JANUARY–MARCH 2007 'Best in Seminar'(Page 4) Applying Learned

JANUARY–MARCH 2007 ‘Best in Seminar’(Page 4) Applying Learned Investigation Lessons Anew (Page 5) Improving the Quality of Investigation Analysis (Page 10) Enhancing the Investigation of Human Performance Issues (Page 14) Failure Analysis of Composite Structures in Aircraft Accidents (Page 17) ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS

“Air Safety Through Investigation” FEATURES Volume 40, Number 1 Publisher Frank Del Gandio 4 ‘Best in Seminar’ Editorial Advisor Richard B. Stone By Dr. Graham Braithwaite—The “Best in Seminar” technical paper presented at Editor Esperison Martinez ISASI’s annual seminar is selected on the basis of “outstanding contribution to the Design Editor William A. Ford Associate Editor Susan Fager advancement of technical methodologies in aircraft accident investigation.” Annual Report Editor Ron Schleede

5 Applying Learned Investigation Lessons Anew ISASI Forum (ISSN 1088-8128) is published quarterly by International Society of By Stéphane Corcos and Alain Agnesetti, BEA France—Virtual airlines, like genuine Air Safety Investigators. Opinions ex- toadstools, can jeopardize the safety and stability of the air transport industry when pressed by authors do not necessarily rep- insufficient oversight is practiced. resent official ISASI position or policy. Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164- 10 Improving the Quality of Investigation Analysis 5405. Telephone (703) 430-9668. Fax (703) 430-

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 4970. E-mail address [email protected]; for edi- By Dr. Michael B. Walker, TSB Australia—The Safety Investigation Information tor, [email protected]. Internet website: Management System (SIIMS) developed by the Australian Transport Safety Bureau www.isasi.org. ISASI Forum is not responsible for its investigation activities holds promises for a significant increase in capability, for unsolicited manuscripts, photographs, or other materials. Unsolicited materials will be particularly with complex investigations. returned only if submitted with a self-addressed, stamped envelope. ISASI Forum reserves the right to reject, delete, summa- 14 Enhancing the Investigation of rize, or edit for space considerations any submitted article. To facilitate editorial produc- Human Performance Issues tion processes, American-English spelling of By Dr. Randall J. Mumaw, Aviation Safety, Boeing—An industry working group is words will be used. formed to develop better guidance for investigating human performance. Copyright © 2007—International Society of Air Safety Investigators, all rights reserved. Publication in any form prohibited 17 Failure Analysis of Composite Structures without permission. ISASI Forum registered U.S. Patent and T.M. Office. Opinions in Aircraft Accidents expressed by authors do not necessarily rep- By Joseph F. Rakow, Ph.D., P.E. (AO4926) and Alfred M. Pettinger, Ph.D., P.E., resent official ISASI position or policy. Per- Exponent Failure Analysis Associates—The authors introduce some of the basic mission to reprint is available upon application to the editorial offices. concepts involved in analyzing failed composites under a variety of fundamental loading conditions such as tension, compression, bending, impact, and fatigue. Publisher’s Editorial Profile: ISASI Fo- rum is printed in the United States and published for professional air safety investigators who are members of the International DEPARTMENTS Society of Air Safety Investigators. Edito- rial content emphasizes accident investiga- 2 Contents tion findings, investigative techniques and 3 President’s View experiences, regulatory issues, industry ac- 24 ISASI RoundUp cident prevention developments, and ISASI 30 ISASI Information and member involvement and information. 32 Who’s Who—A brief corporate member profile Subscriptions: Subscription to members is provided as a portion of dues. Rate for non- of the Transportation Safety Board of Canada members is US$24 and for libraries and schools US$20. For subscription information, call (703) 430-9668. Additional or re- placement ISASI Forum issues: members US$3, nonmembers US$6. ABOUT THE COVER In November 2001, American Airlines Flight 587’s composite stabilizer failed. As a potential harbinger of the failures discussed in “Failure Analysis of Composite Struc- tures in Aircraft Accidents,” the failure of this composite structure is discussed in the article on page 17. (Photo: ISASI 2006)

2 • ISASI Forum January–March 2007 PRESIDENT’S VIEW

ISASI Accepts International Human Factor Role By Frank Del Gandio, President

Our Society has been asked to accept a major ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Understanding that improving comprehension of human role in assisting you, the field accident investiga- factors in accident investigation is an important contribution tors, in using human factor tools to understand, ISASI can make to assist the field investigator in using human guide, and report the role the human played in factor tools to understand, guide, and report the role the human an accident or incident. At our May 2006 Council played in the accident/incident, the Council, at its fall meeting in meeting, Vice-President Ron Schleede reported September, accepted the invitation, but went beyond that. that he had been contacted by Dr. Randy Mumaw, a human factors specialist for Boeing, with an invitation for ISASI to join the recently formed International Human ur Society has been asked to accept a Factors Working Group. This Working Group had begun to Omajor role in assisting you, the field prepare guidance material for accident and incident investiga- accident investigators, in using human tors and others in the field of human factors. The International Human Factors Working Group wanted the endorsement and factor tools to understand, guide, and report assistance of ISASI in preparing and distributing the guidance the role the human played in an accident material. The Council considered this a “heads up” contact and or incident. asked that more information be provided for the fall meeting. Accident statistics show that issues associated with human Research and discussion showed that this effort directly affected performance are major contributors to incidents and accidents in our membership and deserved the fullest participation. Hence, commercial aviation. Ideally, an investigation will seek to the Council established the ISASI International Working Group understand the context of human performance and how it on Human Factors (IIWGHF) and proposed to the Boeing contributes to the observed behaviors and decisions. Worldwide, contingent that ISASI assume sponsorship of the international investigations vary significantly with respect to the beliefs about industry Working Group that aims to develop better guidance the role of humans and appropriate methods for developing an for investigating human performance. understanding. Because of this, these investigations can become The genesis of this effort is described in Randall Mumaw’s article the subject of controversy. Accident and incident investigation “Enhancing the Investigation of Human Performance Issues,” on presents a real opportunity to determine how humans have page 14 of this issue. He also discusses the early-on efforts of the affected the outcome of an operation. industry Working Group and provides some insight into the role ISASI would play in the effort. To head our effort, I turned to our long-time Executive Advisor Dick Stone, who has extensive experience in the HF field, dating back to the years he served in the Air Line Pilots Association’s air safety structure. He accepted the charge, and with MikeWalker, Australian TSB, and Randy Mumaw acting as members of a steering committee began to structure the IIWGHF in a configuration that could enhance existing guidance documents for investigation of human performance issues in accidents and incidents now available to investigators, and that would help establish clear standards for suitable methods of investigating contributing factors of human performance. While

E. MARTINEZ human factors expertise is available, this Ron Schleede, vice-president (left), prepares to brief the Council and put expertise is not uniformly applied. In the forward the resolution creating the ISASI International Working Group on Human next issue of Forum, Capt. Stone will Factors (IIWGHF). Looking on is President Frank Del Gandio. discuss the work of IIWGF. ◆

January–March 2007 ISASI Forum • 3 ‘Best in Seminar’ By Dr. Graham Braithwaite, Selection Panel Chairman

(Described below by the panel chairman is the process summary used in the selection of the “Best in Seminar” technical paper presented at ISASI 2006. The panel enlarged the scope of the review and identified three papers for “special commendation.” All the papers, as adapted for publication, are presented on the following pages. Readers are encouraged to view the full presentations including all images, references, and acknowledgements on the ISASI website.—Editor)

he “Best in Seminar Award” was established through an anonymous donation by an ISASI member who wished Tto acknowledge a paper at the annual seminar that made an outstanding contribution to the advancement of technical methodologies in aircraft accident investigation. The Award was to be The judging panel was given on the basis of pub- made up of seven ISASI lication of new or unique members from civil, application methods to be military, education, used by today’s accident government, and manu- investigators. facturer backgrounds. PHOTOS: E. MARTINEZ For ISASI 2006, a judging panel was made ABOVE: Stéphane Corcos, up of seven ISASI members from civil, military, education, gov- right, on behalf of himself and ernment, and manufacturer backgrounds to grade each paper coauthor Alain Agnesetti, based on the above criteria and reflecting the overall theme of accepts the Award of Excel- the seminar, “Incidents to Accidents: Breaking the Chain.” lence from ISASI President Some presentations would be of particular interest to some of Frank Del Gandio during award the audience, and the panel recognized that selecting an overall ceremonies at ISASI 2006, in best presentation was going to be difficult. Based on the inde- Cancun, Mexico. pendent assessment of the papers and subsequent debate by the LEFT: Alain Agnesetti. panel, three papers were selected for special commendation • Dr. Randy Mumaw’s (Boeing) presentation on the ISASI- investigation and promises a significant increase in capability, par- sponsored initiative to develop guidance material for the inves- ticularly with complex investigations. tigation of human performance issues was felt to represent a • Dr. Joseph Rakow also presented a paper that helped many great, practical development for investigators, and the results investigators to better understand the nature of composite fail- of the project will be awaited with anticipation. ure in aircraft structures—a growing area of interest within • Dr. Mike Walker’s (ATSB) paper on the ATSB’s approach to civil and military aviation. improving the quality of investigation analysis highlighted the The winning presentation was Stéphane Corcos and Alain considerable Agnesetti’s paper detailing the French BEA’s investigation of a effort that serious incident that had many parallels with a previous fatal the Austra- accident investigation. The content was a fascinating insight into lian Trans- the application of a systemic investigation approach in a part of port Safety the industry where the “virtual airline” presents growing chal- Bureau has lenges for safety professionals. Good investigative judgment in put into de- understanding the factors behind the incident provided a clear veloping its illustration of the Society’s aim of “Safety through investigation,” approach to Doctors Mumaw, Walker, and Rakow and the paper was a worthy winner of “Best in Seminar.” ◆

4 • ISASI Forum January–March 2007 Applying Learned Investigation Lessons Anew safety deficiencies still prevail, where cor- Virtual airlines, like genuine toadstools, can jeopardize rective actions have not been implemented. Rogue airlines know this situation and ex- the safety and stability of the air transport industry when ploit these breaches, eventually making insufficient oversight is practiced. their way into Western countries. “Virtual airlines,” made up of parts that are often By Stéphane Corcos and oversight of various operators was per- inconsistent, and which should actually be Alain Agnesetti, BEA (Bureau formed by their national authorities. The called “ticket sellers,” rather than “airlines,” d’Enquêtes et d’Analyses pour la BEA has been involved in a number of in- are created there. Then, like genuine toad- Sécurité de l’Aviation Civile) vestigations to various extents, as state of stools, they jeopardize the safety and sta- the manufacturer, state having citizens bility of the air transport industry. (This article was adapted, with permission, among the victims, but also by assisting The world aviation community has iden- from the authors’ presentation entitled In- several countries in their investigations, in- tified the problem, but implementation of vestigating a “Minor” Incident Using Les- cluding flight recorder readout. solutions is very slow. ICAO has limited sons Learned From A Major Accident pre- Although most of these fatal accidents power, since its system is based on sover- sented at the ISASI 2006 seminar held in occurred outside the western hemisphere, eignty. Many states commit themselves to Cancun, Mexico, September 11-14, which any given citizen of a western country may implement ICAO standards but often have carried the theme “Incidents to Accidents: one day be a passenger on a domestic flight not taken appropriate action to enforce the Breaking the Chain.” The full presentation in a less developed country, or between two standards through regulations, procedures, including cited references index is on the of them. Moreover, an investigation into an and proper staffing. ISASI website at www.isasi.org. The authors incident that occurred during takeoff from But, mostly, such states lack the political received ISASI’s Award of Excellence for de- Paris’s Charles-de-Gaulle in July 2005 will to move forward. Instead, technical velopment of the “Best in Seminar” paper. showed that it is not necessary to travel expertise is often superseded by political The Award was created in 2005.—Editor) abroad to be at risk. considerations for various reasons. Safety In Europe, airlines from countries where regulations are often seen as hindrances to ast summer was a terrible one for avia- safety oversight is weak can operate on a the prosperous operation of an airline, and tion safety, with several fatal accidents, wet-lease basis for national flag carriers both authority and airline technical staff are Lin which more than 500 passengers from EU states, where leasing conditions under pressure from politics or financial died in just 2 months. Most investigations are somewhat overlooked. According to managers. In such cases, safety is not at- are still ongoing, but it is likely many of ICAO findings (35th assembly, September tractive because it may ultimately confront them will highlight shortcomings in the way 2004), there are almost 30 states where one with the taboo of canceling a flight. In aviation culture, especially in a fiercely com- Stéphane Corcos at the and Le Bourget Airports by the DGAC petitive environment, canceling a flight is time of ISASI 2006 was (Direction Générale de l’Aviation Civile). seen as a failure. Consequently, safety per- the head of the BEA sonnel end up being blamed for their ac- (Bureau d’Enquêtes et Alain Agnesetti is a tions and are seen as “the bad guys.” d’Analyses pour la Sécuri- former Air Force pilot Above all, it is our terrible experience in té de l’Aviation Civile) instructor. As a flight society that sometimes it seems as if a price Investigations Depart- safety officer and must be paid in blood before lessons are ment. Prior to joining the BEA, he worked accident investigator in really accepted and the situation changed, for the DGAC (French civil aviation the French Air Force, he before those concerned are convinced by the authority) for 8 years. He was graduated led various military lessons derived from other occurrences and from the French National Civil Aviation accident investigations. A retired major are willing to overcome the inevitable costs School (ENAC) with a masters degree in with more than 6,000 flying hours, he and putting aside of prestige considerations. aeronautical engineering in 1987 includ- joined the BEA in 1999 as a safety When the aviation community says it will ing an internship period at the Flight investigator. He has been IIC on a improve its level of safety, accident investi- Safety Foundation in Arlington, Va. He is number of national and foreign investigators are too often their “efficiency sen- currently employed as head of Safety and gations and an accredited representative sor,” who demonstrate that the picture re- Security Oversight for Charles-de-Gaulle on major investigations abroad. mains imperfect.

January–March 2007 ISASI Forum • 5 According to ICAO findings, there are almost 30 states where safety deficiencies still prevail, where corrective actions have not been implemented. Rogue airlines know this situation and exploit these breaches, eventually making their way into Western countries. “Virtual airlines,” made up of parts that are often inconsistent, and which should actually be called “ticket sellers,” rather than “airlines,” are created there.

