How Past Loss of Control Accidents May Inform Safety Cases for Advanced Control Systems on Commercial Aircraft
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Usair Flight 427
SUBMISSION OF THE AIR LINE PILOTS ASSOCIATION TO THE NATIONAL TRANSPORTATION SAFETY BOARD REGARDING THE ACCIDENT INVOLVING USAIR FLIGHT 427 NEAR PITTSBURGH, PA ON SEPTEMBER 8, 1994 TABLE OF CONTENTS I. EXECUTIVE SUMMARY II. B737 FLIGHT CONTROL SYSTEM DESIGN a. Rudder Blowdown b. B737 Rudder Control System Certification c. B737 Flight Control Incidents d. FAA Critical Design Review Team e. NTSB Safety Recommendations and FAA Actions III. AIRCRAFT PERFORMANCE a. Simulator Validation Testing b. Flight Kinematics Study IV. B737 LATERAL VS. DIRECTIONAL CONTROL AUTHORITY V. HUMAN PERFORMANCE a. Flightcrew General: Health and Background b. Flightcrew Psychological and Psychosocial Factual Information c. Crew Communications - Intra-cockpit d. Task-Related Speech e. Procedural Speech f. Non-Task-Related Speech g. Crew Communications - ATC h. Crew Interactions I. Observance of Sterile Cockpit Procedures j. Spatial Disorientation Studies k. Biomechanics Associated with Attempting to Move Blocked or Jammed Rudder Pedals l. Analysis of CVR - Speech and Physiological Aspects m. Speech Analysis Background n. Breathing Patterns and Muscular Exertion Background o. Crew Psychological Stress During the Upset Event p. Crew Physical Activity During the Upset Event q. In-depth Examination of Attempted Flight Control Manipulations r. Pilot Responses to Uncommanded Upsets s. Unintended Acceleration t. Rudder Pedal Damage u. Seat Track Damage VI. CONCLUSIONS VII. RECOMMENDATIONS Back to Top I. Executive Summary On September 8, 1994, USAir Flight 427, a Boeing 737-300, crashed while maneuvering to land at Pittsburgh International Airport. The airplane was being operated on an instrument flight plan under 14 CFR Part 121 on a regularly scheduled flight from Chicago, Illinois. -
A Qualitative Phenomenological Study
A QUALITATIVE PHENOMENOLOGICAL STUDY: ENHANCED, RISK-BASED FAA OVERSIGHT ON PART 145 MAINTENANCE PRACTICES By BRYAN G. SHEEHAN Bachelor of Science in Aviation Management Southeastern Oklahoma State University Durant, Oklahoma 2008 Master of Science in Aerospace Admin and Logistics Southeastern Oklahoma State University Durant, Oklahoma 2010 Submitted to the Faculty of the Graduate College of the Oklahoma State University in partial fulfillment of the requirements for the Degree of DOCTOR OF EDUCATION May, 2016 A QUALITATIVE PHENOMENOLOGICIAL STUDY: ENHANCED, RISK-BASED FAA OVERSIGHT ON PART 145 MAINTENANCE PRACTICES Dissertation Approved: Dr. Timm J. Bliss Dissertation Adviser and Committee Chair Dr. Chad L. Depperschmidt Committee Member Dr. Steve K. Marks Committee Member Dr. Mwarumba Mwavita Outside Committee Member ii ACKNOWLEDGEMENTS With God, all things (this dissertation) are possible. First and foremost is my loving wife, the hero of my life, Melissa Sheehan. She is truly my inspiration to fulfill so many of my lifelong dreams, especially this dissertation which would not have been possible without her assistance and sacrifices. To our children and grandchildren, thank you for having the patience to endure my busy schedule while I neglected birthdays and other family events. To Grandpa Thomas Sheehan and Aunt Marty, who passed away before I completed this project, you’ve been an enormous inspiration in my life. I am appreciative for the participants of this study, expert panel members, peer reviewer, and triangulation analysts whose identities must be protected. Thank you Dr. Timm Bliss for being my Chair and Advisor, and the committee members to include Vallory Vencill who was a first-rate Education Outreach Manager and Whitney McAllister for being an outstanding IRB Coordinator. -
National Transportation Safety Board Washington, Dc 20594 Aircraft
