Engineering Papers⌕ Search

SEARCH · Engineering Papers

Results for “Accident Analysis”

Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 127 records · Page 7
All sourcesNASA NTRSDOE OSTI
NASA NTRS1989

Lessons learned from trend analysis of Shuttle Payload Processing problem reports

In the wake of the Challenger accident, NASA has placed an increasing emphasis on trend analysis techniques. These analyses provide meaningful insights into system and hardware status, and also develop additional lessons learned from historical data to aid in the design and operation of future space systems. This paper presents selected results from such a trend analysis study that was conducted on the problem report data files for the Shuttle Payload Processing activities. Specifically, the results shown are for the payload canister system which interfaces with and transfers payloads from their processing facilities to the orbiter.

Heuser, Robert E.↗
NASA NTRS2015

Reliability and Probabilistic Risk Assessment - How They Play Together

Since the Space Shuttle Challenger accident in 1986, NASA has extensively used probabilistic analysis methods to assess, understand, and communicate the risk of space launch vehicles. Probabilistic Risk Assessment (PRA), used in the nuclear industry, is one of the probabilistic analysis methods NASA utilizes to assess Loss of Mission (LOM) and Loss of Crew (LOC) risk for launch vehicles. PRA is a system scenario based risk assessment that uses a combination of fault trees, event trees, event sequence diagrams, and probability distributions to analyze the risk of a system, a process, or an activity. It is a process designed to answer three basic questions: 1) what can go wrong that would lead to loss or degraded performance (i.e., scenarios involving undesired consequences of interest), 2) how likely is it (probabilities), and 3) what is the severity of the degradation (consequences). Since the Challenger accident, PRA has been used in supporting decisions regarding safety upgrades for launch vehicles. Another area that was given a lot of emphasis at NASA after the Challenger accident is reliability engineering. Reliability engineering has been a critical design function at NASA since the early Apollo days. However, after the Challenger accident, quantitative reliability analysis and reliability predictions were given more scrutiny because of their importance in understanding failure mechanism and quantifying the probability of failure, which are key elements in resolving technical issues, performing design trades, and implementing design improvements. Although PRA and reliability are both probabilistic in nature and, in some cases, use the same tools, they are two different activities. Specifically, reliability engineering is a broad design discipline that deals with loss of function and helps understand failure mechanism and improve component and system design. PRA is a system scenario based risk assessment process intended to assess the risk scenarios that could lead to a major/top undesirable system event, and to identify those scenarios that are high-risk drivers. PRA output is critical to support risk informed decisions concerning system design. This paper describes the PRA process and the reliability engineering discipline in detail. It discusses their differences and similarities and how they work together as complementary analyses to support the design and risk assessment processes. Lessons learned, applications, and case studies in both areas are also discussed in the paper to demonstrate and explain these differences and similarities.

Safie, Fayssal↗
NASA NTRS2012

An Analysis of Shuttle Crew Scheduling Violations

From the early years of the Space Shuttle program, National Aeronautics and Space Administration (NASA) Shuttle crews have had a timeline of activities to guide them through their time on-orbit. Planners used scheduling constraints to build timelines that ensured the health and safety of the crews. If a constraint could not be met it resulted in a violation. Other agencies of the federal government also have scheduling constraints to ensure the safety of personnel and the public. This project examined the history of Space Shuttle scheduling constraints, constraints from Federal agencies and branches of the military and how these constraints may be used as a guide for future NASA and private spacecraft. This was conducted by reviewing rules and violations with regard to human aerospace scheduling constraints, environmental, political, social and technological factors, operating environment and relevant human factors. This study includes a statistical analysis of Shuttle Extra Vehicular Activity (EVA) related violations to determine if these were a significant producer of constraint violations. It was hypothesized that the number of SCSC violations caused by EVA activities were a significant contributor to the total number of violations for Shuttle/ISS missions. Data was taken from NASA data archives at the Johnson Space Center from Space Shuttle/ISS missions prior to the STS-107 accident. The results of the analysis rejected the null hypothesis and found that EVA violations were a significant contributor to the total number of violations. This analysis could help NASA and commercial space companies understand the main source of constraint violations and allow them to create constraint rules that ensure the safe operation of future human private and exploration missions. Additional studies could be performed to evaluate other variables that could have influenced the scheduling violations that were analyzed.

