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Proceedings-1979.Pdf "'0",0""" ~ 'OG"" ai. " " . The International Society ofAir Safety Investigators Vol. 12, No.3 Winter 1979 Proceedings of the Tenth International Seminar of the International Society of Air Safety Investigators Ritz-Carlton Hotel Montreal, Quebec, Canada September 24-27, 1979 Call for Papers The 1980 International Seminar of the International Society of Air Safety Investigators will be held at the Sir Francis Drake Hotel in San Francisco, California forum September 30 - October 2, 1980 Published Quarterly by the The theme of the seminarwill be: International Society of Air Safety Investigators "Advanced Technology in the Volume 12, No.3 December 1979 Investigation of Aircraft Accidents" (Presentations on other topics will be considered) Editor - Ira J. Rimson The Editorial objective is to report developments and Authors wishing to present papers are invited to submit advanced techniques of particular interest to the profes­ a 200-300 word abstract to: sional aircraft accident investigator. Opinions and con­ clusions expressed herein are those of the writers and Frederick H. Matteson are not official positions of The Society. The Editorial 1874 Cushman Street Staff reserves the right to reject any article that, in its Hollister, CA 95023 opinion, is not in keeping with the ideals and/or objec­ Phone: (408) 637-6598 tives of the Society. It further reserves the right to Abstracts must be received by April 30, 1980. delete, summarize or edit portions of any article when such action is indicated by printing space limitations. Final papers will be required by August 15, 1980. Editorial and Business Office: c/o Editor, lSASI forum 4507 Wakefield Drive Annandale, VA 22003 (703) 978-2944 CHANGE OF ADDRESS: The Jerome F. Lederer Award • • The award is given for outstanding contributions ISaSI to technical excellence in accident investigation. Not West Building, Room 259 more than one award will be made annually and presen­ Washington National Airport tation is at the ISASI Seminar. The recipient is selected Washington, DC 20001 by an ISASI Board of Award. U.S.A. Any ISASI member may submit a nomination for this award . It must be sent to the Chairman of the THE NATIONAL SOCIETY OF Board of Award not later than 15 May 1980, and must AIR SAFETY INVESTIGATORS include a statement describing why the nominee should be considered. This statement should be sufficiently OFFICERS descriptive to justify the selection but no more than one President Laurence Edwards typewritten page in length. Secretary John McDonald Treasurer William Barnhart This award is one of the most significant honors an accident investigator can receive, and so considerable INTERNATIONAL COUNCILLORS care is given in determining the recipient. Each ISASI member should thoughtfully review his or her associa­ Roger W. Smith Canada tion with professional investigators, and submit a Ian S. Milligan Australia nomination when they can identify someone who has Sven Olof Fritsch At-Large really been outstanding in increasing the technical quali­ ty of investigation. David S. Hall Mail to: Chairman, Board of Award, ISASI 8202 E. Vista Scottsdale, AZ 85253 isesi forum TABLE OF CONTENTS Seminar Organization & Acknowledgements 11 Ground Impact and Propeller Pitch Position 49 Jerome F. Lederer Award 1 David S. Hall, Crash Research Institute, ASV Incident Reporting in Australia . .. 2 Investigator Can Prevent Aircraft Accidents 55 Griff V. Hughes, DOT Australia George B. Parker, V.S.c. A Low-Cost Constraint-Based Incident The Use of Accident Scenarios in Reporting System 5 Accident Prevention 60 Richard Bartel, Human Factors Engineer Gerard M. Bruggink Incident Analysis: A Key to Accident Application of a Decision-Making Model to Prevention ............................... .. 8 the Investigation of Human Error in Aircraft John B. Galipault, Aviation Safety Institute. and Accidents 62 Ira J. Rimson, P.E., System Safety Associates Ltd. Ronald L. Schleede, NTSB Techniques to Increase the Effectiveness of A Reviewofthe Unexpected in Aircraft Design. .. 79 the Capable Investigator 11 Captain Hal L. Sprogis Ted. S. Ferry, Ph.D., V.S.c. How Does the Investigator Develop The Role of the Canadian Military Recommendations? ........................ .. 81 Accident Investigator 16 Richard H. Wood, V.S.c. COL J. R. Chisholm, DFS, CAF Punishment: the Pros and Cons 86 The Accident Investigator - A Viewpoint Jerome F. Lederer, E.P.R.I. and V.S.c. from the Private Sector 19 Civil Aircraft Liability and the Investigator . 92 John L. McWhorter, J. L. McWhorter & Associates James E. Satterfield The Challenges of Digital Flight Data Helicopter Wreckage Analysis 94 Recorders' Readout and Analyses 23 Jerry T. Dennis, NTSB Bernard Caiger, NRC Canada The Need to Go Beyond the Cause-Related Cockpit and Visual System Limitations to Facts 35 See and Avoid 111 James L. Harris, Sr. Joseph R. Bailey, AMSI The Probable Cause: A Detriment to Air Safety? ... 