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NASA NTRS1997

Operational Interventions to Maintenance Error

A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

Kanki, Barbara G.↗
NASA NTRS1998

Feedback Linearized Aircraft Control Using Dynamic Cell Structure

A Dynamic Cell Structure (DCS ) Neural Network was developed which learns a topology representing network (TRN) of F-15 aircraft aerodynamic stability and control derivatives. The network is combined with a feedback linearized tracking controller to produce a robust control architecture capable of handling multiple accident and off-nominal flight scenarios. This paper describes network and its performance for accident scenarios including differential stabilator lock, soft sensor failure, control, stability derivative variation, and turbulence.

Jorgensen, C. C.↗
NASA NTRS2005

Implementation of Programmatic Quality and the Impact on Safety

The purpose of this paper is to discuss the implementation of a programmatic quality assurance discipline within the International Space Station Program and the resulting impact on safety. NASA culture has continued to stress safety at the expense of quality when both are extremely important and both can equally influence the success or failure of a Program or Mission. Although safety was heavily criticized in the media after Col~imbiaa, strong case can be made that it was the failure of quality processes and quality assurance in all processes that eventually led to the Columbia accident. Consequently, it is possible to have good quality processes without safety, but it is impossible to have good safety processes without quality. The ISS Program quality assurance function was analyzed as representative of the long-term manned missions that are consistent with the President s Vision for Space Exploration. Background topics are as follows: The quality assurance organizational structure within the ISS Program and the interrelationships between various internal and external organizations. ISS Program quality roles and responsibilities with respect to internal Program Offices and other external organizations such as the Shuttle Program, JSC Directorates, NASA Headquarters, NASA Contractors, other NASA Centers, and International Partner/participants will be addressed. A detailed analysis of implemented quality assurance responsibilities and functions with respect to NASA Headquarters, the JSC S&MA Directorate, and the ISS Program will be presented. Discussions topics are as follows: A comparison of quality and safety resources in terms of staffing, training, experience, and certifications. A benchmark assessment of the lessons learned from the Columbia Accident Investigation (CAB) Report (and follow-up reports and assessments), NASA Benchmarking, and traditional quality assurance activities against ISS quality procedures and practices. The lack of a coherent operational and sustaining quality assurance strategy for long-term manned space flight. An analysis of the ISS waiver processes and the Problem Reporting and Corrective Action (PRACA) process implemented as quality functions. Impact of current ISS Program procedures and practices with regards to operational safety and risk A discussion regarding a "defense-in-depth" approach to quality functions will be provided to address the issue of "integration vs independence" with respect to the roles of Programs, NASA Centers, and NASA Headquarters. Generic recommendations are offered to address the inadequacies identified in the implementation of ISS quality assurance. A reassessment by the NASA community regarding the importance of a "quality culture" as a component within a larger "safety culture" will generate a more effective and value-added functionality that will ultimately enhance safety.

Huls, Dale Thomas↗
NASA NTRS2007

Metallic Concepts for Repair of Reinforced Carbon-Carbon Space Shuttle Leading Edges

The Columbia accident has focused attention on the critical need for on-orbit repair concepts for wing leading edges in the event that potentially catastrophic damage is incurred during Space Shuttle Orbiter flight. The leading edge of the space shuttle wings consists of a series of eleven panels on each side of the orbiter. These panels are fabricated from reinforced carbon-carbon (RCC) which is a light weight composite with attractive strength at very high temperatures. The damage that was responsible for the loss of the Colombia space shuttle was deemed due to formation of a large hole in one these RCC leading edge panels produced by the impact of a large piece of foam. However, even small cracks in the RCC are considered as potentially catastrophic because of the high temperature re-entry environment. After the Columbia accident, NASA has explored various means to perform on-orbit repairs in the event that damage is sustained in future shuttle flights. Although large areas of damage, such as that which doomed Columbia, are not anticipated to re-occur due to various improvements to the shuttle, especially the foam attachment, NASA has also explored various options for both small and large area repair. This paper reports one large area repair concept referred to as the "metallic over-wrap." Environmental conditions during re-entry of the orbiter impose extreme requirements on the RCC leading edges as well as on any repair concepts. These requirements include temperatures up to 3000 F (1650 C) for up to 15 minutes in the presence of an extremely oxidizing plasma environment. Figure 1 shows the temperature profile across one panel (#9) which is subject to the highest temperatures during re-entry. Although the RCC possesses adequate mechanical strength at these temperatures, it lacks oxidation resistance. Oxidation protection is afforded by converting the outer layers of the RCC to SiC by chemical vapor deposition (CVD). At high temperatures in an oxidizing environment, the SiC layer forms a protective SiO2 scale. However, CVD processing to form the SiC layer can result in the formation of small cracks in the outer surface. Hence, as a final fabrication step, a sodium silicate glass, known as "Type A," is applied as a sealant to fill any surface porosity and/or cracks in the coating and the outer portions of the RCC[1]. At relatively low temperatures, the Type A glass melts and flows into the cracks providing oxidation protection at the higher temperatures. In addition, the Type A coating, provides a "dark" coating with a high emissivity. This high emissivity allows the RCC to transfer heat by radiating outward to space as well as dispersing heat within the leading edge cavity. Lastly, the Type A possesses low catalycity which reduces surface temperatures by limiting oxygen recombination on the surface during re-entry.

