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NASA NTRS2011

The Psychology of Safety

Many studies of mishaps show that human error is a factor in a significant majority of accidents. Trying to decide how to change human behavior to be safer is generally the biggest challenge of any safety program. However, understanding the human psyche is the first step to changing behavior. Many studies focus on the before and after of an accident, but what about the thoughts of a person in the commission of an unsafe act? This is a less understood area. Examining it reveals why it is not well comprehended. This paper attempts to examine a part of the thought process, with an eye to helping influence people to less hurtful actions.

Anderson, Brenda Lindley↗
NASA NTRS2011

Origins of Protein Functions in Cells

In modern organisms proteins perform a majority of cellular functions, such as chemical catalysis, energy transduction and transport of material across cell walls. Although great strides have been made towards understanding protein evolution, a meaningful extrapolation from contemporary proteins to their earliest ancestors is virtually impossible. In an alternative approach, the origin of water-soluble proteins was probed through the synthesis and in vitro evolution of very large libraries of random amino acid sequences. In combination with computer modeling and simulations, these experiments allow us to address a number of fundamental questions about the origins of proteins. Can functionality emerge from random sequences of proteins? How did the initial repertoire of functional proteins diversify to facilitate new functions? Did this diversification proceed primarily through drawing novel functionalities from random sequences or through evolution of already existing proto-enzymes? Did protein evolution start from a pool of proteins defined by a frozen accident and other collections of proteins could start a different evolutionary pathway? Although we do not have definitive answers to these questions yet, important clues have been uncovered. In one example (Keefe and Szostak, 2001), novel ATP binding proteins were identified that appear to be unrelated in both sequence and structure to any known ATP binding proteins. One of these proteins was subsequently redesigned computationally to bind GTP through introducing several mutations that introduce targeted structural changes to the protein, improve its binding to guanine and prevent water from accessing the active center. This study facilitates further investigations of individual evolutionary steps that lead to a change of function in primordial proteins. In a second study (Seelig and Szostak, 2007), novel enzymes were generated that can join two pieces of RNA in a reaction for which no natural enzymes are known. Recently it was found that, as in the previous case, the proteins have a structure unknown among modern enzymes. In this case, in vitro evolution started from a small, non-enzymatic protein. A similar selection process initiated from a library of random polypeptides is in progress. These results not only allow for estimating the occurrence of function in random protein assemblies but also provide evidence for the possibility of alternative protein worlds. Extant proteins might simply represent a frozen accident in the world of possible proteins. Alternative collections of proteins, even with similar functions, could originate alternative evolutionary paths.

Seelig, Burchard↗
NASA NTRS2011

Reliability and Maintainability Engineering - A Major Driver for Safety and Affordability

The United States National Aeronautics and Space Administration (NASA) is in the midst of an effort to design and build a safe and affordable heavy lift vehicle to go to the moon and beyond. To achieve that, NASA is seeking more innovative and efficient approaches to reduce cost while maintaining an acceptable level of safety and mission success. One area that has the potential to contribute significantly to achieving NASA safety and affordability goals is Reliability and Maintainability (R&M) engineering. Inadequate reliability or failure of critical safety items may directly jeopardize the safety of the user(s) and result in a loss of life. Inadequate reliability of equipment may directly jeopardize mission success. Systems designed to be more reliable (fewer failures) and maintainable (fewer resources needed) can lower the total life cycle cost. The Department of Defense (DOD) and industry experience has shown that optimized and adequate levels of R&M are critical for achieving a high level of safety and mission success, and low sustainment cost. Also, lessons learned from the Space Shuttle program clearly demonstrated the importance of R&M engineering in designing and operating safe and affordable launch systems. The Challenger and Columbia accidents are examples of the severe impact of design unreliability and process induced failures on system safety and mission success. These accidents demonstrated the criticality of reliability engineering in understanding component failure mechanisms and integrated system failures across the system elements interfaces. Experience from the shuttle program also shows that insufficient Reliability, Maintainability, and Supportability (RMS) engineering analyses upfront in the design phase can significantly increase the sustainment cost and, thereby, the total life cycle cost. Emphasis on RMS during the design phase is critical for identifying the design features and characteristics needed for time efficient processing, improved operational availability, and optimized maintenance and logistic support infrastructure. This paper discusses the role of R&M in a program acquisition phase and the potential impact of R&M on safety, mission success, operational availability, and affordability. This includes discussion of the R&M elements that need to be addressed and the R&M analyses that need to be performed in order to support a safe and affordable system design. The paper also provides some lessons learned from the Space Shuttle program on the impact of R&M on safety and affordability.

