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At least 19 records

An Application of CICCT Accident Categories to Aviation Accidents in 1988-2004

Interventions or technologies developed to improve aviation safety often focus on specific causes or accident categories. Evaluation of the potential effectiveness of those interventions is dependent upon mapping the historical aviation accidents into those same accident categories. To that end, the United States civil aviation accidents occurring between 1988 and 2004 (n=26,117) were assigned accident categories based upon the taxonomy developed by the CAST/ICAO Common Taxonomy Team (CICTT). Results are presented separately for four main categories of flight rules: Part 121 (large commercial air carriers), Scheduled Part 135 (commuter airlines), Non-Scheduled Part 135 (on-demand air taxi) and Part 91 (general aviation). Injuries and aircraft damage are summarized by year and by accident category.

Evans, Joni K.↗

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.↗

The Columbia Accident: Synopsis of CAIB Report Regarding the Physical Cause of the Accident and and Personal Thoughts

This seminar describes the process of determining the physical cause of The Shuttle Columbia Accident. The presentation is based on the published CIAB Report, and is based mainly on Appendix F2, Vol IV of the CIAB report by J. O. Arnold, H. E. Goldstein and D. J. Rigalli. As a part of the seminar, I would also indicate how my education in Engineering Physics at the University of Kansas helped prepare me to accept the assignment to serve as an investigator for the CAIB. A similar presentation was given at Purdue in 2005. Presentation charts are attached.

Arnold, James O.↗

An Analysis of U.S. Civil Rotorcraft Accidents by Cost and Injury (1990-1996)

A study of rotorcraft accidents was conducted to identify safety issues and research areas that might lead to a reduction in rotorcraft accidents and fatalities. The primary source of data was summaries of National Transportation Safety Board (NTSB) accident reports. From 1990 to 1996, the NTSB documented 1396 civil rotorcraft accidents in the United States in which 491 people were killed. The rotorcraft data were compared to airline and general aviation data to determine the relative safety of rotorcraft compared to other segments of the aviation industry. In depth analysis of the rotorcraft data addressed demographics, mission, and operational factors. Rotorcraft were found to have an accident rate about ten times that of commercial airliners and about the same as that of general aviation. The likelihood that an accident would be fatal was about equal for all three classes of operation. The most dramatic division in rotorcraft accidents is between flights flown by private pilots versus professional pilots. Private pilots, flying low cost aircraft in benign environments, have accidents that are due, in large part, to their own errors. Professional pilots, in contrast, are more likely to have accidents that are a result of exacting missions or use of specialized equipment. For both groups judgement error is more likely to lead to a fatal accident than are other types of causes. Several approaches to improving the rotorcraft accident rate are recommended. These mostly address improvement in the training of new pilots and improving the safety awareness of private pilots.

Iseler, Laura↗

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.↗

Columbia Accident Investigation Board Report

The Columbia Accident Investigation Board's independent investigation into the tragic February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months and involved 13 Board members, approximately 120 Board investigators, and thousands of NASA and support personnel. Because the events that initiated the accident were not apparent for some time, the investigation's depth and breadth were unprecedented in NASA history. Further, the Board determined early in the investigation that it intended to put this accident into context. We considered it unlikely that the accident was a random event; rather, it was likely related in some degree to NASA's budgets, history, and program culture, as well as to the politics, compromises, and changing priorities of the democratic process. We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing. The Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASA's Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry. Findings and recommendations are in the relevant chapters and all recommendations are compiled in Chapter 11. Volume I is organized into four parts: The Accident; Why the Accident Occurred; A Look Ahead; and various appendices. To put this accident in context, Parts One and Two begin with histories, after which the accident is described and then analyzed, leading to findings and recommendations. Part Three contains the Board's views on what is needed to improve the safety of our voyage into space. Part Four is reference material. In addition to this first volume, there will be subsequent volumes that contain technical reports generated by the Columbia Accident Investigation Board and NASA, as well as volumes containing reference documentation and other related material.

Gehman, Harold W., Jr.↗

Visualization of Traffic Accidents

Traffic accidents have tremendous impact on society. Annually approximately 6.4 million vehicle accidents are reported by police in the US and nearly half of them result in catastrophic injuries. Visualizations of traffic accidents using geographic information systems (GIS) greatly facilitate handling and analysis of traffic accidents in many aspects. Environmental Systems Research Institute (ESRI), Inc. is the world leader in GIS research and development. ArcGIS, a software package developed by ESRI, has the capabilities to display events associated with a road network, such as accident locations, and pavement quality. But when event locations related to a road network are processed, the existing algorithm used by ArcGIS does not utilize all the information related to the routes of the road network and produces erroneous visualization results of event locations. This software bug causes serious problems for applications in which accurate location information is critical for emergency responses, such as traffic accidents. This paper aims to address this problem and proposes an improved method that utilizes all relevant information of traffic accidents, namely, route number, direction, and mile post, and extracts correct event locations for accurate traffic accident visualization and analysis. The proposed method generates a new shape file for traffic accidents and displays them on top of the existing road network in ArcGIS. Visualization of traffic accidents along Hampton Roads Bridge Tunnel is included to demonstrate the effectiveness of the proposed method.