Traceability of airplanes can be impos- obligations of states in relation to safety Throughout the past 15 years, aviation sible across borders, except with the help oversight are derived from the Convention has experienced rapid and steady growth of private companies or individuals, whose of Dec. 7, 1944, on international civil avia- and has always been ahead of global eco- websites may include interesting information, known as the Chicago Convention: “in nomic growth, which it has accompanied tion on a given situation. Thanks to Internet order that international civil aviation may effectively, as a fundamental tool for devel- search engines, which are more and more be developed in a safe and orderly manner opment of exchanges. But this economic frequently used in difficult investigations, and that international air transport services growth has been characterized by increased some achievements are possible. But trace- may be established on the basis of equality globalization, which has also affected avia- ability of pilots, their initial and recurrent of opportunity and operated soundly and tion. The system has become so complex training, their ratings and their actual ex- economically.” The Convention recognizes that in order to maintain an acceptable level perience, is almost impossible especially (Article 1) that “each state has complete and of safety, increasing human, financial, orga- when, de facto, they act as mercenaries. exclusive sovereignty over airspace above nizational, and technological resources are Such pilots often move from airline to air- its territory.” required. Not all contracting states can cope line and have no time to become familiar Furthermore, the Convention stipulates with this challenge, and ICAO has noted with the airline, the working environment, (Article 12) that a state should ensure that that more and more contracting states are the standard operating procedures, the net- any aircraft flying over its territory or ma- faced with difficulties in exercising their work, and they are not always in a position neuvering thereon, as well as any aircraft oversight function. to perform at an acceptable safety level. with its registration mark, wherever it may The concern that all states keep up with To illustrate this, we could reiterate the be found, should be in conformity with the their responsibilities has been shared by occurrence the BEA presented at ISASI rules and regulations applicable in the place more and more states. In August 1992, the 2005. The investigation into this incident in where the flight or the maneuver is taking U.S. Federal Aviation Administration (FAA) Nantes (approach flown well below and out- place. The Convention also specifies (in Ar- established the International Aviation side normal final approach path) had shown ticles 31 and 32) that states of registry must Safety Assessments (IASA) program. The that the captain lacked knowledge on instru- issue certificates of airworthiness to aircraft foreign assessment program focuses on the ment approach procedure principles and undertaking international flights and cer- ability of a country, rather than that of an limitations and on the autopilot of his air- tificates and licenses to their crews. How- individual air carrier, to adhere to interna- plane. This pilot, who held a Venezuelan li- ever, Article 83b authorizes the partial or tional standards and recommended prac- cense but flew with an Egyptian airline, was total transfer of these responsibilities, as tices for aircraft operations and mainte- sacked before the investigation was com- well as those relating to Article 12, to the nance established by ICAO. It was recog- pleted. He, quite probably, has now trans- state of operator of the aircraft. nized that in order to ensure that all foreign ferred his inadequacies to another country, To ensure harmony between these vari- air carriers that operate to or from the to another employer who has no reason to ous obligations, the Convention introduces, United States were offering an acceptable believe his knowledge is inadequate. No one in Article 12, an obligation for national regu- level of safety, it was necessary to ascertain has any way of knowing where he is now, lations to be in conformity with the rules es- that safety oversight of these carriers was much less to have him enrolled in additional tablished pursuant to the Convention and, provided by a competent civil aviation au- training. in Article 33, the international recognition thority (CAA) in accordance with ICAO Finally, traceability of airline managers, of documents issued by the state of registry standards. and even of airlines themselves, is no easier, insofar as they correspond to the standards. In 1996, ICAO set up a voluntary pro- all the while this situation is increasingly This implies that each state commits it- gram for safety assessment of national avia- becoming a safety concern as well. self to adopt a law or a civil aviation code, tion authorities within contracting states. completed by the necessary rules of appli- In 1998, this was replaced by a Universal Safety oversight cation, to put into place and apply the in- Safety Oversight Audit Program (USAOP), Through safety oversight, a state ensures ternational standards. This also implies that adopted by resolution A32-11 of the 32nd that national actors in the aviation indus- each state may ascertain that other states Assembly. try (airmen, operators, maintenance orga- are satisfactorily undertaking their commit- These audits started in 1999 and covered nizations) perform their duty in a safe man- ments. Specifically, if the rules adopted by airworthiness, personnel licensing, and op- ner and meet the applicable requirements other states are inferior to international erations. Their purpose was to assess and standards. standards, Article 38 stipulates that the whether a given contracting state was The responsibilities and international council be notified of these differences. implementing critical elements of oversight

6 • ISASI Forum January–March 2007 in pertinent standards and recommended The above discussed oversight issue was sig- flaps on the right wing. The airplane banked practices or SARPs in an acceptable man- nificantly brought to light in the course of slightly to the right and crashed onto the ner, following established procedures. the investigation into an accident that oc- beach. It broke into several pieces and Meanwhile, in 1995, the BEA issued a curred in Cotonou (Benin) on Dec. 25, 2003. ended up in the ocean. safety recommendation requesting that the History of flight—A Boeing 727-223, regis- Operational failings—The overall opera- French DGAC (French civil aviation author- tered 3X-GDO and operated by Guinean Air- tion of the airplane, both at its base and at ity) play a lead role in the reinforcement of line UTA (Union des Transports Africains), the various destinations it served, was not safety oversight of foreign states and car- was on its second leg of its Conakry (Guinea)– organized, undertaken, or overseen in an riers, both through ICAO and the European Cotonou–Kufra (Libya)–Beirut (Lebanon)– appropriate manner. Conference for Civil Aviation (ECAC). The Dubai (United Arab Emirates) route. Dur- In Cotonou, the station manager had no DGAC was designated coordinator of the ing the takeoff run, the airplane experienced aeronautical knowledge. The resources new European Safety Assessment of For- a long, delayed, and shallow angle of liftoff. (counters, vehicles, and staff) were rented eign Aircraft (SAFA) program, which It struck an ILS building located 118 meters from a company based at Cotonou airport, started in 1996 as a complement to USOAP past the runway end on the extended run- but this company was not tasked with any audits. way centerline and crashed onto the beach duty related to dispatch or handling, in par- The Puerto Plata accident (a Boeing 757 with most parts ending up in the ocean. There ticular providing the crew with performance operated by Birgenair, a Turkish operator were at least 160 people on board, among data. Basic loading elements (number of with mostly German citizens on board) in whom 22 survived the accident, including the passengers, estimated weight of luggage) 1996 accelerated this process. Both the captain and the airline’s general manager. were provided to the aircrew by a repre- SAFA and USOAP programs are interre- The Benin government delegated the inves- sentative of the airline, flying on board the lated through a memorandum of under- tigation to the BEA. airplane. standing. Accident description—The investigation At its main base in Conakry, apart from Although the SAFA inspections are lim- showed that the airplane weight was 7 to 8 a rented check-in counter, the airline had ited and seldom thorough, they give a gen- tons above the maximum allowable weight two containers in which spares, drinking eral overview of the foreign operator’s and that the cargo compartments were water, and the printed paperwork required safety. Furthermore, these inspections may loaded by poorly managed employees, in an for operations were stored. lead to mandatory repairs, which contrib- anarchic way. The aircrew was unable to ob- There was no competent technical man- ute to safety on a given airplane. Finally, tain precise data concerning passengers and agement and operational and maintenance inspections foster cooperation between the luggage, nor for possible freight on board. activity were non-existent (no maintenance inspecting state and the competent author- Furthermore, the aircrew was lacking documents could be supplied to the investi- ity of the inspected operator to solve safety documentation to establish a precise load gators), and no training was provided for issues almost in real time. sheet: they were not informed that the for- ground crew. ward cargo hold had been heavily loaded, UTA Boeing 727 accident which significantly displaced forward the History of operations center of gravity. Therefore, the crew took The airline, UTA, was initially based in Si- into account a weight of 78 tons with a stan- erra Leone and operated as West Coast dard loading, and a configuration of flaps Airlines. In 1997, its home base was trans- 25°, trim setting 6¾, packs off, brakes referred to Guinea under the name of UTA. lease on takeoff thrust. At V1-VR callout, It started operating rather light airplanes: the airspeed was 137, which is in fact a V1- a Let 410 and an Antonov 24. Both airplanes VR for 85.5 tons. On reaching this airspeed, belonged to a Russian citizen, who was also the copilot (who was the pilot flying) pulled the technical director of the airline. The air- back on the column but the airplane failed line was owned by a Lebanese citizen living to pitch up. The airplane rotated slowly and in Guinea; several family members were lifted off in the very last meters of the run- among top managers of the airline, includ- way. The main landing gear struck a 2.45- ing the director general and the operations meter-high building containing the localizer manager. system. The right main landing gear broke UTA performed local flights in western off and ripped off a part of the underwing Africa up to 2003. In April 2003, the airline

January–March 2007 ISASI Forum • 7 Satisfactory investigations are essential, since in some cases they now mostly consist of an audit on the safety structures, rather than an identification of previously unknown safety weaknesses. This implies that confidence and cooperation be total between accident investigation authorities and that nobody be influenced during an investigation by economic, political, or image considerations.

elected to extend its range of operations UTA operations actually began with an- plication to operate, no checks on opera- and, in June of the same year, long-distance other B 727, registration 3X-GDM, also the tions, documentation, flight time limitation, flights to Lebanon and the UAE were or- property of FAG, which was grounded in crew or airplane activity follow-up. ganized using a Boeing 727. When the Lebanon at its first flight for a number of During stopovers in Beirut, the Lebanese Boeing 727 was added to the airline fleet, major deficiencies. The airplane was then civil aviation authority conducted ramp in- none of the technical staff had any knowl- replaced by the 3D-FAK and FAG got it spections on 3X-GDM and 3D-FAK/3X- edge about the airplane. In April 2003, a back. The BEA deeply regrets that, due to GDO. Although limited in time and depth, request to open a Conakry–Abidjan– time constraints and since this was not a a ramp check showed such deficiencies that Cotonou–Beirut route was made to the au- part of the investigation, this airplane was 3X-GDM was banned from flying with pas- thorities in the various countries concerned. not tracked after it returned under FAG sengers and was replaced by 3D-FAK. On On June 28, 2003, the route was opened responsibility. this second plane, the ramp check revealed between Conakry, Cotonou, and Beirut. In Organizational failings—BEA’s investi- 18 deficiencies. The plane was grounded in November, it was extended to Dubai. gation brought to light the inadequacy of turn. It took at least three iterations to the The Boeing 727 was leased from FAG both the airplane’s and the airline’s man- Lebanese CAA to have all deficiencies even- (Financial Advisory Group), formerly based datory documentation. The airline’s opera- tually corrected. in Miami (Florida), then allegedly based in tions manual was a “cut-and-paste” job, Causes—The direct cause of the accident the Virgin Islands. Except for the airplane seemingly based on that of a Jordanian air- was a forward center of gravity, unknown lease, the sole interface was through its of- line. The manual contained descriptions of to the crew. fice in Sharjah (United Arab Emirates). The systems, human resources, and equipment The root causes of the accidents were leasing contract included the aircrew and that the airline, UTA, did not possess. As • The operator’s lack of competence, or- technical maintenance of the airplane. It the operator had no knowledge of the world ganization, and regulatory documentation, also stated that insurance and wages were of aviation, it could neither organize nor plan which prevented it from appropriately or- to be paid by the airline. FAG did not hold any operational follow-up at all, much less ganizing line operation and checking the an air operator certificate. ensure the safety of its flights. The airline’s airplane’s loading. • The airplane was first delivered to Ameri- only office was a ticket office in downtown • Insufficient monitoring exercised by the can Airlines (USA) in 1977. It had normal Conakry. Overall, the airline was hardly Civil Aviation Administration of Guinea, and flying activity in the USA until 2001. more than purely a commercial structure. Swaziland prior to it, in the area of safety • Between 2001 and 2003, it was stored in Oversight—The DNAC (Direction Nation- oversight. the Mojave desert. In 2003, the B-727 be- ale de l’Aviation Civile), the Civil Aviation Several contributory factors were noted, came the property of a bank, still with a U.S. Administration of Guinea, exercised over- among which were a spread of responsibili- registration. sight of the airline. An air operator certifi- ties between the parties that made checks • In January 2003, it was operated by cate was issued in November 2001. When all the more difficult, as well as the failure Ariana Afghan Airlines, Kabul (registered the airline expanded with the leasing of a to use proper dispatch or handling agents YA-FAK). The owner was based in Sharjah Boeing 727, the Guinea civil aviation author- at the Cotonou station. (UAE). ity stipulated that the airplane had to be Safety recommendations—A first set of • In June 2003, it was operated by Alpha maintained according to a program ap- safety recommendations was addressed to Omega Airways—the same owner, regis- proved by the DNAC and in accordance civil aviation authorities, in particular tered in Swaziland (3D-FAK). with the manufacturer’s maintenance Guinea, to reorganize safety oversight and • In July 2003, it was “operated by UTA,” manual. implementation of ICAO SARPs. under wet lease from Alpha Omega, the The DNAC could get no information on Another set was addressed to ICAO, rec- same registry. the maintenance for the first of the two ommending fostering a comprehensive en- • In October 2003, it was newly leased to Boeing 727s. For the second, 3X-GDO, main- hancement of safety oversight within all UTA, this time from FAG, same registra- tenance had been scheduled to occur in member states, to include clarification of tion. Two days later, it was transferred to Kabul, Afghanistan, in January 2004, a few duties of state of the operator, harmoniza- Guinea registry and became 3X-GDO. weeks after the accident. tion between scheduled and non-scheduled • From October 2003 till the day of the The Guinea CAA failed to exercise, in flights, identification of one operator so as accident, it remained leased by FAG and part under pressure from economic and to limit the spread of responsibilities, pub- operated by UTA as 3X-GDO on a Guinea employment issues, its normal duties. It lication of guidelines to be used by civil avia- registry. provided almost no safety audit upon ap- tion authorities….

8 • ISASI Forum January–March 2007 operations. More generally, the investigation 2003 and October 2004. The above are only revealed several shortcomings in the opera- a few of the failings found, and the investi- tions as set up by StarJet: no logbook en- gation is still ongoing; more details will be tries for several flights, several pieces of found in the final report. equipment were not airworthy, and the docu- The experience gained during the inves- mentation was not appropriate (OPS manual tigation into the Cotonou accident helped outdated and inadequate, MEL replaced by investigators operate more effectively and the MMEL, although this was agreed as an explore more precisely the apparent areas Lockheed Tristar incident exemption by the CAA of the UAE). of deficiency, addressing in an even more In July 2005, almost as a precursor to the The oversight from the United Arab pertinent way the root issues of failings in tragic summer, an incident to a Lockheed Emirates, state of registry, and of the op- the oversight process. Tristar operated by StarJet, registered A6- erator revealed shortcomings in the area The two investigations showed that avia- BSM, occurred in Paris CDG. of operations. Although they were aware tion safety faces at least two challenges. The Olympic Airlines was struggling to keep the operation failed to meet the applicable first one is a sound and organized imple- up with its maintenance, and it was short of safety standards, an exemption was mentation of international standards for airplanes. It contracted StarJet on a granted so they could fly for Olympic. The operation of airplanes, and an appropriate wet-lease basis through a broker to perform supervision and checks conducted by the level of supervision to ensure this standard. the scheduled flight OA202 from Paris to civil aviation authority of Greece and Olym- The second challenge is that Western air- Athens. pic Airlines could not prevent this airplane lines, usually subject to a more stringent The airplane arrived late at the gate. from being operated within the European oversight from their authority, may dele- When passengers boarded, loud bangs Union. gate transport activity to operators who are could be heard, produced by mechanics lit- The history of activity for the Boeing 727 subject to a much weaker monitoring activ- erally hammering on the cargo door to close 3X-GDO and the Tristar L-1011 A6-BSM ity. Action taken to guarantee an equivalent it before flight. Several passengers pan- are very similar. In both cases, the pattern level of safety is not robust enough. Ulti- icked, some of them rebelled, and half of of the geographical spread of the respec- mately, fare-paying passengers may “le- them left the airplane, which eventually left tive owners, operators, registry, and over- gally” end up flying with a much lower de- the gate 4 hours and 40 minutes late. On sight authorities—and therefore of respon- gree of safety. takeoff, just after gear retraction, loud sibilities—is similar. Among the challenges of the coming thumps could be heard. The crew noticed • 1981: BWIA (West Indies Airways), years, safety oversight is certainly one for turbine gas temperature rising above lim- Trinidad which every country has a part to play, and its, along with vibrations from engine No. • 2003: stored in Port-of-Spain, then reg- should go beyond the concept of “black- 3. In several cabin rows, passengers saw a istered in Sierra Leone (9L-LED) with a 1- lists”: strengthening of oversight, ramp flame behind the engine and panic spread. year validity certificate of airworthiness. checks extended as far as possible to areas The flames were also seen from the ground • October 2004: bought by Star Air in Si- such as aircrew training, cooperation be- by plane spotters. erra Leone. The base was in Gibraltar and tween states, exchange of information, The crew applied the appropriate proce- the headquarters in Amman (Jordan). The training, assistance to less developed coun- dure, shut the engine down, requested a airplane was ferried to Amman. tries, and use of accident or incident inves- visual approach, and returned to Paris • October 2004: withdrawn from Trinidad tigation reports to be part of the safety as- CDG, with an uneventful landing. The news registry. sessment, to name but a few. media splurge that followed was amplified • June 2005: registered A6-BSM in the In this respect, satisfactory investiga- by residents neighboring the airport. The UAE. New owner: StarJet, company based tions are essential, since in some cases they BEA started an investigation to determine in Sharjah. Same president as Star Air. No now mostly consist of an audit on the safety the facts. formal purchase or sale document formal- structures, rather than an identification of Beyond a “mere” engine surge followed ized this transfer of property. previously unknown safety weaknesses. by exhaust pipe fire, numerous deficiencies • July 2005: StarJet was operating on a wet- This implies that confidence and coopera- were brought to light. Maintenance was not lease basis for Olympic Airlines (Greece). tion be total between accident investigation undertaken by an approved facility, and the Although the aircraft was grounded most authorities and that nobody be influenced lack of documentation made it impossible to of the time, the airplane was registered in during an investigation by economic, politi- conduct a proper follow-up of maintenance more than one state between November cal, or image considerations. ◆

January–March 2007 ISASI Forum • 9 (This article was adapted, with permission, from the author’s pre- • Search: tools to search the investigation documents and forms in sentation entitled The ATSB Approach to Improving the Quality of the workspace, as well as tools to search the occurrence database. Investigation Analysis, presented at the ISASI 2006 seminar held • Contact lists: a means to organize all relevant contacts for the in Cancun, Mexico, September 11-14, which carried the theme “In- investigation and therefore facilitate communication with exter- cidents to Accidents: Breaking the Chain.” The full presentation nal parties about the investigation. including cited references index is on the ISASI website at • Access to a reference library (i.e., a set of documents and links www.isasi.org. Dr. Walker’s paper received “special commendation” that provides useful reference material to investigators, such as in the seminar’s “Best in Seminar” screening by the selection panel. ICAO Annexes, ATSB manuals, and technical manuals). The panel said the paper “promises a significant increase in capa- • Access to the occurrence database. bility, particularly with complex investigations.”—Editor) The System is being developed in consultation with a multidisci- plinary team of investigators, and discussions with the Canadian n 2004, the Australian Transport Safety Bureau (ATSB) ob- Transportation Safety Board (TSB) have aided in its design. tained substantial Australian government funding to replace SIIMS’s expected operational date is early 2007. Iits existing occurrence database (OASIS). There were several reasons for the change: OASIS was based on a very complex data Developing a new analysis framework model, which made trend analysis and research difficult; it also The analysis phase of a safety investigation is where the available had limited functionality beyond being an occurrence database. data are reviewed, evaluated, and then converted into a series of The ATSB wanted to take advantage of developments in infor- arguments, which produce a series of relevant findings. The qual- mation technology to build a system that could enhance the quality of an investigation’s analysis activities obviously plays a critical ity of the investigation process. To meet this aim, ATSB is developing a Safety Investigation Information Management System (SIIMS) for its investigation activities. A key component of the System is a set of tools for the analysis phase of a safety investiga- Improving the tion, which were developed as part of a broader framework for improving the quality of investigation analysis activities.