37 SARSAT, The Search and Rescue Satellite 122 B. J. Trudell and W. N. Redisch, NASA Goddard Tom H. Davis, Esq.; Byrd, Davis & Eisenberg Space Flight Center Conflicts of Interest in Accident Investigation 39 . Myron P. Papadakis, Esq. ELT's - The Canadian Experience 125 Terry Heaslip, MOT Canada Fault-Tree Analysis: Accident Investigator's The ELT and the Investigator's Role in Role in Safe Design 41 James Francois Leggett, Esq. Safety Research 141 David S. Hall, Crash Research Institute Luncheon Address by Dr. Assad Kotaite, NASA Crash Test Program 147 President. ICAO Council 43 Robert J. Hayduk, NASA Langley Research Center A Second Look at a Fatal Accident 44 List of Participants Raymond C. Lee, R. C. Lee & Associates winter 1979 ISASI and the Canadian Society of Air Safety Investiga­ tors gratefully acknowledge the contributions of 'the following patrons to the success of ISASI '79 Interna­ tional Seminar: Allied Pilots Association CANADAIR Ltd. Canadian Air Line Pilots Association Canadian Air Traffic Controllers Association CAE (Electronics) Ltd. Insurance Company of North America (INA) Pratt and Whitney (Canada) Ltd. ISASI '79 SEMINAR ORGANIZATION Budget and Coordinators Olof Fritsch and Roger Smith Final Programme Olof Fritsch CANADAIR Tour, Hotel Social Activities Roger Smith Ladies Programme Gary Merritt Registration Coordinator Larry O'Bierne Assistants Fred Burgess Diana Cooper Anne Marie De Lavison Heather McCully Presentation Coordinator John Gallagher Audio-Visuals Scott Stewart Gilles Nobert Press/Media Chris De Lavison Bill Kidd Photography, Displays Rick Bartel and Troubleshooting Gary Merritt Treasurer Bill Barnhart Miscellaneous Rick Bartel sasi forum ii 1 JEROME LEDERER A WARD 1979 Presented to Gerard M. Bruggink for Outstanding Contributions to Technical Excellence in Accident Investigation Mr. Bruggink's career in aviation has spanned four decades of tremendous growth in aviation. His personal contributions as a pilot, flight instructor, accident investigator, safe­ ty researcher and accident investigation manager have contributed directly to continued im­ provement in the safety of air travel. At the time of his ret irement in 1979 he was the Deputy Director of the Bureau of Acci­ dent Investigation of the United States National Transportation Safety Board. Mr. Brug­ gink has published numerous technical papers on accident investigation, passing on to other investigators his great wealth of understanding of the process of investigation and of the lessons learned through investigation that have made air transportation safer for all members of the public. winter 1979 The Australian Air Safety Incident Reporting System G. V. Hughes 10 Rhodes Drive Victoria, Australia Glenwaverly 3150 The Australian Air Safety Incident Reporting ties for the safe, orderly and expeditious operation of System is possibly unique, in that it is basically a man­ civil aircraft in Australia and Australian aircraft outside datory system. It is administered by the Air Safety In­ Australia. Other complementary systems are the Accl­ vestigation Branch of the Department of Transport. dent Notification and Investigation System and the Air­ Currently, some 6000 reports are received each year ways Facility Fault Reporting and Performance Test· and each one is examined by a professional air safety ing systems. Additionally, operators are required to investigator. establish monitoring systems to ensure that day-by­ day safety standards in aircraft operations are met. The majority of our incident reports concern General Aviation operations. Over the past three years, Further, the Australian aviation safety monitoring for example, our records comprise 71 per cent involving systems are concerned with what happens both in General Aviation aircraft, 21 per cent Airline aircraft, Australia and in other countries. Allied with the func­ and 8 per cent in other categories such as gliding and tion of operating our Incident Reporting system is sport aviation. liaison with overseas aviation authorities for the ex­ change of safety information, such as accidentlinci­ Abroad breakdown of factors shows that about 50 dent investigation reports, safety studies and aviation per cent of reported incidents are found to involve per­ safety recommendations. Information received is care­ sonnel factors, 35 per cent aircraft factors, and 30 per fully examined for its relevance to the Australian avia­ cent other factors. Obviously, on many occasions, a tion environment. report contains factors relating to more than one of Objectives these areas. It is important for any safety monitoring system to Background
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