Ritzert, Frank↗
NASA NTRS2007

Real-time Affective Indices of Potential CRM Breakdown: Qualitative Testing of an Operational Hypothesis

This viewgraph presentation begins by showing several cases where poor crew resource management (CRM) resulted in aircraft accidents. The presenter reviews the emotional states that are present in a situation that frequently leads to an accident. The operational answer suggested is given as an acronym: PACE, which stand for Probe, Alert, Challenge, Emergency Action.

Dickerson, Mark↗
NASA NTRS2007

Shuttle Entry Imaging Using Infrared Thermography

During the Columbia Accident Investigation, imaging teams supporting debris shedding analysis were hampered by poor entry image quality and the general lack of information on optical signatures associated with a nominal Shuttle entry. After the accident, recommendations were made to NASA management to develop and maintain a state-of-the-art imagery database for Shuttle engineering performance assessments and to improve entry imaging capability to support anomaly and contingency analysis during a mission. As a result, the Space Shuttle Program sponsored an observation campaign to qualitatively characterize a nominal Shuttle entry over the widest possible Mach number range. The initial objectives focused on an assessment of capability to identify/resolve debris liberated from the Shuttle during entry, characterization of potential anomalous events associated with RCS jet firings and unusual phenomenon associated with the plasma trail. The aeroheating technical community viewed the Space Shuttle Program sponsored activity as an opportunity to influence the observation objectives and incrementally demonstrate key elements of a quantitative spatially resolved temperature measurement capability over a series of flights. One long-term desire of the Shuttle engineering community is to calibrate boundary layer transition prediction methodologies that are presently part of the Shuttle damage assessment process using flight data provided by a controlled Shuttle flight experiment. Quantitative global imaging may offer a complementary method of data collection to more traditional methods such as surface thermocouples. This paper reviews the process used by the engineering community to influence data collection methods and analysis of global infrared images of the Shuttle obtained during hypersonic entry. Emphasis is placed upon airborne imaging assets sponsored by the Shuttle program during Return to Flight. Visual and IR entry imagery were obtained with available airborne imaging platforms used within DoD along with agency assets developed and optimized for use during Shuttle ascent to demonstrate capability (i.e., tracking, acquisition of multispectral data, spatial resolution) and identify system limitations (i.e., radiance modeling, saturation) using state-of-the-art imaging instrumentation and communication systems. Global infrared intensity data have been transformed to temperature by comparison to Shuttle flight thermocouple data. Reasonable agreement is found between the flight thermography images and numerical prediction. A discussion of lessons learned and potential application to a potential Shuttle boundary layer transition flight test is presented.

Horvath, Thomas↗
NASA NTRS2008

Test-Analysis Correlation for Space Shuttle External Tank Foam Impacting RCC Wing Leading Edge Component Panels

The Space Shuttle Columbia Accident Investigation Board recommended that NASA develop, validate, and maintain a modeling tool capable of predicting the damage threshold for debris impacts on the Space Shuttle Reinforced Carbon-Carbon (RCC) wing leading edge and nosecap assembly. The results presented in this paper are one part of a multi-level approach that supported the development of the predictive tool used to recertify the shuttle for flight following the Columbia Accident. The assessment of predictive capability was largely based on test analysis comparisons for simpler component structures. This paper provides comparisons of finite element simulations with test data for external tank foam debris impacts onto 6-in. square RCC flat panels. Both quantitative displacement and qualitative damage assessment correlations are provided. The comparisons show good agreement and provided the Space Shuttle Program with confidence in the predictive tool.