Safie, Fayssal M.↗
NASA NTRS2011

Shuttle Propulsion System Major Events and the Final 22 Flights

Numerous lessons have been documented from the Space Shuttle Propulsion elements. Major events include loss of the Solid Rocket Boosters (SRB's) on STS-4 and shutdown of a Space Shuttle Main Engine (SSME) during ascent on STS-51F. On STS-112 only half the pyrotechnics fired during release of 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. 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. 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 Shuttle system, though not as operable as envisioned in the 1970's, successfully assembled the International Space Station (ISS). By the end of the program, the remarkable Space Shuttle Propulsion system achieved very high performance, was largely reusable, exhibited high reliability, and was a heavy lift earth to orbit propulsion system. During the program a number of project management and engineering processes were implemented and improved. Technical performance, schedule accountability, cost control, and risk management were effectively managed and implemented. Award fee contracting was implemented to provide performance incentives. The Certification of Flight Readiness and Mission Management processes became very effective. A key to the success of the propulsion element projects was related to relationships between the MSFC project office and support organizations with their counterpart contractor organizations. The teams worked diligently to understand and satisfy requirements and achieve mission success.

Owen, James W.↗
NASA NTRS2006

Characterization of Deposits on Glass Substrate as a Tool in Failure Analysis: The Orbiter Vehicle Columbia Case Study

In connection with the accident investigation of the space shuttle Columbia, an analysis methodology utilizing well established microscopic and spectroscopic techniques was implemented for evaluating the environment to which the exterior fused silica glass was exposed. Through the implementation of optical microscopy, scanning electron microscopy, energy dispersive spectroscopy, transmission electron microscopy, and electron diffraction, details emerged regarding the manner in which a charred metallic deposited layer formed on top of the exposed glass. Due to nature of the substrate and the materials deposited, the methodology proved to allow for a more detailed analysis of the vehicle breakup. By contrast, similar analytical methodologies on metallic substrates have proven to be challenging due to strong potential for error resulting from substrate contamination. This information proved to be valuable to not only those involved in investigating the break up of Columbia, but also provides a potential guide for investigating future high altitude and high energy accidents.

Olivas, J. D.↗
NASA NTRS2012

Aircraft Design Considerations to Meet One Engine Inoperative (OEI) Safety Requirements

Commercial airlines are obligated to operate such that an aircraft can suffer an engine failure at any point in its mission and terminate the flight without an accident. Only minimal aircraft damage is allowable, such as brake replacement due to very heavy application, or an engine inspection and/or possible removal due to use of an emergency rating. Such performance criteria are often referred to as zero exposure, referring to zero accident exposure to an engine failure. The critical mission segment for meeting one engine inoperative (OEI) criteria is takeoff. For a given weight, wind, and ambient condition, fixed wing aircraft require a balanced field length. This is the longer of the distance to take off if an engine fails at a predetermined critical point in the takeoff profile, or the distance to reject the takeoff and brake to a stop. Rotorcraft have requirements for horizontal takeoff procedures that are equivalent to a balanced field length requirements for fixed wing aircraft. Rotorcraft also perform vertical procedures where no runway or heliport distance is available. These were developed primarily for elevated heliports as found on oil rigs or rooftops. They are also used for ground level operations as might be found at heliports at the end of piers or other confined areas.

