuss its implications for the safety of space operations.

X-15↗
NASA NTRS1971

Application of system safety to rail transit systems

Management emphasis on system safety in the rapid transit industry includes the granting and use of funds by the Federal Government according to systematic analysis of safety hazards in advance. Likelihood predictions that those hazards will be activated by exposure of the system to a system failure, a human error, external conditions, or combinations of these aspects determine alternatives to the assumption of risk and recommend corrections before the system is operational. Rigorous safety analyses are projected to assure operational safety for prolonged periods under varied maintenance conditions; these analysis encompass station accident possibilities as well as train-person collisions, car equipment and design, traffic control systems, and tunnel design problems.

Thomas DeW. Styles↗
NASA NTRS1971

Designing for auto safety

Safety design features in the motor vehicle and highway construction fields result from systems analysis approach to prevent or lessen death, injury, and property damage results. Systems analysis considers the prevention of crashes, increased survivability in crashes, and prompt medical attention to injuries as well as other postcrash salvage measures. The interface of these system elements with the driver, the vehicle, and the environment shows that action on the vehicle system produces the greatest safety payoff through design modifications. New and amended safety standards developed through hazard analysis technique improved accident statistics in the 70'; these regulations include driver qualifications and countermeasures to identify the chronic drunken driver who is involved in more than two-thirds of all auto deaths.

Elwood T. Driver↗
NASA NTRS1972

Testing of models of VVH particle sources and propagation

For comparisons between theoretical and observed charge spectra of the VVH particles to be meaningful, at least two conditions must be met. First, charge resolution must be adequate to separate important groups of nuclei, and there should be no significant systematic errors in the charge scale developed. Second, there must be adequate rejection of slower particles of smaller Z, which have been observed in several flights. Within these conditions, it has been shown that observed features of the charge spectrum are not accidents of the analysis but reflect real variations in the relative abundances that must be explained by any successful model.

Blanford, G. E., Jr.↗
NASA NTRS1974

Testing of models of VVH particle sources and propagation

For comparisons between theoretical and observed charge spectra of VVH particles to be meaningful, at least two conditions must be met. First, charge resolution must be adequate to separate important groups of nuclei, and there should be no significant systematic errors in the charge scale developed. Second, there must be adequate rejection of slower particles of smaller Z, which have been observed in several flights. Within these conditions, it has been shown that observed features of the charge spectrum are not accidents of the analysis but reflect real variations in the relative abundances that must be explained by any successful model.

Blanford, G. E., Jr.↗
NASA NTRS2004

Effect of Clouds on Optical Imaging of the Space Shuttle During the Ascent Phase: A Statistical Analysis Based on a 3D Model

Clouds are highly effective in obscuring optical images of the Space Shuttle taken during its ascent by ground-based and airborne tracking cameras. Because the imagery is used for quick-look and post-flight engineering analysis, the Columbia Accident Investigation Board (CAIB) recommended the return-to-flight effort include an upgrade of the imaging system to enable it to obtain at least three useful views of the Shuttle from lift-off to at least solid rocket booster (SRB) separation (NASA 2003). The lifetimes of individual cloud elements capable of obscuring optical views of the Shuttle are typically 20 minutes or less. Therefore, accurately observing and forecasting cloud obscuration over an extended network of cameras poses an unprecedented challenge for the current state of observational and modeling techniques. In addition, even the best numerical simulations based on real observations will never reach "truth." In order to quantify the risk that clouds would obscure optical imagery of the Shuttle, a 3D model to calculate probabilistic risk was developed. The model was used to estimate the ability of a network of optical imaging cameras to obtain at least N simultaneous views of the Shuttle from lift-off to SRB separation in the presence of an idealized, randomized cloud field.

