Breaking the Mishap Chain: Human Factors Lessons Learned From Aerospace Accidents and Incidents in Research, Flight Test, and Deveopment: Human Factors Lessons Learned From Aerospace Accidents and Incidents in Research, Flight Test, and Development

Overview

This volume contains a collection of case studies of mishaps involving experimental aircraft, aerospace vehicles, and spacecraft in which human factors played a significant role. In all cases the engineers involved, the leaders and managers, and the operators (i.e., pilots and astronauts) were supremely qualified and by all accounts superior performers. Such accidents and incidents rarely resulted from a single cause but were the outcome of a chain of events in which altering at least one element might have ...

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Overview

This volume contains a collection of case studies of mishaps involving experimental aircraft, aerospace vehicles, and spacecraft in which human factors played a significant role. In all cases the engineers involved, the leaders and managers, and the operators (i.e., pilots and astronauts) were supremely qualified and by all accounts superior performers. Such accidents and incidents rarely resulted from a single cause but were the outcome of a chain of events in which altering at least one element might have prevented disaster. As such, this work is most certainly not an anthology of blame. It is offered as a learning tool so that future organizations, programs, and projects may not be destined to repeat the mistakes of the past. These lessons were learned at high material and personal costs and should not be lost to the pages of history.

 

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Product Details

  • ISBN-13: 9780160904141
  • Publisher: US National Aeronautics and Space Admin
  • Publication date: 5/23/2012
  • Edition description: First
  • Pages: 243
  • Product dimensions: 6.20 (w) x 9.60 (h) x 0.80 (d)

Table of Contents

Table of Contents

Acknowledgments vii

Introduction ix

Part 1: Design Factors

Chapter 1: “It May Not Be Hooked Up”: Automation Bias, Poor Communication, and Crew Resource Management Factors in the X-31 Mishap ............................................................................3

Chapter 2: Habit Pattern Transfer During the First Flight of the M2-F2 Lifting Body ..............................................................................23

Chapter 3: Pilot-Induced Oscillation During Space Shuttle Approach and Landing Tests ..........................................................................33

Part 2: Physiological Factors

Chapter 4: Screening Versus Design: The X-15 Reentry Mishap .................55

Chapter 5: Six Million Dollar Man: The M2-F2 Task Saturation Mishap ........81

Chapter 6: Almost-Loss of Consciousness in the F-22A Raptor ..................101

Part 3: Organizational Factors

Chapter 7: Decision Chain Leading to the XB-70/F-104 Midair Collision ...............................................................................................127

Chapter 8: Mission Management and Cockpit Resource Management in the B-1A Mishap ..................................................................143

Chapter 9: Collision in Space: Human Factors in the Mir-Progress Mishap ......................................................................................159

Conclusions 189

Bibliography 191

Index 207

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