SIIMS overview Quality of SIIMS will provide a workspace for each investigation with the following components: Investigation • Investigation log: a form to record and categorize significant events and decisions made during the investigation. • Document management: a structured set of folders to store and Analysis organize all of the evidence collected during the investigation, including text documents, images, and other multimedia files. This described Safety Investigation Informa- • Evidence tracking: a tool to manage the movement and exami- tion Management System (SIIMS) developed nation of original items of evidence (e.g., logbooks, wreckage, recorders) held by the investigation team. by the Australian Transport Safety Bureau for • Analysis: a set of tools to help guide the analysis phase of the its investigation activities holds promises investigation, as well as document the results of analysis activities. for a significant increase in capability, • Project management: a tool to identify and manage risks to the particularly with complex investigations. investigation, as well as project management software to formally manage the tasks and resources of an investigation. By Dr. Michael B. Walker, Senior Transport Safety • Report workflow: tools to assist the development of an investiga- Investigator, Australian Transport Safety Bureau tion report and its modification through the different stages of review. role in determining whether the investigation’s findings are suc- Dr. Michael B.Walker is a senior transport cessful in enhancing safety. safety investigator with the Australian Trans- The analysis phase is also rarely easy. Safety investigations report Safety Bureau (ATSB) and has been at the quire analysis of complex sets of data and in situations where the ATSB since 1995. (Prior to July 1999, the available data can be vague, incomplete, and misleading. There aviation investigation section of the ATSB was are no detailed, prescriptive rules that can be applied in all situa- known as the Bureau of Air Safety Investiga- tions and provide guaranteed success, and analysis activities ulti- tion.) His primary role has been to investigate mately rely on the judgment of safety investigators. the human and organizational aspects of aviation accidents Despite its importance, complexity, and reliance on investigators’ and incidents. He has substantially contributed to more than 20 judgments, analysis has been a neglected area in terms of standards, significant investigations and has been actively involved in guidance, and training of investigators in most organizations. Many developing investigation methodology at the ATSB. Mike has a investigators seem to conduct analysis activities primarily using in- Ph.D. in organizational psychology, a masters degree in human tuition rather than any structured process. It also appears that much factors, a BSc honors (1st class) in psychology, and a diploma of the analysis is typically conducted while the investigation report of transport safety investigation. is being written. As a result, the writing process becomes difficult,

10 • ISASI Forum January–March 2007 supporting arguments for findings may be weak or not clearly pre- low standard such as “on the balance of probabilities” (which could sented, and important factors can be missed. produce factors that may be considered weak by external parties) To help address this situation, the ATSB wanted to introduce a and a high standard such as “beyond a reasonable doubt” (which comprehensive framework (including tools in SIIMS) to guide and would usually produce few factors other than those involving tech- support the analysis activities of its investigators. The ultimate aims nical failures or the actions of flight crew). of this framework were to improve the rigor, consistency, and • Safety issue—is defined as a safety factor that (1) can reason- defendability of investigation analysis activities and to improve the ably be regarded as having the potential to adversely affect the ability of investigators to detect safety issues in the transportation safety of future operations and (2) is a characteristic of an organi- system. Such a framework, the ATSB believed, would have a direct zation or a system, rather than a characteristic of a specific indi- role in more effectively “breaking the chain” of accident development. vidual or characteristic of an operational environment at a specific The ATSB initially reviewed existing analysis frameworks and point in time. methods applicable to safety investigation. None were found to Not all contributing safety factors will be safety issues (e.g., pi- meet the ATSB’s needs: Common limitations included applicabil- lot handling and fatigue during approach may contribute to a land- ity to a narrow domain (e.g., aircraft maintenance), focus on a lim- ing accident but are not safety issues). Similarly, not all safety is- ited part of the analysis process, lack of flexibility to handle novel sues will be contributing safety factors (e.g., an investigation may situations, lack of flexibility to deal with both small and major in- identify problems with an operator’s fatigue-management system vestigations, and lack of guidance material about the process. but cannot conclude that these problems probably contributed to Consequently, the ATSB developed its own analysis framework, the flight crew’s fatigue). Accident and incident investigations have borrowing useful ideas from other organizations’ existing processes traditionally focused on identifying the contributing safety factors, where appropriate, but also substantially adding to this material as this is of most interest to stakeholders, the news media, and the in many areas. The result is a framework with public. However, for safety-enhancement purposes, investigations • standardized terminology and definitions for analysis-related should also focus on identifying safety issues, regardless of whether terms. they can be demonstrated to have contributed to the occurrence. • an accident development model. Although the definition of contributing safety factor uses the • a defined process or workflow. term “probably,” the definition is not the same as “probable cause.” • analysis tools in SIIMS. In the ATSB framework, contributing safety factors are not ranked • policies, guidelines, and training. in terms of the degree to which such factors contributed to an occurrence. If safety factors are to be ranked in any way, it should be Standardized terminology in terms of the safety risk level for future operations: e.g., only The ATSB recognized the need for clear definitions and consistent safety issues should be ranked, and the ranking should be in terms usage of analysis-related terms. It determined that rather than of the risk level associated with the issue. use terms based on “cause,” which are associated with a range of semantic and communication problems, it would use “safety factor,” Accident development model “contributing safety factor,” and “safety issue.” Many different proposals of models or theories exist of how acci- • Safety factor—defined as an event or condition that increases dents develop. Such models can play a useful role during an inves- safety risk, e.g., something that, if it occurred in the future, would tigation by helping investigation teams identify potential safety increase the likelihood of an occurrence, and/or the severity of the factors and by providing a framework for classifying safety fac- adverse consequences associated with an occurrence. Safety factors in a database. Unfortunately, some analysis methods provide tors include a wide range of events and conditions, such as acci- no guiding model to assist with the identification of factors, while dent events, technical failures, individual actions, local conditions, other methods focus too much on a model and not enough on the and a range of organizational or systemic conditions. Safety fac- identification process. tors can be classified in terms of whether they contributed to the In recent years, the ATSB and other safety investigation agen- occurrence of interest or in terms of their future influence on safety. cies successfully used the Reason Model of organizational acci- • Contributing safety factor—defined as a safety factor that, if dents (Reason 1990, 1997) to guide the analysis phase of some in- it had not occurred or existed at the relevant time, then (1) the vestigations. Although the Reason Model is widely accepted, some occurrence would probably not have occurred; (2) adverse conse- of its features limit its usefulness. The ATSB has adapted the Model quences associated with the occurrence would probably not have to better suit the requirements of safety investigation and to make occurred or have been as serious; or (3) another contributing safety the Model more applicable to a wider range of investigations. factor would probably not have occurred or existed. This defini- The primary changes to the Reason Model include broadening tion is based on a counterfactual conditional (i.e., if “A” did not hap- the scope beyond a focus on human factors, and to more functionally pen, then “B” would not have happened), which is a common way define the components of the model so as to reduce overlaps and of defining cause. However, the ATSB has expanded the definition confusions when categorizing a factor. In particular, ATSB’s model to more easily allow the reasoning process to move in steps from clearly distinguishes between the things an organization puts in place one contributing safety factor to the next. This mechanism pro- at the operational level to minimise risk (i.e., “risk controls” such as vides a clearer basis for identifying organizational conditions as training, procedures, warning alarms, shift rosters) and the condi- contributory to an occurrence. The definition also specifically in- tions that influence the effectiveness of these risk controls (i.e., “or- cludes the term “probably,” which the ATSB defines as meaning a ganizational influences” such as risk-management processes, train- probability of 75% or more. This ensures that the standard of proof ing needs analysis processes, regulatory surveillance). used in safety investigations is a practical compromise between a The resulting model can be arranged into a series of levels, as

January–March 2007 ISASI Forum • 11 Figure 1 Figure 2

shown in Figure 1. Representing the model in this format facili- identified by asking a set of generic questions about the occur- tates the identification of safety factors, and can also help the in- rence (based on the accident development model) and asking a set vestigation team maintain awareness of their progress when iden- of focussed questions to explain specific factors. In some situa- tifying potential factors during the investigation. tions, specialized techniques may also be useful to identify explanations for specific types of factors (e.g., barrier analysis, problem The analysis process analysis, failure mode effects analysis). A major part of the ATSB analysis framework is a defined process Safety factor identification activities start early in the investi- or workflow to be used when conducting analysis activities. The gation and are repeated at regular intervals until there is suffi- overall process is divided into five separate processes, each of which cient data available to conduct safety factor processing. Investiga- comprise a set of stages. The relationship between the below described five processes is shown in Figure 2. Figure 3 • Preliminary analysis: A range of activities to convert data into a format suitable for the analysis of safety factors. This involves the use of techniques to interpret and organize data, including the sys- tematic review of the sequence of events associated with an occurrence. Preliminary analysis may require the use of arguments to develop intermediate findings on a range of topics (e.g., angle of impact, handling pilot, wind speed during approach). • Safety factors analysis: A structured process to determine which events and conditions were safety factors, with an emphasis on determining the contributing safety factors and safety issues. Fur- ther information on safety factors analysis is provided below. • Risk analysis: A structured process to determine the risk level associated with any verified safety issues. This involves determining the worst feasible scenario that could arise from the safety issue and ranking the consequence and likelihood levels associ- tors are encouraged to use charting techniques to display the rela- ated with such a scenario. The resulting risk level is classified as tionships between potential factors and to regularly review the list “critical,” “significant,” or “minor.” of potential factors to determine if there may be critical safety • Safety action development: A structured process of facilitating issues that need to be urgently addressed, as well as to determine safety action by communicating safety issues to relevant organi- needs for additional data collection. zations. The nature and timeliness of the ATSB communication is Safety factor processing focuses on each potential safety factor determined by the risk level associated with the safety issue. that has been identified and selected for further analysis. This fur- • Analysis review: A review of the analysis results to identify gaps ther analysis involves defining and testing the factor. Each veri- or weaknesses. This process involves checking the investigation find- fied factor is then classified in the occurrence database. The final ings for completeness and fairness. It also involves reorganizing the stage is to ensure that, where possible, the factor has been poten- findings into a more coherent format and sequence (if required). tially explained by other factors (i.e., a revision and extension of As indicated in Figure 2, safety factors analysis is the heart safety factor identification). of the analysis process. It consists of two main components: The “test” stage of safety factor processing is an area where the safety factor identification and safety factor processing. An over- ATSB framework has placed substantially more emphasis than view of safety factors analysis is presented in Figure 3. other analysis frameworks. For every potential safety factor that During safety factor identification, potential safety factors are is identified as needing further analysis, a series of tests are per-

12 • ISASI Forum January–March 2007 Figure 4 SIIMS analysis tools SIIMS tools support each of the five analysis processes, as sum- marized in Table 1. The tools provide a broad level of guidance when conducting the analysis process. They also provide a means for the investigation team members to document their thoughts and activities when doing analysis activities. This documented trail of reasoning is invaluable when reviewing the investigation or keep- ing track of its progress. Evidence tables are a critically important part of the ATSB analysis framework. Before discussing these tables further, it is useful to discuss the different types of findings produced by an investigation. Borrowing a concept from the Canadian TSB, the ATSB has started dividing the findings section of its investigation reports into three subsections: • Contributing safety factors (as defined in the section on standardized terminology above). • Other safety factors: safety factors identified during the investigation that did not meet the definition of contributing safety factor, but which were still considered to be important (i.e., they passed the test for importance). formed to determine whether the factor can be “verified.” These • Other key findings: any other finding considered relevant to in- tests include the test for existence, test for influence, and test for clude in the findings section of the final report. This may include importance. An overview of the flow of the testing process is pre- findings to resolve ambiguity or controversy, and findings about sented in Figure 4. possible scenarios or safety factors when firm safety factor find- The result of the testing process will determine whether a po- ings were not able to be made. It may also include positive safety tential safety factor is a contributing safety factor (existence plus factors or events or conditions that “saved the day” or played an influence), another safety factor of interest (existence plus impor- important tole in reducing the risk associated with the occurrence. tance), or of no consequence to the investigation. The existence The intention of this format is to more clearly communicate the and influence tests are based on concepts presented in an ICAO important safety messages from the investigation. In addition to human factors document (ICAO 1998). However, the ATSB has the “key findings,” an investigation may also develop a number of extensively expanded the guidance for conducting the tests. For intermediate findings (during preliminary analysis) to help facili- example, to help conduct the test for influence, investigators are tate the process of moving from the collected data to a key finding. provided guiding questions on the following criteria: relative tim- In the past, investigators have not always clearly presented the ing, reversibility, relative location, magnitude of proposed factor, supporting arguments for their findings, other than in paragraph plausibility, known history of influence, presence of enhancers, form in an investigation report. Such a format can be ambiguous, presence of inhibitors, characteristics of the problem (i.e., factor incomplete, and time consuming to finalize. The ATSB wanted in- being explained), required assumptions, alternative explanations vestigators to present their supporting arguments in a more struc- for the problem, and directionality of influence. tured and understandable way prior to writing up the analysis section of a report. Table 1 Evidence table development Process Tool Purpose The traditional way of presenting arguments in the field of critical Preliminary Basic evidence Tests the supporting argument for a reasoning is use a series of statements—premises followed by the analysis table non-safety factor finding finding. Developing an argument in this format can be a difficult Sequence of Records summary data of key events process, particularly when dealing with complex sets of data, or events list associated with an occurrence, and produces various types of charts of this sequence situations where there are concerns regarding the credibility or Safety factors Safety factors list Records summary data of potential safety relevance of items of evidence. The ATSB developed the evidence analysis factors identified during the analysis table to be a more flexible and easier-to-use format. Safety factor form Records the results of the define, test, classify, Basic evidence tables are used to test proposed “other key find- and explain stages of safety factor processing ings” and proposed intermediate findings. The tables consist of Safety factor Tests the supporting argument for a safety factor three columns: one for the items of evidence or information that evidence table finding (built in to the safety factor form) may be relevant to the finding, one for clarifying comments about Risk analysis Risk analysis Records the results of each stage of a risk each item, and one for rating how the item may impact on the find- form analysis conducted on a safety issue ing (i.e., supports, opposes, no effect, or unsure). Based on the in- Safety action Safety action Records details of communications with external formation in the three columns, an overall assessment can be made development form organizations regarding a safety issue, as well as any proposed or completed safety action as to whether the proposed finding is supported. A simple example Analysis Summarize Reorganizes key findings of an investigation of a basic evidence table is provided in Figure 5. In SIIMS, inves- review findings form into a more coherent format for the final report tigators will also be able to provide links to supporting evidence in (if required) (continued on page 29)

