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NASA NTRS2007

A Look at Aircraft Accident Analysis in the Early Days: Do Early 20th Century Accident Investigation Techniques Have Any Lessons for Today?

In the early years of powered flight, the National Advisory Committee on Aeronautics in the United States produced three reports describing a method of analysis of aircraft accidents. The first report was published in 1928; the second, which was a revision of the first, was published in 1930; and the third, which was a revision and update of the second, was published in 1936. This paper describes the contents of these reports, and compares the method of analysis proposed therein to the methods used today.

Holloway, C. M.↗

NASA NTRS2010

NASA Medical Response to Human Spacecraft Accidents

Manned space flight is risky business. Accidents have occurred and may occur in the future. NASA's manned space flight programs, with all their successes, have had three fatal accidents, one at the launch pad and two in flight. The Apollo fire and the Challenger and Columbia accidents resulted in a loss of seventeen crewmembers. Russia's manned space flight programs have had three fatal accidents, one ground-based and two in flight. These accidents resulted in the loss of five crewmembers. Additionally, manned spacecraft have encountered numerous close calls with potential for disaster. The NASA Johnson Space Center Flight Safety Office has documented more than 70 spacecraft incidents, many of which could have become serious accidents. At the Johnson Space Center (JSC), medical contingency personnel are assigned to a Mishap Investigation Team. The team deploys to the accident site to gather and preserve evidence for the Accident Investigation Board. The JSC Medical Operations Branch has developed a flight surgeon accident response training class to capture the lessons learned from the Columbia accident. This presentation will address the NASA Mishap Investigation Team's medical objectives, planned response, and potential issues that could arise subsequent to a manned spacecraft accident. Educational Objectives are to understand the medical objectives and issues confronting the Mishap Investigation Team medical personnel subsequent to a human space flight accident.

Patlach, Robert↗

NASA NTRS1975

A study of carburetor/induction system icing in general aviation accidents

An assessment of the frequency and severity of carburetor/induction icing in general-aviation accidents was performed. The available literature and accident data from the National Transportation Safety Board were collected. A computer analysis of the accident data was performed. Between 65 and 90 accidents each year involve carburetor/induction system icing as a probable cause/factor. Under conditions conducive to carburetor/induction icing, between 50 and 70 percent of engine malfunction/failure accidents (exclusive of those due to fuel exhaustion) are due to carburetor/induction system icing. Since the evidence of such icing may not remain long after an accident, it is probable that the frequency of occurrence of such accidents is underestimated; therefore, some extrapolation of the data was conducted. The problem of carburetor/induction system icing is particularly acute for pilots with less than 1000 hours of total flying time. The severity of such accidents is about the same as any accident resulting from a forced landing or precautionary landing. About 144 persons, on the average, are exposed to death and injury each year in accidents involving carburetor/induction icing as a probable cause/factor.

Obermayer, R. W.↗

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 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

Differences in Characteristics of Aviation Accidents During 1993-2012 Based on Aircraft Type

Civilian aircraft are available in a variety of sizes, engine types, construction materials and instrumentation complexity. For the analysis reported here, eleven aircraft categories were developed based mostly on aircraft size and engine type, and these categories were applied to twenty consecutive years of civil aviation accidents. Differences in various factors were examined among these aircraft types, including accident severity, pilot characteristics and accident occurrence categories. In general, regional jets and very light sport aircraft had the lowest rates of adverse outcomes (injuries, fatal accidents, aircraft destruction, major accidents), while aircraft with twin (piston) engines or with a single (piston) engine and retractable landing gear carried the highest incidence of adverse outcomes. The accident categories of abnormal runway contact, runway excursions and non-powerplant system/component failures occur frequently within all but two or three aircraft types. In contrast, ground collisions, loss of control - on ground/water and powerplant system/component failure occur frequently within only one or two aircraft types. Although accidents in larger aircraft tend to have less severe outcomes, adverse outcome rates also differ among accident categories. It may be that the type of accident has as much or more influence on the outcome as the type of aircraft.

Evans, Joni K.↗

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 NTRS1987

Analysis of Convair 990 rejected-takeoff accident with emphasis on decision making, training and procedures

This paper analyzes a NASA Convair 990 (CV-990) accident with emphasis on rejected-takeoff (RTO) decision making, training, procedures, and accident statistics. The NASA Aircraft Accident Investigation Board was somewhat perplexed that an aircraft could be destroyed as a result of blown tires during the takeoff roll. To provide a better understanding of tire failure RTO's, The Board obtained accident reports, Federal Aviation Administration (FAA) studies, and other pertinent information related to the elements of this accident. This material enhanced the analysis process and convinced the Accident Board that high-speed RTO's in transport aircraft should be given more emphasis during pilot training. Pilots should be made aware of various RTO situations and statistics with emphasis on failed-tire RTO's. This background information could enhance the split-second decision-making process that is required prior to initiating an RTO.