Scott, Mark W.↗
NASA NTRS2013

Understanding Crew Decision-Making in the Presence of Complexity: A Flight Simulation Experiment

Crew decision making and response have long been leading causal and contributing factors associated with aircraft accidents. Further, it is anticipated that future aircraft and operational environments will increase exposure to risks related to these factors if proactive steps are not taken to account for ever-increasing complexity. A flight simulation study was designed to collect data to help in understanding how complexity can, or may, be manifest. More specifically, an experimental apparatus was constructed that allowed for manipulation of information complexity and uncertainty, while also manipulating operational complexity and uncertainty. Through these manipulations, and the aid of experienced airline pilots, several issues have been discovered, related most prominently to the influence of information content, quality, and management. Flight crews were immersed in an environment that included new operational complexities suggested for the future air transportation system as well as new technological complexities (e.g. electronic flight bags, expanded data link services, synthetic and enhanced vision systems, and interval management automation). In addition, a set of off-nominal situations were emulated. These included, for example, adverse weather conditions, traffic deviations, equipment failures, poor data quality, communication errors, and unexpected clearances, or changes to flight plans. Each situation was based on one or more reference events from past accidents or incidents, or on a similar case that had been used in previous developmental tests or studies. Over the course of the study, 10 twopilot airline crews participated, completing over 230 flights. Each flight consisted of an approach beginning at 10,000 ft. Based on the recorded data and pilot and research observations, preliminary results are presented regarding decision-making issues in the presence of the operational and technological complexities encountered during the flights.

Young, Steven D.↗
NASA NTRS2014

HEMODOSE: A Set of Multi-parameter Biodosimetry Tools

After the events of September 11, 2001 and recent events at the Fukushima reactors in Japan, there is an increasing concern of the occurrence of nuclear and radiological terrorism or accidents that may result in large casualty in densely populated areas. To guide medical personnel in their clinical decisions for effective medical management and treatment of the exposed individuals, biological markers are usually applied to examine the radiation induced changes at different biological levels. Among these the peripheral blood cell counts are widely used to assess the extent of radiation induced injury. This is due to the fact that hematopoietic system is the most vulnerable part of the human body to radiation damage. Particularly, the lymphocyte, granulocyte, and platelet cells are the most radiosensitive of the blood elements, and monitoring their changes after exposure is regarded as the most practical and best laboratory test to estimate radiation dose. The HEMODOSE web tools are built upon solid physiological and pathophysiological understanding of mammalian hematopoietic systems, and rigorous coarse-grained biomathematical modeling and validation. Using single or serial granulocyte, lymphocyte, leukocyte, or platelet counts after exposure, these tools can estimate absorbed doses of adult victims very rapidly and accurately. Some patient data in historical accidents are utilized as examples to demonstrate the capabilities of these tools as a rapid point-of-care diagnostic or centralized high-throughput assay system in a large scale radiological disaster scenario. Unlike previous dose prediction algorithms, the HEMODOSE web tools establish robust correlations between the absorbed doses and victim's various types of blood cell counts not only in the early time window (1 or 2 days), but also in very late phase (up to 4 weeks) after exposure

Hu, Shaowen↗
NASA NTRS2013

Systems Analysis of NASA Aviation Safety Program: Final Report

A three-month study (February to April 2010) of the NASA Aviation Safety (AvSafe) program was conducted. This study comprised three components: (1) a statistical analysis of currently available civilian subsonic aircraft data from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system to identify any significant or overlooked aviation safety issues; (2) a high-level qualitative identification of future safety risks, with an assessment of the potential impact of the NASA AvSafe research on the National Airspace System (NAS) based on these risks; and (3) a detailed, top-down analysis of the NASA AvSafe program using an established and peer-reviewed systems analysis methodology. The statistical analysis identified the top aviation "tall poles" based on NTSB accident and FAA incident data from 1997 to 2006. A separate examination of medical helicopter accidents in the United States was also conducted. Multiple external sources were used to develop a compilation of ten "tall poles" in future safety issues/risks. The top-down analysis of the AvSafe was conducted by using a modification of the Gibson methodology. Of the 17 challenging safety issues that were identified, 11 were directly addressed by the AvSafe program research portfolio.