January–March 2007 ISASI Forum • 13 come more reliable. Flight crews, maintenance technicians, air traffic controllers, airplane system designers, and others are identi- Enhancing the fied as significant contributors to an event 60-70% of the time (e.g., see Boeing annual statistical summary as one index: http:// www.boeing.com/news/techissues/pdf/statsum.pdf). Investigation In fact, even in cases where there are failures in airplane systems that precede a tragedy, accident investigations have revealed that human performance contributed to degraded system perfor- Of Human mance. This is not only true in commercial aviation; mishaps in other highly complex sociotechnical systems also reveal the important role of humans in the accident chain. This influence on the Performance accident chain may have links to system design, operational procedures, training, and organizational policies and practices. To “break the chain,” we need to become even better at under- Issues standing and addressing issues in human performance (HP). My personal accident investigation experience, and the experience of An industry working group is formed to several colleagues at Boeing, suggests that approaches to investi- develop better guidance for investigating gating HP issues around the world can vary widely and are some- human performance. times ineffective. To understand the current situation better, a small research team By Dr. Randall J. Mumaw, Aviation Safety, Boeing at Boeing surveyed major accident investigation agencies to document their approaches to HP issues in accidents and incidents. (This article was adapted, with permission, from the author’s pre- Below are some key results from this survey, after which is de- sentation entitled Industry Working Group for Enhancing the scribed a proposed response to the current situation—specifically, Investigation of Human Performance Issues, presented at the the establishment of an industry working group to develop better ISASI 2006 seminar held in Cancun, Mexico, September 14-17, guidance for investigating human performance. which carried the theme “Incidents to Accidents: Breaking the Chain.” The full presentation including cited references index is Current practice on the ISASI website at www.isasi.org. Dr Mumaw’s paper re- Twelve groups were interviewed (those listed below plus a major ceived “special commendation” by the panel selecting the “Best in airline) to attempt to establish the current state of investigating Seminar” paper. The panel said the paper “represented a great, HP issues (note that there is a mix of commercial aviation and practical development for investigators….”—Editor) other modes of transportation): • Air Accidents Investigation Branch (UK), ach new or revised summary of accidents and incidents in • Railway Safety & Standards Board (UK), commercial aviation reemphasizes the significance of the role • National Air Traffic Services (UK), Eof humans. Accidents attributed to failures in airplane sys- • National Transportation Safety Board (USA), tems have decreased over the years as those elements have be- • Bureau d’Enquêtes et d’Analyses (France), • Bundesstelle für Flugunfalluntersuchung (Germany), Dr. Randy Mumaw is a human factors special- • Transportation Safety Board (Canada), ist and associate technical fellow in the Aviation • Civil Aviation Department (Hong Kong), Safety Group at Boeing Commercial Airplanes. • Aviation Safety Council (Taiwan), Dr. Mumaw received his M.S. and Ph.D. in • Australian Transport Safety Bureau, and cognitive psychology from the University of • Transport Accident Investigation Commission (New Zealand). Pittsburgh. He has studied human performance Each interview covered a range of topics, including the following: and safety in nuclear power plant control room • The framework used for addressing HP issues. operations, air traffic control, and military and commercial • Existing guidelines, checklists, and procedures used for investi- aviation. He is the author of more than 80 technical papers, gating HP issues. most of which address human performance and error in • Types of HP expertise available to them. complex, high-risk systems. • How they assign HP specialists to investigations.

14 • ISASI Forum January–March 2007 Four of the 12 investigation agencies had no guidance documents at all for HP investigations. Four agencies had one or more checklists (typically dures that agencies have in place to guide the investigation of HP one) that investigators could use issues. Guidance can take many forms; for example, checklists (types of data to collect, HP issues to consider); methods/techniques for identifying potentially important for data gathering; a framework for identifying important actions, issues. The remaining four agencies decisions, and conditions; a system for classifying human errors; methods for identifying contributing factors that may have influ- actually had an accident investigation enced performance; or analysis techniques. manual or a general guidance The responses spanned a wide range. Four of the 12 investigation agencies had no guidance documents at all for HP investiga- document that aided them in tions. Four agencies had one or more checklists (typically one) that investigating HP issues. investigators could use for identifying potentially important issues. The remaining four agencies actually had an accident investiga- • HP-related data-gathering techniques. tion manual or a general guidance document that aided them in • HP-related analysis techniques. investigating HP issues. • How HP accident data are structured for input to an accident Interestingly, there was more development of guidance for agen- database. cies that had more expertise. We believe that the reason for this • What gaps have been identified in investigating HP issues. finding is that the expertise is required to develop the guidance. The following are summaries of the findings for two of these Agencies with no expertise are unable to develop the types of guid- issues: HP expertise and HP guidance materials. ance that could benefit their investigators, and they are unable to HP expertise and training—One question concerned the number obtain guidance from other sources. of investigators or staff formally trained as HP experts. More spe- One potential solution to this apparent dilemma is to get guid- cifically, we identified the number of people with an M.S., M.A., or ance from an outside source. However, when we looked at potential Ph.D. in a human factors-related (HF) field of study. The result— sources—the ICAO HF Digest (ICAO 1993) and several recent books on the topic (Dekker 2002; Strauch 2002)—we found little guidance 0 HF investigators 5 agencies that could be readily adopted by an investigation agency. 1 HF investigator 1 agency The ICAO document provides guidance at a very high level and 4 HF investigators 2 agencies focuses on the checklist from the SHELL Model. Strauch’s book 6 HF investigators 2 agencies provides some background knowledge on a number of potentially 10 HF investigators 2 agencies relevant topics (e.g., computer displays) but little in the way of guidance for conducting an investigation. He does offer some prac- The above shows that responses varied considerably. While there tical guidance for various aspects of field work. The Dekker book were five agencies that had no investigators trained in an HF field, focuses on describing inappropriate ways to conduct an investiga- there were two agencies that each had 10 people with HF training, tion but offers little guidance on conducting an investigation. and another two with six HF investigators. Those agencies that have Thus, there are several agencies with strong skills in HP inves- no HF expertise in house often hire consultants with that expertise. tigation that are leading the way in defining how to conduct an HP However, our investigation experience also indicates that agencies investigation: what questions to ask, what data to collect, how to that may not have a full-time existence (but come together when an frame the data and identify the underlying causes, etc. In addition, accident occurs) may have no ready access to this type of expertise. there are investigation agencies outside of aviation (e.g., nuclear What types of training do agencies provide their investigators power) that are also establishing more detailed guidance, espe- on HP issues? Most agencies reported that all investigators re- cially in the area of organizational factors. Unfortunately, the work ceive some HF-related training. For four agencies, the HF train- of these few groups is not easily conveyed to other agencies that ing is part of a broader investigation course. Four other agencies lack HP expertise. expose each investigator to a dedicated HF course (usually a week in length). The remaining four agencies have no HF training that Boeing response is required of all investigators; instead, a few investigators may Our data gathering reinforced our beliefs that get some HF training. So, the overall picture is a mixed bag— • HP expertise exists primarily within the larger investigation some pockets of strong HP expertise and other agencies with little agencies and is not readily acquired from a consistent source when training or in-house expertise. it is needed. Those with training both in accident investigation and HP guidance documents—A key question concerned the proce- HP issues are too rare for today’s needs.

January–March 2007 ISASI Forum • 15 By limiting our topics to those that can be backed up with data, we hope to • Accident investigation agencies. avoid the speculative arguments made • Aviation regulators. about what “may have” influenced • Those representing the people who may be “blamed” (pilots, ATC, maintenance technicians). actions and decisions. • Airlines. • Aviation safety organizations. • HP guidance is either insufficiently detailed or is being devel- • Training organizations. oped within the agencies that have the most expertise (and it is not Therefore, we turned our attention to organizing stakeholder formally shared outside of that agency). representatives to develop an industry solution to this problem. • There is no shared framework across agencies for understand- We started by seeking and being granted sponsorship from ISASI. ing and describing HP issues; the Reason (Swiss cheese) Model ISASI appointed Capt. Dick Stone as the ISASI chairman of an has been influential but falls short of creating a unifying approach. industry working group; Capt. Stone has since added an advisory Without this shared framework, the findings from individual acci- board that, under Capt. Stone, will approve our development plan dents cannot be easily compiled and analyzed as a set. and review guidance material before it is distributed. The Group The initial Boeing response was to begin developing the HP in- has been named the ISASI International Working Group on Hu- vestigation guidance that most agencies are missing. We laid out a man Factors (IIWGHF). plan to develop a set of individual modules on specific HP topics. The next step was to bring together the HP expertise in the These modules would cover a range of topics— industry. We have a team of 10 human factors professionals with • Data-collection techniques (e.g., cognitive interview). accident investigation experience who are continuing to develop • Human performance issues (e.g., spatial disorientation). guidance modules. This team will work with a set of reviewers (in- • Factors that contribute to human performance problems (e.g., dustry representatives) who will make an early evaluation of a fatigue, stress). module to ensure that it is fair and useful for the work of investiga- • Analysis techniques (e.g., speech frequency analysis). tors. Through a number of review-and-rewrite cycles, we hope to • Safety-assessment techniques (e.g., barrier analysis). produce a significant set of guidance modules that we can then Each module would provide a brief background on the issue package and distribute through ISASI. and then lead into practical guidance for investigators on tech- Another potential role of the IIWGHF is to put forward posi- niques, references for more information, names of experts in the tion statements that can establish a standard on how HP issues area, and training that is available. We targeted each module to should be investigated. There are a number of potential issues to about five pages; the idea was to have a quick, easy-to-use refer- be addressed here. An example being considered is the following: ence document for investigators on key HP topics. • The collection of human performance data should not be seen Further, we wanted to ensure that the topics covered were tied as implying that human error is a working hypothesis for the in- to actual performance data—that is, areas in which there are data vestigation. Initial interviews of operational personnel involved in on the effects of a factor on human performance. For example, the accident or incident (e.g., pilots, air traffic controllers, mainte- quite a bit is known about how inadequate sleep affects task per- nance technicians) should be conducted in a way to maximize the formance. By limiting our topics to those that can be backed up retrieval of information about the event; they should not focus on with data, we hope to avoid the speculative arguments made about finding fault with the actions taken or decisions made. what “may have” influenced actions and decisions. This is not to As of this writing, the IIWGHF is just ramping up. We plan to say there is no place for speculative arguments when there is little deliver a number of guidance modules by mid-2007. After a core set hard data about performance, but this type of account needs to be of materials is developed and approved, we will use ISASI to dis- clearly labeled as such. tribute the materials to key industry stakeholders. If these materials achieve a good level of acceptance within the industry (and per- Industry working group haps within other areas of accident investigation), they will start to As we proceeded with module development, we realized that it shape how investigations are conducted and reports are written. was important to create guidance that would be acceptable to all Ideally, we will eventually establish a well-defined set of expecta- major stakeholders in commercial aviation accident investigation. tions about the policies and practices of HP investigations. ◆ Expertise is distributed across these stakeholders, and a consen- sus position is required to make a significant change to industry (Acknowledgments: Many thanks to the following Boeing people practice. These stakeholders include the following: who made significant contributions to this project: Simon Lie, • Airplane manufacturers. Hans-Juergen Hoermann, Richard Kennedy, and Rich Breuhaus.)

16 • ISASI Forum January–March 2007 Failure Analysis of Composite Structures in Aircraft Accidents The authors introduce some of the basic concepts involved in analyzing failed composites under a variety of fundamental loading conditions such as tension, compression, bending, impact, and fatigue. By Joseph F. Rakow, Ph.D., P.E. (AO4926), Engineer, Exponent Failure Analysis Associates, and Alfred M. Pettinger, Ph.D., P.E., Managing Engineer, Exponent Failure Analysis Associates

(This article was adapted, with permission, structures, similar to the transition from Historically reserved for from the authors’ presentation entitled Fail- wood to metal in the 1920s. ure Analysis of Composite Structures in Air- Historically reserved for control surfaces control surfaces and craft Accidents , presented at the ISASI 2006 and secondary structures, composites are secondary structures, seminar held in Cancun, Mexico, Septem- now being employed for primary structures ber 11-14, which carried the theme “Incidents in major aircraft programs. The airframe composites are now being to Accidents: Breaking the Chain.” The full of the Boeing 787, currently scheduled to employed for primary presentation including cited references index enter service in 2008, will be approximately structures in major aircraft is on the ISASI website at www.isasi.org. This 50% composite structure by weight, with paper received “special commendation” in nearly 100% of the skin, entire sections of programs. the seminar’s “Best in Seminar” screen- the fuselage with integral stiffeners, and the ing by the selection panel. The panel said wing boxes constructed of composites. This the paper “helped many investigators to can be compared to the Boeing 777, which better understand the nature of compos- entered the market just more than a decade ite failure in aircraft structures—a grow- ago with an airframe of 10% composite ing area of interest within civil and mili- structure by weight. Powering the B-787 tary aviation.”—Editor) will be the GEnx turbofan engine with fan blades and containment casing made of omposites are not new. Composite composites, rather than traditional metals. structures have been developed and The Airbus 380 is scheduled to enter ser- Cused for military aircraft for more vice in the coming year with an airframe than 50 years. Composite aircraft have been that is approximately 25% composite struc- commercially available to homebuilders for ture by weight. One notable feature of the decades. Even an all-composite spacecraft, A380 is an all-composite central wing box. SpaceShipOne, has flown to space with re- Complementing this transition in the large petitive success. Continuing with this his- transport market are the all-composite air- tory, aircraft structures of the current de- frames for very light jets, such as the Adam cade are progressing through a major tran- A700 and parallel advances with military sition from metallic structures to composite aircraft. The F-22, for example, contains

Dr. Joseph Rakow is an published a number of articles in engineer with Exponent scientific journals and frequently speaks Failure Analysis at international conferences. Associates, a leading scientific and engineer- Dr. Alfred Pettinger is a managing ing consulting firm. He engineer with Exponent Failure Analy- specializes in aeronauti- sis Associates. He specializes in the cal structural engineering, structural evaluation and design of metal as well as failure, and the design of mechanical composite aerospace components. Dr. components. Dr. Rakow’s work has Pettinger has been retained in numerous addressed products, failures, and accident investigations and design initiatives of a variety of commercial and reviews for transportation-category government organizations. He has aircraft. (Photo not available)

January–March 2007 ISASI Forum • 17 Figure 2. Indications of fatigue cracking in the lower right wing spar cap of the Chalks Ocean Airways Grumman Mallard G73 that crashed during takeoff Dec. 19, 2005. This is an example of using accumulated knowledge and experience with metallic structures to identify potential factors in an accident (NTSB 2005).