PB99-910401 ‘I NTSB/AAR-99/01 DCA94MA076 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED DESCENT AND COLLISION WITH TERRAIN USAIR FLIGHT 427 BOEING 737-300, N513AU NEAR ALIQUIPPA, PENNSYLVANIA SEPTEMBER 8, 1994 6472A Abstract: This report explains the accident involving USAir flight 427, a Boeing 737-300, which entered an uncontrolled descent and impacted terrain near Aliquippa, Pennsylvania, on September 8, 1994. Safety issues in the report focused on Boeing 737 rudder malfunctions, including rudder reversals; the adequacy of the 737 rudder system design; unusual attitude training for air carrier pilots; and flight data recorder parameters. Safety recommendations concerning these issues were addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal Agency dedicated to promoting aviation, raiload, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety at http://www.ntsb.gov/. Other information about available publications may also be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, East, S.W. Washington, D.C. 20594 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. -
The Impact of Human Factors and Maintenance Documentation on Aviation Safety: an Analysis of 15 Years of Accident Data Through the PEAR Framework
Collegiate Aviation Review International Volume 39 | Issue 2 Peer-Reviewed Article #1 6-2-2021 The Impact of Human Factors and Maintenance Documentation on Aviation Safety: An Analysis of 15 Years of Accident Data Through the PEAR Framework Natalie Zimmermann Purdue University Flavio Antonio Coimbra Mendonca Embry-Riddle Aeronautical University Regardless of the type of maintenance performed on aircraft, instructions are to be used to provide the aviation technicians completing the maintenance activities with guidance on, and an outline of, the maintenance items to be performed and completed. However, the use of instructions does not guarantee the correct and proper completion of the maintenance activities as the instructions may be erroneous and/or maintenance personnel can misunderstand, misinterpret, or improperly follow the procedures outlined. Resulting maintenance errors can potentially result in aircraft accidents, as illustrated by Air Midwest Flight 5481. With the purpose of understanding how human factors associated with written maintenance instructions have contributed to aircraft accidents, the researchers qualitatively analyzed, using the people (P), environment (E), actions (A), resources (R) – PEAR – framework, 12 aircraft accidents that occurred from January 1, 2003, through December 31, 2017, under Part 121 or Part 135 operations in the United States that had maintenance instruction-related errors as contributing or causal factors. The detailed accident information, including causal factors, were retrieved from the aircraft accident reports provided by the National Transportation Safety Board (NTSB). The findings indicated that maintenance activities, specifically in terms of the adequacy and proper use of maintenance instructions, are largely impacted by human factor elements, such as the overall organizational environment and the resources available. -
Teaching the Air Midwest Case: a Stakeholder Approach to Deliberative Technical Rhetoric
IEEE TRANSACTIONS ON PROFESSIONAL COMMUNICATION, VOL. 47, NO. 4, DECEMBER 2004 233 Teaching the Air Midwest Case: A Stakeholder Approach to Deliberative Technical Rhetoric —MEREDITH W. ZOETEWEY AND JULIE STAGGERS Abstract—What constitutes a cause is a particularly important question for those who teach or study technical writing. This article describes a case that helps students look beyond the technical “causes” of a commuter airplane crash in order to address the complex web of policies, practices, actions, and events that contributed to the crash. Using an approach grounded in stakeholder theory and ethical theory, students use real documents ranging from news accounts to Federal Aviation Administration policies to National Transit Safety Board hearing exhibits to identify systemic problems that contributed to the disaster. Working from particular stakeholder perspectives, they work collaboratively to develop and argue for policy changes that will help prevent future tragedies. The abundance of real documents that drive this case make it an especially useful tool for engaging students in difficult-to-teach subject matter, including the role of writing in the failure of technical systems, deliberative and judicial rhetoric, stakeholder theory, visual rhetoric, and ethics. Index Terms—Aviation, case studies, decision making, education, ethics, policy making, rhetoric, risk communication, stakeholder theory. Sauer’s work raises this question: What constitutes a When technical systems fail, our first impulse cause? That is a particularly important question for is often to speculate about causes. In a world with those who teach, or study, technical writing. It is the round-the-clock news, whenever a space shuttle question at the heart of the Air Midwest case, which burns up on re-entry, a ferry slams into a pier, or we developed for our introductory technical writing an airplane falls from the sky, news people and classes in the fall of 2003. -