Bristol, Douglas↗
NASA NTRS1971

The practical application of mishap data in Army aircraft system safety programs

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

James T. Darrah, Jr↗
NASA NTRS2013

Prospective Safety Analysis and the Complex Aviation System

Fatal accident rates in commercial passenger aviation are at historic lows yet have plateaued and are not showing evidence of further safety advances. Modern aircraft accidents reflect both historic causal factors and new unexpected "Black Swan" events. The ever-increasing complexity of the aviation system, along with its associated technology and organizational relationships, provides fertile ground for fresh problems. It is important to take a proactive approach to aviation safety by working to identify novel causation mechanisms for future aviation accidents before they happen. Progress has been made in using of historic data to identify the telltale signals preceding aviation accidents and incidents, using the large repositories of discrete and continuous data on aircraft and air traffic control performance and information reported by front-line personnel. Nevertheless, the aviation community is increasingly embracing predictive approaches to aviation safety. The "prospective workshop" early assessment tool described in this paper represents an approach toward this prospective mindset-one that attempts to identify the future vectors of aviation and asks the question: "What haven't we considered in our current safety assessments?" New causation mechanisms threatening aviation safety will arise in the future because new (or revised) systems and procedures will have to be used under future contextual conditions that have not been properly anticipated. Many simulation models exist for demonstrating the safety cases of new operational concepts and technologies. However the results from such models can only be as valid as the accuracy and completeness of assumptions made about the future context in which the new operational concepts and/or technologies will be immersed. Of course that future has not happened yet. What is needed is a reasonably high-confidence description of the future operational context, capturing critical contextual characteristics that modulate both the likelihood of occurrence of hazards, and the likelihood that those hazards will lead to negative safety events. Heuristics extracted from scenarios, questionnaires, and observed trends from scanning the aviation horizon may be helpful in capturing those future changes in a way conducive to safety assessment. What is also needed is a checklist of potential sources of emerging risk that arise from organizational features that are frequently overlooked. The ultimate goal is to develop a pragmatic, workable method for using descriptions of the future aviation context, to generate valid predictions of safety risks.

prospection↗
NASA NTRS2010

The Reconstruction and Failure Analysis of The Space Shuttle Columbia

This viewgraph presentation describes a very detailed reconstruction plan and failure analysis of The Space Shuttle Columbia accident. The contents include: 1) STS-107 Timeline; 2) Foam Impact; 3) Recovery; 4) Reconstruction; 5) Reconstruction Plan; 6) Reconstruction Hanger; 7) Pathfinders; 8) Aluminum Pathfinder; 9) Early Analysis - Left MLG Door Area; 10) Emphasis Switched to Left Hand Wing Leading Edge; 11) Wing Leading Edge Subsystem (LESS); 12) 3D Reconstruction of Left WLE; 13) Left Wing Tile Table; 14) LESS Observations; 15) Left Hand Wing Debris Points to RCC 8/9 - Slumped Tile; 16) Reconstructed View of LC/P 9 tile with I/B Tile; 17) Reconstructed View of Lower C/P 9 Tile; 18) Carrier Panel 8 - Upper; 19) Left Hand Wing Debris Points to RCC 8/9 - Erosion and RCC with attach hole intact; 20) Erosion on Panel 8 Upper Outboard Rib; 21) RCC Panels 8 & 9 Erosion Features; 22) Slumping Source for Carrier Panel 9 Tile was Revealed; 23) Debris Indicated Highest Probability Initiation Site; 24) Left Hand Wing Debris Points to RCC 8/9- Metallic Deposits; 25) Relative Metallic Deposition on L/H Wing Materials; 26) Metallic Deposit Example, LH RCC 8; 27) High Level Questions; 28) Analysis Plan Challenges; 29) Analysis Techniques; 30) Analysis Approach; 31) RCC Panel 8 Erosion Features; 32) Radiographic Features; 33) Radiography WLE LH Panel 8; 34) LH RCC 8 Upper Apex; 35) LH RCC 8 - Deposit Feature: Thick Tear Shaped; 36) LH RCC 8 - Deposit Feature: Thick Globules; 37) LH RCC 8 - Deposit Feature: Spheroids; 38) LH RCC 8 - Deposit Feature: Uniform Deposit; 39) Significant Findings - Sampling All Other panels; 40) Proposed Breach Location and Plasma Flow; 41) Corroborating Information - RCC Panel Debris Locations; 42) Corroborating Information - LH OMS Pod Analysis; 43) Corroborating Information - Impact Testing; and 44) Overall Forensic Conclusions.