Figure 1 (the 3 photos above). The tained within the wreckage ductility of metal structures provides in two categories—macro- macrostructurally visible information structural evidence and mi- regarding an accident (Wanttaja 1994). crostructural evidence. Macrostructural evidence approximately 60% composite structure, refers to the overall defor- compared with slightly more than 20% for craft structures and multiple-site damage. mation of failed struc- the F/A-18C/D, which entered production Through more than 80 years of accidents tures—a buckled fuselage panel, a twisted just a decade earlier. involving metallic aircraft, the community propeller blade, a dented leading edge. Fig- With the increased use of composites in of aircraft accident investigators has devel- ure 1 shows an example of macrostructural primary structures, accident investigators oped a considerably mature understanding evidence, deformation of the spinner, verti- will likely encounter failed composite struc- of failure in metallic structures. This ac- cal stabilizer, and leading edges. tures with increasing frequency in the com- crued knowledge and experience must be The value of macrostructural evidence in ing decades, and these structures may be extended to composite structures. failed metal structures is enhanced by the primary structures of significance to the in- This article is intended to contribute to fact that typical aircraft metals, such as alu- vestigation. Why may these composite struc- that effort by introducing some of the basic minum, are ductile, which means they un- tures fail? First, we are building composite concepts of failure in composite structures dergo significant deformation prior to final structures on a scale never before achieved. as a result of a variety of loading conditions— failure. Ductility allows for the permanent The B-787 fuselage will be the largest com- tension, compression, bending, impact, and bending, twisting, and denting of structures, posite pressure vessel ever built. Second, we fatigue. The analysis is frequently discussed which essentially records evidence of events are building composite structures through with respect to corresponding failures in in the accident. The evidence contained in relatively new, automated techniques rather metallic structures. Select failure character- Figure 1 (deformation of the spinner, verti- than relying on traditional methods of con- istics are then illustrated through a discus- cal stabilizer, and leading edges) immedi- structing composites by hand (conversely, sion of the failure of the composite vertical ately identifies impact as a factor in this automation will eliminate some sources of stabilizer of American Airlines Flight 587. accident. The evidence also identifies the error associated with traditional construc- possible size, shape, and energy associated tion methods). And third, our inspection and Examination of failed metallic with the impactor or impactors. According maintenance requirements will no longer be structures to the NTSB, this aircraft impacted a set of driven by fatigue and corrosion performance, The science and art of analyzing failed me- power lines on approach (NTSB 1995). as they are for metallic structures, because tallic structures has matured in part as a Ductility in metals provides macrostruc- composites are not as susceptible to these result of the analysis of accidents involving tural evidence in a variety of ways. One failure mechanisms (accidental subsurface metal aircraft. Employing knowledge ac- method for determining whether a jet en- damage and subsequent failure progression crued during this period of time, investiga- gine was powered at the time the aircraft will be more important). tors often rely heavily on their ability to impacted the ground is to examine the fan These advances, a collective departure analyze failed structures in an effort to de- blades. Metallic fan blades of a powered from applications, techniques, and methods termine the cause and events of an accident. turbofan will generally bend upon impact of the past, may lead to landmark lapses in Some investigators, such as M.P. Papadakis, in a direction opposite the direction of rota- safety with subsequent “lessons learned” S. Taylor, and B.W. McCormick, have em- tion. This deformation can reveal whether for composites, in the manner that the phasized the role of such analysis as “The the engine was powered at the time of the Comet accidents provided lessons learned bent metal speaks.” “The story is written accident. Another example is the deforma- regarding stress concentrations and metal in the wreckage.” “You have to learn how tion produced by an explosion occurring fatigue and Aloha Airlines Flight 243 pro- to read the bent metal.” inside a metallic fuselage. The bulging of vided lessons learned regarding aging air- This article refers to the evidence con- fuselage panels, the curling of ruptured

18 • ISASI Forum January–March 2007 Figure 4. Example of fiber pullout as a result of tensile loads (Friedrich and Karger- Kocsis 1989).

Figure 3. Tension failure in composites. Macroscopically, even simple tension can produce fractures with a wide variety of wing spar cap reveals beach marks, which Transitioning from failed features. Microscopic analysis becomes is evidence widely accepted to be indicative important (Ginty and Chamis 1987). of fatigue failure. As a result of this estab- metallic structures to lished analysis, the microstructural evi- failed composite edges away from the explosion, and the dence, supported by an accrued body of stretching and unzipping of panels along knowledge regarding the interpretation of structures requires, in rivet lines all indicate the presence of an fracture surfaces in metals, rapidly estab- many ways, a new explosion in an accident. lished the wing spar cap as a critical com- mindset. Typical aircraft composites, however, are ponent to consider in this investigation. not ductile; they are brittle, which means they The analysis of failed composite structures undergo relatively minor permanent defor- cannot rely solely on the knowledge and ex- mation prior to final failure. Without ductil- perience accrued for metallic structures. The ity, without permanent deformation, the mac- analysis of failed composite structures in- rostructural evidence from an accident, such volves terms such as fiber pullout, delami- as the examples discussed above, may no nation, and interfacial failure. These terms longer be available. What evidence would be do not even exist in the analysis of failed produced by a GEnx engine, with its compos- metallic structures. These and other rudi- ite fan blades, impacting the ground? What mentary elements of knowledge must be evidence would be produced by an explosion understood by accident investigators in or- inside a B-787 composite fuselage? der to analyze failed composite structures. With changes in macrostructural evidence associated with the loss of ductility in brittle Examination of failed structural materials, the analysis of micro- composite structures structural evidence becomes paramount. Transitioning from failed metallic struc- Microstructural evidence refers to local de- tures to failed composite structures re- formation and damage in the structure, such quires, in many ways, a new mindset. Al- as fracture surfaces, that typically require though composites are often considered to close visual or microscopic analysis. To in- be materials and are generally classified as terpret microstructural evidence in failed engineered materials, composites are actu- metallic structures, investigators rely upon ally structures, made of multiple materials. a well-established and widely used body of Typical aircraft composites are made of two knowledge, which has, in the past, often pro- materials: (1) long fibers that are stiff and vided rapid and insightful results. strong (typically carbon or glass) and (2) a One example is the recent crash of Chalks matrix, essentially hardened plastic glue, Ocean Airways Flight 101 in December that holds the fibers together. The glued fi- 2005 off the coast of Miami, Fla. Initial evi- bers are typically assembled layer by layer, dence indicated that the right wing had called plies. The fibers in each ply typically separated in flight. Within days, the NTSB run parallel to each other or are woven to- had identified fatigue damage in metallic gether in the manner of a textile. Ply-wise structural components in the right wing variations in fiber orientation and other (Figure 2), with corresponding damage in variables often exist in a composite. the structure of the left wing. As shown in In contrast to typical aircraft metals, the Figure 2, an unaided visual inspection of the physical properties of composites vary from

January–March 2007 ISASI Forum • 19 Figure 5. (right) Example of fiber kinking as a result of compressive loads (Bolick et al 2006). Figure 6. (below) Chop marks can be produced on the ends of broken fibers that have buckled and failed under compressive loads (Stumpff 2001).

location to location, and their response to loads Figure 7. (above) Composite specimen usually varies with the direction in which the that failed in bending. The relatively load is applied. Composites can respond to rough area of tension failure and the loads in ways aircraft metals cannot. A simple relatively smooth area of compression tensile load, for example, can cause a compos- failure are clearly identifiable (Beaumont ite to twist; a simple twisting load can cause a and Schultz 1990). composite to bend. While designers know of, understand, and can predict these phenom- fibers, holes in the matrix that were created ena, accident investigators must be able to by other pulled-out fibers. recognize and reconstruct them. In some cases of tensile failure, the fibers Composites have design variables that is that these composites, all of which failed do not completely fracture and only the ma- are not available in metals. Some of these in tension, demonstrate a wide variety of trix completely fractures. The fibers then variables are fiber orientation, fiber-to-ma- appearances. This is one of the challenges of span the matrix fracture in a phenomenon trix volume ratio, ply thickness, and ply analyzing failed composites. In many cases, called fiber bridging. In either case, the in- stacking sequence, among others. With new this challenge can be addressed by perform- vestigator can use the pulled-out fibers to variables come new opportunities for manu- ing a microscopic analysis of the failure sur- identify tensile loading, and in the case of facturing errors or imperfections. Some of faces to identify common features that indi- stacked laminates, identify those plies that these imperfections are fiber waviness, poor cate failure in tension. These features, along have been loaded in tension. The length of adhesion between fibers and matrix, poor with features associated with other loading the pulled-out fibers can indicate important adhesion between plies, excessive voids in conditions, are introduced below. conditions present in the composite at the the matrix, and an improperly cured ma- time of fracture, such as temperature, expo- trix, among others. Changes in design vari- Tension sure to moisture, and rate of loading. ables and accumulated imperfections di- Tensile fractures of fibrous composites typi- As long, thin members, the fibers are de- rectly affect the failure of a composite. cally exhibit common characteristics that signed to carry tensile loads, and compos- As an example, consider Figure 3, which can help identify failure under tensile loads, ites are nominally designed such that the fi- shows 20 failed composite specimens. Each even in the presence of large variations in bers run parallel to the tensile loads. How- specimen was subjected to simple tensile the macroscopic appearance. One charac- ever, in the common case of composites with loading. Despite the similarity in loading, teristic is that the fracture surface gener- ply-wise variations in fiber orientation, ten- the failure in each specimen has a unique ally has a rough appearance, as can be seen sion loads do not run parallel to the fibers, appearance. Some of the failed specimens in the failed specimens in Figure 3. and failure can occur in the matrix. Common have a shredded appearance with a very Figure 4 shows a microscopic view of a matrix failures associated with such loading rough fracture surface; some of the speci- fracture surface of a composite that failed conditions are tension failures between fi- mens have a smoother, angular appearance. under tensile load, with the fibers aligned bers, particularly at the fiber-matrix inter- Some specimens even broke into several with the direction of the load. One clear char- face, and shear failures in the matrix-rich pieces, while others broke into only two. acteristic of the fracture surface is that frac- region between plies, typically associated The differences in the appearance of these tured fibers are sticking out of the fractured with rough features on the fracture surface failures are a result of two primary sources matrix, contributing to the rough appearance called hackles. Such inter-ply shear failures of variation among the specimens. The first of the fracture surface. Called fiber pullout, can also be produced under compression. source of variation is the intentional varia- this characteristic is a typical indication of tion in design variables among the speci- tension failure in a composite. Fiber pullout Compression mens, such as fiber orientation. The second is the result of a fiber breaking and being Under compression, the fibers are structur- source of variation is the accumulation of im- extracted from the matrix. Close inspection ally less effective than they are in tension. perfections, as discussed above. The result of Figure 4 reveals, in addition to pulled-out One common characteristic of the compres-

20 • ISASI Forum January–March 2007 Figure 8. (right) Com- posite wing that reportedly failed in bending. The relatively rough area of tension failure with significant fiber pullout, and the relatively smooth area of compression failure are clearly identifiable (Stumpff 2001).

Figure 9. (right) Example of composite failure in- sive failure of fibrous composites is the for- volving delamination (Bas- mation of kink bands, as shown in Figure 5. com and Gweon 1989). Kink bands are a result of structural insta- Figure 10. (right above) bility, much like a person standing on and Striations at the interface eventually crushing a soda can. The fibers between fibers and matrix buckle as the compressive load approaches (Stumpff 2001). a critical level, which is primarily a function of material and geometric factors. bending, has a very fibrous texture relative Impact loading can cause Fiber buckling can also be identified by to the top side of the wing, which was sub- examination of the fiber ends. As shown in jected to compression in bending. damage to a composite Figure 6, chop marks indicate fibers that without any visible have buckled and have bent to failure. The Impact chop marks coincide with the neutral axis of As discussed above, ductile metal structures evidence on the surface. the fiber in bending, separating the tension undergo relatively high levels of permanent side from the compression side of the fiber. deformation prior to final failure, and this Often associated with kink bands is ma- deformation provides information regard- trix splitting, which can be seen in Figure 5 ing the events preceding structural failure. as gaps in the matrix. Matrix splitting oc- The metallic aircraft discussed above and curs at weak points in the matrix or at ar- shown in Figure 1 clearly indicates impact eas of high stress concentration, such as at by a foreign object. Since composites, on the the fiber-matrix interface and the interface other hand, exhibit relatively little perma- between plies. Matrix splitting at the inter- nent deformation prior to final failure, such face between plies is referred to as delami- impact evidence may not be as readily ob- nation and is discussed further in the para- served in a composite aircraft. graphs below regarding impact. Impact loading can cause damage to a composite without any visible evidence on the Bending surface. Consider an aircraft mechanic drop- The difference between tensile and compres- ping a wrench on the top surface of a wing. sive fracture surfaces is readily demon- If the wing is made of aluminum, the impact strated in composites that have failed in may leave a dent, essentially recording the bending, such as the specimen shown in Fig- impact and providing some rudimentary in- ure 7. Divided by a neutral bending axis, one dication of the significance of the resultant part of the fracture surface contains pulled- damage. If the wing is a composite, the im- out fibers and the other part is relatively flat. pact of the wrench may produce local crush- This is a result of the fact that, in bending, ing of the fibers and matrix or it may not one part of the cross-section is in tension and produce any damage on the surface at all. In the other part is in compression. either case, the level of damage below the The characteristics of bending failure surface of a composite can be much more can readily translate to a macroscopic level. extensive than that indicated on the surface. Figure 8 shows a composite aircraft wing One common type of sub-surface dam- that has reportedly failed in bending age from impact is delamination. A delami- (Stumpff 2001). The bottom surface of the nation is a split between plies in a compos- wing, which was subjected to tension in ite. The split can propagate along the inter-

January–March 2007 ISASI Forum • 21 Figure 11. (above) Along with several other fractures, the fractures of the right aft lug were rough, consistent with tensile loading (NTSB 2002). Figure 12. (right) Fractures in multiple locations exhibited chop marks (marked with a “c”) on the ends of fractured fibers, consistent with compressive loading and buckling of fibers (NTSB 2002). face at which neighboring plies were joined with beach marks, an example of during manufacturing or it can propagate which was already discussed and shown in Although the structure was originally de- along the fiber-matrix interface. Figure 9 Figure 2. Fatigue fracture surfaces in com- signed with metallic materials, the metallic shows a couple views of the cross-section of posites, on the other hand, do not typically design was eventually replaced by a com- a composite plate after impact. have visible beach marks. In fact, fatigue posite design employing carbon fibers in an As indicated in the figures, the impact fractures in composites typically do not ap- epoxy matrix. Since that time, the compos- caused extensive delamination among mul- pear any different from a corresponding ite stabilizer has accumulated more than 20 tiple plies. Such damage can dramatically overload failure. years of service. In November 2001, Ameri- degrade the load-bearing capability of the While fatigue fractures lack macroscopic can Airlines Flight 587’s composite stabi- composite even though the fibers may re- evidence, some evidence may be identified lizer failed. As a potential harbinger of the main intact. Moreover, the damage, if un- microscopically. Figure 10 shows striations failures discussed in this article, the failure noticed, can continue to propagate upon at the fiber-matrix interface of a composite. of this composite structure is discussed in further loading of the composite. One striation typically corresponds to one the paragraphs below. The discussion fre- Without visible evidence on the surface, load cycle. Although these striations indicate quently refers to the features of failed com- delaminations must be identified by cross- fatigue failure, they can be difficult to find. posites discussed above. sectioning the composite in the location of Areas containing striations are typically The vertical stabilizer of the A300-600 is the delamination or by employing non-de- small in size, few in number, and may be dis- attached to the fuselage by three pairs of structive techniques such as ultrasonics or persed over multiple locations in the com- composite lugs—forward, middle, and aft— X-ray tomography. If destructive tech- posite. In addition, the striations are often along the union between the stabilizer and niques are employed, delaminations may be identifiable only under high magnification the fuselage. The lugs transfer bending identified visually. In graphite-epoxy com- and oblique lighting (Figure 10 was captured moments applied to the stabilizer through posites, delaminations can be identified by under a magnification of 2000x). In short, the large-diameter bolts. Between each pair of a dull, whitish appearance, relative to the identification of fatigue failure in composites lugs is a composite transverse load fitting shiny, black appearance of neighboring ar- can be very challenging. One macroscopic that transfers to the fuselage lateral loads eas free from delamination. feature that can provide evidence of fatigue applied to the stabilizer. Analysis of flight is abrasion between mating fracture sur- recorder data by the NTSB indicates that Fatigue faces. With repeated loading, the growing the aircraft was subjected to a violently One of the attractive qualities of composites fracture surfaces may rub against each other changing oscillatory sideslip motion, caus- is that they generally have better fatigue and leave abrasive marks on the ends of bro- ing loads in excess of the ultimate design performance than typical aircraft metals ken fibers and in the matrix. loads of the stabilizer. The NTSB deter- such as aluminum. Despite this fact, compos- mined that the right rear lug of the stabi- ites can fail under fatigue loading and such American Airlines Flight 587 lizer suffered a tensile overload failure failures result in identifiable failure features. Soon to be eclipsed by the center wing box that caused the progressive failure of the Fatigue failure in metals can be readily of the A380 and the fuselage of the B-787, remainder of the attachment points. identified, in many cases, by an unassisted the vertical stabilizer of the Airbus A300- As discussed above, tensile failures in com- visual inspection. A typical fatigue failure 600 is one of the largest composite primary posites generally produce rough fracture sur- in metals will produce a fracture surface structural elements in commercial aviation. faces. Figure 11 shows the fracture surface

22 • ISASI Forum January–March 2007 Figure 13. Interlaminar fractures in multiple locations exhibited hackles, consistent with failure in shear (NTSB 2002).