Lyle, Karen H.↗
NASA NTRS2006

Rapid Structured Volume Grid Smoothing and Adaption Technique

A rapid, structured volume grid smoothing and adaption technique, based on signal processing methods, was developed and applied to the Shuttle Orbiter at hypervelocity flight conditions in support of the Columbia Accident Investigation. Because of the fast pace of the investigation, computational aerothermodynamicists, applying hypersonic viscous flow solving computational fluid dynamic (CFD) codes, refined and enhanced a grid for an undamaged baseline vehicle to assess a variety of damage scenarios. Of the many methods available to modify a structured grid, most are time-consuming and require significant user interaction. By casting the grid data into different coordinate systems, specifically two computational coordinates with arclength as the third coordinate, signal processing methods are used for filtering the data [Taubin, CG v/29 1995]. Using a reverse transformation, the processed data are used to smooth the Cartesian coordinates of the structured grids. By coupling the signal processing method with existing grid operations within the Volume Grid Manipulator tool, problems related to grid smoothing are solved efficiently and with minimal user interaction. Examples of these smoothing operations are illustrated for reductions in grid stretching and volume grid adaptation. In each of these examples, other techniques existed at the time of the Columbia accident, but the incorporation of signal processing techniques reduced the time to perform the corrections by nearly 60%. This reduction in time to perform the corrections therefore enabled the assessment of approximately twice the number of damage scenarios than previously possible during the allocated investigation time.

Alter, Stephen J.↗
NASA NTRS2008

Aspects of Synthetic Vision Display Systems and the Best Practices of the NASA's SVS Project

NASA s Synthetic Vision Systems (SVS) Project conducted research aimed at eliminating visibility-induced errors and low visibility conditions as causal factors in civil aircraft accidents while enabling the operational benefits of clear day flight operations regardless of actual outside visibility. SVS takes advantage of many enabling technologies to achieve this capability including, for example, the Global Positioning System (GPS), data links, radar, imaging sensors, geospatial databases, advanced display media and three dimensional video graphics processors. Integration of these technologies to achieve the SVS concept provides pilots with high-integrity information that improves situational awareness with respect to terrain, obstacles, traffic, and flight path. This paper attempts to emphasize the system aspects of SVS - true systems, rather than just terrain on a flight display - and to document from an historical viewpoint many of the best practices that evolved during the SVS Project from the perspective of some of the NASA researchers most heavily involved in its execution. The Integrated SVS Concepts are envisagements of what production-grade Synthetic Vision systems might, or perhaps should, be in order to provide the desired functional capabilities that eliminate low visibility as a causal factor to accidents and enable clear-day operational benefits regardless of visibility conditions.

Bailey, Randall E.↗
NASA NTRS2008

Apollo Lesson Sampler: Apollo 13 Lessons Learned

This CD-ROM contains a two-part case study of the Apollo 13 accident. The first lesson contains an overview of the electrical system hardware on the Apollo spacecraft, providing a context for the details of the oxygen tank explosion, and the failure chain reconstruction that led to the conditions present at the time of the accident. Given this background, the lesson then covers the tank explosion and immediate damage to the spacecraft, and the immediate response of Mission Control to what they saw. Part 2 of the lesson picks up shortly after the explosion of the oxygen tank on Apollo 13, and discusses how Mission Control gained insight to and understanding of the damage in the aftermath. Impacts to various spacecraft systems are presented, along with Mission Control's reactions and plans for in-flight recovery leading to a successful entry. Finally, post-flight vehicle changes are presented along with the lessons learned.

