Table Of ContentPeter W. Merlin, Gregg A. Bendrick, and Dwight A. Holland
Library of Congress Cataloging-in-Publication Data
Merlin, Peter W., 1964-
Breaking the mishap chain : human factors lessons learned from aerospace
accidents and incidents in research, fight test, and development / Peter W.
Merlin, Gregg A. Bendrick, Dwight A. Holland.
p. cm.
“NASA SP-2011-594”--T.p. verso.
Includes bibliographical references and index.
ISBN 978-0-16-090414-1
1. Aircraft accidents--Human factors--Case studies. 2. Research aircraft--
Accidents--Case studies. 3. Space vehicle accidents--Case studies. 4. Research
aircraft--Design and construction--Case studies. 5. Space vehicles--Design and
construction--Case studies. 6. Aeronautics--Research--Case studies. 7. Flight
testing--Case studies. I. Bendrick, Gregg A. II. Holland, Dwight A. III. Title.
TL553.5.M39 2012
363.12’414--dc23
2012008429
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Peter W. Merlin is an aerospace historian with
extensive knowledge of the various factors involved
in aerospace mishaps. Under contract to the
National Aeronautics and Space Administration
(NASA) at Dryden Flight Research Center,
Edwards, CA, since 1997, he has authored a
variety of books, including several NASA Special
Publications on aeronautical research projects.
He served as coauthor of research pilot Donald
Mallick’s autobiography, Te Smell of Kerosene: A
Test Pilot’s Odyssey, and X-Plane Crashes: Exploring
Experimental, Rocket Plane, and Spycraft Incidents, Accidents and Crash Sites, with
Tony Moore. He has also authored several technical papers for the American
Institute of Aeronautics and Astronautics, as well as numerous journal articles on
aerospace history and technology. In addition, he serves as contributing editor for
historical publications at Dryden and has appeared in more than a dozen docu-
mentary television programs for the Discovery Channel, the History Channel,
National Geographic Channel, and others. He holds a bachelor of science degree
in aviation management from Embry-Riddle Aeronautical University.
Gregg A. Bendrick, M.S., M.D., M.P.H., is the
chief medical ofcer at NASA Dryden Flight
Research Center. He previously served 9 years in
the U.S. Air Force as a fight surgeon before join-
ing the Ochsner Medical Center in New Orleans,
LA, where he practiced occupational medicine for
nearly 3 years. At Dryden he oversees all aspects of
aerospace medicine, occupational medicine, and
ftness center operations. Additionally, he is the
medical review ofcer for workplace drug test-
ing and served as onsite medical coordinator for
Space Shuttle landings at Edwards Air Force Base (AFB). He is board-certifed
in aerospace medicine and designated by the Federal Aviation Administration
(FAA) as a senior aviation medical examiner. He is a fellow of the Aerospace
iii
Breaking the Mishap Chain
Medical Association, an instructor in the University of Southern California’s
Aviation Safety and Security Program, and an afliate faculty member with
Embry-Riddle Aeronautical University. He has authored several technical
papers on various aspects of aerospace medicine as well as a novel.
Dwight A. Holland, M.S., M.S.E., Ph.D., M.D.,
is a principal with Human Factors Associates, a
fellow in the Aerospace Medical Association, and
an academician in the International Academy of
Aviation and Space Medicine. He has served as
the president of the International Association of
Military Flight Surgeon Pilots and of the Space
Medicine Association. In 2003, he served as the
technical cochair of the largest International
Systems Engineering Conference held to date. He
has over 100 academic presentations, abstracts,
book chapters, journal special editions, and papers to his credit. As a U.S.
Air Force Reserve ofcer, he has taught and codeveloped the Human Factors in
Flight Test courses at the Air Force and Navy test pilot schools. He holds com-
mercial and jet ratings with over 2,000 hours’ fying time in more than 40 civil
and military aircraft. He also participated as a geophysicist on a remote feld
expedition to the Antarctic, later writing a study comparing the human factors
issues of polar exploration to those of long-duration space fight operations.
iv
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
v
Te authors would like to thank the many people who helped make this book
possible. First of all, thanks to Tony Springer, NASA Aeronautics Research
Mission Directorate, for sponsoring this project. We are grateful for the
eforts of many people at NASA Dryden Flight Research Center including,
but not limited to, Dr. Christian Gelzer, Tom Tschida, Karl Bender, and espe-
cially to Sarah Merlin for copyediting the fnal manuscript. Special thanks
to Dr. Tomas Hofmann and Dr. Philip J. Scarpa at the John F. Kennedy
Space Center, Dr. William J. Tarver at the Lyndon B. Johnson Space Center,
and Dr. James W. Butler, who reviewed our material for technical accuracy.