With a broad range of associated design of the right aft composite lug. Similar rough the NTSB did not find any indication of fa- variables, the inves- fracture surfaces were found on the other two tigue damage in the vertical stabilizer. lugs on the right side of the stabilizer. As a tigation of composite result, the NTSB concluded that the lugs on Looking ahead structural failures the right side of the stabilizer failed due to With the impending generation of compos- requires particular overstress under tensile loading. ite aircraft, the analysis of failed composite According to the analysis by the NTSB, structures will be of significance to aircraft expertise. after the lugs on the right side failed, the dam- accident investigators. The introduction of aged stabilizer deflected from right to left, composites presents new variables, such as loading the lugs on the left side of the stabi- fiber orientation, geometric variations lizer in bending. In bending, tension developed among plies, and curing processes, which on the inboard side of the lugs and compres- in turn present new failure modes, such as sion developed on the outboard side of the fiber pullout, fiber kinking, and delamina- lugs. The NTSB identified evidence consis- tion. Contributing to these relatively new tent with tension failure on the inboard side concepts is the prevalence of brittle failure and compression failure on the outboard side in composites, as opposed to ductile failure of the lugs on the left side of the stabilizer. in metals, and the potential reduction in This is consistent with failure in bending. macrostructural evidence. Consequently, As discussed above, when fibers are sub- the analysis of failed composite structures jected to compressive loads, they can buckle cannot rely solely upon the body of accrued and the fracture surface on the end of a failed knowledge and experience related to failed fiber may indicate chop marks. The left aft, metallic structures. left center, and left forward lugs of the failed This article has introduced some of the stabilizer each contained fractured fibers basic concepts involved with analyzing failed with chop marks, as shown in Figure 12. Also composites under a variety of fundamental found on the left aft lug were hackles associ- loading conditions. Fractographic details ated with shear failure in the matrix-rich have been presented and subsequently il- region between plies (Figure 13). Hackles lustrated by a brief discussion of the analy- were found on the left forward lug as well. sis by the NTSB of the failed composite Evidence consistent with bending was vertical stabilizer from American Airlines also found in the aft transverse fitting. Frac- Flight 587. With a broad range of associ- tures on the attachment points on the right ated design variables, the investigation of side of the transverse fitting were rough in composite structural failures requires par- appearance, indicating tensile failure, while ticular expertise. It is likely that, given such the fracture on the left-most attachment complexity, future investigations involving point had a relatively smooth appearance, composite primary structures will require indicating compressive failure. This evi- significant input from accident investigators dence was found by the NTSB to be consis- with expertise in the analysis of failed com- tent with bending of the stabilizer from posite structures, as was required in the in- right to left. Finally, it must be noted that vestigation of Flight 587. ◆

January–March 2007 ISASI Forum • 23 ISASI ROUNDUP

Singapore AAIB Hosts ISASI 2007

ISASI 2007, the Society’s 38th annual ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the East and the West for centuries, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the venues for ISASI annual seminars international seminar, will be held in Singapore, located in the heart of fasci- through 2010, adoption of a new human Singapore from Monday, August 27 to nating Southeast Asia, continues to factors effort (see page 3 and 14), review Thursday, August 30. Hosted by the Air embrace tradition and modernity today. of ISASI By-Laws revision, acceptance of Accident Investigation Bureau of Singapore is slightly more than 3.5 times a comprehensive review of Reachout Singapore (AAIB), the seminar will carry the size of Washington, D.C. Its climate is Program history and current status. the theme “International Cooperation: tropical. The wetter northeast monsoon Routine reports of Executive members, From Investigation Site to ICAO.” season is from December to March, and societies, and working groups and Chan Wing Keong, seminar chairman, the drier southwest monsoon season is committees were also received. says that the seminar will follow the from June to September. Singapore is Representatives of the Singapore established format of past seminars, with also considered the Asia Pacific air hub, as AAIB discussed preparations for ISASI 1 day devoted to tutorial workshops and 3 it is connected to more than 180 cities in 2007. The Canadian Society’s bid to host days of technical paper presentations. 57 countries by more than 80 airlines with ISASI 2008 in Halifax, Nova Scotia, The technical program will address over 4,100 weekly flights. Singapore will Canada, was accepted as was Japan’s current safety and investigation issues, be a convenient gateway to the many Aircraft and Railway Accidents Investiga- including recent air safety occurrences interesting tourist destinations in tion Commission bid to host ISASI 2010 and investigations, with particular Southeast Asia, for example, Angkor Wat in Sapporo, Japan. The ISASI Florida emphasis on international cooperation in Cambodia, Bali and Borobudur in Regional Chapter provided an update on efforts demonstrated during the various Indonesia, Langkawi and Malacca in its previously accepted bid to host ISASI investigative endeavors. Malaysia, and Cebu in the Philippines. 2009 in Orlando, Fla. The issued “Call for Papers” seeks Registration for ISASI 2007 is ex- Jim Stewart, chairman of the abstracts by March 31 with final elec- pected to open by March. Final details are Reachout Program, provided a compre- tronic submission in early July. Members now being completed. It is expected that hensive review of the Program’s history of the technical papers selection commit- registration fees will be between US$400- and its current status. He reported that tee include Chan Wing Keong (AAIB 500 and tutorial fees about US$80-100. there are now five instructors, the Singapore, chair), Michael Toft (AAIB Delegate registration will include original “core” of himself, Caj Frostell, Singapore), Caj Frostell, Jim Stewart, breakfasts, lunches, and morning/ and Ron Schleede, plus the recent Keith McGuire, Ken Smart, Capt. afternoon teas on the 3 days of the addition of Steve Corrie and Vic Gerden. Mohammed Aziz, Dr. Rob Lee, and Y.P. seminar, as well as the off-site visit/dinner Stewart and Corrie are now “ICAO Tsang (Hong Kong CAD). and the awards banquet. A CD-ROM of certified” SMS instructors. Tutorials to be presented are aftermath the technical papers will also be provided Stewart said the goal of Reachout of a sea crash and investigation in a to the delegates. remains getting accident investigation litigious environment. The tutorial day ○○○○○○○○○○○○○○○○○○○○○○○○○○ The social program and the optional ○○○○○○○○○○○○○○○○○○○○○○○○○○ expertise and the Society’s affiliation to will be held at the Singapore Aviation tour scheduled for Friday are also being parts of the world that are not affected by Academy. Arrangements have been made finalized and will be reported in the next ISASI’s annual seminar. The Program to also provide tutorial participants a tour issue. ISASI 2007 went on line at press length is tailored and has evolved into a of the Academy’s excellent facilities, time. It can be accessed at variable length—from 2 days to 2 weeks. which received the 1996 Flight Interna- www.isasi07.org. ◆ ICAO is committed to the Reachout tional Aerospace Industry Award for process. Program successes have been training. In addition, the Academy was International Council well noted on pages of the ISASI Forum. presented the prestigious Edward He stated that Reachout has, in general, Warner Award by the ICAO Council in Meets in Cancun exceeded initial expectations and urged 2000. The Society’s International Council met all the councillors and international The venue for the seminar will be the in Cancun on Sept. 10, 2006, in conjunc- officers to participate. Swissôtel The Stamford, Singapore, in a tion with its 37th annual international In addition to a detailed roundup of city that is billed as being dynamic and seminar. Among its actions was accep- Society activities since the last meeting, rich in contrast and color where one finds tance of a certified copy of the Society President Frank Del Gandio set the next a harmonious blend of culture, cuisine, election ballot results (see page 24 of the International Council meeting for May 4, arts, and architecture. A bridge between October/December Forum, ) selection of 2007, in the Washington, D.C., area to be

24 • ISASI Forum January–March 2007 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ age and assist college-level students interested in the field of aviation safety Call for Papers—ISASI 2007 and aircraft occurrence investigation. Applicants enrolled as full-time students The International Society of Air Safety Investigators Presents in a recognized (note ISASI recognized) th its 38 International Seminar Aug. 27-30, 2007 education program, which Swissôtel The Stamford, Singapore includes courses in aircraft engineering Theme: “International Cooperation: From Investigation Site to ICAO” and/or operations, aviation psychology, aviation safety and/or aircraft occurrence investigation, etc., with major or minor The Technical Committee is looking for 20- Selected papers will be produced on subjects that focus on aviation safety/ 30 papers on current investigation experi- a CD-ROM before the seminar com- investigation are eligible for the scholar- ence, techniques, and lessons learned with mences. Please note that although a pre- particular emphasis on international inves- senter may need to withdraw at short no- ship. A student who has received the tigation cooperation, coordination, and tice from a scheduled presentation, the annual ISASI Rudolf Kapustin Memorial challenges. written material will remain part of the Scholarship will not be eligible to apply If you wish to offer a presentation in CD-ROM if already produced. for it again. This year the seminar will be line with the seminar’s theme, please pro- held at the Swissotel The Stamford, vide a brief abstract (approximately 200 Please send indication of interest and ab- August 27–31. words) plus personal details by March 31, stract to Singapore, 2007. Please indicate in your abstract the Continued funding for the Memorial key points you wish the audience to take Chan Wing Keong Fund is through donations, which in the away with them from your presentation. Technical Program Chair United States are tax-deductible. An You are welcome to indicate your in- E-mail: [email protected] award of $1,500 is made to each student terest before you provide the abstract. Telephone: (65) 6541-2800 who wins the competitive writing require- Selected papers should be provided or mail to in electronic format no later than July 5, ment, meets the application require- 2007. Please note that PowerPoint presen- Air Accident Investigation ments, and who registers to attend the tations are not acceptable for publication Bureau of Singapore ISASI annual seminar. The award will be in seminar Proceedings or seminar CDs. Changi Airport Post Office used to cover costs for the seminar Submittal of an abstract implies an agree- ment that the author authorizes publica- P.O. Box 1005 registration fees, travel, and lodging/ tion of the complete paper in the seminar Singapore 918155 meals expenses. Any expenses above and Proceedings and the ISASI Forum. Republic of Singapore beyond the amount of the award will be covered by the recipient. In addition, the following are offered to the winner(s) of ○○○○○○○○○○○○○○○○○○○○○○○○○○ held in conjunction with the May 3 MARC ○○○○○○○○○○ The full minutes of the September 10 the scholarship. dinner and meeting. meeting are available to the membership • A 1-year membership to ISASI. Treasurer Tom McCarthy reported a on the ISASI website: www.isasi.org. ◆ • The Southern California Safety current bank balance of $63,443.65 in the Institute (SCSI) offers tuition-free primary CAP account. The ISASI Rudy Kapustin Scholarship attendance to ANY regularly scheduled Kapustin Memorial account has a balance SCSI course to the winner of the ISASI of $4,308.00. He also reported on the final Issues Application Call Scholarship. This includes the 2-week proceeds of ISASI seminars from 1997 ○○○○○○○○○○○○○○○ The ISASI Rudolf Kapustin Memorial aircraft accident investigator course or through 2005, which can be found on the Fund has issued its call for scholarship any other investigation courses. Travel to/ appropriate section of the ISASI website. applications to universities and colleges from the course and accommodations are Mike Hynes, audit chair, reported that his whose students are eligible to participate not included. More information can be review of accounting data for the years in the program, according to the Fund’s found at http://www.scsi-inc.com/. 2004 and 2005, including an on-site review administrators, ISASI Executive Advisor • The Transportation Safety Institute of ISASI records in 2006, showed that the Richard Stone and ISASI Vice-President offers a tuition-free course for the data reviewed reflected proper account- Ron Schleede. The deadline for applica- winner of the scholarship. Travel to/from ing practices and successful management tions is April 3, 2007. the course and accommodations are not of funds. The purpose of the Fund is to encour- included. More information is available

January–March 2007 ISASI Forum • 25 ISASI ROUNDUP Continued . . . In Memorium

Samuel E. Brodie (MO22504), Bakers- field, CA, USA

George D. Butler (Life Member 2831), April 10, 2006, Sun City, FL, USA ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ at http://www.tsi.dot.gov/. • Completed applications should be Capt. Harold R. Miller (Life Member Last year, two awards were presented. forwarded to ISASI, 107 Holly Ave., Suite 0169), July 2006, Dallas, TX, USA They went to Leonardo Ferrero, 11, Sterling, VA 20164-5405 USA. E-mail Frank T. Taylor (Life Member 2513), Politeenico di Torino, Italy, and Sheena D. address: [email protected]; Telephone: 1- August 2006, Ellicott City, MD, USA McCune, Embry-Riddle Aeronautical 703-430-9668. Frances M. Wokes (AO4025), Nov. 11, University, Florida, USA. • The Judges’ decision is final. ◆ 2006, Winnipeg, Manitoba The Fund is administered by an appointed committee and oversight of Lederer Award expenditures is done by the ISASI association with professional investiga- treasurer. The committee ensures that the Nominations Sought tors, and submit a nomination when they education program is at an ISASI- The ISASI Awards Committee is seeking identify someone who has been outstand- recognized school and applicable to the nominations for the 2007 Jerome F. ing in increasing the technical quality of aims of the Society, assesses the applica- Lederer Award. For consideration this accident investigation. tions, and determines the most suitable year, nominations must be received by the Nominations should be mailed or candidate(s). Donors and recipients will end of May, noted Committee chairman, e-mailed to the ISASI office at 107 Holly be advised if donations are made in honor Gale Braden Ave., Suite 11, Sterling, VA 20164-5405 of a particular individual. He added that “the purpose of the USA. E-mail address: [email protected]; Students who wish to apply for the Jerome F. Lederer Award is to recog- Telephone: 1-703-430-9668. scholarship may acquire the application nize outstanding contributions to Nomination may also be sent directly to form and other information at the ISASI technical excellence in accident investi- the Awards Committee Chairman, Gale website: www.isasi.org. Students may also gation. The Award is presented each Braden at 13805 Edmond Gardens Drive, request applications by e-mail to year during our annual seminar to a Edmond, OK 73013-7064 USA; e-mail [email protected]. The ISASI office recipient who is recognized for positive address, [email protected]. Home phone: telephone number is 1-703-430-9668. advancements in the art and science of 1-405-359-9007, cell: 1-405-517-5665. ◆ air safety investigation.” Application requirements The nomination process allows any Reachout Program • Applicants must be enrolled as full-time member of ISASI to submit a nomination. students in a recognized (note ISASI The nominee may be an individual, a Continues Winning Ways recognized) education program, which group of individuals, or an organization. The ISASI Reachout Program that began includes courses in aircraft engineering The nominee is not required to be an in May 2001 with the goal of getting and/or operations, aviation psychology, ISASI member. The nomination may be accident investigation expertise, as well as aviation safety and/or aircraft occurrence for a single event, a series of events, or a the ISASI name, to parts of the world that investigation, etc., with major or minor ○○○○○○○○○○○○○○○○○○○○○○○○○○ lifetime of achievement. The ISASI ○○○○○○○○○○○○○○○○○○○○○○○○○○ are not affected by the Society’s annual subjects that focus on aviation safety/inves- Awards Committee considers such traits seminars ended its sixth year with tigation are eligible for the scholarship. as duration and persistence, standing continued success in its final two training • The student is to submit a 1,000 among peers, manner and techniques of workshops, held in Larnaca, Cyprus, and (+/- 10 percent) word paper in English operating, and of course achievements. Jeddah, Saudi Arabia, according to reports addressing “The Challenges For Air Once nominated, a nominee is considered filed by the two lead ISASI trainers, Ron Safety Investigators.” for the next 3 years and then dropped. Schleede and Caj Frostell. Other recent • The paper is to be the student’s own After an intervening year, the candidate successes were recorded in India; Sri work and must be countersigned by the may be nominated for another 3-year Lanka; Pakistan; China; and Helsinki, student’s tutor/academic supervisor as period. The nomination letter for the Finland (for the Nordic countries). authentic, original work. Lederer Award should be limited to a Schleede reported that the Air Acci- • The papers will be judged on their single page. dent and Incident Investigation Board content, original thinking, logic, and This award is one of the most signifi- (AAIIB) of Cyprus hosted the 17th ISASI clarity of expression. cant honors an accident investigator can Reachout Workshop, held on May 29- • The student must complete the receive; therefore, considerable care is June 9. It was organized under the application form and submit it to ISASI given in determining the recipient. ISASI leadership of AAIIB Chairman Costas with the paper by April 3, 2007. members should thoughtfully review their (continued on page 28)