Wang, Jie↗

Fatigue failure of metal components as a factor in civil aircraft accidents

A review of records maintained by the National Transportation Safety Board showed that 16,054 civil aviation accidents occurred in the United States during the 3-year period ending December 31, 1969. Material failure was an important factor in the cause of 942 of these accidents. Fatigue was identified as the mode of the material failures associated with the cause of 155 accidents and in many other accidents the records indicated that fatigue failures might have been involved. There were 27 fatal accidents and 157 fatalities in accidents in which fatigue failures of metal components were definitely identified. Fatigue failures associated with accidents occurred most frequently in landing-gear components, followed in order by powerplant, propeller, and structural components in fixed-wing aircraft and tail-rotor and main-rotor components in rotorcraft. In a study of 230 laboratory reports on failed components associated with the cause of accidents, fatigue was identified as the mode of failure in more than 60 percent of the failed components. The most frequently identified cause of fatigue, as well as most other types of material failures, was improper maintenance (including inadequate inspection). Fabrication defects, design deficiencies, defective material, and abnormal service damage also caused many fatigue failures. Four case histories of major accidents are included in the paper as illustrations of some of the factors invovled in fatigue failures of aircraft components.

Holshouser, W. L.↗

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.↗

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↗

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.↗

A description of the general aviation fixed wing accident

The Emergency Local Transmitter (ELT) is a radio transmitter with a self-contained power source designed to provide notification of and homing to aircraft accident sites. The Crash Research Institute has monitored general aviation fixed-wing accidents in the United States and in Canada and has found that: (1) the ELT was destroyed in approximately 25% of all fatal accidents; (2) the ELT activated in about 62% of the fatal accidents, 69% of the fatal with survivors accidents, almost 80% of the serious accidents and about 57% of the minor accidents; (3) in fatal accidents the aircraft sections least likely to be destroyed are the vertical and horizontal tail surfaces; (4) antenna cable disconnection and antenna breakage caused failure to transmit usable signals; and (5) initial alerting control occurred in nearly half of the situations where the ELT aided in search.

Hall, D. S.↗

The Role of Spatial Disorientation in Fatal General Aviation Accidents

In-flight Spatial Disorientation (SD) in pilots is a serious threat to aviation safety. Indeed, SD may play a much larger role in aviation accidents than the approximate 6-8% reported by the National Transportation Safety Board (NTSB) each year, because some accidents coded by the NTSB as aircraft control-not maintained (ACNM) may actually result from SD. The purpose of this study is to determine whether SD is underestimated as a cause of fatal general aviation (GA) accidents in the NTSB database. Fatal GA airplane accidents occurring between January 1995 and December 1999 were reviewed from the NTSB aviation accident database. Cases coded as ACNM or SD as the probable cause were selected for review by a panel of aerospace medicine specialists. Using a rating scale, each rater was instructed to determine if SD was the probable cause of the accident. Agreement between the raters and agreement between the raters and the NTSB were evaluated by Kappa statistics. The raters agreed that 11 out of 20 (55%) accidents coded by the NTSB as ACNM were probably caused by SD (p less than 0.05). Agreement between the raters and the NTSB did not reach significance (p greater than 0.05). The 95% C.I. for the sampling population estimated that between 33-77% of cases that the NTSB identified as ACNM could be identified by aerospace medicine experts as SD. Aerospace medicine specialists agreed that some cases coded by the NTSB as ACNM were probably caused by SD. Consequently, a larger number of accidents may be caused by the pilot succumbing to SD than indicated in the NTSB database. This new information should encourage regulating agencies to insure that pilots receive SD recognition training, enabling them to take appropriate corrective actions during flight. This could lead to new training standards, ultimately saving lives among GA airplane pilots.

Scheuring, RIchard↗

An Examination of Aviation Accidents Associated with Turbulence, Wind Shear and Thunderstorm

The focal point of the study reported here was the definition and examination of turbulence, wind shear and thunderstorm in relation to aviation accidents. NASA project management desired this information regarding distinct subgroups of atmospheric hazards, in order to better focus their research portfolio. A seven category expansion of Kaplan's turbulence categories was developed, which included wake turbulence, mountain wave turbulence, clear air turbulence, cloud turbulence, convective turbulence, thunderstorm without mention of turbulence, and low altitude wind shear, microburst or turbulence (with no mention of thunderstorms).More than 800 accidents from flights based in the United States during 1987-2008 were selected from a National Transportation Safety Board (NTSB) database. Accidents were selected for inclusion in this study if turbulence, thunderstorm, wind shear or microburst was considered either a cause or a factor in the accident report, and each accident was assigned to only one hazard category. This report summarizes the differences between the categories in terms of factors such as flight operations category, aircraft engine type, the accident's geographic location and time of year, degree of injury to aircraft occupants, aircraft damage, age and certification of the pilot and the phase of flight at the time of the accident.

Evans, Joni K.↗

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.↗

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.↗

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.↗

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.↗