Interbartolo, Michael A.↗
NASA NTRS2009

NASA Standard for Models and Simulations (M and S): Development Process and Rationale

After the Columbia Accident Investigation Board (CAIB) report. the NASA Administrator at that time chartered an executive team (known as the Diaz Team) to identify the CAIB report elements with Agency-wide applicability, and to develop corrective measures to address each element. This report documents the chronological development and release of an Agency-wide Standard for Models and Simulations (M&S) (NASA Standard 7009) in response to Action #4 from the report, "A Renewed Commitment to Excellence: An Assessment of the NASA Agency-wide Applicability of the Columbia Accident Investigation Board Report, January 30, 2004".

Zang, Thomas A.↗
NASA NTRS2010

Commercial Aircraft Integrated Vehicle Health Management Study

Statistical data and literature from academia, industry, and other government agencies were reviewed and analyzed to establish requirements for fixture work in detection, diagnosis, prognosis, and mitigation for IVHM related hardware and software. Around 15 to 20 percent of commercial aircraft accidents between 1988 and 2003 involved inalftfnctions or failures of some aircraft system or component. Engine and landing gear failures/malfunctions dominate both accidents and incidents. The IVI vl Project research technologies were found to map to the Joint Planning and Development Office's National Research and Development Plan (RDP) as well as the Safety Working Group's National Aviation Safety Strategic. Plan (NASSP). Future directions in Aviation Technology as related to IVHlvl were identified by reviewing papers from three conferences across a five year time span. A total of twenty-one trend groups in propulsion, aeronautics and aircraft categories were compiled. Current and ftiture directions of IVHM related technologies were gathered and classified according to eight categories: measurement and inspection, sensors, sensor management, detection, component and subsystem monitoring, diagnosis, prognosis, and mitigation.

Reveley, Mary S.↗
NASA NTRS2010

Changing the Safety and Mission Assurance (S and MA) Paradigm

This slide presentation reviews the change in the work and impact of the Safety and Mission Assurance directorate at Marshall Space Flight Center. It reviews the background and the reasons given for a strong Safety & Mission Assurance presence in all planning for space flight. This was pointed out by the Rogers Commission Report after the Space Challenger accident, by the Columbia Accident Investigation Board (CAIB) and by a 2006 NASA Exploration Safety Study (NESS) Team. The overall objective of the work in this area was to improve and maintain S&MA expertise and skills. Training for this work was improved and the S&MA organization was reorganized. This has resulted in a paradigm shift for NASA's safety efforts, which is described. The presentation then reviews the impact of the new S&MA work in the Ares I design and development.

Malone, Roy W.↗
NASA NTRS2010

NASA Contingency Shuttle Crew Support (CSCS) Medical Operations

The genesis of the space shuttle began in the 1930's when Eugene Sanger came up with the idea of a recyclable rocket plane that could carry a crew of people. The very first Shuttle to enter space was the Shuttle "Columbia" which launched on April 12 of 1981. Not only was "Columbia" the first Shuttle to be launched, but was also the first to utilize solid fuel rockets for U.S. manned flight. The primary objectives given to "Columbia" were to check out the overall Shuttle system, accomplish a safe ascent into orbit, and to return back to earth for a safe landing. Subsequent to its first flight Columbia flew 27 more missions but on February 1st, 2003 after a highly successful 16 day mission, the Columbia, STS-107 mission, ended in tragedy. With all Shuttle flight successes come failures such as the fatal in-flight accident of STS 107. As a result of the STS 107 accident, and other close-calls, the NASA Space Shuttle Program developed contingency procedures for a rescue mission by another Shuttle if an on-orbit repair was not possible. A rescue mission would be considered for a situation where a Shuttle and the crew were not in immediate danger, but, was unable to return to Earth or land safely. For Shuttle missions to the International Space Station (ISS), plans were developed so the Shuttle crew would remain on board ISS for an extended period of time until rescued by a "rescue" Shuttle. The damaged Shuttle would subsequently be de-orbited unmanned. During the period when the ISS Crew and Shuttle crew are on board simultaneously multiple issues would need to be worked including, but not limited to: crew diet, exercise, psychological support, workload, and ground contingency support