Jones, Sharon M.↗
NASA NTRS2014

HEMODOSE: A Set of Multi-parameter Biodosimetry Tools

There continues to be important concerns of the possibility of the occurrence of acute radiation syndromes following nuclear and radiological terrorism or accidents that may result in mass casualties in densely populated areas. To guide medical personnel in their clinical decisions for effective medical management and treatment of the exposed individuals, biological markers are usually applied to examine radiation induced biological changes to assess the severity of radiation injury to sensitive organ systems. Among these the peripheral blood cell counts are widely used to assess the extent of radiation induced bone marrow (BM) injury. This is due to the fact that hematopoietic system is a vulnerable part of the human body to radiation damage. Particularly, the lymphocyte, granulocyte, and platelet cells are the most radiosensitive of the blood elements, and monitoring their changes after exposure is regarded as a practical and recommended laboratory test to estimate radiation dose and injury. In this work we describe the HEMODOSE web tools, which are built upon solid physiological and pathophysiological understanding of mammalian hematopoietic systems, and rigorous coarse-grained biomathematical modeling and validation. Using single or serial granulocyte, lymphocyte, leukocyte, or platelet counts after exposure, these tools can estimate absorbed doses of adult victims very rapidly and accurately to assess the severity of BM radiation injury. Some patient data from historical accidents are utilized as examples to demonstrate the capabilities of these tools as a rapid point-of-care diagnostic or centralized high-throughput assay system in a large-scale radiological disaster scenario. HEMODOSE web tools establish robust correlations between the absorbed doses and victim's various types of blood cell counts not only in the early time window (1 or 2 days), but also in very late phase (up to 4 weeks) after exposure.

Hu, Shaowen↗
NASA NTRS2014

Human Reliability and the Cost of Doing Business

Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%‐80% of failures, accidents and incidents in high‐risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.

DeMott, D. L.↗
NASA NTRS2009

Semantic Theme Analysis of Pilot Incident Reports

Pilots report accidents or incidents during take-off, on flight and landing to airline authorities and Federal aviation authority as well. The description of pilot reports for an incident contains technical terms related to Flight instruments and operations. Normal text mining approaches collect keywords from text documents and relate them among documents that are stored in database. Present approach will extract specific theme analysis of incident reports and semantically relate hierarchy of terms assigning weights of themes. Once the theme extraction has been performed for a given document, a unique key can be assigned to that document to cross linking the documents. Semantic linking will be used to categorize the documents based on specific rules that can help an end-user to analyze certain types of accidents. This presentation outlines the architecture of text mining for pilot incident reports for autonomous categorization of pilot incident reports using semantic theme analysis.

Thirumalainambi, Rajkumar↗
NASA NTRS2014

A Multiple Parameters Biodosimetry Tool with Various Blood Cell Counts - the Hemodose Approach