26 • ISASI Forum January–March 2007 Airliner Accident Statistics 2006 (Reprinted from Airliner Accident Statistics 2006, Jan. 1, 2007, with permission of Harro Ranter, Aviation Safety Network; Copyright 1996-2007. Source of data is regulatory transportation safety boards, including ICAO, insurance companies, and regional news media. The full document is available on the ASN website, which can be accessed at http://www.aviation-safety.net/pubs.—Editor) The year 2006 in historical perspective From a historical perspective, 2006 was an average year. Although the number of fatal accidents (27) was significantly lower than the 10-year average (36), the number of fatalities was almost equal to the 1996-2005 10-year average. • The 2006 death toll of 888 was far below the 1986-2005 average • The 2006 number of 27 fatal airliner accidents was far below the 1976-2005 average of 15.3 accidents per year. death toll of 1,088 casualties. 1986-2005 average number of fatal airliner accidents of 43.2 per • The 2006 number of 18 fatal prop airliner accidents was lower • The 2006 death toll of 888 was well below the 1996-2005 average year. than the 1976-2005 average of 23.3 accidents per year. death toll of 1,005 casualties. • The 2006 number of 27 fatal airliner accidents was far below the • The 2006 number of 0 fatal piston airliner accident was far be- • The 2006 number of occupants involved in fatal airliner accidents 1996-2005 average number of fatal airliner accidents of 36.3 per low the 1976-2005 average of 8.5 accidents. of 1,156 was lower than the 1996-2005 average of 1,379. year. • The 2006 number of 0 fatal piston airliner accident was below • The 2006 fatality rate (percentage of occupants killed in fatal • The 2006 number of accidents resulting in 100 or more fatalities the 1996-2005 average of 2.9 accidents. airliner accidents) of 77% was slightly lower than the 1996-2005 was high: 4, which is the ninth highest number in aviation history. ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ average of 79%. • The 2006 number of 9 fatal jet airliner accidents was below the Statistical summary regarding fatal multiengine airliner accidents The year 2006 recorded 27 fatal airliner hull-loss accidents, causing 888 fatalities and 4 fatalities on the ground. Last year recorded the first Boeing 737NG written off in a fatal accident. Around 1,700 Boeing 737-600, -700, -800 and -900 series have been built since 1997. Below, statistics shown in the following order: Date, Aircraft Type, Operator, Location, Fatalities. 1. February 5, Shorts 360, Air Cargo Carriers, near Watertown, 3 11. June 21, DHC-6 Twin Otter, Yeti Airlines, near Jumla, 9 20. August 27, Canadair CRJ100ER, Comair, Lexington, 49 2. February 8, Swearingen Metro II, TriCoastal Air, near Paris, 1 12. July 7, Antonov 12, Mango Airlines, near Sake, 6 21. September 1, Tupolev 154, Iran Air Tours, Mashad, 28 3. March 18, Beechcraft C.99, Ameriflight, near Butte, 2 13. July 9, Airbus A310, S7 Airlines, Irkutsk, 125 22. September 29, Boeing 737-800, GOL, near Peixoto Azevedo, 154 4. March 31, Let 410, TEAM, near Saquarema, 19 14. July 10, Fokker F-27, PIA, near Multan, 45 23. October 10, BAe 146-200, Atlantic Airways, Stord, 4 5. April 16, Fokker F-27, TAM, Guayaramerín, 1 15. July 29, DHC-6 Twin Otter, Quantum Leap Skydiving, 24. October 26, CASA 212 Aviocar, Kustbevakning, 6. April 24, Antonov 32, U.S. Department of State, Lashkar Sullivan, 6 Falsterbokanalen, 4 Gah, 2+3 16. August 3, Antonov 28, TRACEP, near Bukavu, 17 25. October 29, Boeing 737-200, ADC Airlines, Abuja, 96+1 7. April 27, Convair CV-580, LAC-SkyCongo, Amisi, 8 17. August 4, Embraer 110 Bandeirante, AirNow, near 26. November 17, DHC-6 Twin Otter, Trigana Air Service, 8. May 3, Airbus A320, Armavia, off Adler/Sochi, 113 Bennington, 1 Puncak Jaya, 12 9. May 14, Convair CV-580, Saskatchewan gov., near La Ronge, 1 18. August 13, Lockheed L-100, Hercules Air, Algérie near 27. November 18, Boeing 727, Aerosucre, Colombia, near Leticia 5 10. May 23, DHC-6 Twin Otter, Air São Tomé, off São Tomé Piacenza, 3 Total Fatalities 888+4 Island, 4 19. August 22, Tupolev 154, Pulkovo near Donetsk, 170 Other fatal occurrences One occurrence resulted in a ground casualty, without any fatal injuries to the occupants of the airplane. This accident has not been included in the analysis. Date, Aircraft Type, Operator, Location, Fatalities 1. November 9, Let 410, Goma Air, Walikale, 0+12. December 8, Boeing 737-700, Southwest Airlines, Chicago, IL, 0+1 Number of fatal airliner accidents per country [where the accident happened] 2006 (2005, 2004, 2003, 2002 in parentheses) In 2006, the United States suffered the highest number of fatal airliner accidents: six. Despite the measures taken by the Congolese Ministry of Transport in 2005, three aircraft still crashed in the Democratic Republic of Congo. Having suffered two serious accidents in 2005 and another one in 2006, Nigerian authorities continued taking steps to make aviation safer. A new civil aviation act was signed into law. The new law seeks to establish aviation safeguards, enforce safety guidelines, improve security checks, prescribe ministerial powers during emergencies, define offenses that endanger safety, and also enact penalties for violation. Almost immediately four airlines had their air operator certificates (AOC) suspended pending recertification. Afghanistan 1 (2 0 0 0) Congo (Brazzaville) (1 0 0 0) Indonesia 1 (2 1 1 2) Papua New Guinea (1 1 0 0) Tunisia (0 0 0 1) Algeria (0 1 1 0) Congo (Dem. Rep.) 3 (4 0 0 0) Iran 1 (1 0 0 2) Peru (1 0 1 0) Turkey (0 0 2 0 Argentina (0 0 1 0) Djibouti (0 0 0 1) Italy 1 (3 0 0 0) Philippines (0 0 0 1) Uganda (1 0 0 0) Australia (1 0 0 0) East Timor (0 0 1 0) Kenya (0 1 2 1) Romania (1 0 0 0) Ukraine 1 Azerbaijan (1 1 0 0) Egypt (0 1 0 0) Liberia (0 0 0 1) Russia 2 (1 1 1 2) United Arab Emirates (0 1 0 0) Benin (0 0 1 0) Equatorial Guinea (1 0 0 0) Luxembourg (0 0 0 1) Sao Tomé et Principe 1 USA 6 (2 4 3 3) Bolivia 1 Estonia (0 0 1 0) Mexico (0 0 0 1) Spain (0 0 0 2) Uzbekistan (0 1 0 0) Brazil 2 (0 2 0 2) France—incl. overseas (1 0 1 0) Morocco (0 0 0 1) South Africa (0 0 0 1) Venezuela (1 1 1 0) Canada 1 (0 1 1 0 1) Gabon (0 1 1 0) Nepal 1 (0 1 0 2) South Korea (0 0 0 1) Atlantic Ocean (0 1 0 0) Central African Rep. (0 0 0 1) Germany (0 0 0 1*) New Zealand (1 0 1 0) Sudan (3 3 2 0) Pacific Ocean (0 0 0 1) China (0 2 0 1) Greece (1 0 0 0) Nigeria 1 (2 0 0 2) Sweden 1 Total 27 (35 26 25 37) Colombia 1 (1 1 1 3) Guyana (0 0 1 0) Norway 1 Taiwan (0 0 0 1) *) collision Comoros (0 0 0 1) Haiti (0 0 1 0) Pakistan 1 Tanzania (1 0 0 0)

Number of fatal airliner accidents per region 2006 (2005, 2004 2003, 2002, 5-yr avg, 10-yr avg in parentheses) The moving 10-year average trends show a decrease in the average number of fatal accidents for all regions. All regions have recorded a steadily decreasing accident rate over the past 7 years, except for Africa. In 2006, Africa was again the most unsafe continent: 18.5% of all fatal airliner accidents happened in Africa, while the continent only accounts for approximately 3% of all world aircraft departures. Africa 5 (13 7 7 10 8 7.4) Central America 0 (0 1 1 0 0.6 1.2) South America 4 (3 4 5 5 4.6 5) Asia 5 (6 7 2 10 5.8 8.3) Europe 6 (7 1 5 7 5.8 6.5) Int’l waters 0 (0 0 0 1 0.6 0.8) Australia 0 (3 1 1 0 1 1.2) North America 7 (3 5 4 4 4.2 5.9) Total 27, 35, 26, 25, 37, 30.6, 36.3 Flight nature [number of fatal airliner accidents per flight nature] 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses) ○○○○○○○○○○○○○○○○○○○ ○ ○ Eleven fatal passenger flight accidents in 2004 was an all-time low. After a brief spike in 2005, the number of accidents in○○○○○○○○○○○○○○○○○○○○○○○○○○○ 2006 decreased to 15, which is below the 5-year average of 17 accidents. Where in 2004 cargo planes were reason for concern, 2006 showed a continuing decrease in cargo plane crashes to 6. Scheduled passenger 11 (14 8 8 13 10.4 13.8) Cargo 6 (8 13 7 9 8,4 10,4) Other 3) 3 (2 1 3 2 2.2 1.9) Non-scheduled passenger 3 (5 3 5 4 4.8 5,8) Ferry/positioning 1 (0 1 2 5 1.6 1.7) Unknown 3 (1 0 0 0.8 0.9) Passenger 2) 1 (2 0 0 4 1.8 1.3) Training 2 (1 0 0 0 0.6 0.5) Total 27, 35, 27, 25, 37, 30.6, 36, 3 Flight phase: Number of fatal airliner accidents per flight phase 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses) The number of approach and landing accidents decreased to nine. As the September 1 accident involving an Iranian Tupolev 154 showed, the survival rate of approach and landing accidents is relatively high. The airplane swerved off the runway in landing and caught fire. Of the 148 occupants, 120 survived the crash. Statistics show that in the last 10 years 33% of all occupants survived approach and landing accidents. Most accidents happened in the enroute phase of flight; 14 accidents was higher than the 5- and 10-year averages. Standing (STD) 0 (0 0 0 0 0.2 0.1) Enroute (ENR) 14 (14 8 9 14 10.8 11.9) Landing (LDG) 5 (4 3 0 2 2 3.5) Takeoff (TOF) 1 (1 2 2 2 2.2 2.3) Maneuvering (MNV) 0 (1 0 2 2 1 1.1) Unknown (UNK) 0 (2 2 0 0 1 1.2) Initial climb (ICL) 3 (5 2 4 0 2.4 3) Approach (APR) 4 (8 9 8 17 11 13.2) Total 27, 35, 26, 25, 37, 30.6, 36.3

Average survival percentage per flight phase: Phase 2006, 10-yr avg Standing (STD) Initial climb (ICL) 7%, 14.5% Maneuvering (MNV) 0%, 31.4% Landing (LDG) 61.3% 82% Takeoff (TOF) 2%, 50.1% Enroute (ENR) 0.5%, 9.2% Approach (APR) 0%, 17.7% Total 23.2%, 25.9% Accident classification: Type 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses) Number of fatal airliner accidents per accident type. The probable cause for most accidents has not been established yet. However, for most accidents the factual information known at this stage makes it possible to classify these accidents. The number of “loss of control” accidents shows a marked increase to 17. Controlled flight into terrain (CFIT) accidents remained very low at 5. Loss of control 17 (13 14 11 15 12.6 [54%] CFIT—level ground 1 (2 2 4 1 2.8 [12%] 2.8 [11%]) Emergency/forced landing—outside Unknown 5 (12 4 3 5) 15.6 [59%]) CFIT—water 0 (0 0 0 0 0 0.3 [1%]) airport 0 (0 1 2 2 1 [4%] 0.5 [2%]) Total 27, 35, 26, 25, 37 CFIT—hill, mountain 4 (6 3 5 12 5.6 Emergency/forced landing—ditching 0 (1 2 0 2 1.2 Runway mishap 0 (1 0 0 0 0.2 [1%] 0.8 [3%]) [24%] 5.4 [21%]) [5%] 0.9 [3%])

January–March 2007 ISASI Forum • 27 ISASI ROUNDUP Continued . . . New Members

Individuals Cyprus Muñoz, Juan, M., MO5322, Mexico D.F., Rahman, Iad, MO5335, Mississauga, Canada Mexico Reed, Jeffrey, J., AO5320, Spokane Valley, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Orphanos and his team, with considerable Nicholl, Heath, K., MO5274, Wayne, MI, U.S.A. WA, U.S.A. assistance from Capt. Akrivos Tsolakis, Nicolaou, Nicos, P., AO5305, Latsia, Cyprus Reinhart, Paul, S., AO5327, Pensacola, FL, Obumselu, Julie, N., AO5283, Logos, Nigeria U.S.A. chairman of the Hellenic Air Accident O’Donnell, James, P., ST5317, Bay Village, Renshaw, Robert, MO5325, Thornton, CO, Investigation & Safety Board (HAAISB). OH, U.S.A. U.S.A. Workshop sponsors included Olympic O’Donnell, Jennifer, ST5264, South Wirral, Ribeiro, Paulo, M., MO5324, Davie, FL, United Kingdom U.S.A. Airways, Cyprus Airways, and Air BP. Onken, Jenna, E., ST5339, Lawrenceville, Ryan, John, R., FO5286, Robertson, OLD, Content of the workshop was about GA, U.S.A. Australia equally divided into accident/incident Öztürk, Ahmet, ST5273, Istanbul, Turkey Salvestrini, Jarrod, A., ST5265, Daytona Pafitis, Kyriakos, P., MO5296, Limassol, Beach, FL, U.S.A. investigation and prevention (AIIP) Cyprus Schwarz, Scott, A., MO5275, Ocean City, NJ, conducted by Schleede and safety Papanastasiou, Georgios, MO5297, Paphos, U.S.A. management systems (SMS) conducted Cyprus Slaven, Walter, J., MO5266, Glen Forrest, Park, Won Beom, ST5279, Daytona Beach, W.A., Australia by Jim Stewart. Other instructors FL, U.S.A. Tagarino, Bose, T., AO5271, Lagos, Nigeria providing considerable support included Pattides, Andreas, C., MO5298, Nicosia, Tehrani, Morteza, AO5333, Castle Hill, NSW, Dr. Loukia Loukopolous from Greece Cyprus Australia Pilalis, Dina, FO5321, Melbourne, VIC, Tritschler, Kristjof, AO5269, Bonn, Germany (NASA employee), who covered human Australia Wandall, Edward, H., MO5290, North Wales, factors; Dr. Ioannis Markou from Greece, Pitsillides, Constantinos, MO5302, Larnaca, PA, U.S.A. ◆ who covered aeromedical factors; Capt. Vangelis Demosthenos from Cyprus, who covered SMS and related topics; and from Greece, the Egyptian Air Traffic ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ All participants received certificates of Capt. Elias Nikolaides from Greece, who Services, Cyprus Airsports Federation, training completion at a closing dinner, addressed European regulatory require- Cyprus Intercollege, Cyprus Fire which featured the minister of Communi- ments and operational safety oversight Service, Cyprus Ministry of Defence, cations and Works, and the director- (internal and external audits). Helios Airways, Eurocypria Airlines, general of the DCA, as guest speakers, In all, 45 persons attended represent- Cyprus Airways, Cyprus Police Depart- among others. ing the Cyprus AAIIB, the Cyprus DCA, ment (aviation department), and the Recruiting effectiveness of ISASI’s Hellenic AAIASB, an aviation magazine Ministry of Communications and Works. effort was again proven by the gain of 22 new ISASI members. Also proven was the workshop’s value, as the trained group now plans to “organize a future meeting among themselves and is considering forming a local chapter,” said Schleede.