Optimal Aircraft Control Upset Recovery with and Without Component Failures
Proceedings of the American Control Conference Anchorage, AK May 8-10.2002 Optimal Aircraft Control Upset Recovery With and Without Component Failures Dean W. Sparks Daniel D. Moerder Guidance and Control Branch NASA Langley Research Center Hampton, Virginia 2368 1-2 199 1 Introduction 2 Vehicle Model The aircraft on which this study closely adapted from a 6- degree-of-freedom simulation of Langley Research Center’s This paper treats the problem of recovering sustainable non- now-retired 737-100 research aircraft, documented in [ 1,2]. descending (safe) flight in a transport aircraft after one or more of its control effectors fail. Such recovery can be a The model assumes constant mass, rotating spherical Earth, challenging goal for many transport aircraft currently in the and U.S 1976 standard atmosphere [3] with no winds. The operational fleet for two reasons. First, they have very little airframe dynamics are expressed in body axes, and vehicle redundancy in their means of generating control forces and attitude is propagated using quaternions. moments. These aircraft have, as primary control surfaces, The vehicle’s control effectors are rudder, flaps, horizon- a single rudder and pairwise elevators and ailerodspoiler tal stabilizer, elevator, ailerodspoiler, and right and left en- units that provide yaw, pitch, and roll moments with suffi- gines. The aerodynamic and thrust forces are represented cient bandwidth to be used in stabilizing and maneuvering as tabular functions of these variables, along with aerody- the airframe. Beyond this, throttling the engines can pro- namic angles and airspeed or Mach number and altitude. vide additional moments, but on a much slower time scale. -
Mental Health Services Provided in the Aftermath of Aviation Disasters
MENTAL HEALTH SERVICES PROVIDED IN THE AFTERMATH OF AVIATION DISASTERS A Dissertation Presented to the Faculty of the School of Human Service Professions Widener University In Partial Fulfillment Of the Requirements for the Degree Doctor of Psychology By William Christopher Rizzo Institute for Graduate Clinical Psychology June, 2003 2 COPYRIGHT BY WILLIAM CHRISTOPHER RIZZO JUNE 2003 3 ACKNOWLEDGEMENT AND DEDICATION I would like to acknowledge the support and assistance of my dissertation committee in completing this project: Dr. Beth Howlett (Chair), Dr. Clifford DeCato, Dr. Dennis Debiak, and Dr. Virginia Brabender (Reader). Without their guidance and careful editing, the quality of this work would not have been able to shine as brightly. I also want to acknowledge the support I received from Gail Dunham, president of the National Air Disaster Alliance/Foundation and friend, who showed her generosity by creating a space within NADA/F for this research to take place. Her tireless efforts to improve air safety have been recognized by many. To Beverly, my beautiful wife, I cannot say how grateful I am to have you and Nathan in my life. Your love and understanding during this seemingly endless process has at times been the sole driving force that helped me see it through. To many more happy days for all of us. To my family, you have always been there for me and encouraged me to do my best. Your support during this time has been invaluable, and you gave it freely even when this process interfered with us having time together. 4 This dissertation is dedicated to those whose lives have been forever changed by the tragedy of an aviation disaster. -
Aviation Accidents Aetiology from Catastrophe Theory Point of View