Russell, Richard W.↗
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 NTRS1971

Pyrotechnic hazards classification and evaluation program. Phase 2, segment 3: Test plan for determining hazards associated with pyrotechnic manufacturing processes

A comprehensive test plan for determining the hazards associated with pyrotechnic manufacturing processes is presented. The rationale for each test is based on a systematic analysis of historical accounts of accidents and a detailed study of the characteristics of each manufacturing process. The most hazardous manufacturing operations have been determined to be pressing, mixing, reaming, and filling. The hazard potential of a given situation is evaluated in terms of the probabilities of initiation, communication, and transition to detonation (ICT). The characteristics which affect the ICT probabilities include the ignition mechanisms which are present either in normal or abnormal operation, the condition and properties of the pyrotechnic material, and the configuration of the processing equipment. Analytic expressions are derived which describe the physical conditions of the system, thus permitting a variety of processes to be evaluated in terms of a small number of experiments.

Source record↗
NASA NTRS1988

Safety research of insulating materials of cable for nuclear power generating station

The polymers PE, EPR, PVC, Neoprene, CSP, CLPE, EP and other similar substances are frequently used as insulation and protective covering for cables used in nuclear power generating stations. In order to test these materials for flame retardation, environmental resistance, and cable specifications, they were given the cable normal test, flame test, chemical tests, and subjected to design analysis and loss of coolant accident tests. Material was collected on spark tests and actual experience standards were established through these contributions and technology was accumulated.

Lee, C. K.↗
NASA NTRSDate not supplied

Creating Formal Characterizations of Routine Contingency Management in Commercial Aviation

The identification, modelling, and analysis of root causes of accidents and incidents dominate conventional safety management approaches. However, the effect of humans’ safety-producing behavior on the overall resilience of the system is often neglected. Additionally, emerging aviation markets are giving rise to concepts of operation, such as urban air mobility and optionally piloted air cargo operations, that are leading to a shift in locus of control between humans and automation. Without an understanding of the human contribution to safety, it is difficult to assess the effects of these novel role allocations on overall system safety. In this work, safety-producing behaviors are identified and abstracted into resilient performance strategies. Production rules that encapsulate these strategies are then generated and classified in the Soar cognitive architecture. The strategies are then applied to a remotely-operated air cargo example to demonstrate how safe learning is facilitated. The learned rules and strategies are then formally verified.

Safety Critical Systems↗
NASA NTRSDate not supplied

The Contribution of Pilots to Resilience in Normal Operations: A Survey Approach

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety↗
NASA NTRSDate not supplied

The Contribution of Pilots to Resilience in Normal Operations. Part II: A closer look at briefings: Anticipation and Monitoring Also Known as Planning and Coordination

Much of our knowledge about human performance in flight safety has come from the analysis of undesired events, whether accidents, incidents, or crew behaviors identified via flight exceedance monitoring or observational techniques. In recent years, there has been an acknowledgement that operational personnel are not merely sources of “human error”, but also make a unique human contribution to safe outcomes. In a few celebrated cases, this takes the form of “heroic saves”, but on many more occasions, operational personnel contribute to safety through everyday, often-unnoticed actions that turn potentially hazardous situations into non-events. An emerging approach to safety, frequently referred to as “Safety II,” proposes that the positive human contribution is an important and largely untapped source of safety information. Some airlines have successfully trained observers to identify and record the positive behaviors exhibited by the crew over the course of a flight. In other cases, flight crew are interviewed about good practices or positive behaviors. However, each of these methods are relatively limited in scale and resource intensive. A survey could provide a relatively low-cost approach to systematically gather this information on a larger scale. The primary purpose of the research was to develop and assess a surveys methodology for assessing crews' activities in normal flights and the operational perturbations encountered during normal operations. We hope that such a survey could be both a research tool as well as a safety management aid for the aviation industry. We collected responses concerning revenue flights from two groups of airline pilots (N = 25 & N= 65). The results indicated that relatively few flights proceeded exactly as in the original flight plan. Pilots routinely anticipated and adapted to changing circumstances. We will review the challenges encountered in developing the survey and summarize preliminary findings from two administrations of the survey to airline pilots.

human contribution safety↗
NASA NTRS1985

Pilots of the future - Human or computer?