Batthauer, Byron E.↗

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 NTRS2004

Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence

Almost every year there is at least one technological disaster that highlights the challenge of managing technological risk. On February 1, 2003, the space shuttle Columbia and her crew were lost during reentry into the atmosphere. In the summer of 2003, there was a blackout that left millions of people in the northeast United States without electricity. Forensic analyses, congressional hearings, investigations by scientific boards and panels, and journalistic and academic research have yielded a wealth of information about the events that led up to each disaster, and questions have arisen. Why were the events that led to the accident not recognized as harbingers? Why were risk-reducing steps not taken? This line of questioning is based on the assumption that signals before an accident can and should be recognized. To examine the validity of this assumption, the National Academy of Engineering (NAE) undertook the Accident Precursors Project in February 2003. The project was overseen by a committee of experts from the safety and risk-sciences communities. Rather than examining a single accident or incident, the committee decided to investigate how different organizations anticipate and assess the likelihood of accidents from accident precursors. The project culminated in a workshop held in Washington, D.C., in July 2003. This report includes the papers presented at the workshop, as well as findings and recommendations based on the workshop results and committee discussions. The papers describe precursor strategies in aviation, the chemical industry, health care, nuclear power and security operations. In addition to current practices, they also address some areas for future research.

Phimister, James R.↗

NASA NTRS2005

NASA Structural Analysis Report on the American Airlines Flight 587 Accident - Local Analysis of the Right Rear Lug

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. From the analyses conducted and presented in this paper, the following conclusions were drawn. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985-certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003- subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs. I.

Raju, Ivatury S↗

NASA NTRS2011

NASA Accident Precursor Analysis Handbook, Version 1.0

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.

Groen, Frank↗

NASA NTRS2016

Differences in Characteristics of Aviation Accidents during 1993-2012 Based on Flight Purpose

Usually aviation accidents are categorized and analyzed within flight conduct rules (Part 121, Part 135, Part 91) because differences in accident rates within flight rules have been demonstrated. Even within a particular flight rule the flights have different purposes. For many, Part 121 flights are synonymous with scheduled passenger transport, and indeed this is the largest group of Part 121 accidents. But there are also non-scheduled (charter) passenger transport and cargo flights. The primary purpose of the analysis reported here is to examine the differences in aviation accidents based on the purpose of the flight. Some of the factors examined are the accident severity, aircraft characteristics and accident occurrence categories. Twenty consecutive years of data were available and utilized to complete this analysis.

Evans, Joni K.↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Context: The manufacture and operation of sUAS are not as regulated as today’s commercial operation, and their widespread use introduces new risks and hazards to the general public. Aim: Our intent is to understand the various processes that prevent or portend sUAS incidents or accidents and the influence that pilots’ expectations and training have on these processes. Method: We use classic grounded theory on sUAS reported accidents (and incidents). Results: We identified three categories, Control Interference, Reviewing and Reporting, which describe various processes surrounding UAS accidents based on the dataset analyzed. Conclusion: The use of grounded theory can offer a different perspective in the analysis of UAS accidents. In addition, the traceability between data sources and the method results facilitate result validation, and navigation. While the results are preliminary, the concepts can be expanded through the use of other accident datasets or used as basis for UAS accident surveys.

Carlos Paradis↗

NASA NTRSDate not supplied

A Grounded Theory of UAS Reported Accidents

Carlos Paradis↗

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 NTRS1977

An analysis of three weather-related aircraft accidents

Two aircraft accidents in 1975, one at John F. Kennedy International Airport in New York City on 24 June and the other at Stapleton International Airport in Denver on 7 August, were examined in detail. A third accident on 23 June 1976 at Philadelphia International Airport is being investigated. Amazingly, there was a spearhead echo just to the north of each accident site. The echoes formed from 5 to 50 min in advance of the accident and moved faster than other echoes in the vicinity. These echoes were photographed by National Weather Service radars, 130-205 km away. At closer ranges, however, one or more circular echoes were depicted by airborne and ground radars. These cells were only 3-5 km in diameter, but they were accompanied by downdrafts of extreme intensity, called downbursts. All accidents occurred as aircraft, either descending or climbing, lost altitude while experiencing strong wind shear inside downburst cells.

Fujita, T. T.↗

NASA NTRS1979

Accident investigation

Aircraft accident investigations are discussed with emphasis on those accidents that involved weather as a contributing factor. The organization of the accident investigation board for air carrier accidents is described along with the hearings, and formal report preparation. Statistical summaries of the investigations of general aviation accidents are provided.

Brunstein, A. I.↗