27TH INTERNATIONAL CONGRESS OF THE AERONAUTICAL SCIENCES AVIATION ACCIDENTS A ETIOLOGY FROM CATASTROPHE THEORY POINT OF VIEW Maciej Lasek *, Krzysztof Sibilski **,! , Józef Żurek ** *The State Commission of Aircraft Accidents Investigation, Warsaw, Poland, ** Air Force Institute of Technology, Warsaw, Poland !Faculty of Power and Mechanical Engineering, Wroclaw University of Technology, Wroclaw Poland Keywords : Theory of Catastrophe, Aircraft Accidents Reconstruction, Aviation Safety, Flight Dynamics Modeling and Simulation and simulations of specific occurrences. A very interesting work is treatise [15] containing Abstract reconstruction of a crash of Boeing 737-300 Human error is often cited as a major airliner no. N513AU belonging to USAir contributing factor or case of incidents and airlines (flight 427). The crash took place near accidents. Reason proposes a view that many Pittsburgh (the aeroplane fell near the town of th accidents are catalyzed by persons not present Aliquippa, Pennsylvania) on September 8 1994 at the time of the event. In fact, it is this source [79]. Official statement of the commission of of latent conditions that pose a most significant investigating aircraft crashes said that the direct threat to the safety of complex system. Another cause of the crash was uncontrolled descents 1 dimension to human error in aviation are the which lead to hitting the ground . Calkins active errors that can precipitate the alignment showed that the loss of control over the aircraft or trigger the latent conditions. The risk could have been caused by a vortex flowing off associated with aviation is a dynamic element the wings of a Boeing 747 airliner flying in that is affected by both latent conditions and front of N513AU aeroplane. -
International Journal of Applied Aviation Studies
2006 International Journal of Applied Aviation Studies Federal Aviation Administration Volume 6, Number 2 A publication of the FAA Academy International Journal of Applied Aviation Studies A Publication of the FAA Academy Oklahoma City, Oklahoma Volume 6, Number 2, 2006 Government Printing Office REVIEW PROCESS The Federal Aviation Administration Academy provides traceability and oversight for each step of the International Journal of Applied Aviation Studies (IJAAS). IJAAS is a peer-reviewed publication, enlisting the support of an international panel of consulting editors. Each consulting editor was chosen for his or her expertise in one or more areas of interest in aviation. Using the blind-review pro- cess, three or more consulting editors are selected to appraise each article, judging whether or not it meets the requirements of this publication. In addition to an overall appraisal, a Likert scale is used to measure attitudes regarding indi- vidual segments of each article. Articles that are accepted are those that were approved by a majority of judges. Articles that do not meet IJAAS requirements for publication are released back to their author or authors. IJAAS is printed by the Government Printing Office. Individuals wishing to obtain a copy of the journal may contact Kay Chisholm by email at kay.chisholm@faa. gov, or by telephone at (405) 954-3264, or by writing to the following address: International Journal of Applied Aviation Studies Kay Chisholm AMA-530C PO Box 25082 Oklahoma City, OK 73125 International Journal of Applied Aviation Studies Volume 6, Number 2 ISSN Number: 1546-3214 Copyright © 2006, FAA Academy 1st Printing December 2006 197 The International Journal of Applied Aviation Studies 197 POLICY AND DISCLAIMERS Policy Statement: The Federal Aviation Administration (FAA) Academy strongly supports academic freedom and a researcher’s right to publish; therefore, the Federal Aviation Administration Academy as an institution does not endorse the viewpoint or guarantee the technical correctness of any of the articles in this journal. -
Rudder Malfunction Causes Loss of Control of Boeing 737
FLIGHT SAFETY FOUNDATION Accident Prevention Vol. 56 No. 9 For Everyone Concerned with the Safety of Flight September 1999 Rudder Malfunction Causes Loss of Control of Boeing 737 All 132 occupants were killed when the airplane struck terrain near Pittsburgh, Pennsylvania, U.S. The investigation report said that, following an encounter with wake turbulence, the airplane’s rudder moved to the limit of its travel, in a direction opposite to that commanded by the flight crew. The report said that the rudder-control anomaly most likely was caused by a malfunction of the rudder’s main power control unit. FSF Editorial Staff About 1903 local time on Sept. 8, 1994, USAir Flight hours as a Boeing 737 (B-737) captain and 795 flight 427, a