In connection with the occurrence of aircraft accidents and the evolution of the air-travel system, questions arise regarding the computer's potential for making fundamental contributions to improving the safety and reliability of air travel. An important result of an analysis of the causes of aircraft accidents is the conclusion that humans - 'pilots and other personnel' - are implicated in well over half of the accidents which occur. Over 70 percent of the incident reports contain evidence of human error. In addition, almost 75 percent show evidence of an 'information-transfer' problem. Thus, the question arises whether improvements in air safety could be achieved by removing humans from control situations. In an attempt to answer this question, it is important to take into account also certain advantages which humans have in comparison to computers. Attention is given to human error and the effects of technology, the motivation to automate, aircraft automation at the crossroads, the evolution of cockpit automation, and pilot factors.

Chambers, A. B.↗
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 NTRS2012

The Analysis of the Contribution of Human Factors to the In-Flight Loss of Control Accidents

In-flight loss of control (LOC) is currently the leading cause of fatal accidents based on various commercial aircraft accident statistics. As the Next Generation Air Transportation System (NextGen) emerges, new contributing factors leading to LOC are anticipated. The NASA Aviation Safety Program (AvSP), along with other aviation agencies and communities are actively developing safety products to mitigate the LOC risk. This paper discusses the approach used to construct a generic integrated LOC accident framework (LOCAF) model based on a detailed review of LOC accidents over the past two decades. The LOCAF model is comprised of causal factors from the domain of human factors, aircraft system component failures, and atmospheric environment. The multiple interdependent causal factors are expressed in an Object-Oriented Bayesian belief network. In addition to predicting the likelihood of LOC accident occurrence, the system-level integrated LOCAF model is able to evaluate the impact of new safety technology products developed in AvSP. This provides valuable information to decision makers in strategizing NASA's aviation safety technology portfolio. The focus of this paper is on the analysis of human causal factors in the model, including the contributions from flight crew and maintenance workers. The Human Factors Analysis and Classification System (HFACS) taxonomy was used to develop human related causal factors. The preliminary results from the baseline LOCAF model are also presented.

Ancel, Ersin↗
NASA NTRS2002

Characterizing the Severe Turbulence Environments Associated With Commercial Aviation Accidents: 44 Case Study Synoptic Observational Analyses - Part 1

A 44 case study analysis of the large-scale atmospheric structure associated with development of accident-producing aircraft turbulence is described. Categorization is a function of the accident location, altitude, time of year, time of day, and the turbulence category, which classifies disturbances. National Centers for Environmental Prediction Reanalyses data sets and satellite imagery are employed to diagnose synoptic scale predictor fields associated with the large-scale environment preceding severe turbulence. These analyses indicate a predominance of severe accident-producing turbulence within the entrance region of a jet stream at the synoptic scale. Typically, a flow curvature region is just upstream within the jet entrance region, convection is within 100 km of the accident, vertical motion is upward, absolute vorticity is low, vertical wind shear is increasing, and horizontal cold advection is substantial. The most consistent predictor is upstream flow curvature and nearby convection is the second most frequent predictor.

Kaplan, Michael L.↗
NASA NTRS2005

Application of Electron Microscopy Techniques to the Investigation of Space Shuttle Columbia Accident

This viewgraph presentation gives an overview of the investigation into the breakup of the Space Shuttle Columbia, and addresses the importance of a failure analysis strategy for the investigation of the Columbia accident. The main focus of the presentation is on the usefulness of electron microscopy for analyzing slag deposits from the tiles and reinforced carbon-carbon (RCC) wing panels of the Columbia orbiter.

Shah, Sandeep↗
NASA NTRS1986

The analysis of airline flight records for winds and performance with application to the Delta 191 accident

Advanced analytical methods applied to airline digital flight records and ATC radar tracking data are providing new insights into atmospheric disturbances that cause serious operating problems for aircraft. Performance-based methods for estimating unmeasured flow angles and the possible influence of rain on lift and drag, and a state-estimation procedure for determining winds along the flightpath are reviewed. The methods are applied to data records from the Delta Flight 191 wind-shear accident at the Dallas/Ft. Worth Airport (August 2, 1985) which involved an L-1011 airliner on final approach. The results indicate that the aircraft encountered a strong downlow followed by a strong outflow accompanied by large and rapid changes in the vertical wind. This pattern of low-level winds is consistent with the model that treats a downburst as a vortex ring. Although rain was present in the downburst, the analysis showed no evidence of performance loss. The results obtained from analyses of airline turbulence encounters provide a means for simulating turbulence phenomena and for training pilots for future encounters.

Bach, R. E., Jr.↗