Tanks to the staf of the Air Force Flight Test Center, particularly Dr. Craig
Luther, for providing valuable source material and images. Apologies to
anyone we missed. Any factual errors are the authors’ responsibility. We
made an attempt in good faith to get the facts straight by using the best
available source material.
vii
The popular image of test pilots as cowboys is misleading. Actual research pilots and test pilots
like Joe Walker, seen here exiting the cockpit of the X-1A, were and are highly trained, educated
professionals. (NASA)
viii
When a team of military and civilian researchers conquered the sound barrier
with the rocket-powered Bell X-1 piloted by Capt. Charles E. “Chuck” Yeager
in October 1947, fight performance was considered to be primarily a func-
tion of the airframe/powerplant confguration, fight controls, and pilot skill.
Design focus in the 1940s and 1950s, sometimes called the golden age of fight
test, concentrated on vehicle confguration; aerodynamic control problems;
and performance during low-speed, transonic, and supersonic fight. Human-
machine interaction was not considered a key issue, except for the narrow
1
dimension of fying handling qualities.
Within the fight-test community, a good pilot needed not only fying skills,
but also engineering knowledge. An optimal pilot embodied a combination
of the requisite skills, training, courage, and experience (i.e., the “right stuf,”
2
as described by author Tom Wolfe in his brilliant book of the same name).
Such pilots few dozens of experimental craft, known collectively as X-planes,
to evaluate a wide variety of cutting-edge confgurations and capabilities. Tey
few in regimes of fight where new rules had to be written for aerodynamics,
3
propulsion, navigation, and thermal efects. Aviators were frequently exposed
to extreme and unpredictable fight conditions that provided both physiologi-
cal and cognitive challenges. In the early years of aviation, mishaps were often
unfairly attributed to “pilot error,” a catchall term too often used to describe a
variety of issues related to human factors.
As early as the 1920s, however, a trio of Army Air Corps ofcers began to
think about the efects of the human neurovestibular system on spatial orienta-
tion in fight. Bill Ocker, David Myers, and Carl Crane often went against the
prevailing wisdom of the era, which was that instruments were not essential
to fying safely in what are now termed “instrument fying conditions” (when
visual references are obscured by darkness or weather). When Ocker and Crane
1. Richard P. Hallion, Test Pilots: The Frontiersmen of Flight (Garden City, NY: Doubleday, 1981);
Peter W. Merlin and Tony Moore, X-Plane Crashes—Exploring Secret, Experimental, and Rocket
Plane Crash Sites (North Branch, MN: Specialty Press, 2008).
2. Tom Wolfe, The Right Stuff (New York: Farrar, Straus and Giroux, 1979).
3. Dennis R. Jenkins, X-15: Extending the Frontiers of Flight (Washington, DC: NASA SP-2007-562,
2007).
ix
Breaking the Mishap Chain
wrote the very frst book on instrument fight in 1932, Blind Flight Guidance,
it became the basis for most aviation instrument-training programs of the day.
Te book was quickly adopted by the civilian aviation community and was used
4
throughout the world but was only reluctantly accepted by the U.S. military.
When James H. “Jimmy” Doolittle made the frst successful airplane fight
without the use of outside visual references—using only fight instruments—
in 1929, those involved in aviation began to recognize the signifcance of the
interaction between a pilot and an aircraft’s controls and display systems. In
the 1930s, as Sir Frederick Bartlett of Cambridge University began to research
pilot error in a simulator known as
the Cambridge Cockpit, there was an
increasing, though limited, realization
that the design of the hardware inter-
face could afect human performance.
During World War II, technological
advances resulted in the production of
faster, higher-fying, and more efcient
aircraft. At the same time, researchers
began to notice an increasing number
of errors in human performance in the
cockpit. As a scientifc approach to
fight operations replaced earlier, more
intuitive methods, psychologists such as
Paul Fitts began to write about the birth
of modern human factors engineering.
By the 1950s and 1960s, it appeared
as though aircraft designs were reach-
ing the limit of human performance in
terms of pilot workload and task satura-
tion. Such aircraft as the F-4 Phantom
Jimmy Doolittle piloted the frst airplane and B-52 Stratofortress featured classic
fight made without outside visual refer-
examples of steam gauge–type cockpits,
ences—using only fight instruments—in
with their confusing array of dials and
1929, demonstrating the signifcance of the
switches. Pilots often found instrument
interaction between a pilot and an aircraft’s
controls and display systems. (U.S. Air Force faces too small to see clearly (espe-
via Hill Air Force Base Museum) cially during violent maneuvers), or
4. Fred H. Previc and William R. Ercoline, eds., “Spatial Disorientation in Aviation,” in Progress
in Astronautics and Aeronautics, vol. 203 (Reston, VA: American Institute of Astronautics and
Aeronautics, 2004).
x