Eighteenth Workshop Caj Frostell noted the 18th ISASI Reachout workshop ran from November 4 to 15 and was hosted by Saudi Arabian Airlines (SVA) in Jeddah. Capt. Fareed Alshingiti, general manager–Flight Operations Standards and Quality Assurance, opened the program held in the facilities of Saudi Arabian Airlines, the CRM and human factors training auditorium of the Prince Sultan Aviation Academy. It was Reachout’s second visit Mike Dorion cuts the ISASI logo cake as Dr. Osama Bahannan—director, Aviation to the group. Medicine, General Authority of Civil Aviation, Saudi Arabia (3rd from left)—and The technical content of the workshop Capt. Talal Ageel—vice-president, Flight Operations Department (with plate in comprised three modules: aviation hand)—look on. medicine conducted by Dr. Anthony Evans,

28 • ISASI Forum January–March 2007 ○○○○ chief of the Aviation Medicine Section in ○○○○ accident investigation, conducted by A majority of the 31 participants were ICAO; safety management systems (SMS), Frostell and assisted by Alain Guilldou from within Saudi Arabian Airlines. Other conducted by Mike Doiron; and aircraft from BEA, France, and Mike Dorion. attendees included inspectors with the

Improving the Quality of Investigation Analysis (from page 13) the document-management system for each of the items or com- lines. These guidelines provide information on analysis terminol- ments in the table. ogy, accident development models, and principles of critical rea- Safety factor evidence tables are used to test proposed safety soning (e.g., components of arguments, deductive versus induc- factors. They have separate parts for the test for existence, test tive arguments, common fallacies of reasoning, characteristics of for influence, and test for importance. The existence and influence evidence that influence its credibility and relevance, preferred ter- parts are essentially the same as the basic evidence table. The in- minology to use for describing probabilities, and similar concepts). fluence part (if required) is simply a free-text box allowing investi- The guidelines also provide detailed guidance on how to conduct gators to justify why they think the safety factor should be ana- each of the processes and stages of the analysis phase. For many lyzed further. of the stages in the analysis process, the guidance is presented in Investigators are provided with guidance for developing an evi- the form of a series of questions or criteria to consider. This ap- dence table in four stages: review related information, identify rel- proach breaks down the general “why” question into more useful evant items of information, evaluate the strength of each item, and and manageable components. evaluate the overall strength of the potential finding. The guid- The guidelines and tools are being introduced and reinforced ance consists of a series of questions or criteria to consider at each through a 4-day training course for all investigators at the ATSB. stage. The training involves a large component of practical experience in applying the framework’s concepts, process, and tools. Policies, guidelines, and training One feature of the guidelines and training is a strong emphasis To emphasize the importance of using the terminology, model, pro- on teamwork. Investigators have excellent skills and knowledge cess, and tools in the analysis framework, the ATSB has devel- of particular domains, but it is unlikely that any one investigator is oped a set of policies for its investigators. Examples of these poli- going to have sufficient knowledge in all relevant domains to deal cies include requiring a sequence of events analysis for each occur- with the complexity that arises during investigations. As the range rence investigation, completing an evidence table for each key of experience that contributes to analysis judgments is broadened, finding, conducting a risk analysis of each verified safety issue, then the quality of the resulting findings will improve. and encouraging external organizations to initiate safety action prior to the ATSB issuing any recommendations. Concluding comments The policies are supported by a comprehensive set of guide- Analysis activities ultimately rely on the judgment of investigators. The ATSB analysis framework is designed to guide and Figure 5 support these difficult judgements, rather than replace the central role of its investigators. By providing standardized terminology, a generic accident development model, a defined process, tools, policies, guidelines, and training, the ATSB believes its analysis framework will improve the rigor, consistency, and defensibility of its investigation analysis activities, and improve the ability of its investigators to detect safety issues in the transportation system. The new ATSB analysis framework is just a starting point. The intention is that, as investigators become more familiar with it, they will actively contribute to its ongoing improvement. In other words, the framework is a platform for documenting the ATSB’s organizational learning about analysis methods. Any feedback anyone has for enhancing the quality of the ATSB framework would be gratefully received. ◆

January–March 2007 ISASI Forum • 29 ISASI ROUNDUP ISASI Information Continued . . .

General Authority of Civil Aviation ISASI By-Laws Being (GACA). The participants received ISASI OFFICERS certificates for the combined accident Revised President, Frank Del Gandio ([email protected]) investigation and safety management At its fall 2005 meeting the Society’s Executive Advisor, Richard Stone systems workshop. International Council, noting that the last ([email protected]) Vice-President, Ron Schleede At the closing ceremony completion revision to the important document was in (ronschleede@aol.com) certificates were presented by Capt. Talal August 1993, established a committee, Secretary, Chris Baum ([email protected]) Ageel (vice-president–Flight Operations chaired by Darren Gaines, to undertake Treasurer, Tom McCarthy Department). Other executive and the daunting task of revising the docu- ([email protected]) managerial-level participation from SVA ment, which contained a significant num- included Capt. Fareed Alshingiti (general ber of outdated requirements. The By- COUNCILLORS Australian, Lindsay Naylor manager–Flight Operations Standards Laws set goals, philosophy, give direction, ([email protected]) and Quality Assurance) and Capt. and provide intent. Council and office Canadian, Barbara Dunn ([email protected]) Mohammed Hersi (manager–Technical procedures to implement the By-Laws European, Anne Evans Quality Assurance). During the workshop, requirements are more appropriately ([email protected]) International, Caj Frostell ISASI membership forms and corporate spelled out in the ISASI Policy Manual. ([email protected]) membership forms were made available The By-Laws Committee work is near New Zealand, Ron Chippindale ([email protected]) to the participants who were not already completion, and the process to present the United States, Curt Lewis ISASI members. ◆ revised document to the membership for ([email protected]) approval is being put into place. The voting vehicle, Vote Net, can be accessed through NATIONAL AND REGIONAL the Internet, and eligible members will be SOCIETY PRESIDENTS Australian, Kenneth S. Lewis able to vote through a link from the ISASI ([email protected]) MOVING? Canadian, Barbara M. Dunn website. Members without access to the In- ([email protected]) Please Let Us Know ternet will be provided with a printed ballot European, David King Member Number______and a copy of the By-Laws revision upon re- ([email protected]) Latin American, Guillermo J. Palacia quest to the ISASI office. Dates for posting (Mexico) Fax this form to 1-703-430-4970 or mail to the revision have not yet been determined; New Zealand, Peter Williams ISASI, Park Center ([email protected]) 107 E. Holly Avenue, Suite 11 however, the Council wants all members to Russian, Vsvolod E. Overharov Sterling, VA 20164-5405 be aware of this important work product so ([email protected]) ◆ SESA-France Chap.,Vincent Fave Old Address (or attach label) they may be prepared to act. ([email protected]) United States, Curt Lewis Name ______NTSB Names Clark, ([email protected]) Address ______City ______Haueter to New Posts State/Prov. ______National Transportation Safety Board Chairman Mark V. Rosenker has named Zip ______John Clark, formerly director of Aviation Country ______Safety, as the agency’s chief scientist for New Address* aeronautical engineering. Tom Haueter, Name ______deputy director of aviation safety, has been named acting director of the office. Address ______Clark joined the Board in 1981 as an City ______aeronautical engineer and served in several State/Prov. ______investigative capacities. He has served as Zip ______director of aviation safety for the last 6 years. Haueter came to the Board in 1983 Country ______and has served as a structures investigator, E-mail ______an investigator-in-charge, as head of the *Do not forget to change employment and major investigations division, and as deputy e-mail address. director of aviation safety for 6 years. ◆

30 • ISASI Forum January–March 2007 UNITED STATES REGIONAL CORPORATE MEMBERS Federal Aviation Administration Finnair Oyj CHAPTER PRESIDENTS Accident Investigation Board, Finland Flight Attendant Training Institute at Alaska, Craig Beldsoe Accident Investigation Board/Norway Melville College ([email protected]) Aeronautical & Maritime Research Laboratory Flight Safety Foundation Arizona, Bill Waldock ([email protected]) Accident Investigation & Prevention Bureau Flight Safety Foundation—Taiwan Dallas-Ft. Worth, Curt Lewis AeroVeritas Aviation Safety Consulting, Ltd. Flightscape, Inc. ([email protected]) Air Accident Investigation Bureau of Singapore Galaxy Scientific Corporation Florida, Ben Coleman ([email protected]) Air Accident Investigation Unit—Ireland GE Transportation/Aircraft Engines Great Lakes, Rodney Schaeffer Air Accidents Investigation Branch—U.K. Global Aerospace, Inc. ([email protected]) Air Canada Pilots Association Hall & Associates, LLC Los Angeles, Inactive Air Line Pilots Association Mid-Atlantic, Ron Schleede Hellenic Air Accident Investigation Air New Zealand, Ltd. & Aviation Safety Board ([email protected]) Airbus S.A.S. Northeast, David W. Graham ([email protected]) Honeywell Airclaims Limited Hong Kong Airline Pilots Association Pacific Northwest, Kevin Darcy Aircraft Accident Investigation Bureau— ([email protected]) Hong Kong Civil Aviation Department Switzerland IFALPA Rocky Mountain, Gary R. Morphew Aircraft Mechanics Fraternal Association ([email protected]) Independent Pilots Association San Francisco, Peter Axelrod Aircraft & Railway Accident Investigation Int’l. Assoc. of Mach. & Aerospace Workers (p_axelrod@compuserve.com) Commission Interstate Aviation Committee Southeastern, Inactive Airservices Australia Irish Air Corps AirTran Airways Japan Airlines Domestic Co., LTD COMMITTEE CHAIRMEN Alaska Airlines Japanese Aviation Insurance Pool Alitalia Airlines—Flight Safety Dept. JetBlue Airways Audit, Dr. Michael K. Hynes All Nippon Airways Company Limited ([email protected]) KLM Royal Dutch Airlines Allied Pilots Association L-3 Communications Aviation Recorders Award, Gale E. Braden ([email protected]) American Eagle Airlines Learjet, Inc. Ballot Certification, Tom McCarthy American Underwater Search & Survey, Ltd. Lockheed Martin Corporation ([email protected]) ASPA de Mexico Lufthansa German Airlines Board of Fellows, Ron Chippindale Association of Professional Flight Attendants MyTravel Airways ([email protected]) Atlantic Southeast Airlines—Delta Connection National Air Traffic Controllers Assn. Bylaws, Darren T. Gaines ([email protected]) Australian Transport Safety Bureau National Business Aviation Association Code of Ethics, John P. Combs Aviation Safety Council National Transportation Safety Board ([email protected]) Avions de Transport Regional (ATR) NAV Canada Membership, Tom McCarthy ([email protected]) BEA-Bureau D’Enquetes et D’Analyses Nigerian Ministry of Aviation and Accident Nominating, Tom McCarthy ([email protected]) Board of Accident Investigation—Sweden Investigation Bureau Boeing Commercial Airplanes Reachout, James P. Stewart ([email protected]) Parker Aerospace Bombardier Aerospace Regional Aircraft Seminar, Barbara Dunn ([email protected]) Phoenix International, Inc. Bundesstelle fur Flugunfalluntersuchung—BFU Pratt & Whitney Cathay Pacific Airways Limited Qantas Airways Limited WORKING GROUP CHAIRMEN Cavok Group, Inc. Qwila Air (Pty) Ltd. Air Traffic Services, John A. Guselli (Chair) Centurion, Inc. Republic of Singapore Air Force ([email protected]) China Airlines Rolls-Royce, PLC Ladislav Mika (Co-Chair) ([email protected]) Cirrus Design Royal Netherlands Air Force Cabin Safety, Joann E. Matley Civil Aviation Safety Authority Australia Royal New Zealand Air Force ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. RTI Group, LLC Corporate Affairs, John W. Purvis Comair, Inc. Sandia National Laboratories ([email protected]) Continental Airlines SAS Braathens Continental Express Flight Recorder, Michael R. Poole Saudi Arabian Airlines COPAC/Colegio Oficial de Pilotos de la ([email protected]) SICOFAA/SPS Aviacion Comercial Sikorsky Aircraft Corporation General Aviation, William (Buck) Welch Cranfield Safety & Accident Investigation Centre ([email protected]) Skyservice Airlines Ltd. DCI/Branch AIRCO Singapore Airlines, Ltd. Government Air Safety, Willaim L. McNease Delta Air Lines, Inc. SNECMA Moteurs ([email protected]) Directorate of Aircraft Accident Investigations— South African Airways Human Factors, Richard Stone Namibia South African Civil Aviation Authority ([email protected]) Directorate of Flight Safety (Canadian Forces) Southern California Safety Institute Investigators Training & Education, Directorate of Flying Safety—ADF Southwest Airlines Company Graham R. Braithwaite Dutch Airline Pilots Association Star Navigation Systems Group, Ltd. ([email protected]) Dutch Transport Safety Board State of Israel Positions, Ken Smart EL AL Israel Airlines Transport Canada ([email protected]) EMBRAER-Empresa Brasileira de Transportation Safety Board of Canada Aeronautica S.A. U.K. Civil Aviation Authority Embry-Riddle Aeronautical University UND Aerospace Emirates Airline University of NSW AVIATION Era Aviation, Inc. University of Southern California European Aviation Safety Agency Volvo Aero Corporation EVA Airways Corporation WestJet ◆ Exponent, Inc.

January–March 2007 ISASI Forum • 31 WWHO’SHO’S W WHOHO Transportation Safety Board of Canada (Bureau de la Sécurité des Transports du Canada) ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ ○ ○ (Who’s Who is a brief profile of, and ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the TSB be independent and free from investigation will advance Canadian prepared by, the represented corporate any conflicts of interest when investigat- transportation safety, and that doing so member organization to enable a more ing accidents and incidents. TSB’s has the potential for reducing future risk thorough understanding of the organi- independence enables it to be fully to persons, property, or the environment. zation’s role and functions.—Editor) objective in making findings as to causes In effect, the TSB, for the most part, and contributing factors, and in making will focus its efforts on occurrences in the he Transportation Safety Board of transportation safety recommendations. Canadian federally regulated, commercial Canada (TSB) is an independent The TSB consists of up to five Board transportation sector. In addition, in Tagency, created by an act of members, including a chairperson, and accordance with ICAO Annex 13 stan- Parliament (the Canadian Transportation has approximately 220 employees. The dards and recommended practices, the Accident Investigation and Safety Board TSB head office is located in Gatineau, TSB is responsible for ensuring Canadian Act). The TSB’s mandate is to advance Quebec; however, most investigation staff safety interests in foreign investigations transportation safety are located in various regional and field involving aircraft that are registered, • by conducting independent investiga- offices across Canada, where they are licensed, operated, or manufactured in tions into selected transportation occur- better able to Canada. In this regard, the TSB supports rences in order to make findings as to respond quickly to foreign investigations and international their causes and contributing factors, transportation aviation safety by contributing its • by identifying safety deficiencies, as occurrences expertise and resources. evidenced by transportation occurrences, anywhere in the The TSB also contributes to interna- • by making recommendations designed country. tional flight safety through its close to eliminate or reduce any such safety Approximately association and involvement with ICAO, deficiencies, and 2,000 aviation the International Transportation Safety • by reporting publicly on its investiga- transportation Association, the Nordic Accident tions and on the findings in relation occurrences Investigation Group, and ISASI; through thereto. (accidents and incidents) are reported to its participation in aviation safety In making its findings as to the causes the TSB each year. Practical consider- working groups, seminars, and meetings;

and contributing factors of a transporta- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ations dictate that only a small proportion and by providing training opportunities tion occurrence, it is not the function of of these be investigated. Consequently, to other investigation agencies and the Board to assign fault or determine when notified of an occurrence, the TSB safety associations. civil or criminal liability, but the Board will assess the circumstances to deter- For more information on the TSB, its shall not refrain from fully reporting on mine if an investigation is warranted. An investigations, recommendations, and the causes and contributing factors individual occurrence will be investigated subscription services, visit its website at merely because fault or liability might be when there is high probability that the http://tsb.gc.ca. ◆ inferred from the Board’s findings. In respect to aviation occurrences, the Act applies in or over Canada, in or over ISASI NON-PROFIT ORG. any place that is under Canadian air 107 E. Holly Ave., Suite 11 U.S. POSTAGE traffic control, and in or over any other Sterling, VA 20164-5405 PAID place, if Canada is requested to investi- USA Permit #273 gate the aviation occurrence by an ANNAPOLIS, MD appropriate authority, or if the aviation occurrence involves an aircraft in respect of which, or that is operated by a person to whom, a Canadian aviation document has been issued under Part I of the Aeronautics Act. To instill confidence in the public regarding the transportation accident investigation process, it is essential that

32 • ISASI Forum January–March 2007