There continue to be important concerns about the possibility of the occurrence of acute radiation syndromes following nuclear and radiological terrorism or accidents that may result in mass casualties in densely populated areas. To guide medical personnel in their clinical decisions for effective medical management and treatment of the exposed individuals, biological markers are usually applied to examine radiation induced biological changes to assess the severity of radiation injury to sensitive organ systems. Among these the peripheral blood cell counts are widely used to assess the extent of radiation induced bone marrow injury. This is due to the fact that the hematopoietic system is the most vulnerable part of the human body to radiation damage. Particularly, the lymphocyte, granulocyte, and platelet cells are the most radiosensitive of the blood elements, and monitoring their changes after exposure is regarded as a practical and recommended laboratory test to estimate radiation dose and injury. Based upon years of physiological and pathophysiological investigation of mammalian hematopoietic systems, and rigorous coarse-grained bio-mathematical modeling and validation on species from mouse, to dog, monkey, and human, we have developed a set of software tools Hemodose, which can use single or serial granulocyte, lymphocyte, leukocyte, or platelet counts after exposure to estimate absorbed doses of adult victims very rapidly and accurately. Some patient data from historical accidents are utilized as examples to demonstrate the capabilities of these tools as a rapid point-of-care diagnostic or centralized high-throughput assay system in a large-scale radiological disaster scenario. Most significant to the improvement of national and local preparedness of a potential nuclear/radiological disaster, this HemoDose approach establishes robust correlations between the absorbed doses and victim's various types of blood cell counts not only in the early time window (1 or 2 days), but also in the very late phase (up to 4 weeks) after exposure.

Hu, Shaowen↗
NASA NTRS2014

An Overview of the Launch Vehicle Blast Environments Development Efforts

NASA has been funding an ongoing development program to characterize the explosive environments produced during a catastrophic launch vehicle accident. These studies and small-scale tests are focused on the near field environments that threaten the crew. The results indicate that these environments are unlikely to result in immediate destruction of the crew modules. The effort began as an independent assessment by NASA safety organizations, followed by the Ares program and NASA Engineering and Safety Center and now as a Space Launch Systems (SLS) focused effort. The development effort is using the test and accident data available from public or NASA sources as well as focused scaled tests that are examining the fundamental aspects of uncontained explosions of Hydrogen and air and Hydrogen and Oxygen. The primary risk to the crew appears to be the high-energy fragments and these are being characterized for the SLS. The development efforts will characterize the thermal environment of the explosions as well to ensure that the risk is well understood and to document the overall energy balance of an explosion. The effort is multi-path in that analytical, computational and focused testing is being used to develop the knowledge to understand potential SLS explosions. This is an ongoing program with plans that expand the development from fundamental testing at small-scale levels to large-scale tests that can be used to validate models for commercial programs. The ultimate goal is to develop a knowledge base that can be used by vehicle designers to maximize crew survival in an explosion.

Richardson, Erin↗
NASA NTRS2015

An Empirical Non-TNT Approach to Launch Vehicle Explosion Modeling

In an effort to increase crew survivability from catastrophic explosions of Launch Vehicles (LV), a study was conducted to determine the best method for predicting LV explosion environments in the near field. After reviewing such methods as TNT equivalence, Vapor Cloud Explosion (VCE) theory, and Computational Fluid Dynamics (CFD), it was determined that the best approach for this study was to assemble all available empirical data from full scale launch vehicle explosion tests and accidents. Approximately 25 accidents or full-scale tests were found that had some amount of measured blast wave, thermal, or fragment explosion environment characteristics. Blast wave overpressure was found to be much lower in the near field than predicted by most TNT equivalence methods. Additionally, fragments tended to be larger, fewer, and slower than expected if the driving force was from a high explosive type event. In light of these discoveries, a simple model for cryogenic rocket explosions is presented. Predictions from this model encompass all known applicable full scale launch vehicle explosion data. Finally, a brief description of on-going analysis and testing to further refine the launch vehicle explosion environment is discussed.

