1、Lessons Learned Entry: 0493Lesson Info:a71 Lesson Number: 0493a71 Lesson Date: 1989-04-18a71 Submitting Organization: ARCa71 Submitted by: Ken ZanderSubject: Transitory Negative/Positive “G“ Force Effects, Flight Policy, Fact Sheet Material, Upkeep of Pilot Flight Manual, Aircraft Modification Safet
2、y Analysis, Flight Data Recorders, Emergency Escape Decisions Description of Driving Event: A fatal accident involving the Ames/EFRF T-37B Jet Trainer (NASA 807) occurred east of California City, CA. at approximately 1:15 P.M. (PST) on November 8, 1982. NASA pilot Richard E. Gray was killed. The air
3、craft was totally destroyed by ground impact and fire. There were no other personnel injuries and no other property damage. Every attempt to establish probable cause has been unsuccessful. In the course of the research support flight, T-37B entered a spin resulting in an uncontrolled flight conditio
4、n, and the pilot delayed ejection until a successful ejection was no longer possible.Lesson(s) Learned: 1. Lack of knowledge/awareness of the effects of negative “G“ forces may have contributed to the crash.2. No supervision of flight, suggests oversight function could have identified need for prefl
5、ight training.3. Fact sheet material not clearly defined in function may have resulted in directive material being interpreted as advisory.4. Review of flight manual indicated possible lapse in updating material or in pilot training or both.5. Modifications made to aircraft may not have been reviewe
6、d/approved by safety, even though made for safety and flight reasons.6. Board review of accident was less effective because there was no flight data recording to evaluate.7. Flight managers must emphasize importance of adherence to emergency escape decision Provided by IHSNot for ResaleNo reproducti
7、on or networking permitted without license from IHS-,-,-altitudes at preflight for high angle of attack maneuvers.Recommendation(s): 1. Include information on incapacitation or disorienting effects of transitory “G“ forces on pilots, in all aircraft operations documentation.2. Maintain management ov
8、ersight of research support and proficiency flights.3. Clearly define fact sheet information for pilots as advisory or directive.4. Institute adequate procedures to assure pilots flight manuals reflect current training.5. Develop procedures that require written approval for modification of research
9、aircraft involving safety to flight.6. Equip all agency aircraft with flight data recorders.7. Develop procedures to ensure review of emergency escape decision altitudes at preflight.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditiona
10、l Key Phrase(s): a71 Aircrafta71 Human Factorsa71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 1997-03-10a71 Approval Name: Anthony Bricenoa71 Approval Organization: N244-30a71 Approval Phone Number: 415-604-1012Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