Boeing 737-300, entered an uncontrolled hours as a B-737 first officer. descent during approach to Pittsburgh (Pennsylvania, U.S.) International Airport (PIT) and struck terrain “The captain’s initial flight experience was in general near Aliquippa, Pennsylvania. All 132 occupants aviation, and he obtained a private pilot certificate were killed. The airplane was destroyed. in August 1969,” the report said. He joined the U.S. Air National Guard and in 1973 completed U.S. Air The U.S. National Transportation Safety Board Force pilot training. His early military records were (NTSB), in its final report, said, “The probable cause destroyed, but Air Force records from September of the USAir Flight 427 accident was a loss of control 1975 through March 1979 show that he had 227 of the airplane resulting from the movement of the training hours and 667 flight hours in the Cessna rudder surface to its blowdown limit.1 O-2 (military version of the Cessna 337). -
US Airways Flight 427 ALPA Submission Addendum
August 7, 1998 The Honorable James Hall Chairman National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, DC 20594-2000 Dear Chairman Hall: In September 1997 ALPA forwarded to the NTSB its submission regarding the accident involving USAir Flight 427. Today ALPA feels even more strongly that the points raised in that submission are valid and correct. However, during this past year there has been additional investigative work, resulting in additional evidence on which ALPA would like to offer comment. This addendum focuses on this new evidence and is not intended to replace the findings from our 1997 submission, but rather to further explain and refine our positions through use of this new evidence. Thank you for the opportunity to comment. Sincerely, Captain Herb LeGrow ALPA Coordinator Addendum Sections: Aircraft Performance, Human Performance, Hypotheses 1-4, Conclusion Aircraft Performance In ALPA’s September 30, 1997 submission we detailed our thoughts regarding the limitations in any results obtained from the kinematic study conducted during this investigation. We wanted to take this opportunity to reiterate or re-enforce those thoughts. The results of any kinematic study are a function of: Flight Data Recorder data accuracy and sampling rate, Simulator model equations of motion and the accuracy in modeling the effects of wind or other atmospheric disturbances such as wake vortices, Aerodynamic and fight control system data used in the simulator model, and Assumptions regarding aircraft weight, center of gravity, effect of wind or atmospheric disturbances on the aircraft. Changing any of the above can alter the results of the kinematic study. -
The Decade That Terrorists Attacked Not Only the United States on American Soil, but Pilots’ Careers and Livelihoods
The decade that terrorists attacked not only the United States on American soil, but pilots’ careers and livelihoods. To commemorate ALPA’s 80th anniversary, Air Line Pilot features the following special section, which illustrates the challenges, opportunities, and trends of one of the most turbulent decades in the industry’s history. By chronicling moments that forever changed the aviation industry and its pilots, this Decade in Review—while not all-encompassing—reflects on where the Association and the industry are today while reiterating that ALPA’s strength and resilience will serve its members and the profession well in the years to come. June/July 2011 Air Line Pilot 13 The Decade— By the Numbers by John Perkinson, Staff Writer lthough the start of the millennium began with optimism, 2001 and the decade that followed has been infamously called by some “The Lost Decade.” And statistics don’t lie. ALPA’s Economic A and Financial Analysis (E&FA) Department dissected, by the numbers, the last 10 years of the airline industry, putting together a compelling story of inflation, consolidation, and even growth. Putting It in Perspective During the last decade, the average cost of a dozen large Grade A eggs jumped from 91 cents to $1.66, an increase of 82.4 percent. Yet the Air Transport Association (ATA) reports that the average domestic round-trip ticket cost just $1.81 more in 2010 than at the turn of the decade—$316.27 as compared to $314.46 in 2001 (excluding taxes). That’s an increase of just 0.6 percent more.