Blackwood, James M.↗
NASA NTRS2014

Modeling Increased Complexity and the Reliance on Automation: FLightdeck Automation Problems (FLAP) Model

This paper highlights the development of a model that is focused on the safety issue of increasing complexity and reliance on automation systems in transport category aircraft. Recent statistics show an increase in mishaps related to manual handling and automation errors due to pilot complacency and over-reliance on automation, loss of situational awareness, automation system failures and/or pilot deficiencies. Consequently, the aircraft can enter a state outside the flight envelope and/or air traffic safety margins which potentially can lead to loss-of-control (LOC), controlled-flight-into-terrain (CFIT), or runway excursion/confusion accidents, etc. The goal of this modeling effort is to provide NASA's Aviation Safety Program (AvSP) with a platform capable of assessing the impacts of AvSP technologies and products towards reducing the relative risk of automation related accidents and incidents. In order to do so, a generic framework, capable of mapping both latent and active causal factors leading to automation errors, is developed. Next, the framework is converted into a Bayesian Belief Network model and populated with data gathered from Subject Matter Experts (SMEs). With the insertion of technologies and products, the model provides individual and collective risk reduction acquired by technologies and methodologies developed within AvSP.

Ancel, Ersin↗
NASA NTRS1967

Report of Apollo 204 Review Board to the Administrator, National Aeronautics and Space Administration : Schedule of Physical Evidence - Appendix F

Immediately following the Apollo 204 accident of January 27, 1961. all associated equipment and material were impounded. Release of this equipment and material for normal use was under the close control of the Apollo 204 Review Board. Apollo Review Board Administrative Procedure No. 11, February 11, 1961, established the Apollo 204 Review Board Material Release Record (MRR). This MRR was the official form used to release material from full impoundment and was valid only after being approved by the Board and signed by a Member. The form was used as the authority to place any impounded item into one of the three Categories defined in Administrative Procedure No. 11. This appendix contains all of the authorized MRR's. Each item submitted on an MRR was given a control number; a description, including the part number and serial number; the relevance and location to the accident; any constraints before release; and the control category. The categories placed on the equipment were as follows: Category A - Items which may have a significant influence or bearing on the results or findings of the Apollo 204 Review Board; Category B - All material other than Category A which is considered relevant to the Apollo 204 Review Board investigation; Category C - Material released from Board jurisdiction. Several classes of equipment were released by special Board action prior to the establishment of the MRR system. The operating procedure for release of these classes is Enclosure F-l to this appendix.

Source record↗
NASA NTRS2017

Prediction of Cognitive States During Flight Simulation Using Multimodal Psychophysiological Sensing

The Commercial Aviation Safety Team found the majority of recent international commercial aviation accidents attributable to loss of control inflight involved flight crew loss of airplane state awareness (ASA), and distraction was involved in all of them. Research on attention-related human performance limiting states (AHPLS) such as channelized attention, diverted attention, startle/surprise, and confirmation bias, has been recommended in a Safety Enhancement (SE) entitled "Training for Attention Management." To accomplish the detection of such cognitive and psychophysiological states, a broad suite of sensors was implemented to simultaneously measure their physiological markers during a high fidelity flight simulation human subject study. Twenty-four pilot participants were asked to wear the sensors while they performed benchmark tasks and motion-based flight scenarios designed to induce AHPLS. Pattern classification was employed to predict the occurrence of AHPLS during flight simulation also designed to induce those states. Classifier training data were collected during performance of the benchmark tasks. Multimodal classification was performed, using pre-processed electroencephalography, galvanic skin response, electrocardiogram, and respiration signals as input features. A combination of one, some or all modalities were used. Extreme gradient boosting, random forest and two support vector machine classifiers were implemented. The best accuracy for each modality-classifier combination is reported. Results using a select set of features and using the full set of available features are presented. Further, results are presented for training one classifier with the combined features and for training multiple classifiers with features from each modality separately. Using the select set of features and combined training, multistate prediction accuracy averaged 0.64 +/- 0.14 across thirteen participants and was significantly higher than that for the separate training case. These results support the goal of demonstrating simultaneous real-time classification of multiple states using multiple sensing modalities in high fidelity flight simulators. This detection is intended to support and inform training methods under development to mitigate the loss of ASA and thus reduce accidents and incidents.

Harrivel, Angela R.↗