FROM↗
NASA NTRSDate not supplied

Digital Twins and Living Models at NASA

The idea of a “digital twin” was born at NASA in the 1960s as a “living model” of the Apollo mission. In response to Apollo 13’s oxygen tank explosion and subsequent damage to the main engine, NASA employed multiple simulators to evaluate the failure and extended a physical model of the vehicle to include digital components. This “digital twin” was the first of its kind, allowing for a continuous ingestion of data to model the events leading to up to the accident for forensic analysis and exploration of next steps. Fast forward half a century and NASA, along with others in the aerospace community, continues to develop and utilize high-fidelity digital models of physical systems and components as well as the extreme environments in which they operate. NASA aims to travel further and stay longer in space as we realize the Artemis program, taking us from the moon to Mars by establishing a sustainable presence on the Moon to prepare for missions to Mars. We will no longer be able to rely on constant connectivity with an asset nor be in-the-loop for on-demand human intervention in the event of an anomaly. Further, the importance of digital twins is increasing as we seek alternatives for certification of structures so large that they cannot be fully evaluated in existing test facilities and autonomous systems that are not deterministic. The idea of a digital twin is not a new one. What is new is the scale, ordinality, and non-deterministic nature of the models that are critical to achieving NASA’s goals. Their number and autonomy from each other as well as the reference system is suggestive of a changing ecosystem, returning us the idea of a living model.

Digital Twin↗
NASA NTRS1989

Final environmental impact statement for the Galileo Mission (Tier 2)

This Final Environmental Impact Statement (FEIS) addresses the proposed action of completing the preparation and operation of the Galileo spacecraft, including its planned launch on the Space Transportation System (STS) Shuttle in October 1989, and the alternative of canceling further work on the mission. The only expected environmental effects of the proposed action are associated with normal launch vehicle operation, and are treated in published National Environmental Policy Act (NEPA) documents on the Shuttle (NASA 1978) and the Kennedy Space Center (NASA 1979), and in the KSC Environmental Resources Document (NASA 1986) and the Galileo Tier 1 EIS (NASA 1988a). The environmental impacts of a normal launch were deemed insufficient to preclude Shuttle operations. Environmental impacts may also result from launch or mission accidents that could release plutonium fuel used in the Galileo power system. Intensive analysis of the possible accidents associated with the proposed action reveal small health or environmental risks. There are no environmental impacts in the no-action alternative. The remote possibility of environmental impacts of the proposed action must be weighed against the large adverse fiscal and programmatic impacts inherent in the no-action alternative.

Source record↗
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 NTRS2017

Analysis of Alerting System Failures in Commercial Aviation Accidents

The role of an alerting system is to make the system operator (e.g., pilot) aware of an impending hazard or unsafe state so the hazard can be avoided or managed successfully. A review of 46 commercial aviation accidents (between 1998 and 2014) revealed that, in the vast majority of events, either the hazard was not alerted or relevant hazard alerting occurred but failed to aid the flight crew sufficiently. For this set of events, alerting system failures were placed in one of five phases: Detection, Understanding, Action Selection, Prioritization, and Execution. This study also reviewed the evolution of alerting system schemes in commercial aviation, which revealed naive assumptions about pilot reliability in monitoring flight path parameters; specifically, pilot monitoring was assumed to be more effective than it actually is. Examples are provided of the types of alerting system failures that have occurred, and recommendations are provided for alerting system improvements.

aviation accidents↗
NASA NTRS1994

Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation Accident

Flight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.

Rosekind, Mark R.↗
NASA NTRS1998

U.S. Civil Rotorcraft Accidents, 1963 through 1997

The U.S. National Transportation Safety Board (NTSB) has recorded 8,436 rotorcraft accidents during the period mid - 1963 through the end of 1997. Review and analysis of the NTSB summary narrative for each accident has been completed. In addition, FAA (Federal Aviation Administration) counts of the growing registered rotorcraft fleet over this period has obtained. Taken together, a large and informative data base is now available, which indicates that the accident rate (on a per airframe basis) has changed very little since the mid 1970s. The data base, even in the summary form provided by this paper, offers suggestions for safer designs and improved flight operations. For analysis purposes, each accident has been placed in one of 21 top level categories as defined by the NTSB. Analysis of this grouping shows that 70 percent of rotorcraft accidents are associated with four categories. The accident count in these top four categories are: (1) 2,408 Loss of engine power (2) 1,322 In flight collision with object (3) 1,114 Loss of control (4) 1,083 Airframe/component/system failure or malfunction. Single engine rotorcraft dominate these accident statistics because of their sheer numbers over the study period. One-third of the loss of engine power accidents with these aircraft is fuel/air mixture related and fuel exhaustion is a common event. This appears to be the case whether a piston or turbine engine is installed. This paper provides similar study results in the other major mishap categories. It shows that both minor and major design and flight operations changes can -- and should -- be made to reduce rotorcraft accidents in the future. The paper outlines these changes and suggests how they may be made.

Harris, Franklin D.↗
NASA NTRS2007

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

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

Berman, Benjamin A.↗