Adams, Adrien↗
NASA NTRS2010

Checklists and Monitoring in the Cockpit: Why Crucial Defenses Sometimes Fail

Checklists and monitoring are two essential defenses against equipment failures and pilot errors. Problems with checklist use and pilots failures to monitor adequately have a long history in aviation accidents. This study was conducted to explore why checklists and monitoring sometimes fail to catch errors and equipment malfunctions as intended. Flight crew procedures were observed from the cockpit jumpseat during normal airline operations in order to: 1) collect data on monitoring and checklist use in cockpit operations in typical flight conditions; 2) provide a plausible cognitive account of why deviations from formal checklist and monitoring procedures sometimes occur; 3) lay a foundation for identifying ways to reduce vulnerability to inadvertent checklist and monitoring errors; 4) compare checklist and monitoring execution in normal flights with performance issues uncovered in accident investigations; and 5) suggest ways to improve the effectiveness of checklists and monitoring. Cognitive explanations for deviations from prescribed procedures are provided, along with suggestions for countermeasures for vulnerability to error.

Dismukes, R. Key↗
NASA NTRS2009

The Reconstruction and Failure Analysis of the Space Shuttle Columbia

Several days following the Columbia accident a team formed and began planning for the reconstruction of Columbia. A hangar at the Kennedy Space Center was selected for this effort due to it's size, available technical workforce and materials science laboratories and access to the vehicle ground processing infrastructure. The Reconstruction team established processes for receiving, handling, decontamination, tracking, identifying, cleaning and assessment of the debris. Initially, a 2-dimensional reconstruction of the Orbiter outer mold line was developed. As the investigation progressed fixtures which allowed a 3-dimensional reconstruction of the forward portions of the left wing's leading edge was developed. To support the reconstructions and forensic analyses a Materials and Processes (M&P) 'team was formed. This M&P team established processes for recording factual observations, debris cleaning, and engineering analysis. Fracture surfaces and thermal effects of selected airframe debris were assessed, and process flows for both nondestructive and destructive sampling and evaluation of debris were developed. The Team also assessed left hand airframe components that were believed to be associated with a structural breach of Columbia. A major portion of this analysis was evaluation of metallic deposits were prevalent on left wing leading edge components. Extensive evaluation of the visual, metallurgical and chemical nature of the deposits provided conclusions that were consistent with the visual assessments and interpretations of the NASA lead teams and the findings of the Columbia Accident Investigation Board. Analytical data collected by the M&P Team showed that a significant thermal event occurred at the left wing leading edge in the proximity of LH RCC Panels 8-9, and a correlation was formed between the deposits and overheating in these areas to the wing leading edge components. The analysis of deposits also showed exposure to temperatures in excess of 1649 C (3200 F), which would severely degrade support structure, tiles, and RCC panel materials. The integrated failure analysis of wing leading edge debris and deposits strongly supported the hypothesis that a breach occurred at LH RCC Panel 8.

Russell, Richard↗
NASA NTRS2011

Space Shuttle Propulsion Finishing Strong

Numerous lessons have been documented from the Space Shuttle Propulsion elements. Major events include loss of the SRB's on STS-4 and shutdown of an SSME during ascent on STS- 51F. On STS-112 only half the pyrotechnics fired to release the vehicle from the launch pad, a testament for redundancy. STS-91 exhibited freezing of a main combustion chamber pressure measurement and on STS-93 nozzle tube ruptures necessitated a low liquid level oxygen cut off of the main engines. A number of on pad aborts were experienced during the early program resulting in delays. And the two accidents, STS-51L and STS-107, had unique heritage in history from early Program decisions and vehicle configuration. Following STS-51L significant resources were invested in developing fundamental physical understanding of solid rocket motor environments and material system behavior. Human rating of solid rocket motors was truly achieved. And following STS-107, the risk of ascent debris was better characterized and controlled. Situational awareness during all mission phases improved, and the management team instituted effective risk assessment practices. These major events and lessons for the future are discussed. The last 22 flights of the Space Shuttle, following the Columbia accident, were characterized by remarkable improvement in safety and reliability. Numerous problems were solved in addition to reduction of the ascent debris hazard. The propulsion system elements evolved to high reliability and heavy lift capability. The Shuttle system, though not a operable as envisioned in the 1970's, successfully assembled the International Space Station (ISS) and provided significant logistics and down mass for ISS operations. By the end of the Program, the remarkable Space Shuttle Propulsion system achieved very high performance, was largely reusable, exhibited high reliability, and is a heavy lift earth to orbit propulsion system. The story of this amazing system is discussed in detail in the paper.

Owen, James W.↗